Flow-through Anterolateral Thigh Flaps: Report of 3 Consecutive Cases and Review of its Utility.

In the field of plastic and reconstructive surgery, soft tissue reconstruction of Gustilo 3B with peripheral vascular disease or 3C fractures is a complex treatment algorithm. The concomitant issue of soft tissue coverage with vascular reconstruction is the main challenge when opting for free tissue transfer. The flow-through flap offers the surgeon the ability to treat a vascular injury or high-grade stenosis to maintain distal perfusion, while also providing soft tissue coverage. In this study, we present a case series of 3 patients who underwent flow-through anterolateral thigh free flap for lower extremity soft tissue coverage. Each patient had a history of trauma and either single vessel runoff or a dominant branch with diminutive secondary blood flow to the foot. All patients successfully underwent free flap reconstruction of lower extremity wounds while concomitantly reconstructing diseased arterial supply. Only 1 patient suffered partial flap loss postoperatively that was treated with debridement and split thickness skin grafting. Flow-through free tissue transfer is a valuable treatment option not only in Gustilo 3C fractures requiring soft tissue coverage, but also in patients with Gustilo 3B fractures with peripheral vascular disease.

The Role of Mastectomy in De Novo Stage IV Inflammatory Breast Cancer.

INTRODUCTION: The role of modified radical mastectomy (MRM) in patients with de novo stage IV inflammatory breast cancer (IBC) remains controversial. We evaluated the impact of MRM on outcomes in this population. METHODS: Ninety-seven women presenting with stage IV IBC were identified in an institutional database (2007-2016) and were stratified by receipt of MRM or no surgery (non-MRM). Demographic, clinicopathologic, and treatment factors were compared. Local-regional recurrence patterns were described and survival analyses were conducted. RESULTS: All patients initially received chemotherapy. Fifty-two patients (53.6%) underwent MRM; 47 received post-mastectomy radiation. Differences between the non-MRM and MRM groups included tumor receptor subtypes (hormone receptor-positive [HR+]/human epidermal growth factor receptor 2-positive [HER2+]: 4.4% vs. 19.2%; HR+/HER2-negative [HER2-]: 31.1% vs. 44.2%; HR-negative [HR-]/HER2+: 24.4% vs. 15.4%; and HR-/HER2-: 40.0% vs. 21.2%; p = 0.03), number of metastatic sites (3 vs. 2; p = 0.01), and clinical partial/complete response to chemotherapy (13.3% vs. 75.0%; p < 0.001). Of the 47 patients who completed trimodality therapy, 6 (12.8%) had a local-regional recurrence. Median overall survival (OS) was 19 months in the non-MRM group and 58 months in the MRM group (p < 0.001). On multivariable analysis, clinical N3 disease (hazard ratio 2.16, 95% confidence interval [CI] 1.07-4.37; p = 0.03) as well as tumor subtypes HR+/HER2- (hazard ratio 4.98, 95% CI 1.15-21.47; p = 0.03) and HR-/HER2- (hazard ratio 7.18, 95% CI 1.66-31.07; p = 0.008) were associated with decreased OS. Partial/complete response of distant disease to chemotherapy (hazard ratio 0.43, 95% CI 0.24-0.77; p = 0.005) and receipt of MRM (hazard ratio 0.52, 95% CI 0.29-0.93; p = 0.03) were independently associated with improved OS. CONCLUSIONS: In our retrospective study, MRM in de novo stage IV IBC patients is an independent factor associated with improved OS. Our findings strongly support the need for prospective randomized trials evaluating possible survival benefits of MRM in de novo stage IV IBC patients.

Use of Mammographic Measurements to Predict Complications After Nipple-Sparing Mastectomy in BRCA Mutation Carriers.

BACKGROUND: There is limited data evaluating mastectomy skin flap complications of nipple-sparing mastectomy (NSM) in patients with BRCA gene mutations. The purpose of this study was to identify factors associated with post-operative complications in BRCA mutation carriers undergoing NSM. METHODS: Following institutional review board approval, we interrogated a prospectively collected institutional database for patients undergoing NSM who tested positive for BRCA1/2 mutations. Patient characteristics, preoperative details, and complications were evaluated. Digital mammogram was used to estimate the breast volume. RESULTS: From August 2009 to December 2017, 59 patients (2 males) with BRCA1/2 mutations underwent 114 NSMs. Ninety-two (80%) were risk-reduction surgeries. Thirty-two (28%) underwent single-stage reconstruction (24 autologous). The overall complication rate was 26.3% (N = 30), and 10.5% (N = 12) underwent unanticipated reoperation. 8.8% (N = 10) had full-thickness skin flap necrosis, 10.5% (N = 12) nipple necrosis, and 4.4% (N = 5) full-thickness nipple necrosis. These complications were associated with larger breast volume (799.4 cc vs. 544.1 cc, p < 0.001) and greater body mass index (27.8 vs. 24.3, p < 0.001). By univariate analysis, body mass index and breast volume greater than 675 cc were associated with significantly higher complication rate (odds ratios 1.2 and 4.5 respectively, p = 0.001). CONCLUSIONS: This study confirms that NSM in BRCA1/2 mutation carriers is associated with complications in one in four patients. Utilizing the preoperative mammograms to estimate breast size may be more helpful than breast cup size in counseling preoperatively the risks of complications.

