Survival and risk of breast cancer recurrence after breast reconstruction with deep inferior epigastric perforator flap.

BACKGROUND: Women who undergo autologous breast reconstruction have been reported to have an increased risk of breast cancer recurrence compared with those who have mastectomy alone. It has been suggested that more extensive surgery possibly activates dormant micrometastases. The aim of this study was to evaluate whether delayed unilateral deep inferior epigastric perforator (DIEP) flap reconstruction after mastectomy increases the risk of breast cancer recurrence or affects mortality among women previously treated for breast cancer. METHODS: This was a matched retrospective cohort study including women with a previous unilateral invasive breast cancer who received a delayed DIEP flap breast reconstruction and a control cohort of individually matched women with unilateral breast cancer who underwent mastectomy but no autologous breast reconstruction. Matching criteria comprised: year of diagnosis (+/-3 years), age at diagnosis (+/-5 years), type of cancer and demographic region. The primary endpoints were local recurrence or distant metastasis, and overall mortality was a secondary endpoint. Absolute risk of recurrent disease and mortality was analysed, and relative risks were estimated using Cox proportional hazards analysis. RESULTS: There were 225 women in the DIEP cohort and 450 in the no-DIEP cohort. The median follow-up time was 125 months. There was no difference in absolute risk of recurrence between the cohorts. The hazard ratio for breast cancer recurrence in DIEP versus no-DIEP cohorts was 0·76 (95 per cent c.i. 0·47 to 1·21). CONCLUSION: There is no increased risk in breast cancer recurrence after delayed DIEP flap reconstruction compared with mastectomy alone.

Can 3D power Doppler identify levator ani vascularization at its pubic insertion?

INTRODUCTION AND HYPOTHESIS: The levator ani is the most important muscle in the pelvic floor. This pilot study using 3D power Doppler aimed to identify normal vascularization of the puborectalis/pubovisceralis muscle at its insertion in nulliparous and premenopausal women. METHODS: Forty nulliparous and premenopausal women were evaluated at the Gynecological Unit of a tertiary hospital. All women underwent a translabial ultrasound (US) with 3D power Doppler. Pubic insertion of the puborectalis/pubovisceralis muscle was assessed in the axial plane, and vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated bilaterally. Volumes were analyzed offline by two independent observers, and interobserver agreement and correlation between variables was calculated. RESULTS: A high, statistically significant, correlation was found between the three US indices on each side (p < 0.005). No correlation was found between the US index and either of the demographic parameters of body mass index [(BMI), p > 0.241], or age (p > 0.398). The degree of correlation between the same index on the different sides was not statistically significant. CONCLUSION: Puborectalis/pubovisceralis muscle vascularization at its insertion can be identified using 3D Doppler US, but values differ substantially from those of the contralateral side.

Four-dimensional sonographic evaluation of avulsion of the levator ani according to delivery mode.

OBJECTIVE: To determine the frequency of avulsion of the levator ani muscle in primiparous women according to delivery mode, using introital four-dimensional ultrasonography. METHODS: We performed a prospective observational study at a tertiary obstetric unit. One hundred and eighty primiparous women were included and divided into three groups: normal vaginal delivery without episiotomy, forceps delivery and Cesarean section groups. Between 40 and 120 days after delivery, four-dimensional ultrasonography was performed in order to evaluate the integrity of the levator ani muscle. The operator was blinded to all clinical data and was not aware of delivery mode. The influence of other variables associated with delivery such as birth weight, body mass index, maternal age and use of epidural anesthesia was also studied. RESULTS: Avulsion of the puborectalis component of the levator ani muscle was detected on ultrasonography in 61.7% of women who had undergone a forceps delivery, compared with 13.3% of those who had had a normal vaginal delivery and 0% of those who had had a Cesarean section. Bilateral avulsion was observed in 12/60 (20.0%) of the forceps group and in 2/60 (3.3%) of the normal vaginal delivery group (P < 0.001). Other variables did not seem to influence prevalence. CONCLUSIONS: Forceps delivery is associated with an increased rate of avulsion of the puborectalis component of the levator ani muscle. The effect of forceps use is independent of other delivery-related variables.

Risk of recurrence following delayed large flap reconstruction after mastectomy for breast cancer.

