Cosmetic results after wire-guided biopsy of benign breast lesions

Background: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT).

Study Design: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy.

Results: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT.

Conclusions: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.     

Early breast cancer: cosmetic and functional results after treatment by conservative techniques

Between January 1980 and December 1985, 121 patients with early breast cancer were referred to the Department of Radiation Oncology at Westmead Hospital for radiation therapy following initial tumour excision. After a median follow-up of 26 months, five patients developed a loco-regional recurrence (4%) and nine developed metastatic disease but with local control. There were 105 eligible patients who were sent a letter/questionnaire which included: a request to attend a clinic, to allow an objective assessment of the cosmetic result of the treated breast by two clinicians, questions regarding breast function as it affected quality of life, and a request that they undertake a self-assessment of the treated breast from a cosmetic point of view. Seventy-six patients attended for assessment of the following factors: whether surgery was optimal as determined by predefined criteria, measurement of breast oedema, arm oedema, breast retraction and telangiectasia, and an overall cosmetic assessment performed independently by both a radiation oncologist and surgeon. A physician not involved in management undertook a cosmetic assessment using standard photographs. Approximately 20% of patients replied that their choice of clothing had been affected by treatment, 10% were embarrassed and 70% experienced some continuing tenderness or discomfort in their treated breast. The extent of surgery was judged to be suboptimal in 22% but that proportion increased to 34% of cases referred from external clinics. The overall incidence of moderate or severe breast oedema was 9%, breast retraction 50%, telangiectasia 16% and arm oedema 21%. Those patients with longer follow-up (i.e., greater than 36 months) had a higher incidence of breast retraction (67%), telangiectasia (30%) and arm oedema (33%) but less breast oedema (7%). As expected, the patients rated the appearance of their breast more favourably than did clinicians. Overall, the result was rated as good or excellent by 75% of patients compared with 55% when the assessment was made by a surgeon or radiation oncologist. The main factor identified as contributing to a poor cosmetic result was the area of the iridium implant. The area of implant was larger when suboptimal surgery had been carried out, the main component of which was excessive length of scar.     

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.     

保留乳头乳晕复合体的一期硅胶假体乳房再造在乳腺肿瘤手术中的应用

目的：探讨保留乳头乳晕复合体（NAC）的一期硅胶假体乳房再造在乳腺良恶性肿瘤乳房切除术后乳房缺损中应用的可行性。 方法：选取2008年1月—2012年11月乳腺良、恶性肿瘤患者各15例,行乳房切除术后一期胸大肌包裹硅胶假体乳房再造,术中保留NAC;术后随访13~48个月,观察患者乳房美容效果、并发症及临床疗效。 结果：30例患者中28例对术后乳房外形满意,术后1.5、2年出现假体包膜挛缩、假体渗漏各1例,无与保留NAC相关的肿瘤残留、复发或转移。 结论：保留NAC的乳腺肿瘤乳房切除术后一期硅胶乳房假体再造能在治愈患者乳腺肿瘤的同时又满足了患者乳房外形美观的要求,且不增加并发症、肿瘤残留、复发或转移的发生率。     

Can breast carcinoma be anticipated? A follow-up of benign breast biopsies.

110 women who had undergone biopsy for benign lesions of the breast were studied for subsequent development of breast carcinoma over the following 16-20-period. 10 women in the study developed carcinoma in the same or opposite breast within 16-20 years, a rate of incidence 480% greater than among the general population of women of the same age. Average interval time from biopsy to appearance of malignant tumors was 9 years. The original biopsies were studied and categorized with a view to isolating pathologic factors which might indicate high risk. No factor could be associated with subsequent carcinoma development. The incidence of carcinoma appeared related to years of risk only. It is recommended as a result of this study that all women who undergo biopsies for benign breast lesions should have life-long followup since they seem to be at high risk.     

Free jejunal graft reconstruction after extensive head and neck surgery

Seven patients with benign and malignant head and neck lesions underwent reconstruction with free jejunal grafts using microvascular techniques. Benefits included preservation and maximal tongue function, acceptable cosmetic appearance and a short, one-stage reconstructive period.     

