A profile of female academic surgeons: training, credentials, and academic success.

The objective of this study was to determine the profile (credentials, training, and type of practice) of female academic general surgeons and factors that influenced their career choice. A survey was sent to female academic surgeons identified through general surgery residency programs and American medical schools. The women had to be Board eligible/certified by the American Board of Surgery or equivalent Board and have an academic appointment in a Department of Surgery. Data were analyzed using the SPSS program. Two hundred seventy women (age range, 32-70 years) completed the survey (98.9% response rate). Fellowships were completed by 82.3 per cent (223/270), most commonly in surgical critical care. There were 134 (50.2%, 134/367) who had two or more Board certificates, most frequently (46%, 61/134) in surgical critical care. Full-time academic appointments were held by 86.7 per cent of women, most as assistant professors, clinical track; only 12.4 per cent were tenured professors. The majority of women described their practice as "general surgery" or "general surgery with emphasis on breast." The most frequent administrative title was "Director." Only three women stated that they were "chair" of the department. The top reason for choosing surgery was "gut feeling," whereas "intellectual challenge" was the reason they pursued academic surgery. When asked "Would you do it again?", 77 per cent responded in the affirmative. We conclude that female academic surgeons are well trained, with slightly more than half having two or more Board certificates; that most female academic surgeons are clinically active assistant or associate professors whose practice is "general surgery," often with an emphasis on breast disease; that true leadership positions remain elusive for women in academic general surgery; and that 77 per cent would choose the same career again.

Sentinel node staging of early breast cancer using lymphoscintigraphy and the intraoperative gamma detecting probe.

Lymphoscintigraphy combined with intraoperative gamma-probe detection of sentinel lymph nodes in patients with inoperable early primary breast cancers is effective for staging the disease. The clinical alternative is axillary lymph node dissection, which is a far more invasive procedure and is accompanied by significant morbidity. Accuracy of staging is enhanced by immunohistochemical staining of micrometastases, which pathologists can easily perform for one to three sentinel lymph nodes, but not for 20 to 30 nodes, using axillary dissection procedure. Optimum methodology is presented for performing sentinel lymph node imaging and is important for accurate identification of sentinel node(s).

Sentinel node staging of early breast cancer using lymphoscintigraphy and the intraoperative gamma-detecting probe.

Sentinel node staging for breast cancer is increasingly used in place of axillary lymph node dissection but is not yet universally accepted. The problems of non-standardized methodologies and lack of consensus on the optimum techniques to identify sentinel nodes are being addressed. Complementary use of radionuclide imaging before surgery, intraoperative probe detection, and blue dye have yielded the best reported sensitivities for finding a sentinel node (94%). The importance of imaging is summarized as identifying sentinel node(s), distinguishing sentinel from secondary nodes, guiding surgical incision planning, and facilitating lower doses. The learning curve phenomenon, which applies to the surgeon and the nuclear medicine physician, has been recognized; measures to minimize it are being implemented. Radiation exposure to operating room and pathology personnel is very low; estimates of exposure to the surgeon's hands are 0.2% of the annual whole body dose received by every human being from natural background and cosmic sources.

Cellulitis of the breast as a complication of breast-conserving surgery and irradiation.

Breast-conserving therapy (BCT) has become a standard treatment option for patients with early-stage breast cancer. We have observed cellulitis of the treated breast as a complication occurring before, during, and after breast irradiation. The cases of five women (median follow-up, 28 months; range, 24-65 months) who developed cellulitis before (n = 1), during (n = 2), or after (n = 2) breast irradiation were reviewed. A consecutive series of BCT patients at Emory University was reviewed to determine the incidence of this complication. Four of five women had an axillary dissection, yielding a median of 14 negative lymph nodes (range, 6-22 nodes). Two of four patients developed axillary seromas requiring aspiration. In these four patients, only the breast was irradiated. A fifth patient had no axillary dissection and had breast and supraclavicular/axillary irradiation. The median whole breast dose was 50 Gy (range, 46-50.4 Gy). The clinical features of cellulitis included erythema, edema, tenderness, and warmth in all patients. Cellulitis was a relapsing problem for four of the five patients. The incidence of this complication in our series of BCT patients was approximately 1%. Cellulitis in the ipsilateral breast can be a relapsing complication of BCT and can be seen before, during, or after breast irradiation. Axillary seromas and aspiration seem to indicate a subset of patients at risk of early cellulitis. Late cellulitis may be caused by a variety of factors related to modifications of vascular and skin integrity by surgery and radiotherapy. Prompt diagnosis and appropriate antibiotic therapy is recommended. This problem need not interrupt a course of breast irradiation, and does not necessarily lead to a poor cosmetic result.

Skin-sparing mastectomy. Oncologic and reconstructive considerations.

