Mesh erosion to urinary bladder causing fistulation to abdominal wall resulting in necrotizing fasciitis: A case report of late complication of incisional hernia.

INTRODUCTION: Incisional hernia is not an uncommon complication after abdominal operation, and laparoscopic ventral hernia repair with mesh is commonly performed nowadays. It is thought to have less complication compare to the traditional open repair, yet late complication is still observed occasionally and can be disastrous. CASE REPORT: We hereby report a case of abdominal wall necrotizing fasciitis 21 months after laparoscopic incisional hernia repair in lower midline with dual mesh, due to mesh migration and erosion into urinary bladder, resulting in fistulation between bladder and abdominal wall. Repeated debridement and removal of mesh was required for sepsis control and the patient required intensive care support due to multi-organ failure. Subsequent repair of urinary bladder and abdominoplasty was performed after condition stabilized. CONCLUSION: This case was the first reported incident with bladder erosion by dual mesh causing vesico-cutaneous fistula complicated with necrotizing fasciitis. Although dual mesh theoretically reduces the risk of mesh erosion, mesh erosion to viscera can still happen and cause severe complication. Its risk should be balanced and discussed with patient with full consent.

Surgical options for Chinese patients with early invasive breast cancer: Data from the Hong Kong Breast Cancer Registry.

BACKGROUND: Breast conserving surgery (BCS) is preferred for suitable candidates, while mastectomy (MTX) with reconstruction (MTX + R) is considered a better option for patients requiring MTX. In Hong Kong, the rates of BCS and breast reconstruction are relatively low. This paper aims to study the surgical options and their predictors among Hong Kong breast cancer patients. METHODS: Data is retrieved from the Hong Kong Breast Cancer Registry (HKBCR) from 2007 to 2013. A total of 4519 Stage I-II breast cancer patients who had surgical treatments were included in this retrospective study. RESULTS: Our multivariate logistic regression shows that people who were younger (age < 40 years: OR, 1.5; 95% CI, 1.1-2.1; p = 0.010), more educated (undergraduate/postgraduate: OR, 2.8; 95% CI, 1.7-4.4; p < 0.0001), never married (OR, 1.5; 95% CI, 1.1-1.9; p = 0.002), had regular mammography screening (OR, 1.5; 95% CI, 1.3-1.8; p < 0.0001), had screen-detected cancers (OR, 1.3; 95% CI, 1.0-1.6; p = 0.031), and who underwent surgery at a private medical service facility (OR, 1.8; 95% CI, 1.6-2.2; p < 0.0001) were more likely to receive BCS. In addition, people who were younger (age < 40 years: OR, 15.9; 95% CI, 6.5-39.2; p < 0.0001), more educated (undergraduate/postgraduate: OR, 26.8; 95% CI, 3.6-201.4; p = 0.001), had regular mammography screening (OR, 1.6; 95% CI, 1.1-2.3; p = 0.008), had screen-detected cancers (OR, 2.1; 95% CI, 1.4-3.3; p = 0.001), and had smaller tumor (≤ 2.0 cm: OR, 0.39; 95% CI, 0.20-0.76; p = 0.005) were more likely to have reconstruction after MTX. CONCLUSION: Chinese patients have lower BCS and breast reconstruction rate. Besides cultural difference, patient-related factors such as age, education, marital status, mammography screening, the use of private medical facilities, and clinical characteristics including smaller tumor size and peripherally located tumor were significant predictors for type of surgical treatments in Chinese women with early breast cancer.

The Impact of the Oncotype DX Breast Cancer Assay on Treatment Decisions for Women With Estrogen Receptor-Positive, Node-Negative Breast Carcinoma in Hong Kong.