Breast reconstruction: late cosmetic results of implant reconstruction

The long cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate breast reconstruction with various types of implant has been prospectively analysed over a 10-year period. 334 patients who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (<2 months) was 9.1%, with an explantation rate of 1.6%. The late complication rate (>2 months) was 23%, with a pathological capsular contracture rate of 11% at two years and 15% at five years, and an implant removal rate of 7%. The revisional surgery rate was 30.2%. The cosmetic results were prospectively assessed using an objective five point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorates in a linear fashion from an initial acceptable result in 86% of patients two years after completion of their reconstruction to only 54% at five years. This fall off in the cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient or the type of mastectomy incision employed. Radiotherapy was not a significant factor as only 28 patients were irradiated. However, on Cox model analysis pathological capsular contracture was the only factor which significantly contributed to a poor cosmetic outcome(P<0.0001 (relative risk 6.3). In spite of a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of those patients without a capsular contracture who demonstrated a deterioration in their cosmetic scores, it became clear that a possible reason for their poor result was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis as the patients aged.     

The diagnostic accuracy of mammography in the evaluation of male breast disease.

BACKGROUND: The role of mammography in the evaluation of male patients presenting with breast disease is controversial. This controversy is a function of the lack of specific data concerning the diagnostic accuracy of mammography when used in this clinical setting. The purpose of this study was to define the diagnostic accuracy of mammography in the evaluation of male breast disease. METHODS: One hundred and four prebiopsy mammograms from 100 patients with tissue diagnoses were read blindly by two independent radiologists, and placed into one of five predetermined categories: definitely malignant, possibly malignant, gynecomastia, benign mass, and normal. Radiologic/pathologic correlation was performed and the sensitivity (Sn), specificity (Sp), positive (Ppv) and negative predictive value (Npv), and accuracy (Ac) for each of the mammographic diagnostic category determined. RESULTS: The pathologic diagnoses were 12 cancers, including 1 patient with bilateral breast cancer, 70 cases of gynecomastia, 16 benign masses, and 6 normals. The accuracy data for the mammographic diagnostic categories are as follows: malignant (combined definitely and possibly malignant), Sn 92%, Sp 90%, Ppv 55%, Npv 99%, Ac 90%; and overall benignity (combined gynecomastia, benign mass, and normal), Sn 90%, Sp 92%, Ppv 99%, Npv 55%, Ac 90%. Six cancers (50%) coexisted with gynecomastia. CONCLUSIONS: Mammography can accurately distinguish between malignant and benign male breast disease. Although not a replacement for clinical examination, its routine use could substantially reduce the need for biopsy in patients whose mammograms and clinical examination suggest benign disease.     

Replacement of the oesophagus with a segment of colon experience of 30 cases and technical considerations

Thirty consecutive patients who underwent oesophageal replacement with a segment of colon (16 for malignant and 14 for benign disease) were reviewed. The operation was done in one stage in 28 cases and in two stages in two. The interposed colon was always placed isoperistaltically, in the bed of the oesophagus in 24 and retrosternally in 6 cases. In seven patients a valve was constructed to prevent gastrocolic reflux. There was one early postoperative death (3%). Early non-fatal complications occurred in 5 (17%), and late complications in 6 patients (20%). The functional results were excellent to good in 21 (73%), acceptable in 7 (24%), and poor in 1 (3%). The data suggest that colonic interposition offers a good alternative to stomach in selected cases with oesophageal malignancy and represents an excellent choice for reconstruction in benign oesophageal disease.     

