Clinical effectiveness of microporous polysaccharide hemospheres in mastectomy for patients with breast cancer.

Background: Microporous polysaccharide hemospheres (MPH) are hydrophilic particles administered to reduce the incidence of seroma after mastectomy, but their clinical effectiveness remains controversial. Because a previous randomized, controlled study in a small cohort could not demonstrate the effectiveness of MPH in breast surgery, we evaluated their effectiveness in surgery for breast cancer in a larger cohort. Methods: Medical records of 352 patients who underwent total mastectomy for breast cancer were retrospectively reviewed. Clinical data were compared between 126 patients who received MPH during surgery (MPH group) and 226 who did not (control group) according to surgical procedures. Patients were significantly older in the MPH group than in the control group because of selection bias, but other factors, such as body mass index and number of dissected lymph nodes, did not differ between groups. Results: When analyzed by use of axillary manipulation, the drain placement period and drainage volume were significantly less in the MPH group than in the control group for patients with mastectomy and sentinel lymph node biopsy. Only drainage volume was significantly less in the MPH group for patients with mastectomy and axillary lymph node dissection. The frequency of total postoperative complications, such as seroma requiring puncture, did not differ between groups. Conclusions: Use of MPH may decrease the postoperative drainage volume and drain placement period in mastectomy for patients with breast cancer.

Relationship between Delayed Breast Cancer Diagnosis and Behavioral Economic Factors and Personality Characteristics.

BACKGROUND: Delays in breast cancer diagnosis can allow the disease to progress to an incurable stage. However, factors that cause patients to delay seeking treatment are unclear. In this study, we aimed to identify behavioral economic factors and personality characteristics of patients with breast cancer who had a delayed diagnosis. METHODS: We analyzed questionnaires completed by 41 patients with breast cancer. A delayed diagnosis was defined if the time between the first symptom and the medical visit was more than 6 months. RESULTS: We found 11 patients who had a delayed diagnosis. The significant characteristics associated with patients with breast cancer who had delayed diagnosis were: (i) less experience with breast cancer screening; (ii) progressive disease stage; and (iii) low time and future time preference. We found no significant behavioral economic factors other than time preference, and personality that differed between patients with breast cancer who did and did not have a delayed diagnosis. CONCLUSION: Low time preference rate is a characteristic of patients with breast cancer who had a delayed diagnosis.

Accessory breast cancer in the inframammary region: a case report and review of the literature.

BACKGROUND: Although a few cases of accessory breast cancer (ABC) have been reported, most were in the axillary region. We encountered an extremely rare case of ABC in the inframammary region (IMR). CASE PRESENTATION: The patient was a 68-year-old postmenopausal woman who had noticed a congenital accessory nipple in her left IMR with slight, occasional discharge 20 years ago. Recently, she noticed a mass under the accessory nipple and visited a nearby clinic; fine-needle aspiration cytology of the mass revealed that it was malignant. She presented to our department 2 weeks after she had noticed the mass. Physical and imaging examinations showed an irregular tumor mass 1.7 × 1.4 × 1.0 cm in size connected to the accessory nipple beneath the left normal breast. Neither distant metastasis nor lymph node swelling was observed. Ultrasound-guided core needle biopsy revealed the mass to be invasive ductal carcinoma. We diagnosed her tumor as ABC in the left IMR; cT1cN0M0: stage IA. Curative wide resection with sentinel node biopsy was performed. Intraoperative evaluation of the frozen section revealed a hot and green ipsilateral axillary lymph node that was free from carcinoma; therefore, nodal dissection was avoided. Histopathological examination including immunochemical staining revealed that the tumor was invasive ductal carcinoma arising from the accessory breast tissue, scirrhous type, 1.7 × 1.4 × 1.0 cm in size, with a solid intraductal component. There was no lymphovascular infiltration, and the surgical margin was 1.5 cm or more. The tumor was estrogen and progesterone receptor-positive, Her2/neu-negative, and had a Ki-67 labeling index of 20%. There was no involvement of the three hot and/or green nodes. The final classification was pT1cN0(sn)M0: stage IA. Letrozole 2.5 mg/day will be administered for 5 years as adjuvant hormonal therapy. CONCLUSIONS: A cutaneous and/or subcutaneous lesion except for proper breast tissue on the milk line, or mammary ridge from axilla to groin may be an accessory breast tissue. Its serial abnormalities must be worried malignant potential to ductal carcinoma which needs some imaging and pathological examinations for definitive diagnosis and appropriate treatment according to the usual orthotopic breast cancer without delay.