BACKGROUND: The Oncotype DX Breast Cancer Assay is validated to assess risk of distant recurrence and likelihood of chemotherapy (CT) benefit in estrogen receptor-positive ESBC in various populations. In Hong Kong, > 80% of breast cancers are early stage breast cancer (ESBC) and > 60% of these women receive CT. This prospective study measured changes in CT type and recommendations, as well as physician impression of assay impact in a homogenous Chinese population. METHODS: Consecutive patients with estrogen receptor-positive, T1-3 N0-1mi M0 ESBC were offered enrollment. After surgery, physicians discussed treatment options with patients, then ordered the assay, then reassessed treatment recommendation considering assay results. Changes in treatment recommendation, CT utilization, physician confidence, and physician rating of influence on their treatment recommendations were measured. RESULTS: A total of 146 evaluable patients received pre- and post-testing treatment recommendations. CT recommendations (including changes in intensity of CT) were changed for 34 of 146 patients (23.3%; 95% confidence interval, 16.7%-31.0%); change in intensity occurred in 7 of 146 (4.8%). There were 27 changes in treatment recommendations of adding or removing CT altogether (18.5% change; 95% confidence interval, 12.6%-25.8%). CT recommendations decreased from 52.1% to 37.7%, a net absolute reduction of 14.4% (P < .001; 27.6% net relative reduction). Pre-assay, 96% of physicians agreed/strongly agreed that they were confident in their treatment recommendation; post-assay, 90% of physicians agreed/strongly agreed with the same statement. Thirty percent of physicians agreed/strongly agreed that the test had influenced their recommendation, similar to the proportion of changed recommendations. CONCLUSIONS: The Oncotype DX Assay appears to influence physician ESBC adjuvant treatment recommendations in Hong Kong.

Waiting to see the doctor: understanding appraisal and utilization components of consultation delay for new breast symptoms in Chinese women.

BACKGROUND: Delayed consultation for potential cancer symptoms influences treatment outcomes and remains problematic. Delay components (Appraisal versus Utilization) and respective associations are poorly understood. METHODS: Eligible participants were Cantonese-speaking Chinese women, ≥21 years old, with self-discovered breast symptoms, recruited in surgical clinics before their first consultation, and naïve to their diagnosis. Overall 425/433 (98%) women completed a questionnaire on psychosocial, demographic and medical factors, how and when women discovered their breast symptom(s), and their subsequent decision making; 135/425 women (32%) were later diagnosed with breast cancer. RESULTS: Twenty-two per cent of women delayed >3 months before consultation. Women with breast cancer (28%) more often had prolonged delay than women with benign disease (19%). Attributing symptom to a non-cancerous condition, low fear on symptom discovery, not disclosing symptoms to others, and no prior breast symptom history predicted prolonged (>60 days) Appraisal Delay. Low fear on symptom discovery, seldom thinking about the symptom, and consultation for other reasons predicted prolonged (>14 days) Utilization Delay. Factors predicting Appraisal and Utilization Delays differentiated cancer from non-cancer groups. CONCLUSIONS: Indecision over symptom meaning comprised the main component of Appraisal and Total Delay, suggesting that educational strategies targeting atypical symptoms should reduce avoidable delays following self-discovered breast symptoms.

Early data from the first population-wide breast cancer-specific registry in Hong Kong.

BACKGROUND: Current measures for breast cancer prevention and options for treatment adopted in Hong Kong are mainly based on research data and clinical evidence from overseas. It is essential to establish a cancer-specific registry to monitor the status of breast cancer in Hong Kong. OBJECTIVES: We summarized the current status of breast cancer in Hong Kong based on the data collected from Hong Kong Breast Cancer Registry (HKBCR). METHODS: Prevalent and newly diagnosed breast cancers (including in situ and invasive breast cancers) were registered in the HKBCR. Information on patient demographics, risk factors, medical information, and survival were analyzed and reported in this study. RESULTS: Data of 2,330 breast cancer patients were analyzed. We observed an earlier median age at diagnosis in Hong Kong than those reported in other countries. Distribution of cancer stage was: stage 0 (11.4%), stage I (31.4%), stage II (41%), stage III (12.5%), stage IV (0.8%), and unclassified (2.9%). The percentages of patients who received surgery, chemotherapy, radiation therapy, and endocrine therapy were 98.7, 67.9, 64.8, and 64.1%, respectively. At a median follow-up of 1.2 years, locoregional recurrence was recorded at 2%, distant recurrence at 2.8%, and breast-cancer-related mortality at 0.3%. CONCLUSIONS: The HKBCR serves as a surveillance program to monitor disease and treatment patterns. It is pivotal to support research for more effective breast cancer prevention and treatment strategies in Hong Kong.

Mammographic determination of breast volume by elliptical cone estimation.