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??Value analysis of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge HUANG Jia-hui??CHEN Xiao-song, WU Jia-yi, et al. Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
Corresponding author: SHEN Kun-wei, E-mail: kwshen@medmail.com.cn
Abstract Objective To analyze the value of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge. Methods The clinical data of 233 patients treated with surgery for nipple discharge from January 2011 to February 2016 in Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. A total of 233 cases without palpable mass were enrolled in the analysis. Thirty-three patients (14.2%) were diagnosed as breast cancer, and the other 200 patients (85.8%) were diagnosed as benign disease. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, MRI and their combination in predicting malignant disease were calculated. Results Patients with bloody nipple discharge (P=0.008), with suspicious calcification on mammography (P<0.001)??with segmental enhancement (P=0.003) or with washout-pattern kinetic curve (P=0.023) on MRI had higher risk of breast cancer. The sensitivity of mammography in diagnosing breast cancer was 57.6%, significantly lower than that of ultrasound (87.9%,P=0.012) and MRI (93.9%??P=0.001). The sensitivity of mammography combined with ultrasound or with MRI was 90.9% and 100% respectively, significantly higher than that of mammography alone (P=0.004, P<0.001) .Conclusion Bloody nipple discharge, with suspicious calcification on mammography, with segmental or with washout-pattern kinetic curve on MRI are risk factors for predicting breast cancer in patients with nipple discharge without palpable disease. The sensitivity of breast cancer can be elevated with ultrasound or MRI comparing with mammography alone.     

手术切除治疗皮肤良恶性肿瘤

目的:总结手术切除方法在皮肤肿瘤治疗中的应用经验。方法:1225例皮肤良、恶性肿瘤采用外科手术切除,肿瘤切除后创面采用原位缝合或临近皮瓣修复,较大的良性皮损可分次手术切除。结果:所有患者切除皮损后,伤口均一期愈合,术后恢复良好未见皮损复发,只有4例皮脂腺囊肿患者因感染而致伤口延迟愈合。美容效果:良好721例(58.86%);较好457例(37.31);差者47例(3.84%)。结论:对于皮肤的良、恶性肿瘤的治疗,手术切除是治疗效果及美容效果俱佳的一种理想的治疗手段,因而应为治疗皮肤良、恶性肿瘤的首选治疗方法。     

Suspicious Node Found at the Time of Reduction Mammaplasty

A case of a patient with a suspicious glandular node found during reduction mammaplasty is described. The preoperative search for such nodes, the management of cases on which a suspicious node is found intraoperatively, and a situation on which the diagnosis of breast cancer is made during histology are discussed. When a suspicious small node (with a diameter up to 2 cm) is detected during a cosmetic breast surgery, lumpectomy can be performed. It may be a definite surgical treatment, depending on stage and tumor type. In the case presented, histology revealed intraductal papiloma, a benign tumor, therefore lumpectomy was a suitable procedure with an acceptable cosmetic result. With the increased incidence of breast cancer, this situation will happen more often and technical options for the management of such cases deserves the attention of plastic surgeons.     

Transareolar dye-injection microdochectomy.

Single-duct microdochectomy is described for use in patients with bloody or serosanguinous nipple discharge arising from a single duct in the breast. Because most such cases are caused by benign, intraductal papillomata, the technique used in removing the offending ductal system should be fully diagnostic, adequately therapeutic, and cosmetically acceptable. A technique is described that is used in 40 consecutive patients with good diagnostic, therapeutic, and cosmetic result. The procedure itself combines techniques and principles of plastic and reconstructive surgery such as minimal tissue trauma, use of anatomical tissue planes, bloodless-field surgery, and microdissection.     

Productivity of needle localization to facilitate excision of nonpalpable, mammographically suspicious lesions

The use of needle localization to aid excisional biopsy of nonpalpable breast lesions is now common, and the literature suggests that 13% to 33% of such lesions are malignant. During the 4 years from 1984 to 1988, all women who underwent fine-needle localization in preparation for biopsy were studied to identify factors that might facilitate the selection of those more likely to harbour a cancer, thus sparing patients with benign disease operative intervention. In all, 124 biopsies were performed on nonpalpable lesions that were suspicious on mammography; 51 lesions were malignant and 73 benign. The average age of the patients was 56 years (55 years for those with benign lesions and 61 for those with malignant lesions). The family history, history of breast disease, symptoms and calcification seen on mammography were not significantly different between the two groups. Only 25% of the malignant lesions were noninvasive. In 10% of the patients who had invasive lesions there was lymph-node involvement. The rate of malignancy in this patient population (41%) was slightly better than that reported in the literature, and a larger proportion of patients had noninvasive disease. The authors conclude that none of the above-mentioned risk factors could be used in the preoperative selection of patients for open biopsy.     

