Endoscopic breast surgery for breast cancer

Since 1995, endoscopic breast surgery (EBS) has been gradually established in Japan. Establishment of EBS was inextricably linked to explosive development of instruments for endoscopic surgery and profound theoretical understanding, how to perform broad & stable dissection of the compact connective tissue thorough small incisions. EBS consisted chiefly of two procedures added to breast and axilla and procedures to breast is classified into three methods according to incisions, axillar, periareolar and combined incisions. With EBS technique, any kind breast surgery, sentinel node biopsy, reconstruction, augmentation, and benign tumor excision, could be performed through same skin incisions. Curability of breast cancer EBS is same as that with conventional method and local recurrence rate after total and partial mastectomy. All breast cancer without skin involvement of cancer would be candidate for EBS. To minimize invasiveness of treatment and maintain cosmetic outcome of breast, combination treatment of ablation treatment, EBS and evolution of radiation therapy would be important.     

Cancer of the breast and breast prostheses

Plastic surgery operations designed to modify the breast volume do not increase the risk of cancer. Xeroradiography provides the best images of operated breasts. The least interfering prostheses are the most radiolucent and, in particular, retropectoral prostheses. The diagnosis of cancer is based on the detection of microcalcifications and star-shaped images. It is guided by clinical examination which is precise as the content of the breast is thin an lies on top of the anterior surface of the implant. The complications of prostheses (shells, collapse, rupture, displacement) have been well studied. After breast reconstruction examination of the contralateral breast is therefore of prime importance due to the risk of bilateral cancer.     

Association of breast cysts and breast cancer

A review of 915 consecutive patients with breast cancer and 812 with breast cysts showed that an association between the two is uncommon--5% of breast cancers were associated with cysts and 4% of cysts were associated with breast cancer. Four types of association were identified: (a) cystic cancers--easily diagnosed because of the characteristic features of the aspirate, failure of the mass to disappear and early recurrence in a patient whose age and menstrual status were not usually associated with cysts; (b) cancers occurring simultaneously with breast cysts--recognized because they did not contain cyst fluid; (c) cysts occurring after breast cancer--diagnosed by aspiration of the mass in premenopausal women; (d) cancers in patients who have had breast cysts--usually occurring many years after the cyst aspiration when menses had ceased. These associations were not sufficiently frequent to justify specific follow-up, but all suspected cysts should be successfully aspirated to confirm the clinical diagnosis.     

Diagnosis of breast tumors after breast reduction

We conducted a retrospective study to evaluate the diagnosability of breast tumors after breast reductions as this is a frequent surgical procedure. The data should shed light on the hypothesis that routine screening methods concerning the diagnosis of breast tumors prove more difficult after breast operations. All women who had undergone breast reduction at our department between January 1989 and December 1994 were examined. During this period we counted 166 patients; the majority of them (n = 144) had undergone a bilateral breast reduction and the rest of them (n = 22) a unilateral breast reduction for various reasons. After the operation, all patients were checked in standardized intervals. Those who developed any kind of breast mass (n = 6) were recorded and examined by ultrasound and mammography, and occasionally by an additional fine-needle biopsy. In case any doubt about the dignity had remained, an excisional biopsy was carried out. In none of our patients was it possible to get a precise diagnosis of an ill-defined mass with ultrasound. With mammography, some of the existing masses, which were really scars, mimicked different kinds of tumors, and once a carcinoma was initially interpreted as scar tissue with oil cysts. The diagnosis of breast masses after breast reductions with routinely used screening methods has proved to be more difficult as breast reductions lead to architectural alterations of the remaining breast parenchyma. Such alterations can and should be documented shortly after the operation so that later occurring tumors are distinguished more easily. Therefore, a basic mammography 3 months after each breast reduction has to be claimed in order to facilitate further breast tumor diagnosis.     

Ipsilateral breast tumor relapse after breast conserving surgery in women with breast cancer

Ipsilateral breast tumor relapse (IBTR) is a potentially a significant problem after breast conserving surgery (BCS). With a median follow-up period of 64.7 months, IBTR occurred as a first relapse in 67 (3.0%) of a total of 2243 patients and distant recurrence occurred in 167 (7.4%). A positive surgical margin and the omission of radiotherapy (RT) were independently associated with IBTR. The five-year cumulative IBTR rates were 5.1% in patients with positive margins and 2.0% in the patients with negative margins. The five-year cumulative IBTR rates were 1.8% in patients with RT and 8.1% in patients without RT. IBTR was independently associated with distant-recurrence-free survival rates as well as age, nodal metastasis, lymphovascular invasion and progesterone receptor status. The five-year distant-recurrence-free survival rates were 81.9% in patients with IBTR and 93.2% in patients without IBTR. In order to prevent IBTR, a negative margin and the administration of RT are therefore considered to be important in patients who undergo BCS.     

