Skin and nipple-areola complex sparing mastectomy in breast cancer patients: 15-year experience.

Skin and nipple-areola complex sparing mastectomy (SNSM) and primary reconstruction have been popular for breast cancer treatment in the last decade. An advantage of the SNSM technique is the removal of all breast tissue as a radical surgical procedure while preserving native breast integrity, nipple-areola complex (NAC), and submammary fold. This retrospective 15-year clinical study analyzes medical records from our breast surgery database collected at our department between 1997 and 2012. A total number of 3757 patients were treated for breast cancer; 411 (10.9%) patients had a skin-sparing mastectomy with the median (range) length follow-up of 63 months. This is the longest follow-up for SNSM in breast cancer patients; 3.7% of patients who underwent SNSM developed disease local recurrence, whereas occult NAC involvement with cancer occurred in 7.7% and local recurrence in the NAC in 1.2%. Partial necrosis of the NAC developed in 9.4% and total necrosis in 0.7% of operated breasts. All disease recurrences occurred in the first 10 years of the follow-up period. Local recurrence developed as first recurrence event has longer median cancer-specific survival time of 70 months than those with only distant metastases with 50 months and locoregional plus distant metastases with 35.5 months. The "Omega" pattern incision combines an oncological radical procedure with a lower incidence of skin flap necrosis. Patients reconstructed with autologous tissue were the group most satisfied. SNSM is an oncological safe procedure for breast cancer treatment with low recurrence in properly selected patients.

Expression of genes responsible for the repair of mispaired bases of the DNA (MLH1) in invasive ductal breast carcinoma.

Breast cancer is a heterogeneous group of diseases determined and distinguished by cellular type, gene expression and clinical signs and symptoms. Identification of histological and biological markers is of great value in predicting the progression of tumor growth and anticipating the expected response to various treatment options. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific research we wanted to determine the involvement of the genetic polymorphisms of DNA mismatch repair system (MLH1 gene) and the subsequent development of breast carcinoma. This study included 108 patients who were surgically treated for invasive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava". The expression of the MLH1 gene was determined by immunohistochemical methods. The results showed that 82.9% of tumor cells expressed the MLH1 gene. Analysis of survival rate for patients with invasive ductal breast cancer showed a statistically significant (p = 0.043) correlation with the expression of MLH1 genes. The overall five year survival rate of our patients was 78.7%. These results indicate that there is a possible involvement of MLH1 gene in the progression and development of breast cancer.

Who is the patient? Disclosure of information and consent in anesthesia and intensive care (informed consent).

Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the practice, however with the vast advances in science and technology, numerous ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hippocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together represent the complete best interest of the patient. This is the basic goal of the "Informed Consent". The widening of legal boundaries regarding professional liability may consequentially lead to a "defensive medicine" and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evaluating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief explain all the necessary information a "reasonable" anesthesiologist would disclose to a "reasonable" patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient.

Clinical and patohistological factors affecting the 5 year survival rate in a population of Croatian women with invasive ductal breast carcinoma.

Breast carcinoma falls into a heterogeneous group of diseases which can be determined by various prognostic factors. The identification of clinical and histopathologic factors is of great value in predicting the progression of tumor growth and survival outcome. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific study of the expression of genes responsible for mismatch repair of DNA in cells of invasive ductal carcinoma we also compared the patient survival rate with the major prognostic factors. This study included 108 patients who were surgically treated for invasive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava". The overall survival rate was compared to factors such as initial tumor stage, regional lymph node involvement and distant metastasis. The overall five year survival rate of our patients was 78.7%. Patients without the presence of distant metastasis, a lower rate of local lymph node involvement and a lower. tumor stage statistically had a longer overall survival period. It is important that physicians recognize the various clinico-pathohistological factors in patients with breast carcinoma. This study confirms that this prognostic factors determine the type of treatment required and most important, the patient overall survival period.

Intraoperative imprint cytological assessment of the subareolar tissue of the nipple areola complex (NAC).

One of the criteria of selection for skin sparing mastectomy (SSM) with nipple areola complex (NAC) preservation is to exclude the neoplastic involvement of subareolar tissue (NAC base) in order to minimize the possibility of local recurrence. The most common way to assess the possible neoplastic involvement is intraoperative frozen section of the NAC base tissue. Because of its limitations, particularly the false negative results due to unsampling, we tried to use intraoperative imprint cytology for more thorough intraoperative assessment. The aim was to compare intraoperative imprint findings with the definitive histology of the NAC base, to evaluate diagnostic accuracy of this method and possibility to substitute frozen section for intraoperative assessment of NAC base. A prospective clinical study was conducted of 208 consecutive female patients who underwent open biopsy because of carcinoma. Intraoperative imprints were taken from the excised subareolar tissue which was then routinely processed for definitive histology. Imprint findings designated positive, negative, suspicious or atypia, were compared with definitive histological findings. Our results with 7.5% false negative rate, 9.8% false positive rate, sensitivity of 50% and specificity of 87.58% argue that imprint cytology might not be sufficient as an exclusive method for the intraoperative assessment of the NAC base though it should be used routinely in conjunction with frozen section examination.

Early cardioprotective effect of sevoflurane on left ventricular performance during coronary artery bypass grafting on a beating heart: randomized controlled study.

