Review of third and fourth re-excision for narrow or positive margins of invasive and intraductal carcinoma

The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (< or = 1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8-123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14-87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins < 1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.     

Changes in facial shape with age: an analysis with three-dimensional imaging

The appearance of the aged face has traditionally been attributed to soft tissue changes with surgical treatments targeting ptosis of skin, SMAS, and fat. However, true facial aging is recognized as a combination of soft tissue and skeletal changes, which continue to be integrated into a model for facial aging. With a greater understanding of these changes, techniques in facial rejuvenation will continue to evolve. Three-dimensional imaging technology was used in this study. Measurements correlating with mid- and lower-face changes were compared for each three-dimensional facial image of 31 mother–daughter matched controls. Each mother image was superimposed on the corresponding daughter, using registration of the upper face to visualize mid-face differences between pairs. Also, measurements of women in four age groups were compared using a one-way ANOVA. The ratios of Po-A:Po-N were significantly greater in daughters in comparison to their mothers (p = 0.0073), with the majority of mother subjects showing a more acute Po-N-A angle (p < 0.042). An investigation between age groups exhibited significant difference between the youngest (18–29) and oldest (60+) groups for Po-A:Po-N length ratio, Po-B:Po-N length ratio, Po-N-A angle, and Po-N-B angle. Differences between the 30–44 and 60+ age groups were also significant for the Po-A:Po-N and Po-B:Po-N length ratios. The results from this study suggest a posterior movement of the mid and lower face with age. This multi-factorial process makes facial rejuvenation more complex than initially perceived, and recognizing it will facilitate better rejuvenation strategies in the future.     

Identification of Cytosolic Antigens from GW-39 Adenocarcinoma Cells by Crossed Immunoelectrophoresis and Immunofluorescence

Rabbits were immunized with a cytosolic fraction prepared from human adenocarcinoma cells of the colon (GW-39). The antibodies obtained were analyzed using crossed Immunoelectrophoresis and were found to precipitate 23 distinct antigens in the cytosolic fraction from colon tumor cells. After pre-absorption with human serum and plasma as well as acetone powders prepared from 2 normal human tissues and 4 normal hamster tissues, 1 major immunodominant cytosol antigen (CA-3) and two less intense immunoprecipitin peaks (CA-1 and CA-5) remained detectable by the crossed immunoelectrophoretic method. The preabsorptions with normal tissues were sufficiently complete to remove anti-carcinoembryonic antigen antibodies and showed that antigens CA-1, CA-3 and CA-5 are immunologically distinct from carcinoembryonic antigen.

Indirect immunofluorescence localization studies with pre-absorbed anti-cytosol antibodies and FITC-conjugated second antibody showed that these antigens were expressed in the cytoplasm and at the cell surface in several human colon tumor cell lines, their subclones and in primary colon tumor specimens.     

Type-1 transforming growth factor-beta differentially modulates tumoricidal activity of murine peritoneal macrophages against metastatic variants of the B16 murine melanoma

Transforming growth factor-beta 1 (TGF-beta 1) renders mouse peritoneal macrophages tumoricidal against metastatic variants of the B16 mouse melanoma in vitro. Both direct cytotoxicity and indirect cytotoxicity were observed. A subthreshold concentration (10 U/ml) of recombinant murine interferon-gamma (rMuIFN-gamma) enhanced the direct tumoricidal activity of TGF-beta 1-activated macrophages from 29% to 88% but did not change their indirect tumoricidal profile. Data obtained from macrophages preincubated with either TGF-beta 1 or rMuIFN-gamma showed that TGF-b1 can initiate tumoricidal activity better than rMuIFN-gamma. These effects were plasma-membrane mediated because targeting macrophages with liposomal TGF-beta 1 was ineffective. The order of tumoricidal susceptibility of the B16 melanoma lines to activated macrophages was B16F1 > B16F10 > B16BL6, in inverse order of metastatic potential.     

Optimal use of negative pressure wound therapy in treating pressure ulcers

Pressure ulcers (PrUs) are a challenging health concern for both the clinician and the patient. The exact incidence and prevalence of PrUs varies widely among specific clinical populations, from 0.4% to 38% in acute care, from 2.2% to 24% in long-term care and from 0% to 17% in home care. The economic impact of these wounds is impressive with an estimated cost of $11 to $17.2 billion annually in the USA. Guidelines from the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel have provided recommendations for the prevention and treatment of PrUs. Negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF; V.A.C.? Therapy, KCI USA, Inc. San Antonio, TX) has been successfully used for managing PrUs. This review combines expert opinion with scientific evidence to describe the use of NPWT/ROCF in patients with PrUs.     

Optimal use of negative pressure wound therapy for skin grafts

Skin grafting is a technique used for transplanting human skin (i.e. epidermal and some dermal layers) from a harvest site to a recipient site. However, advancements in bioengineered matrices have also introduced alternatives to skin grafts. The method used to secure the graft, whether skin or biomatrix, is critical in reducing graft failure. During the past several years, negative pressure wound therapy using reticulated open-cell foam (NPWT/ROCF; V.A.C.? Therapy, KCI USA, Inc., San Antonio, TX) has become a well-established method for bolstering grafts to recipient beds and is being used more frequently over biomatrices to help improve graft outcomes. This review will combine expert opinion with scientific evidence for the use of NPWT/ROCF over grafts.