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.

Misleading presentations of malignant breast diseases--role of clinical cytology.

We described two examples with misleading presentations to draw attention to the role of clinical cytology as apart of multidisciplinary approach to breast lesions. In the first case--Paget's disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case--primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses.

Algorithm for classification and treatment of poststernotomy wound infections.

The treatment of sternal wound infection still carries a high mortality. Treatment preferences range from more conservative treatments that do not include flaps, to more aggressive reconstructions using different types of flaps, and these could be resolved and standardised using a proper classification with a treatment algorithm. We propose modification of the existing classification, with different proposals for treatment, stressing the importance of the radicality of debridement, and report our results in 31 patients, 24 of whom were well satisfied. Eleven were left with some pain in the chest wall, and eight each with some muscular weakness and less than adequate cosmesis. We would also like to recommend the omental flap as the first choice for selected cases. With our selective approach we have achieved good functional and aesthetic results with satisfied patients.

[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.

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.

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.

Nipple-areola complex preservation: predictive factors of neoplastic nipple-areola complex invasion.

Recently, skin-sparing mastectomy (SSM) with nipple-areola complex (NAC) preservation has been promoted as an oncologically safe procedure in practice for selected patients. The criteria of selection have not been yet defined precisely. The focus of this study was to investigate predictive factors of NAC-base neoplastic involvement to define the indications for NAC preservation. A prospective clinical study was conducted of 108 randomly selected female patients with invasive breast cancer. Analyzed markers of NAC involvement were tumor-nipple distance (TND), tumor size, localization, histologic type, grade, lymphovascular invasion (LVI), site, and axillary lymph-node status. The definitive histologic findings of the NAC base were compared with analyzed markers and the frozen section results. NAC base was positive in 23.15% patients at definitive histology with false-negative results in 4.63% patients at intraoperative frozen section. Significant differences were found in TND, tumor size, axillary lymph-node status, and LVI. There were no significant differences in tumor grade and site and not enough cases for statistical evaluation in histologic type and localization. Clinical indications for NAC preservation, according to this study, include tumors < or =2.5 cm, TND >4 cm, negative axillary lymph node status, and no LVI. Considering the possibility of pre- or intraoperative measurement, tumor size, and TND evaluation will result in the lowest possible mistakes in NAC preservation. Frozen section analyses of the NAC base, because of the "false-negative" possibility, could be deemed as a relative prognostic factor until definitive histologic findings. The presence of an extensive intraductal component (EIC) in the "borderline" cases of these criteria could be an additional argument for NAC removal.

Omega and inverted omega incision: a concept of uniform incision in breast surgery.

In the history of breast surgery, we have seen a lot of changes in orientation, position, and localization of breast incisions. Most of the biopsy incisions have been made with no consideration of future mastectomy or reconstruction because a wide ellipse of skin removed during the mastectomy included the biopsy site. The primary surgical treatment was in the competence of the oncologic or general surgeon. Reconstruction was not an integral part of breast carcinoma therapy and was considered as a secondary, unimportant treatment to be preformed by a plastic surgeon at a later date if desired by the patient. Wide acceptance of conservative breast operations, skin-sparing mastectomy, and reconstruction as an integral part of breast cancer therapy necessitates new consideration about the initial incisions used for breast biopsy. We consider the omega incision not only as a type of incision but also as a concept that can be used for all breast surgery, including biopsy, lumpectomy, skin-sparing mastectomy, and reconstruction.

Deep inferior epigastric perforator flap: a modification that simplifies elevation.

The deep inferior epigastric perforator flap is accepted worldwide as a reliable and relatively safe technique for autologous breast reconstruction. Preserving the continuity of the rectus muscle, it reduces donor site morbidity, allowing less postoperative pain, a faster recovery, and a reduced hospital stay. Nevertheless, the more complex nature of this type of surgery leads to increased operating time and a demand for more tedious microsurgical dissection. The authors present a modification of the deep inferior epigastric perforator flap harvesting technique that allows a more safe, simple, and faster elevation of the flap. They have used it successfully for breast reconstruction in 3 patients.

Heel reconstruction with an iliac osteocutaneous free flap: 10-year follow-up.

During the Homeland War in Croatia, many civilians suffered from war wounds of the extremities. Explosive war wounds create composite and devastating injuries mainly by high-energy transfer to the tissue. We present an early reconstruction of explosive heel wound with an iliac osteocutaneous free flap with late follow-up result.

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.