Apocrine papillary lesion: comparison of pathological findings from 22 years previously and the present.

Apocrine papillary lesion (APL) is difficult to diagnose as benign or malignant. We experienced an APL remaining in the body for 22 years. We present a case of a 71-year-old woman who had undergone excisional biopsy 22 years previously at the first hospital that she visited. 1 year previously, she had undergone fine-needle aspiration cytology at a second hospital, and the lesion was diagnosed as potentially malignant. She underwent core-needle biopsy at a third hospital, but whether the lesion was benign or malignant could not be definitively diagnosed. We performed right mastectomy and sentinel lymph-node biopsy, because her tumor was suspected to be malignant based on imaging means, and malignancy could not be ruled out on either biopsy or cytology. The histopathological diagnosis was tiny foci of apocrine proliferative lesion with massive hemorrhagic necrosis and no tumor metastasis in two sentinel lymph nodes. Retrospectively, we compared all of the patient's previous specimens with the present ones, and applied the recent pathological diagnostic criteria. Although the biopsy specimen excised 22 years ago suggested an encapsulated apocrine papillary carcinoma or a papilloma with apocrine ductal carcinoma in situ, neither infiltration nor metastasis has occurred. Furthermore, neither the pathological findings nor the clinical behavior has changed over time.

Two cases of radiation-associated angiosarcoma of the breast.

BACKGROUND: The incidence of radiation-associated angiosarcoma (RAA) of the breast has been increasing, and its prognosis is reportedly poor. It is important to remove tumor tissues completely to prevent recurrence. CASE PRESENTATION: We report two cases of patients with RAA of the breast. Both patients had a nodule in their remaining breast a few years after undergoing breast-conserving surgery and radiation therapy for breast cancer. The nodules were diagnosed as angiosarcoma by skin biopsy and open biopsy, respectively. To determine the extent of lesion spread, mapping biopsy was performed before surgery. Both patients underwent mastectomy, extensive skin resection, and split skin grafting. Pathological findings showed that their tumors could be completely resected. After surgery, chemotherapy was performed. CONCLUSION: In our cases, no local or distant recurrence has been detected in either patient for over 4 years. We identified the range of tumor invasion by preoperative mapping biopsy and completely resected all tumor tissue.

Rapid diagnosis of lymph node metastasis in breast cancer using a new fluorescent method with γ-glutamyl hydroxymethyl rhodamine green.

Sentinel lymph node biopsy is performed as a standard procedure in breast cancer surgery, and the development of quick and simple methods to detect metastatic lesions is in high demand. Here, we validated a new fluorescent method using γ-glutamyl hydroxymethyl rhodamine green to diagnose metastatic lymph nodes in breast cancer. One hundred and forty-nine lymph nodes from 38 breast cancer patients were evaluated in this study. Comparison of fluorescent and pathological images showed that this fluorescent method was successful for visualizing breast cancer cells in lymph nodes. This method had a sufficiently high sensitivity (97%), specificity (79%) and negative predictive value (99%) to render it useful for an intraoperative diagnosis of cancer. These preliminary findings suggest that this novel method is useful for distinguishing non-cancerous specimens from those in need of careful examination and could help save time and cost for surgeons and pathologists.

Therapeutic mammoplasty combining partial mastectomy with nipple-areola grafting for patients with early breast cancer: a case series.

