Delayed-immediate breast reconstruction: An assessment of complications and outcomes in the context of anticipated post-mastectomy radiotherapy.

INTRODUCTION: The detrimental effects of post-mastectomy radiotherapy on breast reconstruction are well known. We report our experience with a delayed-immediate approach involving an initial subcutaneous implant with definitive reconstruction after adjuvant radiotherapy. METHODS: Patients were identified retrospectively from hospital, theatre and implant registry records. Details regarding demographics, cancer pathology, surgical data and oncological therapies were collected. Primary outcomes included complication rates of first-stage surgery and time to definitive reconstruction. RESULTS: A total of 115 patients underwent mastectomy and temporary subcutaneous implant (36 nipple sparing) between 2008 and 2019. Five were smokers with eleven having a body mass index > 30. The median age was 46 years (27-76 years) and tumour size 50 mm. Almost 95% underwent radiotherapy, 82% chemotherapy and 70% had axillary node clearance. Median mastectomy weight was 464 g (123-1300 g) with median temporary implant volume 375 cc (180-655 cc). Complications of first-stage surgery at three months included 5.2% implant loss (n = 6), 14.8% infection rate, 17.4% readmission rate and 10.4% returned to theatre. Reconstructive failure occurred in four cases (3.5%). A total of 76 patients completed definitive reconstruction, including 26 autologous, 21 latissimus dorsi with implant, and 28 implant-only reconstructions. The median time to reconstruction following the completion of radiotherapy was 12 months. This increased in those who had implant complications (28 vs. 15 months) or radiotherapy (16 vs. 10 months) versus those without. CONCLUSIONS: Delayed-immediate breast reconstruction using a temporary subcutaneous implant has been shown to be a safe, feasible and potentially beneficial method than simple mastectomy and delayed reconstruction with a complication rate comparable to that of immediate implant reconstruction.

One-step nucleic acid amplification CK19 copy number for sentinel node biopsy in breast cancer: Identification of new cutoffs to predict nonsentinel axillary node involvement.

We evaluated novel sentinel node values in breast cancer for one-step nucleic acid amplification (OSNA) to predict further nodal involvement using various methods in clinically node-negative disease with a positive OSNA result and subsequent axillary node dissection. 239 patients (118 macrometastatic) were assessed revealing cutoffs of total tumor load (TTL) 44 500 copies/µL (AUROC 0.793); average copy number (ACN) 9450 (AUROC 0.790); and highest copy number (HCN) 46,000. For macrometastatic patients only: TTL 221 400 copies/µL (AUROC 0.685); ACN 64,000 (AUROC 0.671); HCN 59 500 (AUROC 0.529). Our data favor TTL and represent one of the largest OSNA macrometastatic predictive series.

The Results of Surveillance Imaging After Breast Conservation Surgery and Partial Breast Reconstruction With Chest Wall Perforator Flaps; A Qualitative Analysis Compared With Standard Breast-Conserving Surgery for Breast Cancer.

INTRODUCTION: Partial breast reconstruction (PBR) using chest wall perforator flaps (CWPF) allows for excision of tumors in the outer quadrant of the breast in women with small to moderate non-ptotic breasts resulting in a good aesthetic outcome. There are limited data available in the literature regarding long-term follow-up and the effect of CWPF on subsequent surveillance mammographic interpretation and recall rates. A retrospective audit with qualitative analysis of initial mammograms was performed to assess this. PATIENTS AND METHODS: This retrospective analysis of a prospectively maintained database included all consecutive patients who underwent either PBR with CWPF or wide local excision (WLE) between January 2013 and December 2014 by a single surgeon in a tertiary referral center. Qualitative analysis of the postoperative mammograms was performed after review by 2 blinded radiologists. RESULTS: Thirty-six patients were included in the study, 18 in each arm. The CWPF group was younger and had larger tumor size anticipated on preoperative imaging, which correlated with larger specimens excised. Both groups were comparable with respect to tumor pathological characteristics. Comparing the first postoperative mammograms, both groups were similar in features reported such as calcifications, fat necrosis, volume loss, and radiotherapy changes. During the follow-up period (median 4 years), 138 surveillance mammograms were performed. One patient was recalled for further imaging in the CWPF group. There was no significant difference in the need for diagnostic imaging and biopsy between the groups. CONCLUSION: Patients who underwent PBR using CWPF had similar features on postoperative surveillance mammograms compared with that post WLE.

