Reduction mammaplasty for symptomatic macromastia: which factors influence the post-operative outcome?

Purpose

We evaluated the long-term results and patient’s satisfaction in reduction mammaplasties for symptomatic mammary hypertrophy.

Methods

From 2002 to 2008 a total of 92 women underwent bilateral mammaplasty for a symptomatic macromastia at our department. Three different surgical techniques for reduction mammaplasty were used (Bostwick, Stroembeck, Ribeiro). Patients were re-contacted in 2009 and asked to complete a self-assessment survey in order to asses their satisfaction with the post-operative symptom-relief and the overall outcome.

Results

90.5 % of all patients stated, that they would retrospectively re-opt for a reduction mammaplasty. Preoperative patients' age, BMI and severity of macromasty-related symptoms were found to be factors positively correlated with a high post-interventional satisfaction with the achieved symptom-relief and the overall outcome. No correlation was found between the amount of intra-operatively resected breast tissue and the post-operative patients’ assessment. Patients’ assessment regarding the achieved post-operative symptom relief was comparable for all three surgical techniques, however the overall outcome rating for both bi-pedicled approaches (Stroembeck and Ribeiro) was higher compared to the mono-pedicled Bostwick technique.

Conclusions

Reduction mammaplasty for patients with a mammary hypertrophy and somatic symptoms could offer a causal and effective treatment. The predictive factors for a high patients’ satisfaction identified in this study could become a valuable tool in the pre-operative patients counceling and their role should be further evaluated prospectively. The use of bi-pedicled surgical techniques seems to favor a high post-operative patients’ assessment.     

Chemoradiotherapy‐induced increase in Th17 cell frequency in cervical cancer patients is associated with therapy resistance and early relapse

Cervical cancer therapy is still a major clinical challenge, as patients substantially differ in their response to standard treatments, including chemoradiotherapy (CRT). During cervical carcinogenesis, T‐helper (Th)‐17 cells accumulate in the peripheral blood and tumor tissues of cancer patients and are associated with poor prognosis. In this prospective study, we find increased Th17 frequencies in the blood of patients after chemoradiotherapy and a post‐therapeutic ratio of Th17/CD4⁺ T cells > 8% was associated with early recurrence. Furthermore, Th17 cells promote resistance of cervical cancer cells toward CRT, which was dependent on the AKT signaling pathway. Consistently, patients with high Th17 frequencies in pretherapeutic biopsies exhibit lower response to primary CRT. This work reveals a key role of Th17 cells in CRT resistance and elevated Th17 frequencies in the blood after CRT correspond with early recurrence. Our results may help to explain individual treatment responses of cervical cancer patients and suggest evaluation of Th17 cells as a novel predictive biomarker for chemoradiotherapy responses and as a potential target for immunotherapy in cervical cancer.     

T1 Signal Measurements in Pediatric Brain: Findings after Multiple Exposures to Gadobenate Dimeglumine for Imaging of Nonneurologic Disease

BACKGROUND AND PURPOSE:Signal intensity increases possibly suggestive of gadolinium retention have recently been reported on unenhanced T1-weighted images of the pediatric brain following multiple exposures to gadolinium-based MR contrast agents. Our aim was to determine whether T1 signal changes suggestive of gadolinium deposition occur in the brains of pediatric nonneurologic patients after multiple exposures to gadobenate dimeglumine.MATERIALS AND METHODS:Thirty-four nonneurologic patients (group 1; 17 males/17 females; mean age, 7.18 years) who received between 5 and 15 injections (mean, 7.8 injections) of 0.05 mmol/kg of gadobenate during a mean of 2.24 years were compared with 24 control patients (group 2; 16 males/8 females; mean age, 8.78 years) who had never received gadolinium-based contrast agents. Exposure to gadobenate was for diagnosis and therapy monitoring. Five blinded readers independently determined the signal intensity at ROIs in the dentate nucleus, globus pallidus, pons, and thalamus on unenhanced T1-weighted spin-echo images from both groups. Unpaired t tests were used to compare signal-intensity values and dentate nucleus–pons and globus pallidus–thalamus signal-intensity ratios between groups 1 and 2.RESULTS:Mean signal-intensity values in the dentate nucleus, globus pallidus, pons, and thalamus of gadobenate-exposed patients ranged from 366.4 to 389.2, 360.5 to 392.9, 370.5 to 374.9, and 356.9 to 371.0, respectively. Corresponding values in gadolinium-based contrast agent–naïve subjects were not significantly different (P > .05). Similarly, no significant differences were noted by any reader for comparisons of the dentate nucleus–pons signal-intensity ratios. One reader noted a difference in the mean globus pallidus–thalamus signal-intensity ratios (1.06 ± 0.006 versus 1.02 ± 0.009, P = .002), but this reflected nonsignificantly higher T1 signal in the thalamus of control subjects. The number of exposures and the interval between the first and last exposures did not influence signal-intensity values.CONCLUSIONS:Signal-intensity increases potentially indicative of gadolinium deposition are not seen in pediatric nonneurologic patients after multiple exposures to low-dose gadobenate.

