Accuracy of a multidisciplinary team-led discussion in predicting postmastectomy radiotherapy.

INTRODUCTION: Immediate breast reconstruction (IBR) is performed increasingly following mastectomy for breast cancer. The literature suggests higher reconstructive failure and poorer cosmesis in the subgroup of patients receiving postmastectomy radiotherapy (PMRT) following IBR. We set out to determine the accuracy of a multidisciplinary team (MDT) discussion in predicting PMRT. METHODS: Preoperative MDT discussions were recorded prospectively over a 12-month period (from February 2011) in a symptomatic breast unit. The estimated need for PMRT was stratified into 'PMRT not required', 'PMRT possibly required', 'PMRT probably required' and 'PMRT required' groups. RESULTS: Of 156 referrals included in the study, 76 patients (49%) underwent mastectomy: 61 simple mastectomy, 10 skin sparing mastectomy (SSM) and delayed-immediate breast reconstruction, 3 SSM and implant-based IBR, and 2 mastectomy IBR with an autologous flap. The IBR rate was therefore 19.7%. The proportion of patients who received PMRT was 14% (3/21) in the 'PMRT not required', 30% (7/23) in the 'PMRT possibly required', 65% (9/14) in the 'PMRT probably required' and 94% (17/18) in the 'PMRT required' groups. Assigning a linear numerical score (1-4) to these groups (higher score representing greater likelihood of receiving PMRT), the predicted need for PMRT correlated with the proportion of patients who ultimately received PMRT (linear regression r(2)=0.98, p=0.01). CONCLUSIONS: This study has examined the factors influencing MDT discussions regarding IBR, demonstrating that the MDT is reasonably accurate at predicting need for PMRT. Whether such accuracy is clinically adequate and/or reproducible across units is debatable.

Effect of the neuropeptides vasoactive intestinal peptide, peptide histidine methionine and substance P on human major salivary gland secretion.

OBJECTIVE: The parasympathetic transmitters vasoactive intestinal peptide (VIP) and substance P (SP) are secretagogues in salivary glands of animals. Currently, we hypothesise that in human salivary glands, these neuropeptides and the VIP-related peptide histidine methionine (PHM) also exert secretory actions, reflected morphologically by exocytosis of acinar protein/glycoprotein-storing granules. MATERIALS AND METHODS: Submandibular and parotid gland tissues, exposed in vitro to VIP and PHM, and SP, respectively, were examined by light and transmission electron microscopy. For comparison, the response to in vitro stimulation of isoproterenol, phenylephrine and carbachol was examined. Moreover, the peptidergic innervation of the glands was examined by immunohistochemistry. RESULTS: Vasoactive intestinal peptide- and PHM-immunoreactive nerves were in close proximity to acini and ducts in the two glands, while these elements lacked a SP-positive innervation. While no morphological changes occurred in response to SP (parotid glands), VIP and PHM administration (submandibular glands) caused conspicuous acinar degranulation accompanied by luminal space broadening. In the two glands, both α1 - and ß-adrenergic receptor stimulation and muscarinic receptor stimulation caused similar changes as to VIP/PHM, although to varying extent. CONCLUSIONS: Vasoactive intestinal peptide and PHM, but not SP, are likely transmitters in the parasympathetic control of salivary (protein) secretion in humans.

Bortezomib treatment produces nocifensive behavior and changes in the expression of TRPV1, CGRP, and substance P in the rat DRG, spinal cord, and sciatic nerve.

To investigate neurochemical changes associated with bortezomib-induced painful peripheral neuropathy (PN), we examined the effects of a single-dose intravenous administration of bortezomib and a well-established "chronic" schedule in a rat model of bortezomib-induced PN. The TRPV1 channel and sensory neuropeptides CGRP and substance P (SP) were studied in L4-L5 dorsal root ganglia (DRGs), spinal cord, and sciatic nerve. Behavioral measures, performed at the end of the chronic bortezomib treatment, confirmed a reduction of mechanical nociceptive threshold, whereas no difference occurred in thermal withdrawal latency. Western blot analysis showed a relative increase of TRPV1 in DRG and spinal cord after both acute and chronic bortezomib administration. Reverse transcriptase-polymerase chain reaction revealed a decrease of TRPV1 and CGRP mRNA relative levels after chronic treatment. Immunohistochemistry showed that in the DRGs, TRPV1-, CGRP-, and SP-immunoreactive neurons were mostly small- and medium-sized and the proportion of TRPV1- and CGRP-labeled neurons increased after treatment. A bortezomib-induced increase in density of TRPV1- and CGRP-immunoreactive innervation in the dorsal horn was also observed. Our findings show that bortezomib-treatment selectively affects subsets of DRG neurons likely involved in the processing of nociceptive stimuli and that neurochemical changes may contribute to development and persistence of pain in bortezomib-induced PN.

A technique to correct a malpositioned nipple within the confines of a well-placed areola.

We present a case where the nipple was malpositioned after a wide local excision for breast cancer. Despite the nipple malposition, the areola was symmetrical with the contralateral side. We were able to reproduce symmetry between both breasts by the use of a transposition flap to reposition the nipple and skin grafting.

The Hall-Findlay mammaplasty pattern for skin-sparing mastectomy: case report.

We present an application of the Hall-Findlay mammaplasty skin pattern for skin-sparing mastectomy (SSM). This is a simplified vertical reduction mammaplasty. Vertical reduction mammaplasty is the procedure advised for patients with moderator or large ptotic breasts, who wish to have a simultaneous contra-lateral breast reduction/mastopexy at the time of SSM for cancer or prophylactic mastectomy. It is particularly suitable for breast reconstruction with autologous tissue in the form of free transverse rectus abdominis myocutaneous (TRAM), deep inferior epigastric artery perforator (DIEP) and extended latissimus dorsi (ELD) flaps.

