Factors influencing patient decision-making between simple mastectomy and surgical alternatives.

Background: Despite similar survival rates, breast-conserving therapy (BCT) remains a distant second choice after simple mastectomy for patients with early-stage breast cancer in Singapore. Uptake of reconstruction after mastectomy is also low (18 per cent). The aim of this study was to explore the factors influencing a patient's choice for mastectomy when eligible for BCT, and why patients decline reconstruction after mastectomy. Methods: Patients from the National Cancer Centre Singapore, who were eligible for BCT but chose mastectomy without reconstruction, between December 2014 and December 2015 were included. An interviewer-administered questionnaire focusing on patients' reasons for choosing mastectomy over BCT and not opting for immediate breast reconstruction after mastectomy was used. Tumour characteristics were retrieved from medical records. Spearman's rank correlation coefficient, Mann-Whitney U and Kruskal-Wallis tests were used to analyse the correlation between the patient's self-rated influential factors and variables. Statistical significance was taken as P < 0·050. Results: Ninety-one patients were included (90·1 per cent response rate). The main reasons for choosing mastectomy over BCT were: fear of cancer recurrence (considered very important in 74 per cent), the perception that health outweighs breast retention (49 per cent) and the possibility of second surgery for margins (40 per cent). Key factors for rejecting immediate reconstruction after mastectomy were: patient-perceived 'old age' (very important in 53 per cent), concern about two sites of surgery (42 per cent) and financial cost (29 per cent). Given a second chance, 19·8 per cent of patients would undergo BCT instead of mastectomy. Conclusion: This study has identified the considerations that women in Singapore have when deciding on breast cancer surgery. Some perceptions need to be addressed for women to make a fully informed decision, especially as one-fifth regret their initial choice.

Qualitative mammographic findings and outcomes of surveillance mammography after partial breast reconstruction with an autologous flap.

BACKGROUND: This study describes the qualitative mammographic features after partial breast reconstruction with an autologous flap, and evaluates the diagnostic accuracy and recall rates of surveillance mammography after volume replacement in breast conserving surgery. METHODS: Patients who had autologous partial breast reconstruction (N = 102) after breast-conserving surgery using either the myocutaneous latissimus dorsi mini-flap (N = 39) or fasciocutaneous chest wall perforator flap (N = 63) were reviewed. Mammograms done at one-year post surgery were analysed for characteristic qualitative features. All surveillance mammograms, diagnostic imaging and medical records were retrospectively reviewed. RESULTS: Mammograms of partially reconstructed breasts had distinctive features that correlated well with the surgical procedures. Median follow-up was 3 years, range 0-11 years. Of 295 surveillance mammograms, six (2%) resulted in a recall for further imaging and 3 (1%) proceeded to needle biopsy. Diagnostic imaging was performed for 13 (13/102, 12.7%) patients with symptoms, and only one (1/102, 1%) required a diagnostic biopsy. CONCLUSIONS: A conserved breast with an autologous flap within has characteristic mammographic features that differ from those after standard breast conserving surgery. Surveillance mammography after partial breast reconstruction is accurate, and recall/biopsy rates are low. Diagnostic breast ultrasound examination is effective evaluation for the symptomatic patient.

Medium-term results of ultrasonography-guided, catheter-assisted foam sclerotherapy of the long saphenous vein for treatment of varicose veins.

INTRODUCTION: We previously reported our technique of ultrasonography-guided, catheter-assisted foam sclerotherapy of the long saphenous vein for treatment of primary varicose veins. In this study, we present the technical results, based on follow-up duplex images, and patient-reported symptom improvement and satisfaction. METHODS: All patients treated with ultrasonography-guided, catheter-assisted foam sclerotherapy between March 2006 and August 2007 were included in this review. Prospectively collected clinical data and follow-up postoperative duplex examinations at one day, six months and 12 months were reviewed. Telephone interviews with a standard questionnaire were conducted. RESULTS: During the study period, 66 lower limbs in 62 patients were treated using the described technique. The median follow-up period was 12 months (range one day to 38 months). Successful occlusion rate was 98% at six months and 80% at 12 months for patients who attended follow-up duplex imaging. Seven patients underwent a second procedure. Patient satisfaction was good, with 96% reporting symptom improvement. CONCLUSION: Ultrasonography-guided, catheter-assisted foam sclerotherapy is safe, minimally invasive and yields good medium-term occlusion rates of the treated veins.

Technique and early results of ultrasound-guided foam sclerotherapy of the long saphenous vein for treatment of varicose veins.

INTRODUCTION: The aim of this study was to describe an original technique of using ultrasound-guided foam sclerotherapy in the long saphenous veins (LSV) for the treatment of varicose veins, and report the early results. METHODS: Only patients with lower limb varicose veins and demonstrable incompetent saphenofemoral junction with reflux down the LSVs underwent ultrasound-guided injection of foam sclerosant into the LSV. Foam sclerosant was made by the Tessari's method using three percent sodium tetradecyl sulphate to air in a 1:3 ratio. The LSV was accessed below the knee with a micropuncture set. A Headhunter angiographic catheter was cut to length and advanced over a guide wire to the saphenofemoral junction (SFJ). With the patient in the Trendelenburg position and the leg raised, the SFJ was manually compressed and foam was injected into the Headhunter catheter while the tip was withdrawn. Direct ultrasound visualisation ensured accurate catheter placement. RESULTS: 66 lower limbs in 62 patients were treated in the manner described above. The diameter of the treated LSV ranged from 4 to 13.4 mm. Ultrasound duplex assessment one day post-treatment showed complete occlusion in 62 veins (94 percent). Early complications included superficial thrombophlebitis, skin pigmentation, cellulitis and thrombosis of the superficial femoral vein. CONCLUSION: Immediate results using our method of ultrasound-guided foam sclerotherapy showed a high obliteration rate of the LSV.

Melaena: an unusual presentation of a pseudoaneurysm of the internal carotid artery.

Pseudoaneurysm of the internal carotid artery is a rare but potentially fatal condition, and its clinical manifestations are often varied. Knowledge of this condition is essential to making the diagnosis. We describe a case of a 38-year-old man who presented with melaena. He also reported blood-stained sputum in the morning for several days. The only significant physical finding was a left peritonsillar mass. Initially worked up for a gastrointestinal bleed, computed tomography of the neck showed a large pseudoaneurysm of the internal carotid artery. A bypass from the proximal external carotid artery to the distal middle cerebral artery had to be created prior to angiographic embolisation of the pseudoaneurysm due to an inadequate supply from the contralateral cerebral hemisphere. The patient made an uneventful recovery with no neurological deficits.