Education of medical students in clinical breast examination during surgical clerkship

BACKGROUND: Medical student training in clinical breast examination is deficient at most medical schools. The use of silicone breast models may allow the education of abnormal and normal findings. This study examines the efficacy of silicone breast models to educate medical students in clinical breast examinations during their third-year surgical rotation. METHODS: Medical students were randomly selected to participate in formalized training sessions in clinical breast examination or as a control group. Presession and postsession testing with silicone breast models were performed. True positives (masses that were present and documented by the student) and false positives (masses that were not present but were documented by the student) were recorded. RESULTS: Medical students undergoing the training sessions demonstrated improved true positive scores (2.2 to 2.8; P <0.05) as well as improved false positive scores (3.0 to 2.0; P = 0.30) and total scores (-0.8 to 0.8; P = 0.07). Students who documented an increase in the number of breast examinations during their rotations had statistically lower false positive scores. CONCLUSIONS: Students after formalized clinical breast examination sessions do improve their ability to detect breast masses, although they continue to detect masses that are not present. Experience of actual breast examinations during their surgical rotations may refine their clinical skills.     

Trends in mammography and clinical breast examination: a population-based study

BACKGROUND: There are well-accepted clinical guidelines for early detection of breast cancer through mammography and clinical breast examination. The purpose of this study was to determine trends in the utilization of these techniques over the past 5 years. METHODS: The National Health Interview Survey is a population-based computer survey of noninstitutionalized civilian Americans conducted annually by the National Center for Health Statistics, Centers for Disease Control and Prevention. We evaluated the reported use of mammography and clinical breast examination in women 40 years of age and older between 2000 and 2005. Data were evaluated using SAS and SAS-callable SUDAAN software. RESULTS: Surveyed were 10,994 and 11,128 women over age 40 in 2000 and 2005, respectively. Between these years, there was a decline in women >or=40 years old who reported ever having a mammogram (80.79% versus 79.52%, P<0.0001) and in those who had a mammogram within the preceding 2 years (87.98% versus 86.30%, P=0.0040). In addition, there was a drop in women reporting ever having a clinical breast exam (82.12% versus 75.91%, P<0.0001) and in those reporting having had a clinical breast exam in the 2 years prior to the survey (89.24% versus 87.63%, P=0.0012). Similar results were found in the population aged 50-69. CONCLUSIONS: Despite well-established clinical guidelines for early detection of breast cancer, there has been a decline in the rates of annual mammography and clinical breast exam in women over the age of 40 over the past 5 years.     

Validity and reliability of a virtual reality upper gastrointestinal simulator and cross validation using structured assessment of individual performance with video playback

Background: This study aims to evaluate the ability of an upper gastrointestinal virtual reality simulator to assess skills in endoscopy, and to validate its metrics using a video-endoscopic (VES) technique. Methods: The 32 participants in this study were requested to undertake two cases on the simulator (Simbionix, Israel). Each module was repeated twice. The simulators metrics of performance were used for analysis. Two blinded observers rated performance watching the simulators playback feature. Results: There were 11 novices (group 1), 11 trainees with intermediate experience (10–50 procedures, group 2), and 10 experienced endoscopists (>200 procedures, group 3). There was a significant difference in the total time required to perform the procedure (p < 0.001), percentage of mucosa visualized (p < 0.001), percentage of pathologies visualized (p < 0.001), and number of inappropriate retroflexions (p = 0.015) across the three groups. The reliability of assessment on the simulator was greater than 0.80 for all parameters. The VES assessment also was able to discriminate performance across the groups (p < 0.001). There was a significant correlation between the VES score and the percentage of mucosa visualized (rho = 0.60; p < 0.001). Conclusions: The upper gastrointestinal simulator may be a useful tool for determining whether a trainee has achieved a desired level of competence in endoscopy. The next step will be to validate the VES score in real procedures. Presented as a poster at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Los Angeles, 10–15 March 2003     

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year

Background

Although mammography is the gold standard for breast cancer screening, clinical breast examination (CBE) and self breast examination (SBE) are important adjuncts whose utility has been questioned.

Methods

A retrospective review of invasive breast cancer patients from 2000 to 2008 was performed. We compared 3 groups: breast cancer detected by (1) imaging only (nonpalpable) or palpable mass with a normal mammogram (2) ≥1 year (mammogram ≥1 year) or (3) <1 year (mammogram <1 year).