Excellent Locoregional Control in Inflammatory Breast Cancer With a Personalized Radiation Therapy Approach.

PURPOSE: Inflammatory breast cancer (IBC) has been characterized by high locoregional recurrence (LRR) rates even after trimodality therapy. We recently reported excellent locoregional control among patients treated since formal dedication of an IBC-specific clinic and research program in 2006. Institutionally, a standard twice-daily (BID) dose escalation regimen for all patients with IBC was de-escalated in select cases in 2006 after review demonstrated that young age, incomplete response to neoadjuvant therapy, and positive margins identified subsets with maximal benefit from dose escalation. We report local control and toxicity rates specific to BID versus once-daily (QD) radiation therapy approaches. METHODS AND MATERIALS: From a prospectively collected database, we identified 103 patients with nonmetastatic IBC who received trimodality therapy at our institution from 2007 to 2015. Descriptive statistics were used to describe the study cohort and compare retrospectively extracted rates of radiation therapy-associated toxicity. The actuarial rate of LRR-free survival was analyzed using the Kaplan-Meier method. RESULTS: The median follow-up is 3.6 years. Thirty-nine patients (37.9%) received postmastectomy radiation therapy (PMRT) to the chest wall and undissected regional lymphatics in QD fractions (median dose, 50.0 Gy in 25 fractions [fx]; median boost dose, 10.0 Gy in 5 fx) and 64 patients (62.1%) received BID PMRT (median dose, 51.0 Gy in 34 fx; median boost dose, 15.0 Gy in 10 fx). Crude rates of toxicity were not different between patients treated with QD or BID PMRT. Two BID patients (3.1%) and no QD patients (0.0%) experienced LRR (P = .53). The 3- and 5-year LRR-free survival were 95.1% and 100.0% for BID and QD patients, respectively (P = .25). CONCLUSIONS: Tailoring radiation therapy to clinical risk factors was associated with excellent locoregional control. De-escalation of PMRT from BID to QD was not clearly associated with reduced toxicity compared with BID, although retrospective data collection may limit this comparison.

Case report of a duplicated cystic duct: A unique challenge for the laparoscopic surgeon.

INTRODUCTION: Anatomical variants of the extrahepatic biliary tree are numerous, adding significantly to the risk of bile duct injury during cholecystectomy, especially when laparoscopic approach is employed. Duplicated cystic ducts draining a single gallbladder are extremely rare. PRESENTATION OF CASE: A 34-year-old female presented with signs and symptoms of acute cholecystitis which was confirmed on imaging. She was found to have an accessory cystic duct on laparoscopic cholecystectomy requiring conversion to open laparotomy with intraoperative cholangiogram to delineate the anatomy. DISCUSSION: In the English literature, there has been 20 reported cases of double cystic duct with a single gallbladder. Most of these cases were diagnosed intraoperatively despite the completion of a preoperative endoscopic retrograde cholangiopancreatography in a few of these patients. CONCLUSION: The limited success of preoperative biliary tract imaging in demonstrating anatomic aberrancies prior to cholecystectomy clearly highlights the importance of maintaining constant vigilance for even the slightest anatomic abnormality at operation. Any uncertainty or concern for ductal injury mandates immediate operative cholangiogram with cannulation of all structures in question.

Factors associated with improved outcomes for metastatic inflammatory breast cancer patients.