PURPOSE: Therapeutic mammoplasty (TM) for breast cancer is a widely practiced oncoplastic technique. Intraductal spread towards the nipple or the location of the cancerous lesion on the central breast may become a contraindication for breast-conserving surgery. We herein report the results of TM in such cases. METHODS: Six patients underwent TM that combined partial mastectomy with free nipple-areola (NA) grafting. The nipple was removed together with the cancerous lesions, and the areola was preserved for NA reconstruction. The tumors were located in the lower quadrant (n = 1), the central area (n = 1), the upper-outer area (n = 2), and the upper-inner area (n = 2). The types of mammoplasty that were performed included: amputation (n = 1), inverted T mammoplasty (n = 3), and L mammoplasty (n = 2). With the exception of one patient, all patients underwent inverted T mammoplasty on the contralateral breast in order to achieve symmetry. RESULTS: The total surgical and plastic periods ranged from 155 to 235 min (mean 207 min) and 100 to 150 min (mean 121 min), respectively. Oncological safety and excellent cosmetic results were achieved. CONCLUSIONS: TM combining partial mastectomy with NA grafting was successfully performed in patients with early-stage cancer in all quadrant areas.

Clinical implication of human leukocyte antigen (HLA)-F expression in breast cancer.

Human leukocyte antigen (HLA)-F is one of the non-classical HLA class I molecules that protects the fetus in pregnancy. HLA-F expression was immunohistochemically examined and the association between clinical parameters and HLA-F expression was analyzed. Cancerous HLA-F and stromal HLA-F-positive infiltrating cells were detected in 91 (40.0%) and 186 (81.6%) cases, respectively. HLA-F positivity in cancer cells was significantly associated with tumor size (P < 0.05). There was a weak correlation between HLA-F positivity of cancer cells and HLA-F positive infiltrative cells (P < 0.01, r = 0.11). HLA-F positivity did not affect patients' survival in 209 breast cancer. However, confined to stage II breast cancer, the HLA-F positive group showed significantly poorer outcomes than the HLA-F negative group (P < 0.05). The present study provides the first evidence that HLA-F positivity in breast carcinoma affects clinicopathological factors and could be selected as a prognostic marker for limited clinical stage.

Rapid intraoperative visualization of breast lesions with γ-glutamyl hydroxymethyl rhodamine green.

We previously developed γ-glutamyl hydroxymethyl rhodamine green (gGlu-HMRG) as a tool to detect viable cancer cells, based on the fact that the enzyme γ-glutamyltranspeptidase (GGT) is overexpressed on membranes of various cancer cells, but is not expressed in normal tissue. Cleavage of the probe by GGT generates green fluorescence. Here, we examined the feasibility of clinical application of gGlu-HMRG during breast-conserving surgery. We found that fluorescence derived from cleavage of gGlu-HMRG allowed easy discrimination of breast tumors, even those smaller than 1 mm in size, from normal mammary gland tissues, with 92% sensitivity and 94% specificity, within only 5 min after application. We believe this rapid, low-cost method represents a breakthrough in intraoperative margin assessment during breast-conserving surgery.

Present status of endoscopic mastectomy for breast cancer.

Endoscopy is now being used for breast cancer surgery. Though it is used for mastectomy, lymph node dissection, and breast reconstruction, its prime use is for mastectomy. Because an incision can be placed inconspicuously in the axillary site, a relatively large incision can be created. A retractor with an endoscope, CO2, and an abrasion device with the endoscope are used for operation space security. It is extremely rare that an endoscope is used for lymph node dissection. For breast reconstruction, it may be used for latissimus muscle flap making, but an endoscope is rarely used for other reconstructions. Endoscopic mastectomy is limited to certain institutions and practiced hands, and it has not been significantly developed in breast cancer surgery. On the other hand, endoscopic surgery may be used widely in breast reconstruction. With respect to the spread of robotic surgery, many factors remain uncertain.

Impaired wound healing and expansion of a large ulcer after bevacizumab with paclitaxel for skin metastases from breast cancer: report of a case.