Recent reports have detailed high signal intensity (SI) in certain brain areas (primarily the dentate nucleus [DN] and globus pallidus [GP]) on unenhanced T1-weighted images following multiple exposures to gadolinium-based contrast agents (GBCAs).^1–20 Many of these reports have focused on apparent differences between macrocyclic and open-chain “linear” GBCAs,^4–13 invariably associating progressive T1 hyperintensity with multiple exposures to linear GBCAs and concluding that observed T1 signal reflects the lower stability of these agents and thus a greater propensity for gadolinium (Gd) release and, subsequently, deposition in the brain. Among the more recent reports are several that describe retrospective assessments in pediatric patients.^15–19 Although each patient evaluated received just 1 specific linear GBCA (gadopentetate dimeglumine; Magnevist; Bayer HealthCare, Wayne, New Jersey), the study-based recommendations in each case were to consider carefully the use of all linear agents in pediatric subjects.Gadobenate dimeglumine (MultiHance; Bracco Diagnostics, Monroe, New Jersey) is an ionic open-chain, linear GBCA that differs fundamentally from gadopentetate and other extracellular GBCAs in having an aromatic substituent on the chelating molecule.²¹ Unique properties conferred by this substituent include increased R1-relaxivity,²² which permits the acquisition of diagnostically valid images with a reduced dose,²³ and liver-specificity, which permits gadobenate use for hepatobiliary-phase liver applications.²⁴ An additional benefit is increased molecular stability compared with gadopentetate, other linear agents, and certain macrocyclic agents.²⁵ Studies that have evaluated brain T1 signal intensities after multiple exposures to gadobenate have yielded conflicting results with one report demonstrating T1 signal increases, albeit to a lesser extent than with gadopentetate,¹⁰ and others demonstrating no direct changes.^11,12We aimed to determine whether multiple exposures to low-dose gadobenate for nonneurologic pathology results in T1 signal changes in the DN and GP of pediatric patients relative to that in age- and weight-matched GBCA-naïve control subjects.     

Artifacts in Contrast-Enhanced Ultrasound during Follow-up after Endovascular Aortic Repair: Impact on Endoleak Detection in Comparison with Computed Tomography Angiography

The study described here systematically analyzed how specific artifacts in contrast-enhanced ultrasound (CEUS) can affect the detection of endoleaks during follow-up after endovascular aortic repair (EVAR). Patients undergoing EVAR of atherosclerotic or mycotic abdominal aortic aneurysms using various standard and branched stent-graft material for visceral and iliac preservation were enrolled over 5 y and followed up with computed tomography angiography (CTA) and CEUS simultaneously. CEUS artifacts were frequently identified after EVAR procedures (59% of examinations) and were caused mainly by contrast agent, different prosthesis or embolization material and postinterventional changes in the aneurysm sac. This article describes how to identify important artifacts and how to avoid false-negative or false-positive interpretations of endoleaks. Despite artifacts, CEUS had higher sensitivity for endoleak detection after EVAR than CTA. CEUS was superior to CTA in the identification of late endoleaks type II and in follow-up examinations after embolization procedures, where beam-hardening artifacts limited CTA.     

Immune landscape of vulvar cancer patients treated with surgery and adjuvant radiotherapy revealed restricted T cell functionality and increased IL-17 expression associated with cancer relapse

For vulvar cancers, radiotherapy is targeting cancer cells, but also affects the host immune system. As this may affect treatment outcome, in this prospective study, we characterized the individual T cell immune milieu induced by surgery and adjuvant radio +/− chemotherapy (aRT) systemically in the blood of vulvar cancer patients and found increased frequencies of Interleukin (IL)-17-producing CD4⁺ and CD8⁺ T cells after aRT while frequencies of Th1 and perforin-producing CD8⁺ killer cells were strongly diminished. Phenotypic characterization revealed enhanced expression of the ectonucleotidase CD39 on Th17 and Tc17 cells as well as CD8⁺ perforin⁺ cells after aRT. Furthermore, the aRT cohort exhibited increased proportions of Programmed Cell Death Protein (PD-1) expressing cells among Th1 and CD8⁺ perforin⁺ cells, but not among Th17 and Tc17 cells. High post-therapeutic levels of Th17 and Tc17 cells and low proportions of Th1 and CD8⁺ perforin⁺ cells expressing PD-1 was associated with reduced recurrence free survival on follow-up. In conclusion, our study defines individual therapy-induced changes in the cellular immune milieu of patients and their association with cancer relapse. Our results may help to explain differences in the individual courses of disease of vulvar cancer patients and suggest PD-1 and IL-17 as targets for immunotherapy in vulvar cancer.     

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

Objective

Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy.

Methods/Patients

To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed.

Results

The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization.

Conclusions

This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

     

A Scoring System for the Assessment of Angiographic Findings in Non-Occlusive Mesenteric Ischemia (NOMI)

Purpose: To establish a standardized scoring system for angiographic findings in patients with non-occlusive mesenteric ischemia (NOMI). Materials and Methods: In 36 patients (mean age: 72 years), 53 angiographies of the superior mesenteric artery (SMA) were performed for suspected NOMI after cardiac or major aortic surgery. All examinations were performed using a standardized DSA technique. Two experienced radiologists performed a consensus reading blinded to the clinical information, on two occasions with an interval of two weeks. In order to investigate the reproducibility of the criteria, the images were assessed once by an intensivist and a medical student. Image analysis was performed with respect to vessel morphology, reflux of contrast medium into the aorta, small bowel parenchymal contrast enhancement and distension and the delay between arterial injection and portal vein filling. Results: Almost perfect intra-observer correlation was obtained for the assessment of the contrast medium reflux (κ = 0.82) and substantial correlation for the time of portal vein filling (κ = 0.66). Moderate correlations were obtained for the vessel morphology (κ = 0.51), small bowel enhancement (κ = 0.63) and distension (κ = 0.53). Contrast medium reflux into the aorta (κ = 0.77 and 0.63) and the time of portal vein filling (κ = 0.42 and 0.58) resulted in the highest inter-observer correlations between the radiologists and the intensivist as well as the radiologists and the student. Conclusion: In patients with suspected NOMI, using our scoring system yields high intra- and inter-observer correlations, allowing a standardized evaluation of angiographic findings.