Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia.

Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.

Factors associated with local recurrence of mammographically detected ductal carcinoma in situ in patients given breast-conserving therapy.

BACKGROUND: The authors reviewed their institution's experience treating patients with mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival and to identify factors associated with local recurrence. METHODS: From January 1980 to December 1993, 132 breasts in 130 patients were treated with BCT for mammographically detected DCIS at William Beaumont Hospital, Royal Oak, Michigan. All patients underwent an excisional biopsy, and 64% were reexcised. All patients received postoperative whole-breast irradiation to a median dose of 45.0 Gray (Gy) (range: 43.1-56.0 Gy). One hundred twenty-four cases (94%) received a boost to the tumor bed for a median total dose of 60.4 Gy (range: 45.0-71.8 Gy). All cases underwent complete pathologic review by one pathologist. The median follow-up was 7.0 years. RESULTS: Of the entire study group, 13 patients developed recurrence within the ipsilateral breast, for 5- and 10-year actuarial rates of 8.9% and 10.3%, respectively. Nine of the 13 recurrences (69%) occurred within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TR/MM). Four patients (31%) had recurrence elsewhere in the breast. Ten of the 13 recurrences (77%) were invasive, whereas 3 (23%) were pure DCIS. Only 1 patient died of disease, corresponding to 5- and 10-year actuarial cause specific survival rates of 100% and 99.0%, respectively. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with ipsilateral breast failure or TR/MM. In multivariate analysis, only the absence of pathologic calcifications was significantly associated with ipsilateral breast failure. When specifically analyzed for TR/MM, younger age at diagnosis, number of slides with DCIS, number of DCIS and cancerization of lobules (COL) foci within 5 mm of the margin, and the absence of pathologic calcifications demonstrated a statistically significant association. Close or positive margin status did not significantly predict for either TR/MM (P = 0.14) or ipsilateral breast failure (P = 0.19). CONCLUSIONS: In patients with mammographically detected DCIS treated with BCT, adequate excision of all DCIS prior to RT can result in improved rates of local control. However, margin status may not adequately predict complete tumor extirpation. The volume of DCIS within 5 mm of the margin appears to be a more reliable surrogate for the adequacy of excision. In addition, young patient age and the absence of pathologic calcifications are independent risk factors for the development of local recurrence.

The effect of radiation on an ambulatory chemotherapy infusion pump.

BACKGROUND: Ambulatory infusion pumps are used to deliver concurrent chemotherapy with pelvic radiation therapy for patients with rectal carcinoma. The pump is worn around the waist and may be exposed to direct as well as scattered radiation, possibly leading to a complete malfunction, requiring a new pump, and/or changes in the pump timing, with clinically significant reductions in chemotherapy administration. METHODS: Two new ambulatory chemotherapy pumps were irradiated using a 6-megavolt linear accelerator. The first pump received gradually increasing doses to determine whether a complete malfunction were possible and the approximate dose. The second pump was irradiated with a single large dose of 20 Gray (Gy) followed by smaller doses of 2 Gy to characterize the dose better. After each dose of radiation was given to both pumps, an internal self-diagnostic test and an independent assessment of the pump timing were performed. RESULTS: The first pump malfunctioned completely at a cumulative dose of 38.6 Gy after receiving an individual dose of 20 Gy. The second pump tolerated the single dose of 20 Gy without difficulty and completely malfunctioned at doses of 40-42 Gy. The second pump exhibited a reduction in pump timing by 25% at a cumulative dose of 40 Gy, which resolved spontaneously by approximately 2 hours. CONCLUSIONS: Even if removed from the direct radiation beam, an individual pump could accumulate enough radiation for complete failure during the treatment of fewer than 20 patients. Prior to a complete malfunction, the flow rate of chemotherapy may decrease by 25% for a number of hours without detection. Additional work will be necessary to define further the nature of the reduction in pump timing observed.

Cancerization of lobules and atypical ductal hyperplasia adjacent to ductal carcinoma in situ of the breast.