Shave Excision of Common Acquired Melanocytic Nevi: Cosmetic Outcome, Recurrences, and Complications

Background. Surgical treatment of benign melanocytic lesions demands the application of simple and effective surgical techniques with the possibility of performing a histopathologic examination with an acceptable cosmetic outcome. However, recurrence rates and the cosmetic result should be taken into account because the main reason for these lesions to be removed is the patient's cosmetic improvement. The present study evaluates the results obtained by shave excision of benign pigmented lesions in terms of cosmetic outcome, recurrence rates, and complications from both a subjective and an objective point of view.
Discussion. An acceptable cosmetic result, along with a low rate of recurrence, should be the aim of the surgical treatment of benign melanocytic lesions. The results obtained in this series allow us to provide more detailed and accurate information regarding the outcome and complications expected.
Material and Methods. Shave excision of common acquired melanocytic nevi was performed. The patients were reviewed 3 months after surgery to evaluate the objective and subjective cosmetic results, recurrences, and postsurgical complications.
Results. Over a 12-week period, 204 common acquired melanocytic nevi were shaved. Objective evaluation revealed excellent results in one-third (32.8%) of the lesions excised, with a poor result in 8.3%. The likelihood of having an imperceptible scar was significantly greater in lesions excised from the face (p < .05). Ninety-eight percent of patients (  n = 192  ) declared that "the scar looked better than the original mole." Clinical and dermatoscopic recurrences were observed in 40 scars (19.6%).     

The Effect of Radiation on Complication Rates and Patient Satisfaction in Breast Reconstruction using Temporary Tissue Expanders and Permanent Implants

The optimal method of reconstruction following mastectomy for breast cancer patients receiving radiation therapy (RT) is controversial. This study evaluated patient satisfaction and complication rates among patients who received implant‐based breast reconstruction. The specific treatment algorithm analyzed included patients receiving mastectomy and immediate temporary tissue expander (TE), followed by placement of a permanent breast implant (PI). If indicated, RT was delivered to the fully expanded TE. Records of 218 consecutive patients with 222 invasive (85%) or in situ (15%) breast lesions from the Salt Lake City region treated between 1998 and 2009 were retrospectively reviewed, 28% of whom received RT. Median RT dose was 50.4 Gy, and 41% received a scar boost at a median dose of 10 Gy. Kaplan–Meier analyses were performed to evaluate the cumulative incidence of surgical complications, including permanent PI removal. Risk factors associated with surgical events were analyzed. To evaluate cosmetic results and patient satisfaction, an anonymous survey was administered. Mean follow‐up was 44 months (range 6–144). Actuarial 5‐year PI removal rates for non‐RT and RT patients were 4% and 22%, respectively. On multivariate analysis (MVA), the only factor associated with PI removal was RT (p = 0.009). Surveys were returned describing the outcomes of 149 breasts. For the non‐RT and RT groups, those who rated their breast appearance as good or better were 63% versus 62%, respectively. Under 1/3 of each group was dissatisfied with their reconstruction. RT did not significantly affect patient satisfaction scores, but on MVA RT was the only factor associated with increased PI removal. This reconstruction technique may be considered an acceptable option even if RT is needed, but the increased complication risk with RT must be recognized.     

Completion pneumonectomy: current indications, complications, and results

OBJECTIVE: Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when done in patients with benign disease. We review our 9 years of experience with this operation to evaluate the postoperative outcome and long-term results of various indications. METHODS: Between January 1990 and December 1998, 66 consecutive patients underwent completion pneumonectomy (6.8% of all pneumonectomies), and their cases were retrospectively reviewed. The indication was benign disease in 17 patients and malignant disease in 49 patients. In patients with malignant indications there were 14 local recurrences, 4 second primary tumors, 5 metastatic diseases, and 26 indications because of incomplete initial resection. RESULTS: There were no intraoperative deaths, and the postoperative mortality rate was 7.6%. Complications were encountered in 32 (53%) patients, without any significant difference between benign indication (71%) and malignant indication (47%; P =.0923). Bronchopleural fistula was encountered in 5 (7.6%) patients, and empyema was encountered in 7 (11%) patients. The actuarial 5-year survival was 57% for all patients, 65% for those with benign indications, and 54% for those with malignant indications (60% for local recurrence, 50% for second primary tumor, and 56% for incomplete resection), without any difference between benign and malignant indications (P =.9478). CONCLUSIONS: Completion pneumonectomy can be performed with acceptable mortality and morbidity, even in patients with benign disease. Patients with preoperative infection can be managed with bronchial stump covering and adequate postoperative drainage. Although complications are common, they can successfully be managed with a proper understanding of them.     

