The Impact Oncoplastic Reduction Has on Long-Term Recurrence in Breast Conservation Therapy.

BACKGROUND: The use of oncoplastic reduction techniques have many proven benefits over lumpectomy alone in the management of women with breast cancer. The impact it has on tumor recurrence is unclear. The purpose of this review was to evaluate the incidence of recurrence in patients who underwent oncoplastic reduction techniques compared to lumpectomy alone. METHODS: A prospectively maintained database of patients at Emory Hospital who underwent oncoplastic reduction techniques at the time of tumor resection was queried. These patients were compared to a series of patients who had lumpectomy alone over a similar period. For inclusion in the study, patients were at least 10 years since the time of the tumor resection. The main outcome of interest was tumor recurrence. RESULTS: There were 97 patients in the lumpectomy-only group and 95 patients in the oncoplastic reduction group, with an average follow-up of 7.8 years and 8.5 years, respectively. Patients in the oncoplastic group were younger (lumpectomy only, 61.4 years; oncoplastic reduction, 51.6 years; p < 0.001) and had larger tumors (lumpectomy only, 1.1 cm; oncoplastic reduction, 1.6 cm; p < 0.001). Local recurrence was 13 percent in the lumpectomy-only group and 9 percent in the oncoplastic reduction group (p = 0.34), and overall recurrence rates were similar (lumpectomy only, 15 percent; oncoplastic reduction, 24 percent; p = 0.13). Overall, surgical intervention (lumpectomy alone versus oncoplastic reduction) was not associated with local recurrence or any recurrence on univariate and multivariate analyses. CONCLUSION: Despite the oncoplastic reduction patients having a higher risk of recurrence and a more generous tumor resection, the long-term recurrence rates were equivalent when compared to breast-conserving therapy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Colon and Rectal Neuroendocrine Tumors: Are They Really One Disease? A Single-Institution Experience over 15 Years.

Colon and rectal neuroendocrine tumors (NETs) are often studied as one entity. Recent evidence suggests that worse outcomes are associated with colon compared with rectal NETs; direct comparisons are lacking. Our aim was to assess clinicopathologic, treatment, and survival differences between these diseases. All patients who underwent resection of colorectal NETs at one institution from 2000 to 2014 were included and analyzed. Of 29 patients, 12(41%) had colon and 17 (59%) had rectal NETs. Baseline demographics were similar between groups, although colon patients tended to be symptomatic at presentation (67% vs 44%, P = 0.41). Eighty-three per cent of colon patients underwent surgical resection, whereas 77 per cent of rectal patients underwent endoscopic or transanal resection (P = 0.003). Colon patients had larger (3.4 cm vs 0.7 cm, P = 0.03), higher T-stage (T3/T4: 91% vs 14%, P = 0.003), higher grade tumors (42% vs 12%, P = 0.09) with more lymph nodes (58% vs 24%, P = 0.12) and lymphovascular invasion positivity (58% vs 24%, P = 0.32). Five-year disease-specific survival was 53% versus 80 per cent for colon and rectal patients, respectively (P = 0.22). After excluding high-grade tumors, colon NETs were associated with lymphovascular invasion positivity (100% vs 17%, P = 0.05) and advanced T-stage (80% vs 8%, P = 0.01). Colon and rectal 5-year disease-specific survival was 67 versus 80 per cent (P = 0.86). Colon and rectal NETs clinically seem to be distinct entities. Colon tumors have more aggressive clinicopathologic features, which may translate to worse outcomes. These differences in tumor biology may demand distinct management and should be further studied in a multi-institutional setting.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

BACKGROUND: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery. METHODS: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded. RESULTS: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication. CONCLUSIONS: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery.

BACKGROUND: Autoaugmentation techniques have been applied to oncoplastic reductions to assist with filling larger, more remote defects, and to women with smaller breasts. The purpose of this report is to describe the use of autoaugmentation techniques in oncoplastic reduction and compare the results with those of traditional oncoplastic reduction. METHODS: The authors queried a prospectively maintained database of all women who underwent partial mastectomy and oncoplastic reduction between 1994 and October of 2015. The autoaugmentation techniques were defined as (1) extended primary nipple autoaugmentation pedicle, and (2) primary nipple pedicle and secondary autoaugmentation pedicle. Comparisons were made to a control oncoplastic group. RESULTS: There were a total of 333 patients, 222 patients (67.7 percent) without autoaugmentation and 111 patients (33 percent) with autoaugmentation (51 patients with an extended autoaugmentation pedicle, and 60 patients with a secondary autoaugmentation pedicle). Biopsy weight was smallest in the extended pedicle group (136 g) and largest in the regular oncoplastic group (235 g; p = 0.017). Superomedial was the most common extended pedicle, and lateral was the most common location. Inferolateral was the most common secondary pedicle for lateral and upper outer defects. There were no significant differences in the overall complication rate: 15.5 percent in the regular oncoplastic group, 19.6 percent in the extended pedicle group, and 20 percent in the secondary pedicle group. CONCLUSIONS: Autoaugmentation techniques have evolved to manage complex defects not amenable to standard oncoplastic reduction methods. They are often required for lateral defects, especially in smaller breasts. Autoaugmentation can be performed safely without an increased risk of complications, broadening the indications for breast conservation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Oncologic Impact of Postoperative Complications Following Resection of Truncal and Extremity Soft Tissue Sarcomas.