TIGR matrix for implant-based breast reconstruction - a long-term resorbable mesh.

The use of biological and synthetic meshes to aid implant coverage in implant-based breast reconstruction is well established. This technique allows single stage implant-based reconstruction compared to the traditional technique which required tissue expansion before permanent implant placement and therefore involved two operations for the patient. They can further be used for pre-pectoral implant reconstructions in a similar direct-to-implant strategy. This retrospective observational study by Pompei et al has evaluated the use of TIGR Matrix, a long-term resorbable mesh, in 49 patients with 60 operated breasts for both reconstructive and aesthetic cases. They have reported their operative method and followed up their cases for a mean of 12 months. They have reported a cumulative mesh complication rate of 5.4% and one implant was explanted due to infection. They identified a significant correlation between obesity and mesh-related complications. This study is significant as there remains little data regarding the long term outcomes of resorbable synthetic mesh for breast reconstruction. Their reported complication rates are consistent with those in other studies for synthetic meshes. As synthetic meshes can be significantly cheaper than their biological counterparts, this work could promote more widespread use.

The role of rapid thromboelastography in trauma.

Evaluation of: Hampton DA, Lee TH, Diggs BJ, McCully SP, Schreiber MA. A predictive model of early mortality in trauma patients. Am. J. Surg. 207(5), 642-647 (2014). In their prospective multi-centred observational study, Hampton et al. tested the ability of rapid thromboelastography (r-TEG) to predict mortality in trauma patients. A total of 795 patients were assessed. The authors analysed both patient demographic and physiological measures. Validation of variables that significantly related to mortality was subsequently undertaken. Ly30 (a measurement of the degree of clot lysis over 30 min) was observed to be a predictor of 24-h mortality in trauma (odds ratio 3.7 p = 0.03). This was incorporated with haemoglobin level, international normalized ratio, Glasgow Coma Score and the presence of penetrating injury to form their five-variable mortality prediction model. Hampton et al. conclude that the correlation between r-TEG measurements and trauma mortality makes it a useful tool in mortality prediction. The report highlights the importance of using this point-of-care coagulation assessment machine in mortality prediction for trauma patients.

Posterior shoulder dislocation while lifting weights: a missed diagnosis.

We present a case of a 24-year-old man who suffered acute shoulder pain and subsequent inability to move his arm while lifting weights in the bench-press position. He attended A&E where he was examined and X-rays were performed. He was diagnosed with presumed pectoralis major tendon rupture and was discharged to fracture clinic the following day with analgesia. On review in clinic he was found to have a posterior shoulder dislocation and was taken to theatre for relocation under anaesthesia. This case report examines the mechanism, investigations and management of posterior shoulder dislocation.

Smokable ("ice", "crystal meth") and non smokable amphetamine-type stimulants: clinical pharmacological and epidemiological issues, with special reference to the UK.

"Ice", "crystal meth", is the smokable form of methamphetamine hydrochloride. This paper will comment on the pharmacological, epidemiological, clinical and social issues related to smoking the drug as opposed to either its injection or ingestion. Furthermore, some data related to amphetamines/methamphetamines consumption, request for treatment, seizures, related offences and deaths in the UK (1990-2002) will be offered here. Peak rates, for most indicators, were reached at the end of the '90s, to fall down in the following years. The only indicator which seemed not to show any declining rates is number of deaths, but this may be related to a more general increase in stimulant death rates recently observed in the UK. It is argued that methamphetamines, and particularly "crystal meth", could reach the same prevalence levels of use in the UK as it is already in the US but recent reclassification of the drug to Class A in the UK could help to better control this emerging issue.