PURPOSE: Controversy exists regarding the role of locoregional therapy for stage IV inflammatory breast cancer (IBC). This study aims to determine indicators of prognosis, including primary tumor resection, for stage IV IBC patients. METHODS: Using the National Cancer Data Base, female patients diagnosed 2010-2013 with unilateral a priori metastatic T4d invasive adenocarcinoma of the breast were identified. We conducted propensity score matched analysis to balance confounders of surgery versus no-surgery. Stratified log-rank test and double-robust estimation under the Cox model were used to assess the effect of surgery, and margins, on overall survival (OS) in the propensity score matched cohort. RESULTS: Of 1266 patients, 41% underwent surgery. In the unmatched cohort, median OS of the surgery and no-surgery groups was 36 and 20 months, respectively (p < 0.001). In the matched cohort (n = 588), the median OS of surgery and no-surgery groups was 29 and 27 months, respectively (p = 0.052). Patients with negative margin surgery (p = 0.024), hormone receptor-positive (p = 0.019), HER2-positive disease (p < 0.0001), treated with chemotherapy (p < 0.0001) and hormonal therapy (p < 0.0001), had better survival. Those with brain metastases had increased risk of death (p < 0.0001). CONCLUSION: This study represents the largest cohort of metastatic IBC patients, and identified negative margin surgery, systemic therapy, hormone receptor and HER2-positive disease as factors associated with improved outcomes. While these findings should be interpreted cautiously, they may be used to guide further investigations into local control and quality of life in this patient population with limited treatment options.

Are There Alternative Strategies for the Local Management of Ductal Carcinoma in Situ?

The management of ductal carcinoma in situ (DCIS) has traditionally followed the evidence base for invasive breast cancer using surgery, radiation therapy, and drug therapy to remove the DCIS from the breast and reduce the risk of recurrence for both DCIS and invasive breast cancer. Because of concerns regarding the overtreatment of DCIS, randomized controlled trials have been established to test the outcomes (invasive breast cancer outcomes and patient-reported outcome measures) of active surveillance compared with guideline-concordant care for low-risk (for progression) DCIS. These strategies are undergoing rigorous evaluation to evaluate alternatives to the current management of DCIS.

Improved Locoregional Control in a Contemporary Cohort of Nonmetastatic Inflammatory Breast Cancer Patients Undergoing Surgery.

BACKGROUND: Inflammatory breast cancer (IBC) is an aggressive form of breast cancer characterized by rapid progression and early metastatic dissemination. The purpose of this study was to assess contemporary rates of local regional recurrence (LRR) in the era of trimodality therapy for nonmetastatic IBC and identify risk factors leading to local failure. METHODS: A total of 114 patients with nonmetastatic IBC receiving trimodality therapy (neoadjuvant chemotherapy, surgery, and radiation therapy) were identified from a prospectively collected database from 2007 to 2015 and outcomes analyzed. RESULTS: Median age at diagnosis was 52 years, and the median follow-up was 3.6 years. Sixty-three (55%) patients presented with N2 IBC, and 52 patients (45%) presented with N3 IBC. Local regional recurrence was observed during follow-up for four patients; 25 died, and 85 were censored at last follow-up. Surgical margins were negative in 99% of patients (n = 113). The 2-year probability of LRR was 3.19% (95% confidence interval 1.03-9.90%). Five-year overall survival for this cohort was 69.14%. Improvement in disease-free survival was seen among patients with HER2+ subtype, clinical stage IIIB, complete or partial radiologic response to neoadjuvant therapy, pathologic complete response, and lower nodal burden on presentation. CONCLUSIONS: Locoregional recurrences were rare at a median of 3.6 years follow-up in a contemporary cohort of IBC patients treated with trimodality therapy. Although longer follow-up is needed, aggressive surgical resection to negative margins in the frame of trimodality therapy with curative intent can lead to LRR rates that mirror non-IBC rates.

Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications.

PURPOSE: Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. METHODS: We detail our technique and report a unique application of this versatile approach. RESULTS: Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. CONCLUSIONS: Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.

Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods.

BACKGROUND: Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities. METHODS: Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device. RESULTS: Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities. CONCLUSIONS: Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.

Pathogenesis, prevention, diagnosis and treatment of breast cancer.

Breast cancer is the most common cancer affecting women worldwide. Prediction models stratify a woman's risk for developing cancer and can guide screening recommendations based on the presence of known and quantifiable hormonal, environmental, personal, or genetic risk factors. Mammography remains the mainstay breast cancer screening and detection but magnetic resonance imaging and ultrasound have become useful diagnostic adjuncts in select patient populations. The management of breast cancer has seen much refinement with increased specialization and collaboration with multidisciplinary teams that include surgeons, oncologists, radiation oncologists, nurses, geneticist, reconstructive surgeons and patients. Evidence supports a less invasive surgical approach to the staging and management of the axilla in select patients. In the era of patient/tumor specific management, the advent of molecular and genomic profiling is a paradigm shift in the treatment of a biologically heterogenous disease.