Recurrent carcinoma develops in approximately 10% of patients with ductal carcinoma in situ (DCIS) of the breast treated with local excision and radiation therapy. Cancerization of lobules (COL) and atypical ductal hyperplasia (ADH)frequently occur at the edge of DCIS. We postulated that recurrent carcinoma is associated with ADH or COL near the DCIS excision margin, and the amount of DCIS left in the breast may be too large for eradication by radiation therapy. To identify histologic features associated with recurrence, we retrospectively studied specimens of 94 patients with DCIS treated by local excision and radiation. We analyzed the rim of tissue near the final margin for the amount of COL, ADH, and DCIS. During a median follow-up of 78 months, local recurrence developed in 9 patients. COL or ADH with DCIS near the final margin was associated with recurrence; the strongest relationship was with recurrences in the same site as the lumpectomy bed. DCIS with ADH was significantly associated with recurrence in the low-grade DCIS group; DCIS with COL was associated with recurrence in the high-grade group. Other features were not associated with outcome. We believe that ADH composed of cells identified as those of DCIS should be considered part of the DCIS lesion. DCIS may be inadequately excised if ADH and DCIS or COL and DCIS are near the margin.

The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy.

PURPOSE: To determine the incidence of regional nodal failure (RNF) and indications for regional nodal irradiation (RNI) in patients with Stage I and II breast cancer treated with breast-conserving therapy (BCT). METHODS AND MATERIALS: Four hundred fifty-six patients with Stage I/II breast cancer were treated with BCT at William Beaumont Hospital. All patients underwent excisional biopsy and 288 (63%) were reexcised. A Level I/II ipsilateral axillary lymph node dissection was performed on 431 patients (95%). Pathologically involved nodes were found in 106 (23%) cases (69 with one to three nodes and 37 with > or = four nodes involved). All patients received whole breast irradiation (median dose 50 Gy) and 415 (91%) were boosted to the tumor bed (median total dose 60.4 Gy). Three hundred and sixty (79%) patients received breast alone irradiation and 96 (21%) also received RNI. The median axilla/supraclavicular fossa dose was 50 Gy. RESULTS: With a median follow-up of 83 months, 15 patients developed a RNF for a 5- and 8-year actuarial rate of 3 and 4%, respectively. The 5- and 8-year actuarial rates of axillary failure (AF) were 0.7 and 1.0%, respectively. The incidence of RNF or AF was not affected by the use of RNI in N0 or N1 patients with one to three positive nodes. Only in patients with four or more positive nodes was there a trend towards improved regional control with RNI (p = 0.09). However, patient numbers were extremely small, and this improvement was limited to a reduction in the rate of failure in the supraclavicular fossa (SCF) (20 vs. 0%, p = 0.04). Multiple clinical, pathologic, and treatment related factors were analyzed for an association with AF. On univariate analysis, AF was associated with the number of lymph nodes excised (p < 0.0001) estrogen receptor status (p = 0.0016), and pathologic node status (p = 0.0021). CONCLUSIONS: Regional nodal failure as the first site of failure is uncommon in patients with early-stage breast cancer treated with BCT with < or = three positive lymph nodes and appears unaffected by RNI. For patients with four or more positive lymph nodes, a trend towards improved RNF was noted with RNI, primarily in the SCF. However, patient numbers were extremely small in all subsets analyzed. Additional studies are needed to further define the need for RNI in these patients and help determine other factors associated with RNF.

Ductal carcinoma in situ detected in the mammographic era: an analysis of clinical, pathologic, and treatment-related factors affecting outcome with breast-conserving therapy.