BACKGROUND: We propose a new breast volume calculation method, treating the breast as an elliptical cone on craniocaudal and medial-lateral-oblique mammograms. This study aims to compare the accuracy and reproducibility of this proposed calculation method to the old Katariya method, which calculates breast volume as a circular cone on the craniocaudal mammogram only. MATERIALS AND METHODS: From January 2005 to December 2006, 83 mastectomy patients with recorded breast weight and available preoperative mammographic films were included in the present study. Two surgeons independently measured breast height and width on the preoperative craniocaudal and medial-lateral-oblique mammograms. Breast volume was calculated as a circular cone in the craniocaudal view, and as an elliptical cone in both the craniocaudal and the medial-lateral-oblique mammograms. The accuracy of each method was determined and compared by linear regression analyses. Interobserver variability was assessed by bivariate correlation. RESULTS: The most accurate formula for calculating breast volume was the one that assumed the elliptical cone projection. The mean error of estimated breast volume using the elliptical cone (EC) formula is 3.8 cm(3) (standard deviation [SD] = 133 cm(3)). The mean error of traditional circular cone (CC) formula is -51.3 cm(3) (SD = 182 cm(3)). From a linear regression model, the correlation coefficient of estimated breast volume using EC formula measured 0.977, whereas that using the CC formula measured 0.952 (Fig. 1). Measurements were reproducible between the two independent observers; the Pearson correlation for the EC formula is 0.93 (p < 0.001), and that for the CC formula is 0.95 (p < 0.001). CONCLUSIONS: Breast volume can be accurately determined from measurements made on mammograms. The proposed EC formula calculating breast volume on both the craniocaudal and the medial-lateral-oblique mammograms may be more accurate, as the horizontal and vertical dimensions of the breast are not always the same. In addition, height measurement on the medial-lateral-oblique film can eliminate the compression error as the craniocaudal film may miss the base of the breast and underestimate the breast volume. Taking both mammogram views for measurement is comparably reproducible to the traditional method. Reproducibility of measurement can be further enhanced by better defining the point of measurements.

Cosmetic outcome and percentage of breast volume excision in oncoplastic breast conserving surgery.

BACKGROUND: Since breast-conserving surgery demonstrated identical long term survival on seven randomized trials, it has become the preferred treatment option over mastectomy. Oncoplastic surgery applying simple reshaping and displacement techniques allows inclusion of patients with large tumors in the group selected for breast-conserving surgery. However, the cosmetic outcome and the degree of patient satisfaction, especially in relation to the original breast volume and the percentage of breast tissue excised is not well documented. OBJECTIVE: The present study was designed to assess patient satisfaction with cosmetic outcome after oncoplastic breast-conserving surgery, and to establish the correlation between patient satisfaction and percentage of breast volume excision (PBVE). MATERIALS AND METHODS: A total of 169 Asian patients underwent breast-conserving surgery for primary breast cancer at either United Christian Hospital (UCH) or Hong Kong Sanatorium and Hospital (HKSH) from Nov 2007 to Jan 2008 by two breast surgeons. Among this group, 162 patients with breast-conserving surgery incorporating oncoplastic techniques were prospectively recruited for study. Tumor characteristics, patient satisfaction, cosmetic outcome and surgeons' score were prospectively documented. Breast volume (BV) calculation was based on preoperative mammography (BV = 1/3pir(1)r(2)h), which was validated by our previous study to correlate strongly with actual BV (r = 0.98). PBVE was calculated by dividing the fresh specimen weight by the calculated BV. A standardized questionnaire was used to assess patient satisfaction and surgeons' score on cosmetic outcome during the first 1-3 postoperative months. The correlation between PBVE and patient satisfaction was studied. RESULTS: The median age of the group of patients studied was 52 years (range: 20-96 years). The median tumor size was 2.5 cm (range: 0.6-5 cm). The median breast volume was 493 cm(3) (range: 210-1,588 cm(3)). The median PBVE was 7.4% (range: 1-42%), and 94% of patients were very satisfied or satisfied with the cosmetic outcome. In addition, 85% of patients felt that the treated breast was nearly identical with or only slightly different from the untreated breast. In scoring breast shape, surgeons indicated that 89% of the treated breasts were identical to or only minimally different from the untreated breast. Patient satisfaction decreased significantly when the PBVE exceeded 20%. Neither tumor location nor distance of the tumor from the nipple had any effect on patient satisfaction. CONCLUSIONS: This study showed high patient satisfaction and good cosmetic outcome after oncoplastic breast-conserving surgery, even in small breast sized Asian women. The application of oncoplastic technique allows large volume excision, and satisfaction remains high with breast volume excision less than 20% regardless of tumor location or distance of the tumor from the nipple. More complicated oncoplastic techniques, e.g., breast replacement, might be required if breast volume excision exceeds 20%.