Results

Of 1,222 women, presentation included 67% nonpalpable, 21% mammogram ≥1 year, and 13% mammogram <1 year. Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors (larger size, lymph node positive, and triple-negative disease) resulting in more aggressive therapy (a higher mastectomy rate and a greater likelihood of chemotherapy).

Conclusion

A significant number of women present with palpable breast cancer within 1 year of a normal mammogram, many with an aggressive cancer. Therefore, we continue to advocate SBE and CBE for breast cancer screening.     

A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator

Aims: This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure. Secondary outcomes included perceived use of simulation in surgical training, with structured feedback from participants.Methods: A comparative interventional study was carried out in a regional orthopaedics trauma unit hospital. Volunteers were stratified into novice, intermediate and expert groups based on self-reported levels of experience. Each participant carried out a simulated proximal femoral nail on an immersive virtual platform following instruction on its use, with objective metrics such as time and x-rays, and novel metrics calculated by the simulation module recorded. Face validity was also assessed.Results: The proximal femoral nail module demonstrated construct validity. Kruskal Wallis test demonstrated a statistically significant difference across all group's novel performance (p=.018). Intermediate surgeons performed significantly better than novices (P=.022), with shorter procedural times (P=.018) Three of the intermediate group achieved the proficiency level set by the expert group, with no significant difference noted between these two groups (=.06). Time taken to completion for expert surgeons was less than intermediate group, although this did not reach significance (P=.19).Conclusion: The proximal femoral nail module on the Precision OS platform demonstrated good face, and construct validity. Further research evaluating use of virtual platform simulation in surgical trauma training is needed.     

Imaging surveillance of the breast in a patient diagnosed with scleroderma after breast-conserving surgery and radiotherapy

Abstract:  Collagen vascular disease (CVD), particularly scleroderma, is a contraindication to radiation therapy because of increased risk of fibrosis. We report a patient with early stage breast cancer diagnosed with scleroderma after breast-conserving surgery and radiation. She developed marked breast fibrosis, rendering mammographic, sonographic, and clinical surveillance ineffective. She has subsequently been followed with magnetic resonance imaging (MRI) of the breast. We illustrate this case and review the literature relating to CVD and radiation therapy. MRI may be a suitable surveillance method in this situation.     

Optimal sentinel node examination and a new strategy for axillary control in breast cancer

The sentinel lymph nodes (SLNs) have been reported to reflect the other nodal status in breast cancer, and it is thought that axillary dissection can be avoided in SLN-negative patients, whereas an additional axillary dissection must be performed for SLN-positive patients. To avoid any unnecessary dissection, non–SLN-negative patients should be distinguished among SLN-positive patients. In this study, an optimal histological examination of SLNs was investigated for a precise indication of additional axillary clearance. A modified radical mastectomy with an axillary dissection was performed for 61 patients. Technetium-labeled tin colloids were used to identify the SLNs. In all lymph nodes that were diagnosed as negative at one section by hematoxylin and eosin (H&E) examination, another additional slice was produced for each lymph node. We evaluated how minute areas of cancer in the SLNs can indicate the non-SLNs to be negative. Among 1,092 lymph nodes previously diagnosed by H&E examination as negative at one section, 3 nodes were revealed to be positive in 46 SLNs (6.52%), whereas in additional slices, only 3 nodes out of 1,046 non-SLNs were positive (0.29%). The mean ratio of the cancer cell area to the whole area of SLN on the slice was 15.6% (10–18%) in 12 non–SLN-negative patients and 45.6% (30–83%) in 16 non–SLN-positive patients. It is possible that additional axillary clearance is not needed for patients with a cancer area of less than approximately 20% in the SLN slice, based on an H&E staining evaluation of two slices. SLNs identified with radiolabeled tin colloids could reflect the other nodal status in breast cancer. There is a possibility that additional axillary clearance is not needed for patients with a cancer area of less than approximately 20% in the SLN slice.     

Fear of missing a lesion: use of simulated breast models to decrease student anxiety when learning clinical breast examinations

BACKGROUND: Medical students experience a considerable amount of discomfort during their training. The purpose of the current study was to identify sources of student anxiety when learning clinical breast examinations (CBEs) and to evaluate the effects of simulated breast models on student comfort. METHODS: Simulated breast models were introduced into the curriculum for 175 second-year medical students. Using surveys, students identified sources of anxiety and rated their comfort levels when learning CBE skills. RESULTS: "Fear of missing a lesion" and the "Intimate/personal nature of the exam" accounted for 73.8% of student anxiety when learning CBEs. In addition, there were significant improvements (P < .05) in student comfort levels when using simulated breast models to learn CBE skills. CONCLUSIONS: We have identified 2 of the top causes of anxiety for second-year medical students learning CBE. In addition, we found simulated breast models to be effective in increasing student comfort levels when learning CBEs.     