INTRODUCTION: Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; however, little is known regarding their effect in soft tissue sarcoma (STS). The aim of this study was to determine the impact of POCs on survival after resection of truncal and extremity STS. METHODS: All patients who underwent resection for a primary truncal or extremity STS at a single academic institution from 2000 to 2015 were included and analyzed. Primary outcome was disease-specific survival (DSS). RESULTS: Among 546 STS patients, POCs occurred in 159 (29%) patients; 57% were major and 55% were surgical site infections. Patients with POCs were older (61 vs. 53 years), had more comorbidities (50 vs. 38%), longer operative time (127 vs. 93 min), higher-grade tumors (93 vs. 86%), and were more likely to receive preoperative radiation (42 vs. 33%; all p < 0.05). There was no difference in receipt of postoperative therapy between the POCs and no POCs groups (19 vs. 18%, p = 0.74). Median follow-up for survivors was 37 months, and the 5-year DSS for the entire cohort was 78%. Compared with patients without POCs, patients with POCs had a worse DSS (68% vs. 81%, p = 0.001). Predictors for decreased DSS on univariate analysis included POCs (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.37-3.28, p = 0.001), advanced age, neurovascular/bone resection, positive margin, high grade, and preoperative and postoperative therapy (all p < 0.05). POCs (HR 1.76, 95% CI 1.08-2.87, p = 0.02) remained an independent predictor for reduced DSS on multivariate analysis, along with age (HR 1.02, p = 0.046) and tumor grade (HR 7.62, p = 0.046). CONCLUSIONS: POCs following resection of truncal and extremity STS are associated with decreased DSS. Efforts to optimize modifiable risk factors and decrease the rate of POCs warrant further investigation.

An atypical presentation of Paget's Disease of the breast without nipple involvement: Case report and review of the literature.

We present a case of a 63 year-old Caucasian female who developed a right breast skin lesion discrete from the nipple that was subsequently diagnosed as Paget's Disease of the breast (PDB). Imaging did not reveal an underlying breast cancer or involvement of the nipple. The patient underwent a segmental mastectomy preserving the nipple and final pathology demonstrated residual Paget's disease of the skin and did not reveal any additional underlying breast carcinoma. To our knowledge, this case represents the first reported diagnosed case of isolated PDB without nipple involvement.

Neoadjuvant Therapy Combined With Oncoplastic Reduction for High-Stage Breast Cancer Patients.

OBJECTIVE: Oncoplastic surgery has been shown to be a good alternative to breast conservation surgery (BCS) alone for patients with breast cancer. Its role in patients with advanced disease is unclear. In this study, we evaluate the safety of oncoplastic BCS (OBCS) in patients who received neoadjuvant therapy (NT) for high stage breast cancer. METHODS: The oncologic outcomes of consecutive patients classified as high stage (>T2 or at least N1) who received NT followed by BCS at EUH by a single breast surgeon (T.M.S.) from September 2004 until June 2015 were compared with those who received BCS combined with an oncoplastic reduction. Patients were surveyed using the BREAST-Q to determine their satisfaction after surgery. RESULTS: A total of 87 patients were included in this series. The mean initial tumor size (4.37 vs 2.56 cm), the weight of the surgical specimen, and the post-NT tumor size were all larger in the OBCS group as compared with BCS alone (1.54 vs 1.29 cm). The mean follow-up was 44 months. The average percent reduction in tumor size in response to NT was slightly greater in the OBCS group (61 vs 52%). Oncologic outcomes were similar for OBCS reduction and BCS groups, respectively: positive margin rate, reexcision rate, completion mastectomy rate, local recurrence rate, and 5-year DSS. Patient satisfaction was similar between the 2 groups. CONCLUSIONS: The oncoplastic approach in high stage patients treated with neoadjuvant systemic Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation therapy appears to be as safe and effective when compared to BCS alone. Oncoplastic BCS paired with NT broadens the indication for BCS for patients with larger tumor size.