Ranula successfully treated by botulinum toxin type A: report of 3 cases.

The conventional treatment of ranula is surgical procedure. We report an innovative method for ranula by using botulinum toxin type A on 3 patients. All 3 cases of ranula resolved after this minimally invasive therapy. The treatment complication was minimal.

Benefit of ultrasonography in the detection of clinically and mammographically occult breast cancer.

OBJECTIVE: The purpose of this study was to evaluate the performance of high-resolution ultrasonography in the detection of clinically and mammographically occult breast cancer. MATERIALS AND METHODS: From September 2003 to November 2006, a total of 1485 patients were confirmed to have in situ or invasive breast cancer in Hong Kong Sanatorium and Hospital Breast Care Centre. All patients underwent mammography (MMG) and/ or sonography (USG) evaluation. Patients' age and size of tumor detected by USG alone were compared with those detected by MMG. RESULTS: Altogether, 222 patients (17%) had positive imaging findings on USG only, among which 22 (13%) patients had nonpalpable tumors. Performing USG increased the cancer detection rate among clinically and mammographically occult breast lesions by 14.3%. The mean size of the tumors detected only by USG was 1.98 cm, which was not significantly different from the mean size of tumor detected by MMG (1.46) (p = 0.23). This remains true in the group of patients with nonpalpable tumors (1.36 vs. 1.46 cm, p = 0.88). The sensitivity of USG is 91%, which is significantly higher than that of MMG (78%) (p = 0.001). This remains true in patients age <40 or > or = 40, tumor grading I toIII, and LVI +/- cases. However, MMG had higher sensitivity in the group of patients with nonpalpable tumors (73% vs. 62%, p = 0.01) and noninvasive cancers (72% vs. 69%, p = 0.01). CONCLUSIONS: The use of high-resolution USG may lead to detection of a significant number of occult cancers that are no different in size from nonpalpable mammographically detected lesions.

Triaging referral to a specialist breast clinic.

BACKGROUND: The aim of this study was to determine the effectiveness of a triage system in predicting patients with malignancy among those referred to a specialist breast clinic. METHODS: A retrospective study of all referrals seen at the specialist breast clinic from January 2002 to June 2002 was conducted. The triage system allocated an urgent appointment if (i) urgent referral was requested by the referring physicians or (ii) 'non-urgent referral' was made and any one of the following 'high-risk' criteria were present: aged more than 50 years when presenting with breast lump, lump larger than 3 cm, bloody nipple discharge or physical signs suggestive of malignancy. Routine appointment was given if these conditions were not met. The outcomes of individual groups were assessed. RESULTS: Three hundred and sixty-three referrals were analysed and 44 cancers (13.2%) were diagnosed. The mean waiting time for urgent and routine appointments was 19 and 154 days, respectively. There were 108 urgent referrals and 21 (19.4%) cancers were diagnosed. Ninety-two patients were given an urgent appointment because of the presence of high-risk criteria, and 21 cancers were detected (22.8%). After the two-stage triage, breast cancer was subsequently diagnosed in only 2 out of the remaining 163 patients (1.2%) given a routine appointment. CONCLUSION: Most of the patients with cancer (96%) were given an urgent appointment through the triage system. In addition to the assessment by referring physicians, certain high-risk criteria are helpful to select patients who should be seen urgently.

Intracranial chloroma in hypereosinophilic myelofibrosis.

BACKGROUND: Chloroma, also called granulocytic sarcoma, is a localized extramedullary tumor composed of leukemic myeloid cells. It is a rare tumor that can occur in various locations. The association of chloroma with leukemic disease or myeloproliferative disorders is limited to isolated case reports. CASE DESCRIPTION: We report a case of intracranial chloroma in an elderly man with myelofibrosis and progressive hypereosinophilia. The presence of leukemic cells within his pleural aspirate suggested an incipient acute leukemic state. CONCLUSION: We report the first case of intracranial chloroma associated with hypereosinophilia developing in the course of myelofibrosis. The significance of hypereosinophilia in predicting the likelihood of development of central nervous system chloroma and acute leukemia in a patient with myelofibrosis needs further evaluation.