Granulomatous lobular mastitis co-existing with ductal carcinoma in situ: Report of three cases and review of the literature.

Granulomatous lobular mastitis (GLM) is a benign and infrequent chronic breast ailment. Although this lesion can be clinically and radiographically mistaken for early-onset breast cancer, it is a rare occurrence for the two to coexist. This report describes three such cases. In all three patients, the primary signs and symptoms were related to the formation of diffuse breast masses or abscesses. Breast ultrasound and MRI revealed glandular edema and dilated breast ducts. The biopsies of all lesions exhibited both granulomatous inflammation confined to the lobules of the breast, abundant interstitial inflammatory cell infiltrates, and apparently cancerous cells located in dilated ducts with intact basement membranes. The surgically excised specimens confirmed the diagnosis of GLM and ductal carcinoma in situ (DCIS) in all three patients who underwent breast mass resection. By clinical imaging and clinical manifestations, GLM may obscure a concurrent DCIS, as highlighted by the cases reported herein.

Alcohol consumption, smoking, and invasive breast cancer risk after ductal carcinoma in situ.

PURPOSE: Alcohol is an established risk factor for invasive breast cancer, and women with a prior ductal carcinoma in situ diagnosis are at higher risk of invasive breast cancer than the general population. However, for women with a prior ductal carcinoma in situ diagnosis, few studies have evaluated the association between alcohol and smoking and risk of subsequent invasive breast cancer. METHODS: Utilizing a population-based case-control design nested among women diagnosed with a ductal carcinoma in situ between 1995 and 2013, we compared 243 cases diagnosed with a subsequent invasive breast cancer and 423 individually matched controls never diagnosed with a subsequent breast cancer. RESULTS: Compared with never to occasional drinkers, drinkers consuming at least 7 alcoholic drinks per week on average at ductal carcinoma in situ diagnosis had a higher risk of invasive breast cancer that was borderline significant (OR 1.79, 95% CI 1.01-3.17, P value = 0.04). Smoking was not significantly associated with risk of developing an invasive breast cancer after adjustment for alcohol consumption. CONCLUSIONS: These findings suggest that consuming at least one alcoholic drink per day on average is positively associated with invasive breast cancer for women with a prior ductal carcinoma in situ diagnosis. If confirmed, modulating alcohol consumption could be one strategy for women with a history of ductal carcinoma in situ to impact their risk of invasive breast cancer.

Mortality After Invasive Second Breast Cancers Following Prior Radiotherapy for DCIS.

BACKGROUND: Women with a history of ductal carcinoma in situ (DCIS) are at increased risk for developing a second breast cancer (SBC). A prior meta-analysis of randomized studies of radiotherapy (RT) for DCIS has shown a trend toward increased breast cancer-specific mortality after SBC, but it did not have the power needed to detect a significant difference, due to a limited number of recurrences. This study sought to evaluate the impact of RT for DCIS on mortality after SBC in a larger cohort. PATIENTS AND METHODS: Using the SEER database, 3,407 patients were identified who received breast-conserving therapy with or without RT for primary DCIS in 2000 through 2013 and subsequently developed a stage I-III invasive SBC within the same time period. Fine-Gray competing risk models were used to study the association between receipt of RT and mortality after SBC. RESULTS: Prior RT was found to be associated with higher rates of breast cancer-specific mortality (hazard ratio [HR], 1.70; 95% CI, 1.18-2.45; P=.005), even after controlling for cancer stage. Interaction analysis suggested that this risk trended higher in patients with ipsilateral versus contralateral SBC (HR, 2.07 vs 1.26; P=.16). Furthermore, compared with patients who developed contralateral SBC, those with ipsilateral SBC were younger (P<.001) and more often lacked estrogen receptor expression (P<.001). CONCLUSIONS: Patients who previously received RT for DCIS had higher mortality after developing an invasive SBC than those who did not receive RT. This finding may have implications for initial treatment decisions in the management of DCIS.