A 48-year-old Japanese woman was found to have local recurrence of breast cancer in the chest wall following neoadjuvant chemotherapy, total mastectomy with axillary lymphadenectomy, postoperative radiation therapy to the chest wall, and adjuvant systemic therapy using trastuzumab. As a third line of treatment after recurrence, bevacizumab with paclitaxel was initiated for several metastatic lesions on the skin of the chest wall, left internal costal lymph nodes, and right axillary lymph nodes. The wound on the chest wall continued to expand in diameter and depth after the third course of bevacizumab with paclitaxel until the rib was exposed. After stopping the bevacizumab, granulation tissue expanded and by 3 months, had covered the bottom of the ulcer. The patient died soon thereafter, despite systemic chemotherapy with eribulin; however, there was no further bleeding from the ulcer on the chest wall or the exposed ribs.

Histological findings of an autologous dermal fat graft implanted onto the pectoralis major muscle of a rat model.

BACKGROUND: The aim of this study was to investigate the maintenance of volume as a spacer by comparing vascular supply and apoptosis in an implanted autologous-free dermal fat graft (FDFG) and free fat graft (FFG). An autologous FDFG is a material used in plastic surgery and oncoplastic breast surgery that is ideal for immediate volume replacement after partial mastectomy because of its easy availability and minimal invasion of the donor site; however, immunohistochemical findings and survival procedures have not yet been reported. METHODS: An experimental protocol using a unique animal model was designed for the present study. The expression of vascular endothelial growth factor (VEGF) was measured in FDFGs and FFGs implanted onto the pectoral major muscle of Wistar rats. Thirty Wistar rats were divided into two groups and postoperatively 1, 2, 4, 8, and 16 weeks (POW1, 2, 4, 8, 16). Six samples from three rats in each group were used as control samples (POW0). RESULTS: The thickness of the implanted FDFG was not significantly different from the control sample at POW1, 2, 4, 8, and 16 between FDFG and FFG group; however, the thickness at POW8 and 16 was significantly lesser in the FFG group than in the control samples. The average proportion of fatty tissue to whole tissue ranged from 34.2 to 48.6 % in the FDFG group and from 57.2 to 76.7 % in the FFG group during the observation period; however, there was no significant difference in the proportion of fatty tissue between these two groups. There were no significant differences between the average number of VEGF-positive cells in the FDFG group and the FFG group at POW1, 2, 4, 8, and 16. The average number of TUNEL-positive cells in the early period at POW1 was significantly lower in the FDFG group than in the FFG group. CONCLUSIONS: This rat model was useful for investigating the mechanisms of angiogenesis, apoptosis, structure maintenance, and fibromatous changes. From the present experimental study, we believe that FDFG is one of the most convenient materials currently available to repair small defects at the time of BCS even in the clinical field.

Computed tomography Hounsfield units can predict breast cancer metastasis to axillary lymph nodes.

BACKGROUND: Axillary lymph node (ALN) status is an important prognostic factor for breast cancer. We retrospectively used contrast-enhanced computed tomography (CE-CT) to evaluate the presence of ALN, metastasis based on size, shape, and contrasting effects. METHODS: Of 131 consecutive patients who underwent CE-CT followed by surgery for breast cancer between 2005 and 2012 in our institution, 49 were histologically diagnosed with lymph node metastasis. Maximum Hounsfield units (HU) and mean HU were measured in non-contrasting CT (NC-CT) and CE-CT of ALNs. RESULTS: Of 12 examined measurements, we found significant differences between negative and metastatic ALNs in mean and maximum NC-CT HU, and mean and maximum CE-CT HU (P < 0.05). We used a receiver operating curve, to determine cut-off values of four items in which significant differences were observed. The highest accuracy rate was noted for the cut-off value of 54 as maximum NC-CT HU for which sensitivity, specificity, and accuracy rate were 79.6%, 80.5% and 80.2%, respectively. CONCLUSIONS: CT HU of a patient with breast cancer are absolute values that offer objective disease management data that are not influenced by the screener's ability.

Oncoplastic breast surgery for centrally located breast cancer: a case series.

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with centrally located breast cancer (CLBC) and Paget's disease. We performed OBS combining partial mastectomy and immediate volume replacement on patients with non-ptotic and/or small breasts, and volume reduction surgery for patients with ptotic breasts, as reported in Western countries. Japanese encounters are described in this report as a case series.

Oncoplastic surgery in a Japanese patient with breast cancer in the lower inner quadrant area: partial mastectomy using horizontal reduction mammoplasty.