AIM: To evaluate the cardioprotective effect of sevoflurane on a beating heart in patients undergoing coronary artery bypass grafting with normal preoperative left ventricular function. METHODS: The randomized controlled study included 32 patients induced with sevoflurane and then randomized to receive either 1 minimal alveolar concentration (MAC) end-tidal concentration of sevoflurane (n=16) or propofol (n=16) 2 to 3 mg kg(-1) hour(-1). The acceleration of the aortic blood flow, cardiac index, heart rate, mean arterial pressure, and central venous pressure were measured 5 minutes after anesthesia induction, at the beginning of ischemia, 15 minutes after ischemia, and 15 minutes after sternum closure. RESULTS: There were no differences in heart rate, mean arterial pressure, and central venous pressure within each group and between groups during surgery. Acceleration increased in the sevoflurane group 15 minutes after ischemia (10.3+/-3.5 m/s(2); P=0.004) and 15 minutes after sternum closure (10.7+/-3.9 m/s(2); P<0.001). Acceleration in the propofol group decreased from the beginning of ischemia (P<0.001) and remained lower 15 minutes after sternum closure (P=0.001 and P=0.024, respectively). Acceleration was higher in the sevoflurane group at the beginning of ischemia and 15 minutes after sternum closure (P=0.017 and P=0.046, respectively). There were no significant differences in cardiac index values within the sevoflurane group. In the propofol group, significant decreases in cardiac index were seen at the beginning of ischemia (P<0.001). There were between-group differences in cardiac index values at the beginning of ischemia and 15 minutes after ischemia (P=0.002, and P=0.011, respectively). CONCLUSION: Cardiac function was better preserved in the patients anesthetized with sevoflurane than in patients anesthetized with propofol.

[Lymphedema of the penis and scrotum: surgical treatment and reconstruction]. / Limfedem penisa i skrotuma: kirursko lijecenje i rekonstrukcija.

Penile and scrotal lymphedema causes significant functional, cosmetic and psychological problems. We present two patients with penoscrotal lymphedema successfully treated with wide radical excision of the lymphedematous tissue and reconstruction with skin flaps and split thickness grafts. No complications occurred postoperatively. Good cosmetic results and functionality are preserved 8 and 15 years after the surgery, with no recurrences.

Levosimendan as a new strategy during off-pump coronary artery bypass grafting: double-blind randomized placebo-controlled trial.

AIM: To determine if levosimendan could improve cardiac performance during off-pump coronary artery bypass grafting in patients with normal preoperative left ventricular function. METHODS: Twenty-four patients included in this double-blind randomized controlled trial received either placebo (n=12) or 12 microg/kg loading dose of levosimendan (n=12) during a period of 15 minutes before the surgery. The heart rate, cardiac index, stroke volume index, and left ventricular ejection fraction were measured before and 10 and 60 minutes after the drug administration. RESULTS: The baseline measurements of hemodynamic parameters did not differ between the groups. Heart rate was not significantly different between the placebo and levosimendan group. Compared with placebo group, cardiac index and left ventricular ejection fraction were significantly higher 10 and 60 minutes (p=0.018 for all) after administration of levosimendan. After 60 minutes, the cardiac index increased from the baseline value of 2.18 to 2.84 L/min/m2. Left ventricular ejection fraction increased by 14% after 10 minutes, and by 10% after 60 minutes. Stroke volume index was significantly higher at 10 minutes (p=0.018), but not at 60 minutes (p=0.063) after the administration of levosimendan. CONCLUSION: Administration of 12 microg/kg of levosimendan enhances the left ventricular performance and offers a promising therapeutic option during off-pump coronary artery bypass grafting in patients with good preoperative left ventricular function.

Surgical treatment of nevoid hyperkeratosis of the areola by removal of the areola and reconstruction with a skin graft.

Hyperkeratosis of the nipple and areola is a rare, sporadic, benign condition characterized by verrucosus thickening and brownish discoloration of the nipple and areola. Approximately 50 cases of hyperkeratosis of the nipple and areola have been reported in the literature. Dermatologists treated most of them conservatively. We have described the case of healthy 19-year-old girl with bilateral nevoid hyperkeratosis of the areola and our treatment by surgical removal of the areola and reconstruction with a skin graft. As far as we know, this is the first report of this kind of treatment. The final result is esthetically excellent and without recurrence during 12 months' follow-up.

Lesion of the common peroneal nerve during arthroscopy.

Arthroscopic knee surgery has been well accepted worldwide and has become an important part of orthopaedic surgery. The use of arthroscopy has reduced the duration of hospitalization, overall costs, and time required for the patient to return to sports activities or work. However, because of the closed nature of the procedure and proximity of neurovascular structures to instruments, substantial risk of injuries exists. Significant anatomic variability in the nerve course has not been reported in previous literature as a cause of a knee arthroscopy complication. We present a case of complete transection of an unusually located common peroneal nerve during a knee arthroscopy for lateral meniscal repair in a 22-year-old football player.

Rare complication of breast cancer irradiation: postirradiation osteosarcoma.

Radiation-induced osteosarcoma is a rare complication of radiation therapy for breast cancer. The authors present a 60-year-old patient in whom osteosarcoma of the chest wall developed 5 years after modified radical mastectomy and radiation therapy for breast cancer. One year after resection of the chest osteosarcoma, metastasis to the contralateral axillary lymph nodes developed and these were removed. Radiation-induced osteosarcoma is difficult to treat and has a poor prognosis, thus early diagnosis is necessary for optimal treatment.