Risk of ischemic heart disease after radiotherapy for ductal carcinoma in situ.

PURPOSE: The use of adjuvant radiotherapy (RT) in the management of ductal carcinoma in situ (DCIS) is increasing. Left-sided breast irradiation may involve exposure of the heart to ionising radiation, increasing the risk of ischemic heart disease (IHD). We examined the incidence of IHD in a population-based cohort of women with DCIS. METHODS: The Breast Cancer DataBase Sweden (BCBase) cohort includes women registered with invasive and in situ breast cancers 1992-2012 and age-matched women without a history of breast cancer. In this analysis, 6270 women with DCIS and a comparison cohort of 31,257 women were included. Through linkage with population-based registers, data on comorbidity, socioeconomic status and incidence of IHD was obtained. Hazard ratios (HR) for IHD with 95% confidence intervals (CI) were analysed. RESULTS: Median follow-up time was 8.8 years. The risk of IHD was not increased for women with DCIS versus women in the comparison cohort (HR 0.93; 95% CI 0.82-1.06), after treatment with radiotherapy versus surgery alone (HR 0.77; 95% CI 0.60-0.98) or when analysing RT by laterality (HR 0.85; 95% CI 0.53-1.37 for left-sided versus right-sided RT). CONCLUSIONS: The risk of IHD was lower for women with DCIS allocated to RT compared to non-irradiated women and to the comparison cohort, probably due to patient selection. Comparison of RT by laterality did not show any over-risk for irradiation of the left breast.

Severe depression more common in patients with ductal carcinoma in situ than early-stage invasive breast cancer patients.

PURPOSE: Ductal carcinoma in situ (DCIS) is associated with an excellent prognosis; historical studies have shown similar levels of psychological distress in patients with DCIS and with early-stage invasive breast cancer (early-IBC). It is suggested that these results might have led to better patient education about prognosis after DCIS. This study reports the current levels of anxiety, depression, and health-related quality of life (HRQoL) in DCIS and early-IBC patients. METHODS: DCIS (n = 89) and early-IBC patients, T1-2N0, (n = 361) were selected from the UMBRELLA breast cancer cohort. Patient-reported outcomes were prospectively collected before the start of adjuvant radiotherapy (baseline) and at 3, 6, 12, 18, and 24 months thereafter. Mixed models were used to compare differences in levels of anxiety, depression, and HRQoL between DCIS and early-IBC patients. RESULTS: DCIS and early-IBC patients reported similar levels of anxiety, which were highest at baseline. Depression scores were comparable between groups, also after stratification by use of adjuvant chemotherapy. The proportion of patients reporting high-risk depression scores (i.e., Hospital Anxiety and Depression Sale score >8) was significantly higher among patients with DCIS at 6, 12 and 18 months, and this proportion increased over the first 18 months. Health-related quality of life was comparable between both groups. CONCLUSION: Severe depression scores are more common in DCIS patients, despite their excellent prognosis. These results suggest that further improvement of patient education and effective patient doctor communication about the prognostic differences between patients with DCIS and invasive breast cancer is still highly needed.

Trends in cardiac mortality in women with ductal carcinoma in situ.