BACKGROUND: The aim of this retrospective matched cohort study was to evaluate the rate of recurrence among women with delayed large flap breast reconstruction after mastectomy for breast cancer. The recurrence rate among women treated at a single hospital was compared with that in an individually matched control group of women with breast cancer who did not have reconstruction after mastectomy. METHODS: Between 1982 and 2001, 125 women with previous invasive breast carcinoma underwent delayed large flap breast reconstruction with pedicled musculocutaneous or microvascular flaps (a median of 32 months after mastectomy). They were matched individually with 182 women with breast cancer who had a mastectomy but did not undergo breast reconstruction. Matching criteria were year of diagnosis, age at diagnosis and treating hospital. Medical records were evaluated until October 2007. Histopathological specimens for all included women were re-evaluated. The endpoint was locoregional or distant breast cancer recurrence. The risk of recurrent disease was calculated using a Cox proportional hazards analysis, adjusted for established prognostic factors. RESULTS: Median follow-up for the entire cohort was 146 months. The reconstruction group had a 2·08 (95 per cent confidence interval 1·07 to 4·06) times higher risk of recurrent disease than the mastectomy only group. CONCLUSION: Women with breast cancer who had delayed reconstruction with a large flap in this study had a higher risk of recurrent disease than those with mastectomy alone.

Ultrasonido endoscópico y puncion aspiración con aguja fina en tumores del páncreas: experiencia de 2 años. Servicio oncológico hospitalario del IVSS 2010 / Endoscopic ultrasound and fine needle aspiration puncture in tumors of the pancreas: 2 years experience. Hospital oncology service IVSS 2010

La punción aspiración guiada por ultrasonido endoscópico (PAAF-USE) se ha convertido en una herramienta fundamental en el diagnóstico de los tumores de páncreas. Es un procedimiento con baja tasa de complicaciones que además provee información determinante que puede modificar la conducta terapéutica. Métodos: Estudio retrospectivo, descriptivo. Se incluyeron pacientes con diagnóstico de tumor de páncreas referidos para la realización PAAF-USE en el período comprendido entre 2008-2009. Resultados: 36 pacientes fueron estudiados, 58.30% (n=21) del sexo femenino. Se evidenciaron tumores sólidos en el 80.5%. Según la histología, fueron reportados adenocarcinoma en el 47.05% (n=16), cistoadenoma mucinoso en el 8.88% (n=3), cistoadenocarcinoma en el 5.88% (n=2), linfoma no Hodgkin en el 5.88% (n=2), tumor neuroendocrino (insulinoma) en el 2.94 % (n=1), cistodenoma seroso en el 2.94% (n=1), tumor sólido pseudopapilar en el 2.94% (n=1), tumor metastásico a páncreas en el 2.94% (n=1) y el 17.64% (n=6) fueron reportados negativos para malignidad. No hubo complicaciones asociadas al procedimiento. Conclusiones: Los hallazgos obtenidos por PAAF-USE permiten establecer el diagnóstico en un alto porcentaje de las lesiones tumorales del páncreas, con una baja tasa de complicaciones, permitiendo seleccionar conductas terapéuticas adecuadas.

Endoscopic ultrasound-guided fine-needle-aspiration (EUS-FNA) has become an essential tool for the diagnosis and staging of pancreatic neoplasms. It is a procedure with low complication rates and also provides crucial information which could alter the therapeutic management. Methods: A retrospective analysis of patients referred for USE-FNA with presumed pancreatic neoplasms between January 2008 and December 2009. Results: 36 patients were studied, 58.30% (n = 21) were females. Solid tumors were evident in 80.5%. According to their histology, adenocarcinoma were reported in 47.05% (n = 16), mucinous cystadenoma in 8.88% (n = 3), cystadenocarcinoma in 5.88% (n = 2), non-Hodgkin lymphoma in 5.88% (n = 2), neuroendocrine tumor (insulinoma) in 2.94% (n = 1), serous cystoadenoma in 2.94% (n = 1), solid pseudopapillary tumor in 2.94% (n = 1), metastatic tumor 2.94 % (n = 1) and 17.64% (n = 6) were reported negative for malignancy. There were no complications associated with the procedure. Conclusions: The fi ndings obtained by EUS-FNA make diagnosis possible in a high percentage of tumoral lesions of the pancreas, with no procedural complication rates overall in this study. Consequently, the accurate histological diagnosis will have the potential to affect the selection of an appropriate treatment.