Interstitial fluid pressure in breast cancer,benign breast conditions,and breast parenchyma

Background: Interstitial fluid pressure (IFP) in rodent malignant tumors is reportedly much higher than in surrounding normal tissue. We hypothesized the same may be true in human invasive breast tumors. Methods: We measured IFP in the operating room in 25 patients undergoing excision breast biopsy under local anesthetic for diagnostic purposes. Results: In patients with invasive ductal carcinomas IFP was 29 ± 3 (SE) mm Hg, compared with ?0.3 ± 0.1 mm Hg in those with normal breast parenchyma (p < 0.001), 3.6 ± 0.8 mm Hg in those with benign tumors (p < 0.003), ?0.3 ± 0.2 mm Hg in those with noninvasive carcinomas (p = 0.034), and 0.4 ± 0.4 mm Hg in those with other benign breast conditions (p = 0.002). There was a direct correlation between IFP and tumor size (R ² = 0.3977; p = 0.021). No correlation was found between IFP and nuclear grade, angiolymphatic invasion, systemic blood pressure, metastasis to lymph nodes, or estrogen and progesterone receptors. Conclusions: IFP measurements may facilitate radiographic or ultrasound localization of small or nonpalpable malignant tumors in those patients undergoing needle aspiration cytology or stereotactic core needle biopsy.     

Correction of breast contour deformities using polyurethane breast implant capsule in revisional breast surgery

Surgeons are commonly confronted with breast contour deformities and defects that result from previous surgical interventions. These soft tissue deformities can be corrected by conventional reconstructive flap surgery using autologous tissue, but there can be donor site morbidity. Smaller volume replacement is possible using temporary fillers such as hyaluronic acid or polylactic acid, or by using 'permanent' fillers such as autologous fat, but large defects are notoriously difficult to fill and often the fillers resorb or migrate. The patient described in this case report had an exchange of polyurethane implant (PU) in the left breast and correction of a contralateral breast contour filling deformity. A left breast partial capsulectomy was performed after implant removal and the capsule graft was inserted into a predissected pocket where soft tissue augmentation was required. A biopsy from the PU capsule was reported to show a foreign body type giant cell reaction to PU material in a fibrous capsule, lined by synovial metaplasia. The post-operative result showed satisfactory soft tissue revolumisation. PU breast implant structured capsule has thus been used as filler to correct breast soft tissue deformity and contour defects. Clearly it may have a use in other anatomical sites.     

Specialist breast surgeons perform less benign breast operations

Objective: to determine the effect a specialist breast surgeon working in a team with a radiologist, cytopathologist and nurse specialist has on surgery for benign breast disease compared with non-specialist surgeons working in the same district general hospital.Data was collected prospectively between 1987 and 1992.Main outcome measures: the accuracy of pre-operative assessment and the number of operations performed for benign disease.Results: clinical assessment is uncertain in 50% of cases. Mammography has a sensitivity of 87% with a specificity of 99.7%. Fine needle aspiration cytology had a specificity of 97% with a sensitivity of 94% if an adequate sample was provided. Using all three malignancy can be predicted with a sensitivity of >99%. Using a policy of leaving benign lumps alone the specialist breast team has reduced the number of benign operations from 19% of new patients seen to 12% of new patients seen (p < 0.01 chi square).Conclusion: patients with breast disease should be seen by a specialist surgeon working in a team with a radiologist, cytopathologist and clinical nurse specialist. Every effort should be made to make a pre-operative diagnosis, and if the lump is benign on clinical, imaging, and cytological assessment it need not be removed.     

Adjustment of the contralateral breast following breast reconstruction

Surgery on the contralateral breast was performed in 64 of 100 patients for adjustment of size and shape or for diagnostic purposes. The patients found it more desirable to adjust size than shape asymmetry on the contralateral breast. There was only one early complication and six late ones. The former was a postoperative hematoma after a reduction mammaplasty. The latter were three cases of capsular contractures after augmentation mammaplasties. In these cases the implant was placed in a submuscular position. In three cases, patients asked for a secondary reduction mammaplasty because of poor symmetry. There were some difficulties in comparing pre- and postoperative mammography after augmentation mammaplasty. In the other adjustment procedures, there were only minor difficulties in a few cases comparing pre- and postoperative mammography. Patients with a high risk of bilateral breast cancer needing size and/or shape symmetry correction should be considered for mastectomy and immediate reconstruction.     