PURPOSE: In certain ductal carcinoma in situ (DCIS) subpopulations, there is no consensus regarding whether to postoperatively irradiate; decisions are often made based on potential risk of cardiac toxicities. Given the utility of Surveillance, Epidemiology, and End Results (SEER) data for studying cardiac mortality in invasive disease, this is the first such study specific for DCIS patients, evaluating trends in cardiac mortality after left-sided radiotherapy (RT). METHODS: The SEER database was queried for patients with DCIS that received RT and had known unilaterality. The central design of this study was to compare cardiac-specific mortality (CSM) between left- and right-sided DCIS patients as stratifying for "older" RT (1973-1982) versus more "modern" RT (1983-1992 or 1993-2002). Survival analysis was performed using Kaplan-Meier methodology and multivariate Cox regression modeling for factors associated with overall survival (OS) and CSS. RESULTS: Left- and right-sided patients were demographically balanced. CSM was worse for left-sided patients with DCIS diagnosed in 1973-1982 [hazard ratio (HR) 1.295; 95% confidence interval (CI) 1.182-1.420], but not in 1983-1992 (HR 1.022; 95% CI 0.949-1.100) or in 1993-2002 (HR 0.989; 95% CI 0.935-1.046)]. On multivariate analysis, laterality was not associated with OS in either decade. However, left-sided laterality was independently associated with CSM during the 1973-1982 time period, but not the more recent time periods. Examining temporal patterns in the 1973-1982 cohort, cardiac mortality was significantly increased during 10-19 and ≥20 years after diagnosis, but there was no significant increase in cardiac mortality for patients diagnosed up to 10 years after diagnosis. CONCLUSIONS: In the largest such DCIS series to date, left-sided RT was an independent risk factor for increased cardiac mortality from 1973 to 1982, but not after 1983. Using modern RT techniques and maintaining low heart doses, RT may not induce excess CSM in the DCIS population.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study.

Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS. METHODS: A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1-3 years after surgery. RESULTS: Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6-14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1-7.0, p = 0.02) and anxiety and depression (measured by HADStotal >15 OR of 3.1 (95% CI: 1.5-6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress. CONCLUSIONS: This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

Breast cancer in a patient with Kindlers syndrome.

Breast Cancer (BC) has associated risk factors and genetic factors like BRCA1, and BRCA2. Many benign and malignant disease processes are found concurrently with BC and believed to be additional risk factors like gall bladder stones (cholelithiasis), hypertension, diabetes mellitus, cerebrovascular lesions, arthritis, spine and spinal cord degenerative lesions, infertility, depression, sleep disturbances, obesity, autoimmune diseases (SLE), and thyroid diseases. There are some malignant disease associations like synchronous or metachronous ovarian, colonic and endometrial tumours with Breast cancer. Kindler Syndrome (KS) is a rare autosomal recessive genetic disorder manifesting as generalized dermatoses, described in 1954 by Theresa Kindler. KS is associated with acral skin blistering inducible by trauma, mucosal inflammation, photosensitivity, progressive pigmentation, telangiectasia, and skin atrophy (Poikiloderma). Repeated and progressive inflammation and subsequent fibrosis leads to ectropion, esophageal, anal, urethral, and vaginal stenosis and dryness. About 100 cases of Kindler syndrome have been reported in literature so far some from Arab World as well. Pathobiology of Kindler syndrome is not well understood. There are defects in KIND1 gene on chromosome 20. This gene expresses itself in basal keratinocytes, where it encodes a protein, called Kindlin 1. We report the second only case of Kindler's syndrome having breast cancer. These very very rare combinations have diagnostic issues, management restrictions, prognostic and follow up implications.

CD4+ T cell-dominant insulitis in acute-onset Type 1 diabetes mellitus associated with intraductal papillary mucinous adenoma.

The loss of insulin-producing pancreatic ß-cells in Type 1 diabetes mellitus (DM) is presumably the result of a T cell-mediated process. In general, CD8+ T cells are the predominant lymphocytes in the insulitis lesions, and CD4+ T cell-dominant insulitis is very rare. We present a case of a 72-year-old woman presented with excessive thirst and a 3-month history of weight loss. She was in a state of ketosis, and her plasma glucose concentration and HbA1c value were elevated. Moreover, anti-islet autoantibodies were positive, thus acute-onset Type 1 DM was diagnosed. At the time of diagnosis, a tumour was detected in the pancreas; total pancreatectomy was carried out 2 months later. The pathological diagnosis was intraductal papillary mucinous adenoma. Immunohistochemical staining of a sample of non-tumorous pancreatic tissue revealed 13 insulitis lesions infiltrated by both CD4+ and CD8+ T cells, and interestingly there were more CD4+ T cells than CD8+ T cells in the lesions. Moreover, B cells and macrophages had also infiltrated the lesions, and these two cell frequencies were both positively correlated with CD4+ as well as CD8+ T cell frequencies. This was a rare case with acute-onset Type 1 DM characterized by CD4+ T cell-dominant insulitis. Proinflammatory cytokines that can promote ß-cell apoptosis or CD8+ T cell function are reported to be secreted from CD4+ T cells. Thus, together with B cells and macrophages, CD4+ T cell-associated immune responses may have, directly and/or indirectly, played a role in the pathogenesis of the Type 1 DM in this patient.

