Ultrasound-Guided Segmental Mastectomy and Excisional Biopsy Using Hydrogel-Encapsulated Clip Localization as an Alternative to Wire Localization.

BACKGROUND: Wire localization is currently the most widely used localization strategy for excision of nonpalpable breast lesions. Its disadvantages include patient discomfort, wire-related complications such as wire displacement/fracture, and operating room delays related to difficulties during wire placement. We have implemented the technique of intraoperative ultrasound-guided excision using hydrogel-encapsulated (HydroMARK) biopsy clips for lesion localization. We hypothesize that this method is as effective as wire localization for breast conserving therapy. METHODS: This is a retrospective review of 220 consecutive patients who underwent segmental mastectomy or excisional biopsy using wire localization or hydrogel-encapsulated clip localization from January 2014 to July 2015. Data were collected and analyzed. Statistical analyses for differences between groups were performed using t tests and Mann-Whitney rank-sum analyses. RESULTS: A total of 107 excisions were performed using hydrogel-encapsulated clip localization, and 113 excisions were performed using the traditional wire localization technique; 68 % of our patients underwent excision for malignant pathology. Wire placement took a mean of 46 minutes (range 20-180 min), compared with 5 minutes for ultrasound localization (p <  .001). Successful intraoperative ultrasound localization and excision was performed on 100 % of patients. There was no difference in re-excision rates for positive margins or overall specimen size between the two groups. CONCLUSIONS: Intraoperative ultrasound-guided excision of nonpalpable breast lesions using a hydrogel-encapsulated biopsy clip for breast conserving therapy is a safe and feasible alternative to the traditional preoperative wire localized excision. This technique will lead to improvement in patient experience, operative efficiency, and alleviate wire-related complications.

Calciphylaxis of the Breast: A Case Report and Literature Review.

Calciphylaxis, or calcific uremic arteriolopathy, is a rare but particularly morbid condition involving systemic medial calcification of arterioles causing ischemia and subsequent tissue necrosis. Although most commonly occurring over the abdomen and proximal extremities, calciphylaxis can present on nearly any skin surface with a tendency toward areas of increased adiposity. We report a case of a 53-year-old female with end-stage renal disease who presented with bilateral palpable breast masses and overlying skin changes. Diagnostic mammography and percutaneous biopsy of the lesion facilitated the diagnosis of calciphylaxis and she was treated with medical therapy, local wound care, and eventual tissue extirpation. Due to the morbidity attributed to calciphylaxis and associated wound complications, surgical extirpation is at times unavoidable. Once malignancy has been excluded, we recommend nonoperative management with prompt referral to Nephrology for medical optimization, reserving surgical debridement for nonhealing wounds and superinfection.

A Case of a Giant Borderline Phyllodes Tumor Early in Pregnancy Treated with Mastectomy and Immediate Breast Reconstruction.

Breast tumors in pregnancy are often times diagnosed at advanced stages secondary to difficulty distinguishing between pathologic from normal physiologic changes. Often benign, phyllodes tumors are rare fibroepithelial stromal tumors of the breast, most commonly diagnosed in the 4th and 5th decades of life. However, these tumors may be characterized by malignancy with metastases in 10% of cases. In this paper, we report a novel case of a young woman presenting at 8 weeks gestation with a large borderline phyllodes tumor. An exceedingly rare condition, with only nine previously reported cases, phyllodes tumors in pregnancy frequently display more aggressive characteristics with larger median tumor size, more malignant potential, and more rapid growth rate. Here, we describe our experience safely and effectively treating this rare condition in a young gravid women with mastectomy and immediate breast reconstruction in the second trimester.

Concomitant proliferation and caspase-3 mediated apoptosis in response to low shear stress and balloon injury.

BACKGROUND: Arterial remodeling occurs as a response to hemodynamic change and direct vessel wall injury through the process of neointimal hyperplasia (NH). A concomitant response of vascular smooth muscle cell (VSMC) proliferation and apoptosis exists. The purpose of this study is to assess the cellular response of vessels following exposure to low shear stress (tau) and balloon injury in order to further elucidate the mechanisms underlying vascular injury. Our hypothesis is that the combination of low tau and balloon injury results in NH approximating that seen in clinical arterial restenosis, and that quantitative analysis of VSMC proliferation and apoptosis correlates with the associated increase in arterial remodeling. METHODS AND RESULTS: New Zealand White rabbits underwent surgery on the carotid artery creating low tau (n =11), balloon injury (n = 11), combined low tau and balloon injury (n =11), and sham (n = 13) groups. Experiments were terminated at 1, 3, and 28 d. Day 1 and 3 arteries were analyzed with immunohistochemistry for apoptotic markers, terminal transferase dUTP nick end labeling (TUNEL), and activated caspase-3, and a cellular proliferation marker, accumulated proliferating cell nuclear antigen (PCNA), as well as immunoblot analysis for activated caspase-3 and PCNA at day 3. There was significantly greater apoptosis in the combined group as compared with the other groups assessed by quantitative TUNEL and activated caspase-3 levels at both days 1 and 3. Similarly, an increase in cellular proliferation assessed by PCNA expression, was significantly greater in the combined group as compared with the other groups. At 28 d there was no difference in NH observed in the low tau (26 +/- 3 microm) and balloon injury (51 +/- 17 microm) groups. However, significantly more NH was observed in the combined group (151 +/- 35 microm) as compared with the other groups. CONCLUSIONS: An increase in VSMC apoptosis via a caspase-3 dependent pathway is up-regulated by 24 h in the face of combined low shear stress and balloon-induced vessel wall injury. Paradoxically, this increase in VSMC apoptosis is associated with a significant increase in neointimal thickening at 28 d. The concomitant increase of both apoptosis and proliferation are indicative of a robust arterial remodeling response.

Metachronous giant brachial artery pseudoaneurysms: a case report and review of the literature.

Brachial artery pseudoaneurysms secondary to intravenous drug abuse represent a limb-threatening problem to patients and a technical challenge to the vascular surgeon. Here information is reported about a patient with metachronous bilateral giant brachial artery pseudoaneurysms secondary to intravenous drug use that were successfully treated with excision of the aneurysm and ligation of the brachial artery. Furthermore, a review of the current literature on the treatment of brachial artery aneurysm is presented.

Improved Breast Cancer Care Quality Metrics After Implementation of a Standardized Tumor Board Documentation Template.

PURPOSE: Cancer treatment requires a coordinated multidisciplinary treatment approach, which led to the development of the Rapid Quality Reporting System by the Commission on Cancer. However, the lack of immediate availability of documented treatment plans and the inefficiency of global medical record reviews represent significant barriers to adherence reporting and the timely implementation of quality improvement measures. METHODS: Adherence to national guidelines in the areas of radiation treatment, chemotherapy, and hormone therapy was assessed after breast conservation surgery (BCS). Adherence rates within 1 year of BCS were analyzed 10 weeks before and after the implementation of a standardized documentation template at weekly multidisciplinary breast cancer conferences. RESULTS: Documented adherence rates increased postimplementation in patients undergoing consideration for both radiation treatment and hormone therapy within 1 year of BCS (89% v 65%; P = .045% and 85% v 62%; P = .002, respectively). No change was observed in patients undergoing evaluation for cytotoxic chemotherapy (80% v 85%; P = 1.00). CONCLUSION: The addition of a documentation template to multidisciplinary breast cancer conferences resulted in increased recorded adherence rates to national guidelines. This template provided a means of both accurate and efficient documentation of evidence-based practice, which represents a concept with broad application in quality improvement. Although evaluation of the project was not continued beyond the pilot stage, current quality measure scores remain within the same range.