PURPOSE: We reviewed our institution's experience treating predominantly mammographically detected ductal carcinoma in situ (DCIS) with breast-conserving therapy (BCT) to determine if any clinical, pathologic, or treatment-related factors affected outcome. METHODS AND MATERIALS: From January 2, 1980 to January 6, 1992, 107 breasts in 105 patients were treated with BCT at William Beaumont Hospital, Royal Oak, MI. All patients underwent at least an excisional biopsy and 70 patients (65%) were reexcised. All patients received whole-breast irradiation to a median dose of 50.4 Gy (range 43.1 to 56.0 Gy). Ninety-nine patients (93%) received a supplemental boost to the tumor bed for a median total dose of 60.4 Gy (range 59.1 to 71.8 Gy) using either photons (2 patients), electrons (69 patients), or an interstitial implant (28 patients). RESULTS: With a median follow-up of 78 months, 10 patients have failed in the treated breast for a 5- and 10-year actuarial local control rate of 91.2 and 89.8%, respectively. Thirteen percent of the population have been followed for 10 years or more. Three recurrences were pure DCIS, and seven were invasive. All patients were salvaged with mastectomy. Nine patients remain without evidence of disease a median of 30.6 months after surgery. One patient failed distantly 36 months after local recurrence for an ultimate cause specific survival of 99%. Potential clinical (age, mammographic findings, method of detection, etc.), pathologic (nuclear grade, margins, etc.), and treatment-related factors (dose, boost technique, reexcision status, etc.) affecting outcome were analyzed. No variable was found to be associated with an ipsilateral breast tumor recurrence. However, when only recurrences that occurred within or immediately adjacent to the lumpectomy cavity were analyzed, both margin status and the extent of cancerization of lobules (COL) near the surgical margin were associated with the development of a local recurrence. CONCLUSIONS: Patients treated with BCT for predominantly mammographically detected DCIS achieve excellent rates of local control and overall survival. Both margin status and the extent of COL near the surgical margin appear to be associated with recurrences within or immediately adjacent to the lumpectomy cavity. These data suggest that careful attention to the completeness of surgical resection of DCIS is an important determinant of outcome.

Surgical aspects of autonomic dysreflexia.

Autonomic dysreflexia (AD) is a characteristic syndrome that occurs in spinal cord injury (SCI) patients with lesions above the sympathetic outflow at T6 and rarely in those with lesions below T10. Symptoms are initiated by noxious stimuli below the level of injury which result in massive sympathetic discharges from the isolated cord. These produce what may be called a sympathetic storm manifest by severe life threatening hypertension. Anesthesiologists and surgeons dealing with SCI patients must know how to recognize this syndrome, how to prevent its occurrence and how to manage it aggressively. Choice of anesthesia is frequently difficult and, in particular, it may be difficult to decide which type of anesthesia is best for patients susceptible to the syndrome. Therefore, we have conducted a retrospective study of SCI patients in the Department of Veterans Affairs Medical Center, Long Beach, California, where the Spinal Cord Injury Service is one of the largest in the country.

Long-term outcome with interstitial brachytherapy in the management of patients with early-stage breast cancer treated with breast-conserving therapy.

PURPOSE: We reviewed our institution's experience with interstitial implant boosts to determine their long-term impact on local control and cosmetic results. METHODS AND MATERIALS: Between January 1, 1980 and December 31, 1987, 390 women with 400 cases of Stage I and II breast cancer were managed with breast-conserving therapy (BCT) at William Beaumont Hospital. All patients were treated with an excisional biopsy and 253 (63%) underwent reexcision. Radiation consisted of 45-50 Gy external beam irradiation to the whole breast followed by a boost to the tumor bed to at least 60 Gy using either electrons [108], photons [15], or an interstitial implant [277] with either 192Ir [190] or 125I [87]. Long-term local control and cosmetic outcome were assessed and contrasted between patients boosted with either interstitial implants, electrons, or photons. RESULTS: With a median follow-up of 81 months, 25 patients have recurred in the treated breast for a 5- and 8-year actuarial rate of local recurrence of 4 and 8%, respectively. There were no statistically significant differences in the 5- or 8-year actuarial rates of local recurrence using either electrons, photons, or an interstitial implant. Greater than 90% of patients obtained a good or excellent cosmetic result, and no statistically significant differences in cosmetic outcome were seen whether electrons, photons, or implants were used. CONCLUSIONS: We conclude that patients with Stage I and II breast cancer undergoing BCT and judged to be candidates for boosts can be effectively managed with LDR interstitial brachytherapy. Long-term local control and cosmetic outcome are excellent and similar to patients boosted with either electrons or photons.