Tumores sólido pseudopapilares del pancreas: presentación de 2 casos / Solid pseudopapillary tumors of the pancreas: presentation of 2 cases

Las neoplasias quísticas del páncreas representan menos del 10 % de las neoplasias pancreáticas, comprendiendo una gama de lesiones benignas, limítrofes y malignas, según la OMS. Dentro de estos tumores reviste importancia el Tumor sólido pseudopapilar, a pesar de su baja incidencia a nivel mundial, entre 1-2% de las neoplasias pancreáticas, y ser considerado como de bajo potencial maligno, es decir limítrofe. Sin embargo, son tumores invasivos, con la capacidad de diseminarse localmente o a distancia hasta en un 15 % aproximadamente. Se ha descrito la resección quirúrgica radical como tratamiento de elección para esta patología; pancreatoduodenectomía para los tumores localizados en la cabeza del páncreas, y pancreatectomía distal combinada o no con esplenectomía, para los ubicados en cuerpo y cola. A propósito de esta infrecuente neoplasia quística del páncreas, reportamos dos (2) casos evaluados y tratados por el Departamento de Vías digestivas del Servicio Oncológico Hospitalario del IVSS, durante el año en curso, con resultados satisfactorios.

Cystic neoplasms of the pancreas represent less than 10% of pancreatic tumors, comprising a range of benign, borderline and malignant, according to WHO. Within these tumors is important solid pseudopapillary tumor, despite its low incidence worldwide (1-2% of cystic neoplasms of the pancreas), and be considered of low malignant potential, considered borderline. However, despite these features, are invasive tumors, with the ability to spread locally or remotely up to 15%. It has been described radical surgical resection as treatment of choice for this disease; pancreatoduodenectomy for pancreatic head tumor and Distal pancreatectomy with or without splenectomy, for pancreatic body and/or tail tumor. About this rare cystic neoplasm of the pancreas, we report two (2) cases evaluated and treated by the Digestive tract disease department at the Oncology Hospital Service of IVSS, during this year, with satisfactory results.

Histopathological findings and follow-up after prophylactic mastectomy and immediate breast reconstruction in 100 women from families with hereditary breast cancer.

AIM: To survey the histopathological abnormalities in breasts of women who have undergone risk reducing mastectomy and to evaluate the effect of this measure on future breast cancer development. PATIENTS/METHODS: Between August 1995 and October 2006 100 consecutive women with a hereditary increased risk of breast cancer underwent prophylactic mastectomy (PM) at Malmö University Hospital. Fifty of the 100 women had no previous breast cancer. Fifty were BRCA1 or BRCA2 mutation carriers. All breast specimens have been examined histopathologically according to a prospective protocol. Follow-up data was collected from medical records and data in the Regional Cancer Registry. RESULTS: In the PM specimens abnormal lesions were found in 18 women (three with invasive cancers, eight in situ cancers and seven atypical hyperplasia). In previously healthy women lesions were more frequent after the age of 40 than among younger women (p=0.03). BRCA mutation carriers were more likely to present with ADH (atypical ductal hyperplasia)/ALH (atypical lobular hyperplasia) compared to the non-carriers/untested cases (p=0.01). After a median follow-up of 52 months (range 1-136 months) none of the women have developed breast cancer in the area of the prophylactically removed breast. CONCLUSIONS: Prevalent atypical or malignant lesions are relatively a common finding in PM specimens in asymptomatic women with hereditary increased risk of breast cancer. Such findings were significantly more common above age 40 in women without previous breast cancer. The risk of newly formed breast cancer after PM is small. The clinical importance of detecting a premalignant or preinvasive lesion in the breast at PM is still unclear.

Aesthetic outcome, patient satisfaction, and health-related quality of life in women at high risk undergoing prophylactic mastectomy and immediate breast reconstruction.