OBJECTIVE: The authors compared skin-sparing mastectomy and traditional mastectomy both followed by immediate reconstruction in the treatment of breast cancer. SUMMARY BACKGROUND DATA: Skin-sparing mastectomy is used increasingly in the treatment of breast cancer to improve the aesthetic results of immediate reconstruction. The oncologic and reconstructive outcomes of this procedure have never been analyzed closely. METHODS: Institutional experience with 435 consecutive patients who underwent total mastectomy and immediate reconstruction from January 1989 through December 1994 was examined. Mastectomies were stratified into skin-sparing (SSM) and non-skin-sparing (non-SSM) types. RESULTS: Three hundred twenty-seven SSMs and 188 non-SSMs were performed. The mean follow-up was 41.3 months (SSM, 37.5 months, non-SSM, 48.2 months). Local recurrences from invasive cancer occurred after 4.8% of SSMs versus 9.5% of non-SSMs. Sixty-five percent of patients who underwent SSMs had nothing performed on the opposite breast versus 45% in the group of patients who underwent non-SSM (p = 0.0002). Native skin flap necrosis occurred in 10.7% of patients who underwent SSMs versus 11.2% of patients who underwent non-SSMs. CONCLUSIONS: Skin-sparing mastectomy facilitates immediate breast reconstruction by reducing remedial surgery on the opposite breast. Native skin flap necrosis is not increased over that seen with non-SSM. Skin-sparing mastectomies can be used in the treatment of invasive cancer without compromising local control.

Mammography of the postreconstruction breast.

Experience with mammographic examination of the reconstructed breast after mastectomy is limited. Typical mammographic changes associated with breast reconstruction are described. When these changes are identified on mammography, they can prevent patients from having unnecessary biopsies and can alleviate patient anxiety. A retrospective review of all mammograms performed in our breast center was made to identify typical as well as unusual findings on the postreconstruction mammogram. The findings were correlated with the type of reconstruction and the physical examination findings. Mammography after mastectomy and breast reconstruction was performed in patients with palpable abnormalities, a suspicion for implant failure, or for patient anxiety. In the postreconstruction patient with a palpable mass, features characteristic of fat necrosis were the most frequent abnormal findings on mammography. Unusually placed implants or focal implant ruptures may explain a mass discovered on breast physical examination. Imaging of the reconstructed breast after mastectomy yields typical mammographic findings. Fat necrosis can be identified on mammography and may explain a new palpable mass on physical examination. Mammography continues to be useful to identify a postoperative complication or implant failure and to differentiate it from tumor recurrence.

Preservation of the inframammary fold: what are we leaving behind?

Preservation of the inframammary fold (IMF) at the time of mastectomy facilitates immediate breast reconstruction. Twenty-four IMF specimens were removed separately after mastectomy for cancer, were serially sectioned, and were examined histologically. Computer image analysis was used to calculate the percentage of breast tissue in each specimen. The mean volume of IMF tissue removed was 99 cm3 (27.3-205.2 cm3), and the mean area examined histologically was 3,036.3 mm2 (294-11,755 mm2). Breast tissue was identified in 13 of the 24 specimens. All cases were negative for carcinoma, but one case had a focus of ductal hyperplasia, usual type. The mean percent breast tissue in those positive for breast tissue was 0.04 percent and 0.02 percent overall. Preservation of the IMF leaves a minimal amount of breast tissue and does not appreciably effect the completeness of a mastectomy.

Autologous breast reconstruction with endoscopic latissimus dorsi musculosubcutaneous flaps in patients choosing breast-conserving therapy: mammographic appearance.

OBJECTIVE: The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap. MATERIALS AND METHODS: Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips. RESULTS: Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible. CONCLUSION: Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.

Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap.

BACKGROUND: The management of state III breast cancer is challenging; it often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate transverse rectus abdominis musculocutaneous (TRAM) flap in 21 patients treated for stage III breast cancer. METHODS: Data have been collected retrospectively on 21 patients diagnosed with stage III breast cancer between 1987 and 1994. All patients had mastectomy and immediate TRAM reconstruction. Thirteen patients received primary systemic therapy, 10 patients received postoperative consolidation radiotherapy to the operative site, and 3 patients received preoperative radiation. RESULTS: Mean follow-up for the group was 26 months. Two patients died with disseminated disease: neither of them developed local disease recurrence in the operative site; 82% of the patients followed for at least two years are free of disease. Sixty-two percent of the patients received preoperative chemotherapy, the remaining patients received postoperative multiagent chemotherapy and/or radiation therapy. Two of the patients received autologous bone marrow transplants after their adjuvant therapy. Ten patients had postoperative radiotherapy for consolidation; three patients received preoperative radiation. CONCLUSIONS: Immediate TRAM reconstruction for stage III breast cancer is not associated with a delay in adjuvant therapy or an increased risk of local relapse. It facilitates wide resection of involved skin without skin grafting. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of stage III breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.

Adjuvant chemotherapy in the node-negative breast cancer patient.