Adaptation of the Hall-Findlay technique for simultaneous contralateral reduction in delayed breast reconstruction with extended latissimus dorsi flap.

UNLABELLED: In the past we have validated Hall-Findlay technique of breast reduction with our independent results. The technique combines the safety of the superomedial pedicle with advantages of a vertical scar in a quick but safe manner ensuring adequate resection and sound healing with less scars and faster recovery for the patient. We now report our experience of using an adaptation of the same in simultaneous contralateral reduction in delayed breast reconstruction with extended latissimus dorsi flap. METHOD: Thirty consecutive patients underwent simultaneous contralateral balancing reduction. The modifications consisted of wider upper pole reduction with smaller, thinner pedicle reducing the projection. RESULTS: All patients had an uneventful recovery with no haematoma, infection or seroma. Two patients (6.66%) wished further reduction and one (3.33%) required dog-ear revision. CONCLUSION: The modifications allow the reduction of the contralateral breast with a lower projection to match the extended latissimus dorsi (ELD) flap reconstruction. We have found the modified technique to be reliable and versatile with a shorter operative and recovery time adding minimal morbidity of simultaneous contralateral reduction and effectively reducing the need of a delayed balancing reduction.

Salvage of Upper Limb following a Severe Crushing Trauma: Immediate Reconstruction with a Free Flap and Subsequent Hyperbaric Oxygen Therapy.

A microsurgical latissimus dorsi flap was performed for resurfacing a large soft tissue defect of the forearm with exposure of the vital structures and contaminated wound. Early coverage of a defect is a generally accepted concept to achieve a better functional result. The authors present a case report where a free latissimus dorsi flap with subsequent hyperbaric oxygen therapy allowed a successful single stage reconstruction of this complex severely contaminated defect.

Circumareolar mastopexy with multiple glandular plications for symmetry of the contra-lateral breast, in patients undergoing breast reconstruction with prosthesis. Experience on 50 cases.

4 years experience on 50 cases using the Elliott's technique for symmetrization of the contra-lateral breast in patients undergoing breast reconstruction with an anatomical prosthesis is presented in this paper.The Elliott's technique with its double superior and horizontal plication is a suitable and long-lasting procedure for patients with small-moderate ptotic breast and elastic skin, who wish to have a simple procedure and an immediate result with minimal scars.

Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap.

A combined microvascular flap composed of serratus anterior myo-osseous and a latissimus dorsi myocutaneous flap has been performed for resurfacing massive scalp and skull defects, accompanied by chronic infection and heavy radiation damage. The authors present a case report where the combined procedure allowed a single-stage reconstruction of this complex defect.

Somatostatin- and Substance P-ergic neurons and Glial cell line-derived neurotrophic factor in the human archicortex.

By means of immunohistochemistry, the localization of Somatostatin (SOM)- and Substance P (SP)-ergic neuronal populations was compared to the occurrence of Glial cell line-derived neurotrophic factor (GDNF) in the human hippocampus from prenatal to adult life stages. The results obtained i) confirm previous reports on the distribution of SOM and SP; ii) show that GDNF-like immunoreactivity occurs in an ample population of hippocampal neurons, with a main location in the pyramidal cells; iii) identify regions of codistribution of either neuropeptide with GDNF-positive elements. Although coexistence of GDNF with SOM or SP was not detected, the possibility that the trophic factor may act on the neuropeptide-containing neurons can be envisaged and is worth further analysis.

An anatomical study of the relationship between excursion of the flexor tendons and digital mobility: proposition of an intraoperative test for flexor tendon tenolysis.

The excursion of the flexor tendons of the thumb and fingers was studied in ten fresh cadaveric upper limbs. For each centimetre of tendon movement, obtained by traction of the flexor tendons at the wrist, the angular changes of the digital articulations were measured; movement started at extension and proceeded to maximum flexion. A further five upper limbs were used to evaluate the effect of pressure over the musculotendinous area of the flexor tendons of the fingers and thumb. Pressure on the muscle bellies in the forearm causes movement of the tendons, different for each finger, with the accompanying digital flexion depends on the magnitude of the movement. On the basis of this anatomical study a test is described which may be beneficial in the diagnosis of pathology and trauma of the flexor tendons and, particularly, in the intraoperative evaluation of the quality of motion obtained during tenolysis.

Glial cell line-derived neurotrophic factor-like immunoreactivity in human trigeminal ganglion and nucleus.

Glial cell line-derived neurotrophic factor (GDNF) is shown by immunohistochemistry in human trigeminal sensory system from 22 weeks of gestation to adulthood. In the trigeminal ganglion, a distinct subpopulation of GDNF-positive neurones is observed, which amounts to about 15% at early pre-term and adult ages and peaks to around 30% at perinatal ages. Labelled neurones are mostly small- and medium-sized. Occasionally, Schwann and satellite cells are stained. GDNF/substance P (SP) and GDNF/calcitonin gene-related peptide (CGRP) double stained neurones occur at all ages examined, whereas GDNF/trkA coexistence can be observed in pre- and full-term newborns only. Centrally, GDNF-immunostained fibers and terminal-like structures are mainly restricted to the spinal trigeminal nucleus, where they are codistributed with SP and CGRP. In the subnucleus caudalis, positive neurones can also be observed both in the superficial laminae and in the magnocellular part, with higher frequency in adults. These results suggest that GDNF may play a functional role in human trigeminal primary sensory neurones throughout life and provide indication for its possible involvement in the regulation of pain-related neuronal circuits in human trigeminal sensory system.