Extent of Primary Breast Cancer Surgery: Standards and Individualized Concepts

Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.     

Comparison of a lightweight polypropylene mesh (Optilene® LP) and a large-pore knitted PTFE mesh (GORE® INFINIT® mesh)—Biocompatibility in a standardized endoscopic extraperitoneal hernia model

Purpose  

The use of a mesh with good biocompatibility properties is of decisive importance for the avoidance of recurrences and chronic pain in endoscopic hernia repair surgery. As we know from numerous experiments and clinical experience, large-pore, lightweight polypropylene meshes possess the best biocompatibility. However, large-pore meshes of different polymers may be used as well and might be an alternative solution.     

Aromatase inhibitors as solely treatment in postmenopausal breast cancer patients

Several studies evaluating the clinical effectiveness of endocrine therapy alone in breast cancer patients aged 70 years or older reported comparable survival rates to conventional surgical therapy, although the incidence of local recurrences was higher. Primary endocrine therapy is therefore only recommended as an alternative approach in elderly woman with estrogen receptor positive tumors who are deemed inoperable or who refuse surgery. We report our experience with aromatase inhibitors as primary endocrine therapy for estrogen receptor positive breast cancer in postmenopausal woman who are impaired by other diseases, refuse surgery or are of old age. Fifty-six patients with fifty-seven ER+ operable breast cancers who refused surgery, were judged ineligible for surgery because of comorbidity, or were of old age were treated with endocrine therapy using aromatase inhibitors only. Digital mammography and high-end breast ultrasound were used to assess tumor sizes. The mean age of the patients was 74 years (range 52-102 years). All patients suffered from breast cancer. The mean follow-up interval was 40 months (range 5-92 months). Seven patients (12%) achieved complete clinical remission, 31 (57%) partial response giving an overall objective response rate of 69%. In addition, seven (12%) patients showed stable disease, giving a clinical benefit rate (complete remission + partial response + stable disease rate) of 81%. Eleven patients (19%) progressed after an initial partial response or stable disease. Only one patient (2%) progressed on endocrine therapy within the first months. Eventually, 22 (39%) patients underwent surgery after informed consent to achieve better local tumor control. Primary endocrine therapy with aromatase inhibitors may offer an effective and safe alternative to surgery giving a high local control rate in postmenopausal women who refuse surgery, who are judged ineligible for surgery, or are of old age.     

Prevalence of dyslipidemic risk factors in hemodialysis and CAPD patients

BACKGROUND: Dyslipidemic factors obviously contribute to the high cardiovascular risk in dialysis patients but are often an underestimated problem. Therefore, we determined the prevalence of dyslipidemic factors in a large group of unselected hemodialysis (N = 564) and CAPD (N = 168) patients. METHODS: We used the recently published recommendations of the Medical Experts Group concerning cardiovascular risk factors for the categorization of dyslipidemic factors. These were total cholesterol>200 mg/dL, low-density lipoprotein (LDL) cholesterol>100 mg/dL, high-density lipoprotein (HDL) cholesterol <40 mg/dL, triglycerides>180 mg/dL, and Lp(a)>30 mg/dL. RESULTS: CAPD patients had, in sum, a markedly worse lipid profile when compared with HD patients. They had higher frequencies of elevated total cholesterol (67% vs. 34%), triglycerides (47% vs. 28%), and Lp(a) concentrations (37% vs. 30%) when compared with HD patients. In both patient groups, about two thirds of the patients had LDL cholesterol above 100 mg/dL and HDL cholesterol below 40 mg/dL. When we analyzed the total frequency of dyslipidemic factors, we observed that the CAPD group included a markedly higher number of patients with three or four concurrent dyslipidemic factors than HD patients (P < 0.001). Furthermore, we analyzed apolipoprotein A-IV (apoA-IV), which was recently shown to be associated with cardiovascular disease, and which was about twice as high in both patient groups when compared with controls (P < 0.001). CONCLUSIONS: Dyslipidemic risk factors are highly prevalent in dialysis patients, and the concomitant occurrence of several risk factors in a given patient is more often observed in CAPD than HD patients.     