For node-negative patients with tumors 2 cm or greater, the advantage of adjuvant therapy seems to outweigh any associated morbidity. For women less than 50, polychemotherapy (CMF, CA, CAF) is the standard of care. For women older than 50 who are hormone receptor positive, tamoxifen provides the major benefit. For estrogen receptor-positive women less than 50, adding tamoxifen and for estrogen receptor-positive women older than 50, adding chemotherapy may provide smaller incremental benefit. For hormone receptor-negative women over 50 years, there is a lesser but real benefit from polychemotherapy and a small benefit from tamoxifen (perhaps because of false receptor-negative results.) For tumors 1 cm or less in size (or tubular, papillary < 2 cm), the prognosis is so favorable that outside a clinical trial, adjuvant therapy is not recommended. For patients with node-negative tumors 1 to 2 cm in size, other prognostic factors, size (1.1 versus 1.9 cm), possibility of tamoxifen benefit, and age (45 versus 80 years) all influence the physician's recommendation to the patient.

Endoscopic techniques in aesthetic breast surgery. Augmentation, mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy, and reconstructive techniques.

Endoscopy is a new tool in the armamentarium for surgery of the breast. Endoscopic techniques may offer decreased scarring and morbidity rates for a variety of aesthetic and reconstructive procedures. Whereas initial clinical experiences are encouraging, most endoscopic procedures of the breast remain developmental, both in technique and instrumentation. Additional development, refinement, and experience will be required to define fully the utility of endoscopic techniques.

Conservative treatment of early-stage breast cancer in a medically indigent population.

The compliance with a program of breast-conservation treatment for early-stage breast cancer and the results of that treatment among women treated between January 1983 and January 1992 was investigated in a large inner-city public hospital serving a primarily black population. Medical records and charts were reviewed for 25 consecutive patients with stage I and II breast cancer seen in consultation in the radiation oncology department. Of those 25 patients, 20 underwent lumpectomy and radiation therapy. Survival, disease-free survival, and local recurrence-free survival were computed using the Kaplan-Meier method. Compliance was evaluated based on time to complete the prescribed course of radiotherapy after a lumpectomy. Five-year local recurrence-free survival for stage I and II patients was 95% (confidence interval [CI]: 71% to 99%). Five-year overall survival for stage II patients was 71% (CI: 31% to 92%), and disease-free survival was 74% (CI: 36% to 91%). This study demonstrates that a program of breast-conservation treatment for early-stage breast cancer can be implemented with good results, excellent treatment compliance, and 100% follow-up in a population of medically indigent women.

Conservative treatment of early-stage breast cancer. The Emory experience.

Between January 1983 and December 1991, 80 women with AJCC clinical stage I or II breast cancer were treated with conservative surgery and radiation therapy. Reexcision of the primary was performed in 40 breasts, and residual tumor was identified in 40% of these. Margins of resection were assessed in 80% and, of these, 46 patients had final margins of resection that were negative, 86% had axillary node dissection, 45 patients had histologically negative axillary nodes, and 24 had histologically positive axillary nodes. Of patients with histologically positive lymph nodes, 92% received systemic adjuvant treatment consisting of chemotherapy in 19/24 and tamoxifen in 14/24. Median follow-up was 34 months (range: 6-90 months). The adjusted 5-year actuarial Overall Survival for the group was 92%, and Disease-Free Survival was 80%. The 5-year Local Recurrence-Free Survival was 96%. The present study confirms the excellent results that can be obtained with conservative surgery plus radiation therapy.

Hickman catheter malposition in central venous tributaries: an avoidable error?

We report three cases of erroneous positioning of Hickman catheters into central venous tributaries. The malposition was not diagnosed intraoperatively because of proximity of such veins to the superior vena cava. Suspicion of misplacement raised by early postoperative catheter malfunction should allow for correction by percutaneous vascular catheters.

The effects of reversal of jejunoileal bypass operations on hepatic triglyceride content and hepatic morphology.

Obesity is associated with significant hepatic steatosis, inflammation, and cirrhosis. These changes may be accentuated by jejunoileal bypass operations. This study is intended to determine if reconstruction of jejunoileal bypass operations alters hepatic triglyceride content and hepatic morphology. Eighty-eight +/- 27 months after jejunoileal bypass, 26 patients underwent reconstruction for a variety of complications of the operation, including five patients with cirrhosis. At the time of reconstruction, hepatic triglyceride content was 132 +/- 13 mg/100 mg protein. After reconstruction, hepatic triglyceride content increased to 205 +/- 32 mg/100 mg protein in patients whose body weight increased and decreased to 84 +/- 6 mg/100 mg protein in patients whose body weight decreased. After reconstruction, hepatic inflammation decreased in 20 patients and hepatic fibrosis decreased in 17. These changes were not related to body weight changes. In five patients with cirrhosis at the time of reconstruction, one died of liver failure and hepatic morphologic findings improved in four after reconstruction of jejunoileal bypass operations. The results of this study suggest that reconstruction of jejunoileal bypass operations with weight loss or maintenance of body weight after reconstruction is associated with decreased fat in the liver. Approximately 65% of the patients will have improvement in hepatic morphologic parameters after reconstruction. Inflammation will be more greatly benefited than will fibrosis. In some patients, hepatic histologic abnormalities are unchanged or will progress despite reconstruction of jejunoileal bypass operations.