Prophylactic mastectomy is an effective risk-reducing option in women with hereditary increased risk of breast cancer. It may be combined with immediate reconstruction, with the intention of improving aesthetic outcome and health-related quality of life. Sixty-one women underwent prophylactic mastectomy and immediate breast reconstruction in Malmö, Sweden, between 1995 and 2003. Forty women underwent bilateral prophylactic mastectomy and immediate reconstruction. Ten of these had a previous breast cancer diagnosis. Twenty-one women underwent contralateral prophylactic mastectomy and immediate reconstruction after a previous breast cancer. Fifty-four of the women (89%) were evaluated clinically for aesthetic results and complications. Patient satisfaction and quality of life were evaluated with one study-specific and two standardised health-related questionnaires administered at time of clinical follow-up. Median follow-up time was 42 months (range 7-99 months). The position of the reconstructed breasts was judged as satisfactory in 77% of breasts. Symmetry in relation to the midline was adequate in 89% of breasts. A capsular contracture grade III according to Baker and indentation tonometry was observed in 1% of breasts (1/104). The complication rate was 18% (7% early and 11% late). Secondary corrections were carried out in 11% of breasts. The study-specific questionnaire revealed a high degree of satisfaction. No woman regretted the procedure, and all women would have chosen the same type of surgery again. An age-stratified comparison of Swedish women using the Short Form 36 Health Survey Questionnaire (SF-36) questionnaire was carried out for this study. The study population scores were high, suggesting that prophylactic mastectomy and immediate reconstruction on both physical and psychological issues in this retrospective study had no negative effect. Also, the Hospital Anxiety and Depression Scale (HAD) questionnaire did not suggest any increased anxiety or depression among the patients. Prophylactic mastectomy and immediate breast reconstruction in women at risk of hereditary breast cancer may be carried out with a satisfactory aesthetic outcome and an acceptable rate of complications comparable to those in other studies, and does not in itself seem to be associated with a decreased quality of life.

[Leg length inequality and rotational deformity after traction treatment of femoral shaft fractures in children]. / Beinlengdeforskjell og rotasjonsfeil etter strekkbehandling av femurskaftfraktur hos barn.

87 patients who experienced femoral shaft fracture at the age of two to 14 years were reviewed, on average, seven (three to 12) years after the injury occurred. Three methods of treatment had been used: Bryant skin traction, and skeletal traction using either the Weber table or the Braun frame. Patients two to three years of age at the time of injury had significantly less leg length inequality than those aged four to ten years. The reason was that in the youngest group, where which 16 out of 21 patients had been treated with skin traction, the effect of traction was less efficient and there was therefore a larger overlap of the fragments at fracture healing than in the older group, where all patients had had skeletal traction. Among ten to 14 year olds there was also less leg length inequality than among four to ten year olds. This was because of lack of growth stimulation in the oldest patients after fracture healing. The results indicate that an initial overlap of approximately 10 mm should be aimed at in patients under 11 years of age, whereas overlap should be avoided in older patients. Rotational deformity, defined as side difference in anteversion angle of 15 degrees or more, occurred in seven patients (8%), but none of them had any complaints. We conclude that traction treatment gives good results, with few complications. Over-growth remains a significant problem in children under 11 years of age.

[Transrectal ultrasonography in the preoperative staging of rectal adenocarcinoma. Cross-sectional study 1991-1994]. / Ultrasonido transrectal en la estadificación preoperatoria del adenocarcinoma de recto. Estudio transversal 1991-1994.

Preoperative evaluation of the depth of invasion in the rectal wall as well as the presence of regional metastatic nodes are considered important factors in order to decide surgical treatment as well as prognosis in cases of cancer of the rectum. This investigation was carried out in order to establish how usefull transrectal ultrasound was for the pre-operative evaluation of cancer of the rectum. We studied 78 patients with different ano rectal pathology, among them 40 patients with confirmed ADC of the rectum that were completely studied and had ultra sonographic as well as surgical and pathological staging using TNM classification. Confiability indicators of transrectal ultrasound when compared with pathology findings, showed a sensibility of 100% in T1-T2 and T4; in T3 lesions sensibility was 76%. Specificity was between 94% and 100% in all stages. We believe that trans-rectal ultrasound is a usefull, precise and reliable diagnostic tool, for staging purposes of rectal carcinoma.

