Nipple-sparing mastectomy and immediate reconstruction in ductal carcinoma in situ: a critical assessment with 41 patients.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of select breast cancers and prophylactic mastectomy. This study aimed to analyze the authors' 11-year experience with NSM and breast reconstruction in cases of ductal carcinoma in situ (DCIS) with an emphasis on indications, complications, and cancer recurrence rate. METHODS: Between January 2000 and December 2010, 41 NSMs were performed in 41 women for DCIS. The mean age of the women was 49.7±8.7 years (range, 33-66 years). The indications for NSM were tumor size greater than 3 cm (18 cases), multifocal tumor (16 cases), and tumor recurrence (7 cases). In all cases, the tumor was located more than 2 cm from the nipple-areola complex (NAC), as shown by preoperative radiologic imaging. Histologic results, secondary NAC resection, complications, and cancer recurrence rates were recorded. RESULTS: The NAC was lost in seven cases (17%) due to postoperative necrosis. In another 10 patients (25%), the NAC was secondarily removed due to proximity of the tumor to the resection margin. Five patients were lost to follow-up evaluation (12%). The authors report the long-term follow-up data for the remaining 19 patients (46%). In this group, they observed one local recurrence (5.3%) and one case of ovarian cancer. CONCLUSION: Despite the low locoregional recurrence rate for DCIS, NSM remains controversial because of the nipple necrosis observed and the irradical tumor excisions. Given the ethical impossibility of conducting randomized controlled studies to compare NSM with conventional or skin-sparing mastectomy in DCIS, only long-term follow-up evaluations can demonstrate the safety of NSM. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postpartum thrombosis of the superior mesenteric artery after vaginal delivery.

BACKGROUND: Several causes of severe and acute postpartum abdominal pain (pelvic infection, complications of pelvic thromboembolism, arterial ischemia) require early diagnosis and prompt therapy. CASE: Eight days after a normal vaginal delivery, a 38-year-old woman presented with severe acute abdominal pain that had been going on for 3 days. Abdominal computed tomography showed a superior mesenteric artery thrombosis with suggested ileal wall ischemia. An emergency thrombectomy associated with ileal resection and ileostomy were performed. No identifiable source of embolism, hemostatic disorder, systemic vasculitis, or systemic disease associated with thrombosis was found. CONCLUSION: Even after a vaginal delivery, the postpartum period is associated with an increased risk of complications of thromboembolism. In the case of acute abdominal pain, abdominal contrast-enhanced computed tomography may be necessary to exclude mesenteric arterial ischemia.

Comparison of the Explantation Rate of Poly Implant Prothèse, Allergan, and Pérouse Silicone Breast Implants within the First Four Years after Reconstructive Surgery before the Poly Implant Prothèse Alert by the French Regulatory Authority.

Background. In March 2010, ANSM (Agence Nationale de Sécurité du Medicament), the French Medical Regulatory Authority, withdrew Poly Implant Prothèse (PIP) breast implants from the market due to the use of non-medical-grade silicone gel. The aim of this study was to compare the removal rate (and reasons thereof) of breast implants produced by different manufacturers before the ANSM alert. Materials and Methods. From October 2006 to January 2010, 652 women received 944 implants after breast cancer surgery at the Gustave Roussy Comprehensive Cancer Center, Paris (France). The complications and removal rates of the different implant brands used (PIP, Allergan, and Pérouse) were evaluated and compared. Results. PIP implants represented 50.6% of the used implants, Allergan 33.4%, and Pérouse 16%. The main reasons for implant removal were patient dissatisfaction due to aesthetic problems (43.2%), infection (22.2%), and capsular contracture (13.6%). Two years after implantation, 82% of Pérouse implants, 79% of PIP, and 79% of Allergan were still in situ. There was no difference in removal rate among implant brands. Conclusion. Before the ANSM alert concerning the higher rupture rate of PIP breast implants, our implant removal rate did not predict PIP implant failure related to the use of nonapproved silicone gel.

