Optimizing microvessel counts according to tumor zone in invasive ductal carcinoma of the breast.

We calculated microvessel counts (MVCs) by analyzing CD31-stained sections in three tumor zones (central, intermediate, and peripheral) in 147 cases of invasive ductal carcinoma (IDC). The purpose of the study was to discover whether there is a difference in MVC in the different zones of tumor, which zone contains the highest MVC within the tumor, from which zone the MVCs best correlate with tumor recurrence or tumor death, and which histologic factors correlate with the MVC of the tumor. Sections were scanned to assess the highest number of microvessels in any single 200 x field (0.384 mm2). In all of our cases, the average MVCs of the central, intermediate, and peripheral zones of the IDCs were 34.4, 39.4, and 51.5 per 200x field, respectively. The MVC significantly increased from the central to the peripheral zones (P < .001). In the univariate analysis, in at least one tumor zone, the MVC was correlated with T classification, tumor necrosis, fibrotic focus (a scar-like area within IDCs), and c-erbB-2 protein expression. The only factor significantly correlated with a higher MVC in all of the three zones was fibrotic focus. Moreover, in the multivariate analysis, tumors having high MVCs in the peripheral zone were significantly associated with higher hazard ratios for tumor recurrence (P < .05). This study showed that the MVC of an IDC significantly increases from the central to the peripheral zones, and it showed that angiogenesis in the peripheral zone is associated with prognosis. Therefore, estimation of angiogenesis should be performed in the peripheral zone for reliable prediction of outcome in breast cancer patients. As a surrogate for angiogenesis, fibrotic focus seems to be a useful marker for malignant potential in breast cancer.

Detection of the first recurrence during intensive follow-up of breast cancer patients.

BACKGROUND: Breast cancer patients are routinely followed after primary treatment. Many intensive diagnostic methods (tumor markers, chest X-ray, mammography, liver echography, bone scans) are performed periodically. However, it remains to be determined how often attempts should be made to detect the first recurrence of breast cancer by these methods. METHODS: To evaluate the effect of imaging diagnosis and tumor markers, we analyzed methods of detection of first recurrence sites during intensive follow-up of breast cancer patients. RESULTS: Of 550 female patients who had been surgically treated between July 1992 and December 1996, 65 recurrent cases had been diagnosed as of December 1997. Thirty cases (46%) had been found as a result of symptoms related to the site of recurrence and 14 cases (22%) were detected by physical examination. In the remaining 21 cases (32%), detection was by other methods: in eight cases by imaging diagnosis, in three cases based on abnormal tumor markers and in 10 cases by imaging diagnosis and abnormal tumor markers. Twenty-nine cases (45%) followed every 1-3 months had presented with symptoms at routine or interval appointments. There was a significant difference between first recurrence sites (loco-regional, bone and viscera) and the methods of detection (symptoms, physical examination and other diagnostic methods) (P < 0.0001). However, no statistical difference in overall survival after operation was observed between the 30 cases found as a result of symptoms and the 35 cases detected by physical examination or other diagnostic methods. CONCLUSIONS: Taken together with ASCO's surveillance guidelines (J Clin Oncol 1997;15:2149-56), intensive follow-up of breast cancer patients should be limited to high-risk breast cancer patients, especially those who enter randomized clinical trials. A careful history and physical examination are in practice indicated every 3-6 months for 3 years and then every 6 months for the following 2 years.

Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects.

OBJECTIVE: The anterolateral thigh flap has many advantages in head and neck reconstruction. However, it has not yet come into widespread use because of the anatomic variations of its perforators. Herein, we describe a safe operative technique related to the patterns of the perforators and discuss its wide versatility. SETTING: A national cancer center hospital. PATIENTS: Thirty-eight anterolateral thigh flaps were transferred. Confirmation and dissection of the flap pedicle were simultaneously performed with tumor resection. The design and elevation of the flap were carried out immediately after the tumor resection was completed. RESULTS: From the study of the anatomic variations of the perforators, septocutaneous patterns were recognized in 10 cases (26.3%) and musculocutaneous patterns in 28 cases (73.7%). All flaps were easily and safely elevated with our techniques. Thirty-six flaps survived. Partial necrosis was noted owing to excessive thinning procedure in one patient and total necrosis was noted owing to venous thrombosis at the anastomosis part in another patient. CONCLUSIONS: We found that the anterolateral thigh flap has numerous advantages. It is possible to perform the flap elevation and the tumor resection simultaneously. The flap is generally thin and is suitable for reconstruction of intraoral defects. Combined flaps with neighboring tissues and other, distant flaps can be used. Furthermore, since our technique minimizes the problems of confirmation and dissection of the perforators, we conclude that this flap can be successfully used to repair a variety of large defects of the head and neck.

Scarpa's adipofascial flap for repair of wide scalp defects.

Scarpa's fascia is a prominent superficial fascial system of the body. It consists of a single membrane between the superficial fatty layer and deep fatty layer, and lies widely in the lower abdominal wall. We describe a case with a wide scalp defect resulting from a resection of a dermatofibrosarcoma, and reconstruction of the defect with Scarpa's adipofascial flap (i.e., a combined paraumbilical perforator-based adipofascial flap-groin adipofascial flap). The primary advantage of Scarpa's adipofascial flap for scalp defects is that (1) the donor site is most acceptable for a free flap with a minimal donor scar and minimal dysfunction; (2) even in cases in which large flaps are used, donor defects can be closed directly without skin grafting; (3) in the obese patient, this flap is preferable because of cosmetic improvement of the abdominal wall; (4) the donor area has so many perforators that an extended adipofascial flap can be obtained with a combination of these perforators; and (5) the flap may be nourished with one of several arteries, such as the superficial or deep inferior epigastric artery, or the superficial or deep circumflex iliac artery. The disadvantages of this flap are that the territory with a single artery may be smaller than a skin flap with the same artery and oversurfacing of the graft results in a poor cosmetic appearance. Scarpa's adipofascial flap is indicated when the defects are in an exposed area, especially in children, young patients, and females, and when this procedure is combined with a skin-expanding method in the secondary repair.