[Endoscopic management of biliary fistula]. / Manejo endoscópico de las fístulas biliares.

From January 1991 to July 1993 we diagnosed 16 patients with biliary fistulas. Nine patients showed a fistula of the stump after cholecystectomy (two laparoscopic and the rest in a conventional form). In none was there any evidence of residual stones. Three patients that showed biliary fistula who had residual stones which was no diagnosed during surgery. Four patients had biliary fistulas at different levels after abdominal traumas due to bullet wounds. All the patients were treated endoscopically by means of endoscopic sphincterotomy and in one of them it was necessary to place a biliary stent due to the fact that there was a stricture under the level of the fistula. One patient who, in addition to the fistula had an abscess was drained guided by ultrasound after the sphincterotomy. The evolution of the patients was satisfactory. There were no complications because of the procedure.

[Colitis due to radiation: endoscopic management with heat probe]. / Colitis por radiación: manejo endoscópico con sonda caliente.

Rectal bleeding is a frequent symptom in radiation colitis, and is due to vascular lesions usually confined to the rectum. We present our preliminary experience with the use of the heater probe, in eight patients with radiation proctitis, whose main symptom was rectal bleeding. Six patients had radiation for carcinoma of the cervix and 2 had endometrial cancer. One to four sessions of coagulation were performed with an intensity of 200 to 400 Joules per session. In all patients a good response was obtained, bleeding diminished or stopped completely, with improvement of blood counts and the need for transfusions. We think that heater probe is a good therapeutic alternative, for the management of these difficult complication.

[Transrectal ultrasonography in the assessment of anal and rectal tumors]. / Ultrasonido transrectal en la evaluación de los tumores de ano y recto.

Transrectal ultrasonography was initially devised for prostatic evaluation but it has also been shown to be useful in the study of carcinoma of Rectum and Anus. 3 patients with carcinoma of the anal canal and 17 with carcinoma of the rectum were studied in order to define invasion of neighbouring organs and regional nodes. In 11 patients (55%) the extension of the tumor was to muscular layer. In 5 patients (25%) the study showed invasion to peri-rectal fat and presence of lymph nodes in 10 cases. In 4 patients (20%) the procedure showed invasion to neighbouring organs and preoperative radiation treatment was the indication.

[Heat probe: its use in the palliation of stenosing and bleeding tumors of the digestive tract. Preliminary report]. / Sonda caliente: su uso en paliación de tumores estenosantes y sangrantes del tubo digestivo. Comunicación preliminar.

We present our experience with the use of Heater Probe (H.P.) of the management of malignant stenoses of Gastrointestinal (G.I.) tract. We treated 6 patients: 4 with esophageal cancer, 1 cancer of rectum and 1 malignant infiltration of sigmoid colon. The symptoms were: dysphagia: 4 cases, rectal bleeding: 1 case and bleeding plus obstruction: 1 case. The symptoms were relieved in 5 of the 6 cases. In 1 case with dysphagia there were not response. The H.P. can represent a valid alternative in the palliation of malignant obstruction.

[Splenic focal lesion in oncologic patients diagnosed by ultrasound]. / Lesiones focales esplénicas en pacientes oncológicos diagnosticadas por ultrasonido.

Focal lesion of the spleen are infrequent, they appear in 2-4% of patients with malignancies, in our experience we found metastases in nineteen oncologic patients (0.54%) this fact modified the staging prognosis and therapeutic. All the cases were correlated with laparoscopy, fine needle biopsy guided by ultrasound, and or laparotomy. It is emphasized tha the spleen's size was normal in 47.4%. The usual appearance was multiple focal lesions in 89.5% and the sonography pattern of the lesion was variable: Hypoechoic in 63.2% hyperechoic an mixed in 15.8% respectively and cystic in 5.3%. We conclude that ultrasound is an excellent non invasive method to detect focal lesions of the spleen in oncologic patient, where is necessary to know the histology of this lesions, fine needle guided biopsies, can be done safely.

[Needle sphincterotomy: a safe method]. / Esfinterotomía de aguja: un método seguro.