Outcome of oncoplastic breast-conserving surgery following bracketing wire localization for large breast cancer.

PURPOSE: The purpose of this study was to evaluate the outcome of breast conserving surgery comparing oncoplastic surgery (OS) and standard lumpectomy (SL) after preoperative bracketing wire localization of large neoplastic lesions. METHODS: We retrospectively reviewed the medical records and the mammograms of patients operated on at the Institut Curie between May 2005 and September 2011 after bracketing wire localization under mammographic and/or sonographic guidance. RESULTS: 113 patients underwent surgery for a pre-operative diagnosis of DCIS (n = 80), micro-invasive carcinoma (n = 9) or invasive carcinoma (n = 24), by OS (n = 73) or SL (n = 40). In the OS group, radiological size (52 mm vs 39 mm, p < 0.001) and resection volumes (246 cc vs 88 cc, p < 0.00001) were significantly higher than in the SL group. Rates of clear histologic margins (60 vs 62%, NS), complete excision of microcalcifications (78% vs 72%, NS) and re-intervention rate (40% vs 42%, NS) were equivalent. The rate of local recurrence at 24 months was 3% [0-7.1] in patients with conservative treatment (n = 3). With a median follow-up of 40 months, 5 local relapses (two with axillary metastatic involvement), two distant metastatic evolution, one contralateral breast cancer and one death unrelated to cancer occurred. CONCLUSION: Following bracketing wire localization, OS allowed the conserving management of significantly larger lesions with wider resection volumes, without significant increase in margin involvement or re-intervention rate, and equivalent rate of microcalcifications clearance compared to SL.

Cervicothoracic reconstruction with an anteromedial thigh flap: a novel flap concept.

The anteromedial thigh region is more popular as a donor site for skin graft than for flap. It is an extended area whose limits are poorly defined. This explains why flaps vascularised by different source arteries but described under the same name can be found in the literature introducing confusion and misunderstanding. This confusion was introduced since the primary descriptions as Baek presented in 1983 an anteromedial skin flap whose source artery was the superficial femoral artery and Song published a year later, under the same name, a flap vascularised by the innominate descending branch of the lateral circumflex femoral artery. Whatever the name and the source artery, the anteromedial thigh region is an under-exploited region which can be useful in the case of composite and complex defects. Anteromedial thigh flaps, either as pedicled or as a microvascular free-tissue transfer, were used in reconstructive surgery. We here describe a chimeric flap of the anteromedial thigh region and used as a flow-through flap.

Factors influencing the decision to offer immediate breast reconstruction after mastectomy for ductal carcinoma in situ (DCIS): the Institut Gustave Roussy Breast Cancer Study Group experience.

BACKGROUND: The increased rate of ductal carcinoma in situ (DCIS) is associated with a rise in indications for mastectomy and immediate breast reconstruction (IBR). The purpose of our study was to evaluate the factors affecting the indications for IBR and its modalities. STUDY DESIGN: Data concerning two hundred and thirty-eight consecutive patients with DCIS who had undergone modified radical mastectomy and a sentinel lymph node biopsy (SLNB) between 2005 and 2011 were extracted from our database. We then conducted a comparative study between patients who had undergone IBR and those who had not, to determine which factors affected the decision to offer IBR (LOE II). RESULTS: About 57.1% had IBR and 42.9% had no reconstruction. The most common reason why IBR had not been performed was that it had not been proposed by the surgeon (33.4%). Of the 136 patients offered IBR, an implant had been proposed to the majority of them (81.6%). The IBR rate was highest among women under 50 years (52.2%), and was lower among women with diabetes (0.7%) or obesity (8.8%). The choice of reconstruction was not affected by tobacco use or positive SLNB results. CONCLUSION: Factors predictive of the IBR reflect the influence of surgeon counselling and, to a lesser extent, consideration of patient comorbidities. However, there is a need to improve patient information and physician referral.