We report the results of oncoplastic surgery in a Japanese patient with early breast cancer. Her breasts were ptotic, and her lesion was considered to be suitable for breast-conserving surgery. Oncoplastic surgery involving partial resection of the gland and a horizontal-type mammoplasty was performed. The technique was easy to perform, and the cosmetic outcome was excellent.

Oncoplastic breast surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap for Paget's disease.

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with Paget's disease. We performed OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap in two patients. In these two patients, who were diagnosed as having Paget's disease with a restricted intraductal component in the central area of their non-ptotic breast, we performed oncoplastic surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap. Neither of the two patients received contralateral surgery to produce symmetrical breasts. The observation period ranged from 6 to 12 months, and the bilateral breast volumes and inframammary lines were symmetric. OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap was successfully performed in two patients with Paget's disease.

Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.

PURPOSE: The treatment of early breast cancer using breast-conserving therapy commonly ensures local control and acceptable cosmetic results. We herein report a useful technique, including the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the outer quadrant area after partial mastectomy, which achieved excellent results. METHODS: We performed partial mastectomy followed by immediate volume replacement using a modified thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis in ten patients. RESULTS: The modified oncoplastic technique was performed without any complications in all patients. Sufficient blood flow to the cutaneous flap with the crescent-shaped dermis was visualized in two patients during the operation after the injection of indocyanine green. The oncological and cosmetic results were excellent to good in these patients. CONCLUSIONS: Oncoplastic surgery using a modified thoracodorsal adipofascial flap with a crescent-shaped dermis was successfully performed in patients with early cancer lesions in the outer quadrant, and the cosmetic results obtained were excellent.

Oncoplastic breast surgery combining periareolar mammoplasty with volume displacement using a crescent-shaped cutaneous flap for early breast cancer in the upper quadrant.

Oncoplastic breast surgery (OBS), which combines the concepts of oncological and plastic surgery, is becoming more common, especially in Western countries; however, only a few reports have been published in Japan. We herein report the results of OBS for Japanese patients with early breast cancer in the upper quadrant. We performed oncoplastic surgery combining partial mastectomy using a periareolar incision with immediate breast reshaping using a crescent-shaped cutaneous flap in three patients with a past history of breast-feeding, ptotic breasts and lesions that were suitable for breast conserving surgery. The lesions were located in the upper quadrant and were 5, 6 and 10 cm from the nipple, respectively. The total length of the operations ranged between 86 and 192 min, with the mean being 164 min. Two patients underwent contralateral surgery to produce symmetrical breasts and one did not. The plastic period after receiving pathological results intraoperatively ranged between 47 and 120 min, with the mean period being 82 min. The observation period ranged between 6 and 12 months, and the cosmetic results were excellent in all three cases. OBS combining partial mastectomy using a periareolar incision with immediate breast reshaping using a crescent-shaped cutaneous flap was successfully performed in patients with early cancer in the upper quadrant.

Immediate reconstruction using a modified inframammary adipofascial flap after partial mastectomy.

Breast conservative therapy (BCT) as treatment for early breast cancer usually ensures local control and acceptable cosmetic results. We describe a new technique of using an inframammary adipofascial flap to reconstruct defects caused by lower-pole partial mastectomy, which achieved excellent results (Kijima et al. in Am J Surg 193:789-91 (1); Sakai et al. in Ann Plast Surg 29(2):173-7, 2; Ogawa Am J Surg 193:514-8, 3). We developed this procedure as an oncoplastic technique for a Japanese woman with a similar defect without ptosis. After partial mastectomy, the superior half of the flap is harvested via an initial incision along the inframammary line, and the inferior half is harvested via an additional incision along the caudal edge of the flap, to produce a crescent of de-epithelialized skin. A tongue-shaped flap containing the crescent of de-epithelialized skin, subcutaneous fat, and the fascia of the vertical rectus abdominis muscle is then rotated upwards, gathered, and inserted into the breast defect.

Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach.

BACKGROUND: Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique. METHODS: Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO2 insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely. RESULTS: Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days. CONCLUSIONS: We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.