Accelerated partial breast irradiation through brachytherapy for ductal carcinoma in situ: factors influencing utilization and risks of second breast tumors.

The purpose of this study was to examine influencing factors and outcomes of accelerated partial breast irradiation through brachytherapy (APBIb) versus whole breast irradiation (WBI) for ductal carcinoma in situ (DCIS). From the Surveillance Epidemiology and End Results program of the US National Cancer Institute, we identified 40,749 women who were diagnosed with first primary DCIS between 2002 and 2011 and treated with breast-conserving surgery and radiotherapy. A multi-level logistic regression analysis was performed to estimate odds ratios of APBIb use. Hazard ratios (HRs) of developing ipsilateral breast tumors (IBTs) and contralateral breast tumors (CBTs) were analyzed in 1962 patients with APBIb and 7203 propensity score-matched patients with WBI, using Cox proportional hazards regression. Overall, 2212 (4.5 %) of 40,749 women (the whole cohort) received APBIb. Factors associated with the increased use of APBIb included older age, non-Hispanic white race/ethnicity, smaller tumor size, hormone receptor positivity, comedo subtypes, and urban residence. During the 46-month follow-up, 74 (0.8 %) and 131 (1.4 %) of 9165 propensity score-matched patients developed IBTs and CBTs, respectively. Compared with WBI, APBIb was associated with a significantly increased risk of IBTs (HR 1.74; 95 % CI 1.06-2.85) but not CBTs (OR 0.91; 95 % CI 0.59-1.41). This population-based study suggests that APBIb use for DCIS was influenced by patient and tumor characteristics as well as urbanization of residence. We observed a moderately increased IBT risk associated with APBIb versus WBI, suggesting that APBIb should be used with caution for DCIS before data from randomized controlled trials with long-term follow-ups are available.

Increased Risk of Surgical Site Infection Among Breast-Conserving Surgery Re-excisions.

PURPOSE: The aim of this study was to determine the risk of surgical site infection (SSI) after primary breast-conserving surgery (BCS) versus re-excision among women with carcinoma in situ or invasive breast cancer. METHODS: We established a retrospective cohort of women aged 18-64 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition (CPT-4) codes for BCS from 29 June 2004 to 31 December 2010. Prior insurance plan enrollment of at least 180 days was required to establish the index BCS; subsequent re-excisions within 180 days were identified. SSIs occurring 2-90 days after BCS were identified by ICD-9-CM diagnosis codes. The attributable surgery was defined based on SSI onset compared with the BCS date(s). A χ (2) test and generalized estimating equations model were used to compare the incidence of SSI after index and re-excision BCS procedures. RESULTS: Overall, 23,001 women with 28,827 BCSs were identified; 23.2 % of women had more than one BCS. The incidence of SSI was 1.82 % (418/23,001) for the index BCS and 2.44 % (142/5,826) for re-excision BCS (p = 0.002). The risk of SSI after re-excision remained significantly higher after accounting for multiple procedures within a woman (odds ratio 1.34, 95 % confidence interval 1.07-1.68). CONCLUSIONS: Surgeons need to be aware of the increased risk of SSI after re-excision BCS compared with the initial procedure. Our results suggest that risk adjustment of SSI rates for re-excision would allow for better comparison of BCS SSI rates between institutions.