35岁以下早期乳腺癌患者保乳术和改良根治术的临床对比研究

【摘要】 目的 分析并比较35岁以下早期乳腺癌患者保乳术与改良根治术的疗效、预后和生存情况。方法 选择本院经手术治疗的早期乳腺癌患者110例作为观察对象,按接受手术方法的不同分为保乳术组61例和改良根治术组49例,对比观察两组患者的围手术期情况、外观疗效、长期疗效和生存质量情况。结果〓保乳术组患者手术时间、术中出血量和住院时间均较改良根治术组显著性减少(P<0.001),且术后并发症发生情况也较改良根治术组明显改善(P<0.05);保乳术组患者术后外观优良率较改良根治术组有显著性提高(P<0.05);两组患者3年无复发生存率和生存期比较无显著性差异(P>0.05);保乳术组患者3年后SF-36生存质量各项评分显著性高于改良根治术组(P<0.05)。结论〓对于35岁以下早期乳腺癌患者而言,保乳手术具有美容佳、创伤小、并发症少和生存质量好等优点,且能保持与传统方式相似的生存率,为临床治疗方法选择提供了一定的理论依据,但尚待多中心、大样本研究进一步证实。     

Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery

BACKGROUND: Women with a history of breast and axillary surgery may demonstrate aberrant lymphatic drainage caused by disrupted lymphatic channels. Lymphoscintigraphy may be valuable in evaluation and staging of an ipsilateral second breast carcinoma. METHODS: We conducted a retrospective review of 16 women treated for a second ipsilateral breast carcinoma who underwent breast lymphoscintigraphy and intraoperative lymphatic mapping. Drainage patterns were compared with pathologic and operative findings. RESULTS: Lymphoscintigraphy succeeded in 69% of patients and demonstrated widely varied drainage patterns including ipsilateral axillary and supraclavicular as well as contralateral axillary and supraclavicular basins. No trend between successful lymphatic mapping and multiple clinical and pathologic measures was seen. CONCLUSIONS: In women with a second ipsilateral breast carcinoma and history of previous breast and axillary surgery, lymphoscintigraphy is feasible. Drainage patterns vary widely including across the midline of the thorax. Preoperative lymphoscintigraphy may be useful to ensure inclusion of potential sentinel nodes within the operative field.     

Learning curves and impact of previous operative experience on performance on a virtual reality simulator to test laparoscopic surgical skills

BACKGROUND: The study was carried out to analyze the learning rate for laparoscopic skills on a virtual reality training system and to establish whether the simulator was able to differentiate between surgeons with different laparoscopic experience. METHODS: Forty-one surgeons were divided into three groups according to their experience in laparoscopic surgery: masters (group 1, performed more than 100 cholecystectomies), intermediates (group 2, between 15 and 80 cholecystectomies), and beginners (group 3, fewer than 10 cholecystectomies) were included in the study. The participants were tested on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) 10 consecutive times within a 1-month period. Assessment of laparoscopic skills included time, errors, and economy of hand movement, measured by the simulator. RESULTS: The learning curves regarding time reached plateau after the second repetition for group 1, the fifth repetition for group 2, and the seventh repetition for group 3 (Friedman's tests P <0.05). Experienced surgeons did not improve their error or economy of movement scores (Friedman's tests, P >0.2) indicating the absence of a learning curve for these parameters. Group 2 error scores reached plateau after the first repetition, and group 3 after the fifth repetition. Group 2 improved their economy of movement score up to the third repetition and group 3 up to the sixth repetition (Friedman's tests, P <0.05). Experienced surgeons (group 1) demonstrated best performance parameters, followed by group 2 and group 3 (Mann-Whitney test P <0.05). CONCLUSIONS: Different learning curves existed for surgeons with different laparoscopic background. The familiarization rate on the simulator was proportional to the operative experience of the surgeons. Experienced surgeons demonstrated best laparoscopic performance on the simulator, followed by those with intermediate experience and the beginners. These differences indicate that the scoring system of MIST-VR is sensitive and specific to measuring skills relevant for laparoscopic surgery.     