Sonoelastography of the prostate: comparison with systematic biopsy findings in 492 patients

OBJECTIVE: The aim of this study was to assess the value of sonoelastography (SE) for prostate cancer detection in comparison with systematic biopsy findings. MATERIAL AND METHODS: Four hundred and ninety two PSA screening volunteers (mean age: 61.9+/-8.6) with an total PSA >1.25 ng/mL and a free to total PSA ration of <18% underwent SE of the prostate before 10 core systematic prostate biopsy. Tissue elasticity of the peripheral zone was investigated only. Tissue elasticity was displayed from red (soft) to green (intermediate) and to blue (hard). Only hard lesions (blue) were considered to be suspicious for prostate cancer. The peripheral zone of the prostate was divided in 3 regions on each side: base, mid-gland, apex. A different investigator performed systematic biopsy, and the biopsy findings were compared with the SE findings. RESULTS: In 125 of 492 patients (25.4%) systematic biopsy demonstrated prostate cancer. Cancer was detected in 321 of 2952 (11%) outer gland areas (74 in the base, 106 in the mid-gland, 141 in the apex). The Gleason score ranged from 3 to 10 (mean: 6.5). In SE 533 of 2952 (18.1%) suspicious areas were detected and 258 of these areas (48.4%) showed cancer. Most of the false-positive findings (275/533 areas; 51.6%) were associated with chronic inflammation and atrophy especially at the basal prostate areas. The sensitivity by entire organ was calculated with 86% and the specificity 72%. The analysis by outer gland areas showed the highest sensitivity in the apex (79%). The specificity by outer gland areas ranged between 85% and 93%. The correlation between SE findings and biopsy results was high (p<0.001). CONCLUSION: Sonoelastography findings showed a good correlation with the systematic biopsy results. The best sensitivity and specificity was found in the apex region. Sonoelastography seems to offer a new approach for differentiation of tissue stiffness of the prostate and may therefore improve prostate cancer detection.     

MRI thermometry: Fast mapping of RF‐induced heating along conductive wires

Conductive implants are in most cases a strict contraindication for MRI examinations, as RF pulses applied during the MRI measurement can lead to severe heating of the surrounding tissue. Understanding and mapping of these heating effects is therefore crucial for determining the circumstances under which patient examinations are safe. The use of fluoroptic probes is the standard procedure for monitoring these heating effects. However, the observed temperature increase is highly dependent on the positioning of such a probe, as it can only determine the temperature locally. Temperature mapping with MRI after RF heating can be used, but cooling effects during imaging lead to a significant underestimation of the heating effect. In this work, an MRI thermometry method was combined with an MRI heating sequence, allowing for temperature mapping during RF heating. This technique may provide new opportunities for implant safety investigations. Magn Reson Med, 2008. © 2008 Wiley‐Liss, Inc.     

Halogenated inhalational anaesthetics

The halogenated inhalational anaesthetics halothane, enflurane, isoflurane and desflurane can produce metabolic hepatocellular injury in humans to a variable extent. During metabolism of these anaesthetics, tissue acetylation occurs due to the formation of reactive intermediates. Proteins modified by acetylation may constitute neo-antigens with a potential for triggering an antibody-mediated immune response. The likelihood of suffering post-operative immune hepatitis depends on the amount of the anaesthetic metabolized and is thereby considerably less with enflurane, isoflurane or desflurane compared with halothane. Plasma inorganic fluoride concentrations are regularly increased after sevoflurane. Elevated inorganic fluoride concentrations have been associated with nephrotoxicity following methoxyflurane anaesthesia but not after sevoflurane. Another source of concern is the products of degradation from reactions with carbon dioxide absorbents. Most important is compound A, which has been shown to exhibit nephrotoxicity in rodents. However, no significant changes in renal function parameters have been reported in surgical patients.     

Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome

BACKGROUND: Pancreatic injury is a dangerous complication in multiple injury, and experience with its diagnosis and treatment is usually limited. METHOD: Retrospective analysis of 3,840 patients admitted after multiple trauma from January 1, 1982, until May 31, 2000. RESULTS: A laparotomy was performed in 121 cases (3.15%) due to suspected intra-abdominal lesion. 32% of the patients (39/121) had a pancreatic lesion; 23% (9/39) had a rupture of the major pancreatic duct. Primary laparotomy was performed in 72% of the patients (28/39). Superficial lesions were treated by explorative laparotomy alone (n = 7), debridement and external drainage (n = 20), or necrosectomy and lavage (n = 3). Complex pancreatic lesions were treated by pancreatojejunostomies (n = 5), pancreatic left resections (n = 2), or exploration alone (n = 2). 8 of 39 patients died (20%), 4 intraoperatively. Of the surviving 35 patients, a pancreas-associated complication developed in 8 patients (23%): pancreatic abscesses (n = 4), traumatic pancreatitis (n = 3), pancreatic fistulas (n = 2), and pseudocysts (n = 2). CONCLUSIONS: Pancreatic injury is an infrequent but dangerous complication in severe trauma. Superficial lesions not affecting the major pancreatic duct can be managed by debridement and external drainage. If the major pancreatic duct is ruptured, organ-preserving, complex reconstructive procedures are necessary. When diagnosed timely and treated according to severity and overall situation, pancreatic injuries have an acceptable morbidity, but usually a high mortality.     

MRI visible Fe<Subscript>3</Subscript>O<Subscript>4</Subscript> polypropylene mesh: 3D reconstruction of spatial relation to bony pelvis and neurovascular structures

Introduction and hypothesis

To demonstrate mesh magnetic resonance imaging (MRI) visibility in living women, the feasibility of reconstructing the full mesh course in 3D, and to document its spatial relationship to pelvic anatomical structures.

Methods

This is a proof of concept study of three patients from a prospective multi-center trial evaluating women with anterior vaginal mesh repair using a MRI-visible Fe₃O₄ polypropylene implant for pelvic floor reconstruction. High-resolution sagittal T2-weighted (T2w) sequences, transverse T1-weighted (T1w) FLASH 2D, and transverse T1w FLASH 3D sequences were performed to evaluate Fe₃O₄ polypropylene mesh MRI visibility and overall post-surgical pelvic anatomy 3 months after reconstructive surgery. Full mesh course in addition to important pelvic structures were reconstructed using the 3D Slicer® software program based on T1w and T2w MRI.

Results

Three women with POP-Q grade III cystoceles were successfully treated with a partially absorbable MRI-visible anterior vaginal mesh with six fixation arms and showed no recurrent cystocele at the 3-month follow-up examination. The course of mesh in the pelvis was visible on MRI in all three women. The mesh body and arms could be reconstructed allowing visualization of the full course of the mesh in relationship to important pelvic structures such as the obturator or pudendal vessel nerve bundles in 3D.

Conclusions

The use of MRI-visible Fe₃O₄ polypropylene meshes in combination with post-surgical 3D reconstruction of the mesh and adjacent structures is feasible suggesting that it might be a useful tool for evaluating mesh complications more precisely and a valuable interactive feedback tool for surgeons and mesh design engineers.

     

Residual motion of cortical versus pedicle screw constructs after decompression,interbody fusion and cross-link augmentation

Purpose

To compare the residual range of motion (ROM) of cortical screw (CS) versus pedicle screw (PS) instrumented lumbar segments and the additional effect of transforaminal interbody fusion (TLIF) and cross-link (CL) augmentation.

Methods

ROM of thirty-five human cadaver lumbar segments in flexion/extension (FE), lateral bending (LB), lateral shear (LS), anterior shear (AS), axial rotation (AR), and axial compression (AC) was recorded. After instrumenting the segments with PS (n = 17) and CS (n = 18), ROM in relation to the uninstrumented segments was evaluated without and with CL augmentation before and after decompression and TLIF.

Results

CS and PS instrumentations both significantly reduced ROM in all loading directions, except AC. In undecompressed segments, a significantly lower relative (and absolute) reduction of motion in LB was found with CS 61% (absolute 3.3°) as compared to PS 71% (4.0°; p = 0.048). FE, AR, AS, LS, and AC values were similar between CS and PS instrumented segments without interbody fusion. After decompression and TLIF insertion, no difference between CS and PS was found in LB and neither in any other loading direction. CL augmentation did not diminish differences in LB between CS and PS in the undecompressed state but led to an additional small AR reduction of 11% (0.15°) in CS and 7% (0.05°) in PS instrumentation.

Conclusion

Similar residual motion is found with CS and PS instrumentation, except of slightly, but significantly inferior reduction of ROM in LB with CS. Differences between CS and PS in diminish with TLIF but not with CL augmentation.