A Prospective Validation Study of Bioimpedance with Volume Displacement in Early-Stage Breast Cancer Patients at Risk for Lymphedema.

BACKGROUND: Although volume displacement (VD) is considered the gold standard for diagnosing breast cancer-related lymphedema, it is inconvenient. We compared bioimpedance (L-Dex) and VD measurements in a prospective cohort of breast cancer patients at risk for lymphedema. METHODS: Between 2010 and 2014, a total of 223 breast cancer patients were enrolled. Following exclusions (n = 37), 186 received baseline VD and L-Dex; follow-up measurements were performed at 3-6 months intervals for 3 years. At each visit, patients fitted into one of three categories: normal (normal VD and L-Dex); abnormal L-Dex (L-Dex > 10 or increase in 10 from baseline and normal VD); or lymphedema (relative arm volume difference of >10 % by VD ± abnormal L-Dex). Change in L-Dex was plotted against change in VD; correlation was assessed using the Pearson correlation. RESULTS: At a median follow-up of 18.2 months, 152 patients were normal, 25 had an abnormal L-Dex, and 9 developed lymphedema without a prior L-Dex abnormality. Of the 25 abnormal L-Dex patients, 4 progressed to lymphedema, for a total of 13 patients with lymphedema. Evaluating all time points, 186 patients had 829 follow-up measurements. Sensitivity and specificity of L-Dex compared with VD were 75 and 93 %, respectively. There was no correlation between change in VD and change in L-Dex at 3 months (r = 0.31) or 6 months (r = 0.21). CONCLUSIONS: VD and bioimpedance demonstrated poor correlation with inconsistent overlap of measurements considered abnormal. Of patients with an abnormal L-Dex, few progressed to lymphedema; most patients with lymphedema did not have a prior L-Dex abnormality. Further studies are needed to understand the clinical significance of bioimpedance.

A comparison of complication rates in early-stage breast cancer patients treated with brachytherapy versus whole-breast irradiation.

BACKGROUND: The adoption of breast brachytherapy into clinical practice for early-stage breast cancer has increased over the last several years. Studies evaluating complication rates following treatment with brachytherapy have shown conflicting results. We compared local toxicity in patients treated with brachytherapy with those treated with whole-breast irradiation (WBI). METHODS: We identified 417 early-stage breast cancer patients treated with breast-conserving surgery and radiation between 2004 and 2010, and compared 271 women treated with intracavitary brachytherapy with 146 women treated with WBI. Long-term complications were assessed using Kaplan-Meier curves with the log-rank test. RESULTS: Median follow-up was 4.6 years, and the 5-year incidence of infectious skin complications (9.7 vs. 11.0 %, p = 0.84), abscess (1.1 vs. 0 %, p = 0.15), telangiectasia (8.0 vs. 5.3 %, p = 0.35), and breast pain (14.2 vs. 9.4 %, p = 0.2) was similar between the brachytherapy and WBI cohorts. The brachytherapy cohort had a higher 5-year rate of seroma (46.5 vs. 18.5 %, p < 0.001), and fat necrosis (39.5 vs. 24.4 %, p < 0.001). Brachytherapy patients trended towards more frequent biopsies as a result of fat necrosis to rule out a recurrence (11.2 vs. 6.7 %, p = 0.13). CONCLUSIONS: Patients treated with intracavitary brachytherapy had more local toxicity, particularly seroma and fat necrosis. Patients should be counseled on the possible increased rate of long-term complications associated with brachytherapy treatment.

The first case of breast cancer in thalassemic patient: case report and review of literature.

Thalassemias are genetic disorders characterized by decreased synthesis of one of the globin chains. Beta-thalassemia is caused by impairment in the production of beta-globin chains leaving the excess alpha chains unstable. With better treatment approaches and improvement in chelation therapy, thalassemic patients are living longer. As a consequence, new complications and associations with other conditions including malignancy have emerged. The occurrence of malignancies in thalassemia has rarely been reported, and our review of the literature revealed only few cases. We report the first case of a thalassemic patient developing breast cancer and discuss the possibility of a link between the two disease entities. This case is intended to alert physicians of the possibility of a malignancy in thalassemia patients.

