How Should We Investigate Breast Implant Rupture?

We aimed to examine a cohort of patients presenting with breast implant complications to establish the sensitivity and specificity of clinical examination, Ultrasound Scanning (US) and Magnetic Resonance Imaging (MRI) in the diagnosis of implant rupture, and to examine the correlation between US and MRI. We performed a 26-month retrospective review. Patients underwent US and MRI to exclude rupture. Results of US and MRI were compared prospectively for concordance, then retrospectively to clinical findings and surgical diagnosis. Thirty-four patients with 60 implants were reviewed. The sensitivities of clinical diagnosis, US, and MRI for rupture was 42%, 50%, and 83%, respectively, while the specificities were 50%, 90%, and 90%. The concordance between US and MRI was 87%. MRI is the investigation of choice for implant rupture. US is a valuable alternative with good concordance with MRI. When US is positive for implant rupture an MRI is not necessary to confirm the diagnosis. Knowledge of the sensitivity and specificity as well as the concordance between the two investigations is useful to ensure the appropriate use of available resources.     

Is a Titanium Implant for Total Knee Arthroplasty Better? A Randomized Controlled Study

BackgroundLighter weight and lower modulus are potential advantages of titanium (Ti) implants over cobalt chrome (CoCr) implants in total knee arthroplasty (TKA). This study was conducted to determine whether Ti implants in TKA resulted in better clinical outcomes and radiologic results.MethodsOne hundred and eight patients (216 knees) with knee arthritis warranting bilateral primary TKA were randomly allocated to undergo Ti rotating-platform TKA in one knee and CoCr rotating-platform TKA in the contralateral knee. The mean follow-up period was 5.3 years (range, 1-7 years). The weight of Ti implants was one-third lighter than that of CoCr implants (133.9 g vs 390.1 g, P < .01). Clinical outcomes were evaluated using clinical scores, patient preferences (lightness, comfort, naturalness, and satisfaction), gait analysis (kinetic and kinematic data), range of motion, and degree of pain. Radiologic results were evaluated based on the radiolucent line (RLL), degree of medial tibial bone loss, and loosening as seen on X-ray.ResultsNo significant differences were observed in clinical scores or patient preference. Regarding implant weight, approximately 70% of patients did not perceive the Ti implant as lighter. No significant differences were observed in gait analysis, range of motion, or degree of pain. The RLL was seen in 9% of the Ti implant group and 19% of the CoCr implant group.ConclusionThe lighter Ti implant did not show any clinical benefit over CoCr implants. The lightness of the Ti implant is not sufficient to matter or be noticeable. However, the Ti implant showed lower rate of RLL than the CoCr implant.Level of Evidencelevel I, randomized controlled trial.     

Intraoperative Findings of Cancer in Delayed Breast Reconstruction: A Dilemma?

Recurrence of breast cancer discovered at the time of reconstruction is rare. However, with increasing numbers of delayed postmastectomy reconstructions being performed, this scenario may become more common. There are no guidelines on how to manage this dilemma. There are two main issues: the effect on the patient and the effect on the reconstruction itself. The authors present two cases and discuss the factors involved in this difficult decision, along with their recommendations.     

Is Lymphatic Mapping in Breast Cancer Adequate and Safe?

Lymphatic mapping with selective lymphadenectomy requires a concerted effort from the nuclear medicine physician, surgeon, and pathologist. Application of preoperative lymphoscintigraphy, and intraoperative use of both a gamma detection probe and a vital dye are recommended. This combined approach increases the likelihood of finding all sentinel nodes without removing nonsentinel nodes. A literature review of current experience reveals that the sentinel node can be found in more than 90% of the patients. When confirmatory lymphadenectomy follows, the false-negative rate can be kept down to about 5% after a certain learning phase. The sensitivity of this novel approach to detect lymphatic dissemination is currently overestimated because lymph node metastases in patients with a tumor-free sentinel node are probably overlooked. This shortcoming will be compensated by the more accurate pathologic evaluation of a sentinel node and the finding of sentinel nodes outside the axilla. Therefore the procedure is probably adequate and safe in patients at low risk of having disseminated disease. Lymphatic mapping with sentinel node biopsy is rapidly becoming the standard of care.     

Is There a Low-Grade Precursor Pathway in Breast Cancer?

Background  

Newly proposed models of breast tumorigenesis suggest that low- and high-grade lesions have distinct tumor progression pathways. Our objective was to examine the relationship between histologic grade and molecular subtype in women with lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) who developed subsequent ipsilateral invasive breast cancers.     

Does Patient Satisfaction with Breast Reconstruction Change over Time? Two-Year Results of the Michigan Breast Reconstruction Outcomes Study

BACKGROUND: Previously, we found patient satisfaction with breast reconstruction at postoperative year 1 significantly higher in the autogenous tissue compared with the expander/implant population. But breast reconstructive procedures have different "aging" processes, and the point at which outcomes stabilize is unclear. So we evaluated patient satisfaction with breast reconstruction at postoperative year 2 and compared the results with those from our previous study. STUDY DESIGN: As part of the Michigan Breast Reconstruction Outcomes Study, women undergoing mastectomy reconstruction (including expander/implants and pedicle and free transverse rectus abdominis musculocutaneous flaps [TRAM]) were prospectively evaluated. Preoperatively and at postoperative years 1 and 2, women completed a questionnaire that collected a variety of validated health status information. The postoperative questionnaire had an additional seven items assessing both general and esthetic satisfaction as separate subscales. To assess the effects of procedure on satisfaction and control for possible confounding, multiple logistic regression was used. RESULTS: At year 2, patients with TRAM flaps (both free and pedicle) continued to have higher levels of esthetic satisfaction compared with expander/implant patients (odds ratio 2.8, p < 0.01). But no significant differences were appreciated in esthetic satisfaction between women with free and pedicle TRAM flaps. In regard to general satisfaction, the type of reconstruction (expander/implant, pedicle TRAM, and free TRAM) had no statistically significant effect. CONCLUSIONS: At postoperative year 2, procedural differences initially found in women's general satisfaction with breast reconstruction diminish. Specifically, women with pedicle TRAM flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction. But at year 2, patients continue to be more esthetically satisfied with autogenous tissue than with expander/implant reconstructions.