The psychological effects of breast cancer and reconstruction: "A stroll down mammary lane"--A patient's artistic journal.

One in 8 women will develop invasive breast cancer. Nationally, it is estimated that about 200,000 women in the United States are diagnosed annually, and approximately 40,000 women die from the disease each year. A diagnosis of breast cancer forces women to consider living without their gender-defining curves, reevaluate their lives, and live with a 1 in 33 possibility of their mortality. Although medical science has made advances in the treatment of breast carcinoma and breast reconstruction, it currently does not adequately address the psychological effects that this disease and its treatment have on its patients. This discussion of a patient's postmastectomy drawings and creative writing sheds some light on one woman's personal battle with breast carcinoma, from diagnosis through breast reconstruction.

Pancreatic and multiorgan resection with inferior vena cava reconstruction for retroperitoneal leiomyosarcoma.

BACKGROUND: Inferior vena cava (IVC) leiomyosarcoma is a rare tumor of smooth muscle origin. It is often large by the time of diagnosis and may involve adjacent organs. A margin-free resection may be curative, but the resection must involve the tumor en bloc with the affected segment of vena cava and locally involved organs. IVC resection often requires vascular reconstruction, which can be done with prosthetic graft. CASE PRESENTATION: We describe a 39-year-old man with an IVC leiomyosarcoma that involved the adrenal gland, distal pancreas, and blood supply to the spleen and left kidney. Tumor excision involved en bloc resection of all involved organs with reimplantation of the right renal vein and reconstruction of the IVC with a polytetrafluoroethylene graft. The patient recovered without renal insufficiency, graft infection, or other complications. Follow-up abdominal imaging at 1 year showed a patent IVC graft and no locally recurrent tumor. Prosthetic graft provides a sufficient diameter and length for replacement conduit in extensive resection of IVC leiomyosarcoma. CONCLUSION: To our knowledge, this is the first case of resection of an IVC sarcoma with prosthetic graft reconstruction in combination with pancreatic resection. Aggressive surgical resection including vascular reconstruction is warranted for select IVC tumors to achieve a potentially curative outcome.

An evaluation of calcium hydroxylapatite (Radiesse) for cosmetic nasolabial fold correction: a meta-analysis and patient centric outcomes study.

The use of calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, California) for cosmetic soft tissue augmentation has increased significantly in recent years. Only a handful of authors have reported patient satisfaction data. A meta-analysis of published data was performed using a 5-point scale for patient satisfaction to allow data comparison across studies. A patient-centric outcomes study was also performed at our institution, using a blinded questionnaire. Five usable studies were identified for meta-analysis. Patient satisfaction was 4.16 of 5 in 324 patients at 3 to 6 months and 4.15 in 86 patients at 1 year. In our institutional patient-centric outcomes study, the early satisfaction rate was 3.7 of 5. At 1 year the rate was only 2.3 of 5. Calcium hydroxylapatite remains a viable option for augmentation of facial soft tissue structures. However, this report shows that further, accurate, large population outcomes assessments are absolutely required.

Primary alveolar soft-part sarcoma of the liver: anomalous presentation of a rare disease.

Alveolar soft-part sarcoma is a highly vascular soft-tissue tumor that is uniformly malignant. It comprises less than 1 per cent of all soft-tissue sarcomas. Patients with alveolar soft-part sarcoma most frequently are aged 15 to 35 years, and the soft tissues of the lower extremities typically are affected. In the pediatric population, it most frequently occurs in the head and neck and particularly affects the tongue and orbit. Alveolar soft-part sarcoma has been described as a primary lesion in the trunk, upper extremities, and retroperitoneum; more novel locations include the mediastinum, female genital tract, stomach, bone, and larynx. Numerous case reports describe alveolar soft-part sarcoma in diverse anatomic locations, but this report is, to our knowledge, the first documentation of primary alveolar soft-part sarcoma of the liver. We describe a 47-year-old woman with such a manifestation. Despite surgical resection and numerous chemotherapeutic regimens, this patient had widespread metastasis and died approximately 2 years after the diagnosis was established.

One hundred consecutive splenectomies for trauma: is histologic evaluation really necessary?