Diagnosis of breast cancer in young women

While the prognosis of younger women with breast cancer is controversial, there have been several significant reports indicating a more unfavourable outcome of the disease in this age group. A review has been conducted of the problems encountered in the diagnosis of breast cancer in younger women. The records of 227 consecutive patients aged 30-40 years who underwent breast biopsy were retrospectively analysed, and data studied in relation to the proportion of malignant to benign biopsies, the clinical and pathological features of the malignant cases, and the method of diagnosis. A total of 235 biopsies was performed in 227 patients, of which 199 were benign (85%) and 36 were malignant (15%), giving a malignant to benign biopsy ratio of 1:5.5. Thirty-six cancers were diagnosed in 35 patients. Among these young women with breast cancer, the average duration of symptoms was 26 weeks, the mean clinical cancer diameter was 3.3 cm and only a small proportion (28%) of women had early (Stage I) disease. There were 4 women with breast cancer (11%), in whom the diagnosis of malignancy was unsuspected preoperatively. Mammography in these younger women appears to have a more limited role, with a sensitivity of only 76%. These findings indicate that the diagnosis of breast cancer in younger women is often more difficult than in older age groups and that the presentation and detection of such cancers is often delayed. Younger women need to be educated in relation to seeking early medical review of breast lumps and clinicians need to be aware of the limitations of mammography in such cases.     

Fine needle aspiration cytology, with immediate reporting, in the outpatient diagnosis of breast disease

One hundred and fifty one new patients attending a breast clinic over a 6 month period underwent fine needle aspiration cytology (FNAC), with immediate reporting of the smears in the clinic. Thirty nine smears (25.8%) were classified as unequivocally malignant, 10 (6.6%) as being suspicious of malignancy, 61 (40.3%) as benign and 41 (27.1%) were acellular. There were no false positive diagnoses and only one false negative cytological diagnosis of breast cancer [corrected]. Immediate reporting of results enabled the diagnosis to be discussed with the patient at the first attendance and allowed improved surgical management of both benign as well as malignant breast disease.     

不同临床及影像学特征对良恶性乳头溢液疾病鉴别诊断价值分析

目的 探讨不同临床及影像学特征对良性及恶性乳头溢液疾病的诊断价值。 方法 回顾性分析2011年1月至2016年2月上海交通大学医学院附属瑞金医院因乳头溢液行手术治疗的233例病人的临床资料。乳腺癌33例（14.2%）,乳腺良性疾病200例（85.8%）。分析不同临床及影像学特征病人良性及恶性乳头溢液的检出率,计算乳腺X线摄影、乳腺超声、乳腺MRI及联合检查对乳腺癌诊断的灵敏度。 结果 血性溢液（P=0.008）、乳腺X线摄影伴可疑恶性钙化（P<0.001）、MRI表现为段样强化（P=0.003）、流出型时间-信号强度曲线（P=0.023）的病人乳腺癌检出率明显增高,差异有统计学意义。乳腺X线摄影对恶性乳头溢液诊断的灵敏度较低（57.6%）,劣于超声检查（87.9%,P=0.012）及MRI检查（93.9%,P=0.001）。乳腺X线摄影联合超声或MRI诊断的灵敏度分别为90.9%及100.0%,显著高于单用乳腺X线检查（P=0.004,P<0.001）。结论 对于不伴肿块的乳头溢液,血性溢液、乳腺X线摄影伴可疑恶性钙化、MRI段样强化、时间-信号强度曲线为流出型的病人患乳腺癌的风险较高。乳腺X线摄影对乳头溢液潜在恶性病变的检出率较低,联合超声或MRI检查可提高检出率。