Rectum mucinous adenocarcinoma metastasis to bilateral breast in a male patient: A case report

A 47‐year‐old male presented to our clinic with complaints of mass in both breasts. In the patient's history, he had undergone low anterior resection for rectum mucinous adenocarcinoma 2 years ago. The masses in both breasts of the patient were excised. Mucinous adenocarcinoma metastases were reported in the pathologic evaluation of the masses. Metastasis should be considered in patients with bilateral breast mass and previously diagnosed cancer even if the patient is male.     

Leiomyosarcoma of the breast —a case report and an electron microscopic study—

We treated a fifty six-year-old woman with leiomyosarcoma of the breast. Light microscopy showed typical findings of leiomyosarcoma and electron microscopy confirmed the smooth muscle origin of the tumor. The patient is well without evidence of metastases or local recurrence of the tumor fifty-five months after radical mastectomy.     

Supraclavicular nodal failure in patients with one to three positive axillary lymph nodes treated with breast conserving surgery and breast irradiation, without supraclavicular node radiation

The purpose of this study was to evaluate the risk factors associated with supraclavicular nodal failure (SCF) in patients with one to three positive axillary nodes treated with breast conserving surgery and axillary dissection without supraclavicular node radiation (S/C RT) to aid in the selection of patients for S/C RT. Two hundred two breast conservation patients with one to three positive axillary nodes on axillary dissection treated with breast irradiation without S/C RT and 20 patients with S/C RT between August 1985 and May 2002 were identified and retrospectively evaluated. The Kaplan-Meier method was used to determine SCF-free and overall survival curves. Risk factors for SCF were examined. The median follow-up from surgery was 72 months (range: 4-195). Nine of 202 patients (4%) failed in the ipsilateral breast, 4 (2%) in the ipsilateral supraclavicular lymph nodes, 4 (2%) in the ipsilateral axillary and/or internal mammary nodes and 30 (15%) distantly. The 5- and 10-year SCF-free survival was 97.92%. The overall survival at 5, 10, and 15 years was 91.35%, 75.58%, and 67.18%, respectively. SCFs were associated with high grade or ER negative cancers, but not with number of positive nodes. Two of the four SCFs were associated with distant metastases, and two with local failures. One patient with a SCF was salvaged and is disease-free at 134 months. The overall low incidence of SCF in patients with one to three positive nodes treated with breast radiation alone after breast conserving surgery and adequate axillary dissection suggests that additional S/C RT is unnecessary in this cohort. When it occurs, supraclavicular nodal failure is often associated with distant metastases.     

A pilot study to investigate the role of the 26S proteasome in radiotherapy resistance and loco-regional recurrence following breast conserving therapy for early breast cancer

Breast conserving therapy is a currently accepted method for managing patients with early stage breast cancer. However, approximately 7% of patients may develop loco-regional tumour recurrence within 5 years. We previously reported that expression of the 26S proteasome may be associated with radio-resistance. Here we aimed to analyse the 26S proteasome in a pilot series of early breast cancers and correlate the findings with loco-regional recurrence. Fourteen patients with early breast cancer who developed loco-regional recurrence within 4 years of completing breast conserving therapy were selected according to strict criteria and compared with those from 14 patients who were disease-free at 10 years. Decreased expression of the 26S proteasome was significantly associated with radio-resistance, manifested as the development of a loco-regional recurrence within 4 years of breast conserving therapy (p = 0.018). This small pilot study provides further suggestion that the 26S proteasome may be associated with response to radiotherapy.     

乳腺癌术后上肢淋巴水肿患者自我管理体验的质性研究

目的 了解乳腺癌术后上肢淋巴水肿患者自我管理中的体验和感受,为临床制订解决方案提供参考。方法 采用质性研究方法对15例乳腺癌术后上肢淋巴水肿患者进行半结构式访谈,采用Colaizzi7步分析法分析资料。结果 提炼出6个主题,包括缺乏自我管理知识、思想上未引起足够重视、管理方式的差异化、自我管理过程中存在诸多障碍、自我管理中的情绪问题和社会支持不足。结论 乳腺癌术后上肢淋巴水肿患者在自我管理过程中存在较多问题,医护人员应帮助患者纠正对疾病的错误认知及处理方式,树立良好的自我管理行为与习惯,重视患者由自我管理产生的心理问题,联合家庭和社会共同提高患者的自我管理能力。