Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infiltrating ductal breast cancer.

OBJECTIVE: To evaluate the efficacy of intraoperative ultrasound in obtaining adequate surgical margins in women undergoing lumpectomy for palpable breast cancer. SUMMARY BACKGROUND DATA: Adequacy of surgical margins is a subject of debate in the literature for women undergoing breast-conserving therapy. The emerging technology of intraoperative ultrasound-guided surgery lends itself well to a prospective study evaluating surgical accuracy and margin status after lumpectomy. METHODS: Two groups of women undergoing lumpectomy for palpable breast cancer were studied, one group using intraoperative ultrasound (n = 27) and the other without (n = 24). Pathologic specimens were evaluated for size, margins, and accuracy, and patients were questioned about satisfaction with cosmetic results. RESULTS: Surgical accuracy was improved with intraoperative ultrasound-guided surgery. Margin status was improved, patient satisfaction was equivalent, and cost was not affected using ultrasound technology. Intraoperative ultrasound appears especially efficacious for women whose preoperative mammogram shows dense parenchyma surrounding the lesion. CONCLUSIONS: The use of ultrasound-guided surgery optimizes the surgeon's ability to obtain satisfactory margins for breast-conserving techniques in patients with breast cancer. Patient satisfaction is excellent and a cost savings is most likely realized.

Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy.

OBJECTIVE: To determine whether infiltrating lobular carcinoma (ILC) is associated with high positive-margin rates for single-stage lumpectomy procedures, and to define clinical, mammographic, or histologic characteristics of ILC that might influence the positive-margin rate, thereby affecting treatment decisions. SUMMARY BACKGROUND DATA: Infiltrating lobular cancer represents approximately 10% of all invasive breast carcinomas and is often poorly defined on gross examination. METHODS: A group of 47 patients with biopsy-proven ILC undergoing breast-conservation therapy (BCT) at the University of Virginia Health Sciences Center between 1975 and 1999 was compared with a group of 150 patients with infiltrating ductal cancer undergoing BCT during the same time period. The pathology of the lumpectomy specimen was reviewed for each patient to confirm surgical margin status. Office and surgical notes as well as mammography reports were examined to determine whether the lesions were deemed palpable before and during surgery. Patients were stratified according to age, family history, tumor size, tumor location, and histologic features of the tumor. RESULTS: The incidence of positive margins was greater in the ILC group compared with the infiltrating ductal cancer group. Patient age, family history, and preoperative palpability of the tumor did not correlate with surgical margin status. Of the mammographic features identified, including spiculated mass, calcifications, architectural distortion, and other densities, only architectural distortion predicted positive surgical margin status. Tumor grade, tumor size, lymph node status, and receptor status were not predictive of surgical margin status. CONCLUSIONS: For patients with ILC, BCT is feasible, but these patients are at high risk of tumor-positive resection margins (51% incidence) after the initial resection. Only the mammographic finding of architectural distortion was identified as a preoperative marker reliably identifying a subgroup of ILC patients at especially high risk for a positive surgical margin. For all patients with ILC considering BCT, careful counseling about the potential need for a second procedure to treat the positive margin should be included in the treatment discussion.

Interventions to reduce decibel levels on patient care units.

The University of Virginia Health System inpatient satisfaction survey identified noise as the most important irritant to surgical inpatients. Analysis of the level and pattern of noise on patient floors and intensive care units was done with baseline measurements followed by then two separate interventions: 1) education of nursing and physician staff 2) closing patient room doors. A decibel meter (M-27 Dosimeter) recorded the noise level over 24 hours. Patients doors were open in the initial measurements. Next, three 1-hour education sessions were conducted by a surgeon and nursing supervisor to review noise-reduction strategies with the staff. These included using pagers in vibrate mode, minimizing overhead announcements, and conducting nurse reports and physician teaching sessions in classrooms away from the nurses' station. Finally, the doors were closed except as visitors and staff entered the room. Little impact was seen from staff education. Closing patient doors on surgical floors decreased noise an average of 6.0 dB, a change that patients can readily perceive. Conversely, intensive care unit patients are exposed to more noise with closed doors, presumably because most noise emanates from equipment within the room. A policy of closing patient floor room doors may increase patient satisfaction.

The mechanics underlying laparoscopic intra-abdominal surgery for obese patients.

Any surgeon experienced with a laparoscopic approach to intra-abdominal surgery on morbidly obese patients is aware of the increased difficulty associated with the patients' obesity. We present a study of the mechanics of laparoscopic surgery that explains the difficulty subjectively experienced in terms of the decreased sensitivity felt by the surgeon as a result of the increased thickness of the abdominal wall and increasing force required for the repositioning of the tip of the operating instrument. We propose that the placement and angling of the trocar in the abdominal wall are of paramount importance in the successful and safe completion of laparoscopic procedures in obese patients.

Modeling the climatic response to orbital variations.

According to the astronomical theory of climate, variations in the earth's orbit are the fundamental cause of the succession of Pleistocene ice ages. This article summarizes how the theory has evolved since the pioneer studies of James Croll and Milutin Milankovitch, reviews recent evidence that supports the theory, and argues that a major opportunity is at hand to investigate the physical mechanisms by which the climate system responds to orbital forcing. After a survey of the kinds of models that have been applied to this problem, a strategy is suggested for building simple, physically motivated models, and a time-dependent model is developed that simulates the history of planetary glaciation for the past 500,000 years. Ignoring anthropogenic and other possible sources of variation acting at frequencies higher than one cycle per 19,000 years, this model predicts that the long-term cooling trend which began some 6000 years ago will continue for the next 23,000 years.