Endoscopic breast subpectoral augmentation for second-degree breast ptosis

Glandular ptosis and first-degree ptosis are treated routinely with breast augmentation in select patients. Second-degree ptosis is difficult to treat with breast augmentation alone. Patients must be well informed and selected properly to obtain a satisfactory result. Historically, second-degree ptosis is treated most commonly with subglandular augmentation. The authors demonstrate that second-degree ptosis may be treated using endoscopic subpectoral augmentation. They think that the endoscopic approach gives more control and precision in the lowering of the inframammary fold and the placement of the implant. Additionally, there may be a decrease or maintenance in the distance from the clavicle to nipple because of shortening the pectoralis major as a result of dividing it from the sixth rib at the sternal attachment laterally to the serratus fascia.     

Calcifications in the breast and digital breast tomosynthesis

Our study was to compare the clarity with which calcifications are seen on conventional mammography (CM) with the same calcifications on digital breast tomosynthesis (DBT). We define clarity as the sharpness, contrast, and diagnostic quality by which the calcifications were depicted. In a HIPPA compliant Institutional Review Board approved study, 3,000 women volunteered to have both a screening mammogram and a DBT study. A total of 119 sequential cases with relevant calcifications (not clearly benign) were reviewed. Two board certified, dedicated, breast imaging radiologists reviewed the CM and DBT images in an unblinded paired comparison. Only the mediolateral oblique (MLO) projection was available for the DBT studies. The MLO and craniocaudal projections were reviewed using the 2D images. Window and leveling, and electronic zoom were permitted. Unlimited time was allowed to provide a subjective assessment as too how well the calcifications were seen, from a diagnostic perspective, when the two studies were evaluated side-by-side. In 41.6% of the cases, the readers felt that calcifications were seen with superior clarity on DBT. In 50.4% of the cases, the visibility of calcifications was the same for DBT and CM, and in 8% of the cases, calcifications were seen with greater clarity on CM than DBT. In 92% of the cases, the clarity with which calcifications were seen on DBT was equal to or better than for CM and in almost half, the clarity on DBT was judged to be better than for CM. Our analysis shows that calcifications can be demonstrated with equal or greater clarity on DBT as on CM, thus allowing for comparable, and, perhaps, improved interpretive analysis of detected calcifications.     

基层医院乳腺癌保乳手术的体会

目的探讨基层医院乳腺癌保乳手术的可行性。方法自2003年10月至2005年10月对早期乳腺癌共施行了15例保乳手术,肿瘤直径在2～3cm,手术切除肿瘤范围约2cm的正常组织以确保切缘阴性,清扫是达到腋淋巴结Ⅰ水平。结果术中冰冻病理报告所有标本各切缘无癌残留,腋淋巴结均无转移。所有病例乳房形态保持良好,患者满意。无术后切口感染、积血、积液和皮肤坏死。术后随访1～48个月,未见局部复发和远处转移。结论只要严格掌握手术指征,在基层医院施行保乳手术是可行的。     

Angiosarcoma of the breast following breast preservation therapy and local radiation therapy for breast cancer

Abstract: This is a case of angiosarcoma following breast preservation therapy and local radiation therapy over a 3-year period.     

Perioperative ultrasound examination of the breast in breast cancer

127 cases of breast carcinoma were examined in a prospective study. By means of preoperative ultrasonography the staging following the pTNM-system validates the tumor size in 85.5% and the lymph node involvement in 77.2%. Multicentric-multifocal carcinomas were diagnosed by ultrasonography in 20 of 29 cases, merely 9 of 29 by mammography. Ultrasonography of specimen is recommended in cases of negative clinical findings and positive ultrasound examination to verify tumour excision. In addition to clinical exploration and mammography the ultrasonography of the breast obtains a diagnostic significance for planning a conservative management of breast cancer.     

经脐孔缘切口置人充注式生理盐水假体隆乳术

目的 探讨经脐孔缘切口行充注式生理盐水假体隆乳术的手术方法,为隆乳术提供新切口选择.方法 沿脐孔缘切口,采用特制专用器械分离皮下隧道至乳房下皱襞,然后穿进胸大肌后间隙,分离假体放置空间,先置人扩张器,充注生理盐水后,调整乳房形态以及扩张器位置.然后取出扩张器,更换为充注式生理盐水乳房假体而完成手术.结果 采用经脐孔缘切口行充注式生理盐水假体隆乳术者,均获得了良好的手术效果,无感染、血肿、假体渗水、Baker Ⅲ或Ⅳ级纤维囊挛缩等并发症发生.结论 采用生理盐水充注式乳房假体,经脐孔缘切口可以完成胸大肌下隆乳术,增加了隆乳手术切口的选择范围.