We performed needle papillotomy in 26 patients. When the biliary tract was not approach by conventional methods. We used an home made sphincterotomy and begin the incision at the papillar orifice and cut in cephalic direction to the 11-12 o'clock, and stop the cutting when we observe bile flow or choledochus mucosa. The only complication was bleeding in two patients and it stopped with epinephrine injection. There were not perforations or mortality. We conclude that needle papillotomy is a safe and useful method in selected cases.

[Colonoscopic dilator: a new instrument in the management of benign stenosis of the colon and rectum]. / Colonoscopio dilatador. Un nuevo instrumento en el manejo de las estenosis benignas de colon y recto.

Experience with a colonoscope with a distal segment that allows for the incorporation of dilating olives of the Eder Puestow type is presented. 15 patients with the diagnosis of benign stenosis of the colon or rectum who suffered of abdominal pain and constipation were treated. In 13 patients it was possible to eliminate the patients symptoms. There where no complications. The dilating colonoscope is a valid, alternative in the management of stenosis of the colon and rectum.

Leg-length discrepancy measured by ultrasonography.

Leg-length discrepancy was determined by real-time ultrasonography (ultrasound) in 45 patients, and the measurements were compared with those of erect-posture radiography. A special device for holding and moving the ultrasound transducer was constructed, and the leg length was measured as the highest level of the femoral head in the standing position. The correlation coefficient r between ultrasound and radiography was 0.94, the mean difference was -1.9 mm, and the limits of agreement (mean +/- 2 SD) were -9.1 to 5.3 mm. The mean difference between examiners 1 and 2 was 1.7 mm, and the 95 percent confidence interval was +/- 7 mm. We conclude that leg-length discrepancy can be reliably determined by ultrasound, although the accuracy is less than that obtained by radiographic methods. Because ultrasound is not limited by radiation hazards, our technique can be used for clinical screening.

[Primary gastrointestinal lymphoma]. / Linfoma primario gastrointestinal.

20 patients were evaluated and found to have a radiologic-endoscopic diagnosis of primary gastrointestinal lymphoma, in the Digestive Tract Department of the "Padre Machado" Oncological Hospital in a 19 years period (1970-1989). In 17 patients diagnosis of non-Hodgkin's Lymphoma was made and the 3 other patients were diagnosed with the Hodgkin's Lymphoma. It was located more frequently in the stomach: 14 (70%). Through double contrast radiology, endoscopy and deep biopsy, the diagnosis was made in 12 (67%) patients. The most frequent hystological type was diffuse histiocytic lymphoma. Surgery was the most used treatment. The value of double contrast radiology, and deep biopsy stand out as adequate methods to obtained a positive diagnostic, avoiding unnecessary surgical procedures.

[Diagnostic accuracy of fine needle aspiration cytology guided by ultrasonography in intra-abdominal and retroperitoneal lesions]. / Exactitud diagnóstica dela citología por punción aspiración con aguja fina guiada por ultrasonido en lesiones intraabdominales y retroperitoneales.

UNLABELLED: Evaluation of the fine needle aspiration cytology guided by ultrasonography in the diagnosis of abdominal and retroperitoneal tumors. DESIGN: Transversal study of diagnostic standard-criterion test. PLACE: Ultrasonographic Unity Digestive Disease Department. Hospital Oncológico Padre Machado. SAMPLE: 98 patients with intraabdominal and retroperitoneal lesions. INTERVENTION: Fine needle aspiration cytology guided by Ultrasonography. INDICE TEST: Laparoscopy and/or laparotomy. MEASUREMENTS: Estimation of sensibility (S), Specificity (E), Efficacy (Ef), positive predictive value (VPP), negative predictive value (VPN), measure of false positives (TFP) and measure of false negatives (TFN) by diagnosis method. RESULTS: VP: 81%; VN: 12%; FP: 1%; FN: 6%; S: 93%; E: 92.3%; Ef.: 97%; VPP: 98.7%; VPN: 66%; TFP: 1.25%; Benign lesions: 22.5%; Malignancy lesions: 65.5%; non lesions: 12%; complications: severe: 1%, non significance: 5%. CONCLUSIONS: Fine needle aspiration cytology guided by ultrasound has high sensibility, specificity, efficacy, with low value of false positive. However, it has high incidence of false negatives and negative predictive value. We recommend diagnostic procedures when the suspicion of tumor is high did the cytology is negative.