Do Patients After Reexcision Due to Involved or Close Margins Have the Same Risk of Local Recurrence as Those After One-Step Breast-Conserving Surgery?

PURPOSE: To explore whether patients after a reexcision due to involved or close margins have the same risk of local recurrence (LR) than those after a one-step breast-conserving surgery (BCS); to learn whether the presence of residual cancer in the reexcision specimen influences the probability of LR. METHODS: We reviewed demographic, clinical, radiologic, and pathologic records of a cohort of women diagnosed with invasive cancer or carcinoma-in situ who underwent BCS surgery as final surgical treatment between January 1, 2003, and December 31, 2011. Univariable and multivariable Cox regression analyses were used to evaluate influencing factors of LR. RESULTS: A total of 2657 patients were eligible for inclusion onto this study. LR was observed in 67 patients (2.5 %) after a median follow-up of 52 months. Reexcision surgery was performed in 486 patients (18.3 %). The 5-year LR-free survival rate was 94.5 % in the reexcision group and 98.0 % in the group with one-step BCS surgery (p < 0.001). In multivariable Cox regression analyses including different covariates patients with a reexcision had a two to eightfold higher risk of LR. Residual cancer in the reexcision specimen did not influence the LR rate (hazard ratio 1.1, p = 0.779). CONCLUSIONS: This study suggests the importance of a complete tumor resection ideally within one surgical procedure. Therefore, rigorous preoperative planning, multidisciplinary decision making, and additional intraoperative techniques (e.g., ultrasound, specimen radiography, and/or cavity shaved margin) should be used to avoid the need for reexcision.

Extent of primary breast cancer surgery: standards and individualized concepts.

Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.

Life cycle assessment of vertical and horizontal flow constructed wetlands for wastewater treatment considering nitrogen and carbon greenhouse gas emissions.

Life cycle assessment (LCA) is used to compare the environmental impacts of vertical flow constructed wetlands (VFCW) and horizontal flow constructed wetlands (HFCW). The LCAs include greenhouse gas (N(2)O, CO(2) and CH(4)) emissions. Baseline constructed wetland designs are compared to different treatment performance scenarios and to conventional wastewater treatment at the materials acquisition, assembly and operation life stages. The LCAs suggest that constructed wetlands have less environmental impact, in terms of resource consumption and greenhouse gas emissions. The VFCW is a less impactful configuration for removing total nitrogen from domestic wastewater. Both wetland designs have negligible impacts on respiratory organics, radiation and ozone. Gaseous emissions, often not included in wastewater LCAs because of lack of data or lack of agreement on impacts, have the largest impact on climate change. Nitrous oxide accounts for the increase in impact on respiratory inorganic, and the combined acidification/eutrophication category. The LCAs were used to assess the importance of nitrogen removal and recycling, and the potential for optimizing nitrogen removal in constructed wetlands.

Delivering sustainable infrastructure that supports the urban built environment.

Sustainable living will require megacity-level infrastructural support designs and paradigms.