Primary Pediatric Breast Lesions: Comparing the Prevalence of Malignancies in the Middle East with North America; Review of 1031 Cases.

Benign breast masses are uncommon but are becoming more recognized among the pediatric population. Malignant breast lesions are very rare. The aim of our study was to review and compare the demographics, clinical presentation, treatment, and outcomes of breast lesions, including primary malignancies, and to discuss theories that may explain why there is an increased rate of breast cancers diagnosed at a younger age in the Egyptian population. A total of 1031 cases were reviewed. Comparisons were made between the Egyptian (n = 846) and US (n = 185) cohorts. There were 30 (3.5%) malignant tumors in the Egyptian group with 17 (2%) deaths versus 3 (1.6%) malignant tumors in the US group with 2 (1%) deaths (p = 0.247). The relative risk of breast cancer in the Egyptian group was 2.16 (95% confidence interval (CI): 0.67-7.01) compared with the US group. The trend for increased risk of breast cancer in Egypt may be due to delayed diagnosis because of decreased awareness.

Oncoplastic Breast Reduction Technique and Outcomes: An Evolution over 20 Years.

BACKGROUND: Reduction mammaplasty at the time of lumpectomy is a good option in women with breast cancer and macromastia. We critically evaluated refinements and outcomes of this technique. METHODS: A prospectively maintained database was reviewed of all women with breast cancer who received lumpectomy and reduction mammaplasty at our institution from 1994 to 2015. Patients' demographics were reviewed. Preoperative and postoperative patient satisfaction (BREAST-Q) was determined. Comparisons were made between early and recent cases. RESULTS: There were 353 patients included. Average age was 54 (range, 21 to 80 years), with the largest number having stage I disease [n = 107 of 246 (43.5 percent)]. Average lumpectomy specimen was 207 g (range, 11.6 to 1954 g) and total reduction weight averaged 545 g (range, 21 to 4102 g). Tumor size averaged 2.02 cm (range, 0.00 to 15.60 cm). The positive margin rate was 6.2 percent (n = 22). Completion mastectomy rate was 9.9 percent (n = 35). Overall complication rate was 16 percent. The recurrence rate was 5.2 percent (n = 10 of 192) at a mean follow-up of 2 years (range, 2 months to 15 years). Resection weights greater than 1000 g were associated with having a positive margin (16.7 percent versus 5.0 percent; p = 0.016), and tended to be associated with having a completion mastectomy (p = 0.069). Positive margin and completion mastectomy rates have been lower in the past 10 years. Over 1 year postoperatively, women reported increased self-confidence (p = 0.020), feelings of attractiveness (p = 0.085), emotional health (p = 0.037), and satisfaction with sex life (p = 0.092). CONCLUSIONS: The oncoplastic reduction technique is effective and results in improved patient-reported outcomes. Resections over 1000 g are associated with a higher incidence of positive margins and may increase the risk for completion mastectomy. Outcomes have improved with experience and refinement in technique.

Paracrine Effects of Leydig Cell Nodular Hyperplasia, Two Case Reports: A Neglected Phenomenon.

Leydig cell nodular hyperplasia (LCNH) is a lesion that is less characterized than the familiar Leydig cell tumors. The paracrine effects of these lesions on adjacent gonadal stroma have not been widely documented. We present two cases of precocious puberty in pre-pubertal boys found to have a single LCNH with adjacent focal maturation of the seminiferous tubules. Blood tests showed elevated serum testosterone and dehydroepiandrosterone (DHEAS). Ultrasound revealed unilateral testicular enlargement with irregular echogenicity. Radical orchiectomy was performed. Histologically Leydig cell nodular proliferation without destruction of surrounding tubules was seen. Mature seminiferous tubules undergoing spermatogenesis were noted adjacent to the lesion, while away from the lesion seminiferous tubules were as expected in pre-pubescent boys. These cases emphasize the potential presence of both paracrine and endocrine effects in Leydig cell nodular hyperplasia. However, instances of the endocrine effects of hyperplastic Leydig cell lesions are more widely reported than the paracrine effects.

Nephrogenic adenoma of the bladder in a prune belly syndrome patient: case report and review of the literature.

Nephrogenic adenoma (NA) is a rare lesion of the urinary tract widely considered to be a metaplastic response to urothelial injury. Herein, we present the case of an 8-year-old male with prune belly syndrome who presented with gross hematuria. Investigation revealed a bladder mass; however, upon cystoscopic examination, multiple polypoid lesions were identified. Microscopic examination revealed NA of the bladder. To our knowledge, this is the second reported case of NA of the bladder in association with prune belly syndrome.