Splenectomy remains the most commonly performed abdominal operation for trauma. Although the vast majority of these patients (pts) are young and healthy, histologic evaluation is still routinely performed. We propose that routine histologic sampling of an injured yet otherwise grossly normal spleen is unnecessary. A retrospective review of 100 consecutive pathologic specimens of pts undergoing splenectomy for trauma at a Level I trauma center was performed during a 25-month period. Data are reported as mean +/- SD. Average age was 34.4 +/- 15.1 years. There were 78 men and 22 women. Average injury severity score was 28.3 +/- 12.9. The most common mechanisms of injury were motor vehicle collisions (56%) and motorcycle collisions (15%). Average length of stay was 17.4 +/- 19 days. Microscopic pathologic findings returned as benign with no evidence for neoplasia in 99 of 100 specimens. Mean specimen weight was 184.6 +/- 188.7 g. Only one spleen, which appeared grossly abnormal and weighed 1,800 g, had abnormal histology demonstrating extramedullary hematopoiesis. This pt died before further workup. Our review suggests that the routine microscopic evaluation of spleens removed after traumatic injury, as is currently the standard of care at our institution, is unnecessary. Such examination should only be performed in cases of marked splenomegaly or in spleens that appear grossly abnormal.

Incidental appendectomy: 18-year pathologic survey and cost effectiveness in the nonmanaged-care setting.

BACKGROUND: Incidental appendectomy (IA) remains a controversial issue. The role of IA in the nonmanaged-care setting has not been evaluated recently. This study evaluates the cost-benefit of IA based on current third-party reimbursements and reports the incidence of pathology from routine IA during an 18-year period. STUDY DESIGN: A retrospective review was performed for all patients who underwent open intestinal operations for nonappendiceal pathology by a single colon and rectal surgeon between 1988 and 2006. Patient records were reviewed for surgical indication, procedure, pathology reports, and complications. A cost-benefit analysis for IA versus laparoscopic appendectomy was performed using previously published epidemiologic data for risk of appendectomy. RESULTS: During this period, 341 patients (mean age 62.9 years) underwent IA during open intestinal operation. Malignancy was the indication for operation in 61.6%. Pathologic findings of clinical significance in the appendix were present in 2.6% of specimens. Combined reimbursements for laparoscopic appendectomy for nonruptured and ruptured appendicitis are 8,500.95 dollars and 15,870.37 dollars, respectively. For patients with a benign surgical indication, there was cost-benefit for IA during open operation for men younger than 55 years and women younger than 50 years of age. For patients with malignant disease, there was cost-benefit for men and women younger than 45 years of age. CONCLUSIONS: IA can be performed safely during open operation for other bowel pathology. Rate of clinically significant appendiceal pathology is low but not negligible. For patients with third-party payor status, IA can be more broadly performed during open gastrointestinal operation when no additional surgeon reimbursement is obtained.

Intraoperative gamma probe localization of the ureters: a novel concept.

BACKGROUND: Ureteral stent placement to localize the ureters during operations is an invasive procedure. The aim of this study was to evaluate the feasibility of using the gamma probe to intraoperatively identify the ureters after intravenous injection of a radiopharmaceutical agent. STUDY DESIGN: Ten patients undergoing elective abdominal operations were prospectively enrolled in this study. An average dose of 4.5 mCi (range 2.8 to 5.3 mCi) of technetium Tc 99m-labeled diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) was administered intravenously before localization of the ureters. The gamma probe was used to localize the ureters. Correct identification of the ureters was confirmed when gentle manipulation induced a typical ureteral peristaltic pattern. RESULTS: Gamma counts were significantly elevated in all ureters examined. Compared with background counts, gamma counts were increased over the ureter in all patients, with an average increase of 465%. The technique was modified after use in the first 3 patients and standardized for patients 4 through 10. Data from those seven patients were analyzed. Both ureters were correctly identified using the gamma probe at a mean of 15 minutes (median, 10 minutes) after a single (99m)Tc-DTPA injection (range 4 to 41 minutes). The mean background count was 80 counts per second (cps, range 50 to 130 cps). The mean ureter count was 393 cps (range 128 to 700 cps). The average percent increase of each ureter count compared with its specific background count was 465% (range 256% to 1,077%). The difference was statistically significant for all values (p < 0.001). CONCLUSIONS: This novel technique of gamma probe localization of the ureters may offer a noninvasive approach for ureteral identification.