Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update

Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.     

Indocyanine green retention is a potential prog-nostic indicator after splenectomy and pericar-dial devascularization for cirrhotic patients

BACKGROUND: Splenectomy and pericardial devasculariza-tion (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and speciifc-ity than the Child-Pugh classiifcation in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.
METHODS: From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classiifcation, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively.
RESULTS: Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function com-pensation was 31.2%, which offered a sensitivity of 68.4% and a speciifcity of 70.8%. Univariate analysis showed preopera-tive ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were signiifcant-ly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of post-operative liver function recovery (P=0.020).
CONCLUSIONS: ICGR15 has outperformed the Child-Pugh classiifcation for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognos-tic indicator for cirrhotic patients after SPD.     

The R.E.N.A.L. Nephrometric Nomogram Cannot Accurately Predict Malignancy or Aggressiveness of Small Renal Masses Amenable to Partial Nephrectomy

Introduction/BackgroundThe prediction of histology of SRM could be essential for their management. The RNN is a statistical tool designed to predict malignancy or high grading of enhancing renal masses. In this study we aimed to perform an external validation of the RNN in a cohort of patients who received a PN for SRM.Materials and MethodsThis was a multicentric study in which the data of 506 consecutive patients who received a PN for cT1a SRM between January 2010 and January 2013 were analyzed. For each patient, the probabilities of malignancy and aggressiveness were estimated preoperatively using the RNN. The performance of the RNN was evaluated according to receiver operating characteristic (ROC) curve, calibration plot, and decision curve analyses.ResultsThe area under the ROC curve for malignancy was 0.57 (95% confidence interval [CI], 0.51-0.63; P = .031). The calibration plot showed that the predicted probability of malignancy had a bad concordance with observed frequency (Brier score = 0.17; 95% CI, 0.15-0.19). Decision curve analysis confirmed a poor clinical benefit from use of the system. The estimated area under the ROC curve for high-grade prediction was 0.57 (95% CI, 0.49-0.66; P = .064). The calibration plot evidenced a bad concordance (Brier score = 0.15; 95% CI, 0.13-0.17). Decision curve analysis showed the lack of a remarkable clinical usefulness of the RNN when predicting aggressiveness.ConclusionsThe RNN cannot accurately predict histology in the setting of cT1a SRM amenable to PN.     

Dynamic mechanisms underlying afterdischarge: A human subdural recording study

ObjectiveNo synoptic understanding exists of how and why afterdischarges (ADs) occur following electrical stimulation of the cerebral cortex. Based on human observations, we formulated a general mechanism for the emergence of ADs.MethodsWe retrospectively analysed spectra of AD time-series and control segments of the resting electrocorticogram (ECoG) in 15 epilepsy patients who underwent cortical stimulation mapping. The observations led to the development of phenomenological models for AD emergence and morphology.ResultsAn analytical relationship exists between the spectrum of the baseline ECoG and the ensuing AD, characterised by ‘condensation’ of the main baseline spectral cluster, with variable inclusion of higher harmonics of the condensate.ConclusionsADs arise by synchronisation of pre-existing local field potentials, likely through temporary inactivation of inhibitory interneurons from repetitive stimulation-induced depolarization. The appearance of higher harmonics indicates that ADs are further modulated by recurrent feedback, likely from the entrained activity of single units.SignificanceFor the first time, a putative mechanism is suggested for AD emergence following electrical stimulation of the cerebral cortex. Insight is also offered into several empirical observations regarding ADs, detailed in the main text. More generally, a novel conceptual synthesis emerges between the behaviour of electrically-excited cortex and the physics of nonlinearly coupled multi-oscillator systems.     

Laparoscopic partial cystectomy with mucosal stripping of extraluminal duodenal duplication cysts

Duodenal duplication cysts are rare congenital anomalies.Duodenal duplication should be considered in the differential diagnosis of patients who present with abdominal symptoms with cystic structures neighboring the duodenum.Here,we present an 8-year-old girl with a duodenal duplication cyst treated with partial cystectomy with mucosal stripping performed laparoscopically.Laparoscopic surgery can be considered as a treatment option for duodenal duplication cysts,especially in extraluminal locations.     

Long-term outcomes of APBI via multicatheter interstitial HDR brachytherapy: Results of a prospective single-institutional registry

PurposeLong-term outcome reports of accelerated partial-breast irradiation (APBI) are limited. Here, we report the 10-year outcomes of APBI delivered using multicatheter interstitial implant (ISI) brachytherapy.Methods and materialsPatients with early-stage breast cancer treated with APBI via ISI brachytherapy were enrolled in a prospective registry. Selection criteria included age ≥40 years, ductal carcinoma in situ or invasive tumor ≤3 cm, negative margins (≥2 mm), and negative axillary nodes. 34 Gy in 10 twice-daily fractions was administered to 2 cm of breast tissue surrounding the surgical bed. Toxicity and cosmetic outcomes were collected prospectively.ResultsA total of 175 patients were included. The median followup time was 10.0 years. Ten-year ipsilateral breast tumor control, regional control, freedom from distant metastasis, breast cancer–specific survival, and overall survival were 92.1%, 96.9%, 97.4%, 97.1%, and 81.2%, respectively. High-grade disease was correlated with increase in the rate of ipsilateral breast tumor recurrence. Grade 1 or 2 skin toxicity was present in 44 patients, and Grade 3 skin toxicity was present in only 1 patient. There were no Grade 4 or higher toxicities observed. Thirty-seven patients developed fat necrosis. Dose Homogeneity Index of ≤0.85 and integrated reference air-kerma of >3400 cGycm²/h correlated with higher rates of fat necrosis. There were 115 (66%), 51 (29%), 8 (5%), and 0 (0%) patients having excellent, good, fair, and poor cosmetic outcomes, respectively.ConclusionsAPBI using ISI brachytherapy offers excellent clinical outcomes in appropriately selected patients with excellent cosmetic outcomes and low rates of toxicities such as symptomatic fat necrosis.