A Comparative Retrospective Analysis of Complications After Oncoplastic Breast Reduction and Breast Reduction for Benign Macromastia: Are These Procedures Equally Safe?

INTRODUCTION: Oncoplastic breast reduction has been shown to be an effective approach to breast conservation surgery in women with macromastia. Clear surgical margins can be achieved while simultaneously improving symptomatic macromastia and enhancing aesthetic outcomes. Little has been written about postoperative complications after this procedure, beyond the risk of locoregional recurrence. This study aimed to compare the complication profile for oncoplastic breast reduction versus reduction for benign macromastia. METHODS: A retrospective review of our experience with oncoplastic breast reduction was performed. This represented a consecutive series of 118 patients undergoing bilateral breast reduction during the 7-year study period from March 2005 to March 2012. There were 64 patients identified who underwent oncoplastic breast reduction. Patients were determined to be a good candidate for breast conservation therapy if it was felt that clear surgical margins could be obtained without mastectomy. Postoperative complications (within 6 weeks of surgery) were compared to a control group of 56 patients undergoing reduction for benign macromastia. The associations between complications and potential risk factors were analyzed using logistic regression. RESULTS: Patients undergoing oncoplastic breast reduction and reduction for benign macromastia had some key differences. In general, macromastia patients were younger (mean age, 42.3 vs 57.5 years; P < 0.001) and had lower body mass index (mean, 26.1 vs 30.6 kg/m2; P < 0.001) compared to those patients having oncoplastic reduction. Within the oncoplastic reduction group, 14 (21.9%) patients had a total of 16 complications; among the benign macromastia group, 9 (16.1%) patients had a total of 10 complications (P = 0.420). On univariate analysis, oncoplastic reduction was not predictive of having a perioperative complication (odds ratio, 1.462; 95% confidence interval, 0.579-3.696; P = 0.422). Body mass index was found to be predictive of having a complication after reduction for either indication (odds ratio, 1.108; 95% confidence interval, 1.018-1.206; P = 0.017). Within the oncoplastic reduction cohort at an average follow-up of 34.6 months (range, 0.3-90.3 months), 5 (7.9%) patients developed locoregional recurrence and 2 patients developed distant metastasis. CONCLUSIONS: Compared with reduction mammoplasty for benign macromastia, a widely accepted procedure, patients undergoing oncoplastic breast reduction were equally likely to have a postoperative complication. Elevated body mass index was shown to be a statistically significant predictor of having a complication after reduction for either indication. Overall complication rates were acceptably low for both procedures.

Racial differences in breast cancer, cardiovascular disease, and all-cause mortality among women with ductal carcinoma in situ of the breast.

Ductal carcinoma in situ (DCIS) of the breast represents 15-20% of new breast cancer diagnoses in the US annually. However, long-term competing risks of mortality, as well as racial differences in outcomes among US women with DCIS, are unknown. Case data from the years 1978-2010 were obtained using SEER*Stat software available through the National Cancer Institute from the 2010 SEER registries. Included were all women aged 40 and over with newly diagnosed DCIS. There were 67,514 women in the analysis, including 54,518 white women and 6,113 black women. A total of 12,173 deaths were observed over 607,287 person-years of follow-up. The 20-year cumulative incidence of all-cause death among women with DCIS was 39.6% (CI 38.9-40.3). The corresponding 20-year rates for breast cancer death and CVD death were 3.2% (CI 3.0-3.4) and 13.2% (CI 12.8-13.7), respectively. Black women with DCIS had a higher risk of death compared to white women, with these hazard ratios elevated throughout the entire study period. For example, between 1990 and 2010, black women had a higher risk of all-cause death (HR 3.06, CI 2.39-3.91), breast cancer death (HR 5.78, CI 3.16-10.57), and CVD death (HR 6.43, CI 3.61-11.45) compared to white women diagnosed between 50 and 59 years of age. The risk of all-cause and CVD death was greater than breast cancer death among women diagnosed with DCIS over 20 years. Black women had higher risks of dying from all-causes compared to white women. These differences persisted into the modern treatment era.