Excellent functional outcome in patients with squamous cell carcinoma of the base of tongue treated with external irradiation and interstitial iodine 125 boost.

BACKGROUND: Local control, functional outcome, and complications in patients with carcinoma of the base of tongue (BOT) were analyzed to assess the impact of interstitial implant boost with I-125 seeds. METHODS: Between December 1986 and May 1995, 16 patients with squamous cell carcinoma of the BOT received treatment at the William Beaumont Hospital and 4 received treatment at the Northern Virginia Cancer Center. The primary tumor classification for this group consisted of T1/T2-11 patients, T3/T4-9 patients. All patients initially received 50.4-66.6 Gray (Gy) (median: 54 Gy) external beam irradiation to the primary site and regional lymph nodes followed by an interstitial implant boost 2 to 3 weeks later. Implant dose ranged from 20 to 32 Gy (median: 27 Gy). The implanted volume included the tumor and glossotonsillar sulcus in all patients and the pharyngeal wall or tonsil in select cases. RESULTS: Median follow-up was 47 months (range, 6-88 mos). Two patients have failed within the tumor bed (T2 and T4) for a 5-year actuarial local control rate of 88%. The T2 patient was salvaged surgically, for an overall 5-year actuarial local control rate of 93%. No patients have relapsed within the neck as the only or first site of failure. The 5-year actuarial overall survival rate was 72%. Complications included three cases of exposed bone and one case of cranial nerve XII palsy. All complications were managed conservatively. Excellent to good functional outcome, including speech and swallowing, was preserved in 18 of the 20 patients. CONCLUSIONS: Patients with cancer of the BOT can be treated effectively with an interstitial boost utilizing I-125 seeds. Overall, local control is excellent and complications are minimal. Of greatest significance, organ preservation with excellent understandability of speech and diet tolerance was achieved in 90% of the patients.

Cat carotid body: oxygen consumption and other parameters.

Cats were anesthetized with pentobarbital, pump ventilated with air, and given heparin, and the carotid body (CB) was vascularly isolated except for the supplying artery. The CB could be normally blood perfused, or alternatively, perfused with Locke's solution; flow of either could be stopped suddenly. Sinus nerve discharge was measured. Tissue oxygen tension (TPO2) in the CB was measured with an O2 microelectrode. Oxygen consumption rates (VO2) calculated from the disappearance curve of O2 during stopped flow were PO2 dependent. When TPO2 was high (100-130 Torr), VO2 (ml.100 g-1.min-1) averaged 1.9 +/- 0.18 (SE) during blood perfusion and either 1.9 +/- 0.1 during perfusion with Locke's solution equilibrated with 25% O2-5% CO2-70% N2 or 1.4 +/- 0.08 when the Locke's solution was equilibrated with air. This significant effect of CO2 could have been due to the delayed onset of sinus nerve discharge when CO2 was not added to the perfusion solution. The number of red blood cells in histological sections from CB frozen during stopped flow of blood was significantly below normal. We concluded that the similarity of the disappearance curves during stopped flow of blood and Locke's solutions was primarily due to the extrusion of red blood cells. In five experiments the broken-off tip of the O2 microelectrode was found in the core of the CB.

Rare metastasis of primary bronchogenic carcinoma to sigmoid colon: report of a case.

The authors present a case of a rare metastasis of bronchogenic carcinoma to sigmoid colon. Carcinoma of the lung usually spreads locally to adjacent mediastinum or paratracheal lymph nodes via the lymphatics. When tumor invades the pulmonary vein, distal metastases are most often to brain, suprarenal glands, or bones. Primary bronchogenic carcinoma has been reported to metastasize to jejunum, maxillary antrum, small bowel, tongue, and rarely to other organs. The authors believe that metastasis to the large intestine is most exceptional. Occurrences of rare metastasis are not well understood, though one theory implicates sites of previous trauma.