Does a continuous local anaesthetic pain treatment after immediate tissue expander reconstruction in breast carcinoma patients more efficiently reduce acute postoperative pain--a prospective randomised study.

BACKGROUND: Immediate breast reconstruction with an expander is a reasonable option for properly selected patients. After reconstruction, patients have severe postoperative pain, which responds poorly to opioids. Our aim was to evaluate if continuous wound infusion of a local anaesthetic into the surgical wound reduces postoperative pain, consumption of opioids and incidence of chronic pain compared to standard intravenous piritramide after primary breast reconstruction in breast carcinoma patients. METHODS: Altogether, 60 patients were enrolled in our study; one half in the group with wound infusion of a local anaesthetic, and the other half in the standard (piritramide) group. Parameters measured included: pain intensity (visual analogue scale), drug requirements, alertness, hospitalisation, side-effects and late complications. A p-value of < 0.05 was considered statistically significant. RESULTS: In the recovery room, the test group reported less acute pain at rest (P = 0.03) and at activity (P = 0.01), and on the day of the surgical procedure they reported less pain at activity (P = 0.003). Consumption of piritramide and metoclopramide was lower in this group (P < 0.0001), but their alertness after the surgical procedure was higher compared to the standard group (P < 0.001). After three months, the test group reported less chronic pain (P = 0.01). CONCLUSIONS: After primary tissue expander breast reconstruction, wound infusion of a local anaesthetic significantly reduces acute pain and enables reduced opioid consumption, resulting in less postoperative sedation and reduced need for antiemetic drugs. Wound infusion of a local anaesthetic reduces chronic pain.

Long-term risk perceptions of women with ductal carcinoma in situ.

INTRODUCTION: Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years. PATIENTS AND METHODS: In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort. RESULTS: One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading. CONCLUSION: Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.

Etiology of breast masses after autologous breast reconstruction.

BACKGROUND: Determining the nature of a breast mass after autologous reconstruction can be difficult. METHODS: A retrospective review of all autologous breast reconstructions was performed over 10 years. All postoperative breast masses were identified. Tumor characteristics, adjuvant treatment, timing of the development of the mass, and correlation with radiology were reviewed. RESULTS: A total of 365 flaps were performed on 272 patients [253 deep inferior epigastric perforator (DIEP), 35 superficial inferior epigastric artery (SIEA), 22 muscle-sparing free transverse rectus abdominis myocutaneous (free MS-TRAM), 25 latissimus, and 30 pedicled TRAM]. Breast masses were identified in 66 breasts (18 %). The majority of these were from fat necrosis, occurring in 54 breasts (15 % overall; DIEP 13.4 %, SIEA 5.7 %, free MS-TRAM 15 %, latissimus 0 %, pedicled TRAM 47 %), first identified at a mean of 3 months. Recurrent carcinoma was diagnosed in 13 breasts (3.6 %). Factors associated with the postreconstruction mass representing recurrent carcinoma were later time period after reconstruction (mean 24 months), closer surgical margins, and lymphovascular invasion. Radiographic imaging accurately diagnosed recurrent carcinoma in 11 (92 %) of 12 patients in whom it was utilized and suggested a benign diagnosis in all 16 patients with fat necrosis in whom it was utilized. CONCLUSIONS: Breast masses frequently present after autologous reconstruction. Fat necrosis is the most common cause. Recurrent carcinoma can occur in the reconstructed breast and presents later. A higher index of suspicion for recurrence should accompany any mass in which prior lymphovascular invasion was present or if original margins were <1 cm. Radiographic imaging accurately identifies the cause of these masses.