Chest wall resection and reconstruction for locally advanced primary breast cancer.

OBJECTIVE: We sought to evaluate clinical and oncologic outcomes of selected patients with locally advanced breast cancer undergoing full thickness chest wall resection (FTCWR) and reconstruction in a multidisciplinary setting. PATIENTS AND METHODS: Between 2008 and 2010, five women underwent FTCWR followed by chest wall repair for locally advanced primary breast cancer. In all cases, chest wall repair was performed with a Peri-Guard Repair Patch (Synovis, St. Paul, MN, USA). At follow-up (7-12 months) quality of life, respiratory function and oncologic status were assessed. RESULTS: Successful chest wall resection and repair were achieved in all patients. Plastic reconstruction of post-mastectomy tissue defects was necessary in one case. One patient was treated by breast conserving therapy. Chest ultrasound imaging confirmed absence of adhesions, haematoma or seroma and normal expansion and respiratory movement of the underlying lung in all patients. On follow-up all patients reported good quality of life. CONCLUSION: Multidisciplinary surgical approaches to chest wall resection and reconstruction in selected patients with locally advanced primary breast cancer are feasible, safe, associated with short operation time and hospital stay and negligible morbidity.

Aromatase inhibitors as solely treatment in postmenopausal breast cancer patients.

Several studies evaluating the clinical effectiveness of endocrine therapy alone in breast cancer patients aged 70 years or older reported comparable survival rates to conventional surgical therapy, although the incidence of local recurrences was higher. Primary endocrine therapy is therefore only recommended as an alternative approach in elderly woman with estrogen receptor positive tumors who are deemed inoperable or who refuse surgery. We report our experience with aromatase inhibitors as primary endocrine therapy for estrogen receptor positive breast cancer in postmenopausal woman who are impaired by other diseases, refuse surgery or are of old age. Fifty-six patients with fifty-seven ER+ operable breast cancers who refused surgery, were judged ineligible for surgery because of comorbidity, or were of old age were treated with endocrine therapy using aromatase inhibitors only. Digital mammography and high-end breast ultrasound were used to assess tumor sizes. The mean age of the patients was 74 years (range 52-102 years). All patients suffered from breast cancer. The mean follow-up interval was 40 months (range 5-92 months). Seven patients (12%) achieved complete clinical remission, 31 (57%) partial response giving an overall objective response rate of 69%. In addition, seven (12%) patients showed stable disease, giving a clinical benefit rate (complete remission + partial response + stable disease rate) of 81%. Eleven patients (19%) progressed after an initial partial response or stable disease. Only one patient (2%) progressed on endocrine therapy within the first months. Eventually, 22 (39%) patients underwent surgery after informed consent to achieve better local tumor control. Primary endocrine therapy with aromatase inhibitors may offer an effective and safe alternative to surgery giving a high local control rate in postmenopausal women who refuse surgery, who are judged ineligible for surgery, or are of old age.

Variations in the Elasticity of Breast Tissue During the Menstrual Cycle Determined by Real-time Sonoelastography.

OBJECTIVES: The purpose of this study was to determine the dependence of breast tissue elasticity on the menstrual cycle of healthy volunteers by means of real-time sonoelastography. METHODS: Twenty-two healthy volunteers (aged 18-33 years) were examined once weekly during two consecutive menstrual cycles using sonoelastography. Group 1 (n= 10) was not taking hormonal medication; group 2 (n = 12) was taking oral contraceptives. RESULTS: The breast parenchyma appeared softer than the dermis and harder than the adipose tissue, and elasticity varied over the menstrual cycle and between groups. Group 1 (no hormone intake) showed continuously increasing elasticity with relatively soft breast parenchyma in the menstrual and follicular phases and harder parenchyma in the luteal phase (P = .012). Group 2 (oral contraceptives) showed no statistically significant changes in breast parenchymal elasticity according to sonoelastography. The parenchyma was generally softer in group 1 compared with group 2 throughout the menstrual cycle (P = .033). The dermis, the subcutaneous adipose tissue, and the pectoralis major muscle showed no changes in elasticity. Comparison of measurements made during the first and the second menstrual cycles showed similar patterns of elasticity in both groups. CONCLUSIONS: Sonoelastography is a reproducible method that can be used to determine the dependence of breast parenchyma elasticity on the menstrual cycle and on the intake of hormonal contraceptives.

Identification of differentially expressed microRNAs in human male breast cancer.

BACKGROUND: The discovery of small non-coding RNAs and the subsequent analysis of microRNA expression patterns in human cancer specimens have provided completely new insights into cancer biology. Genetic and epigenetic data indicate oncogenic or tumor suppressor function of these pleiotropic regulators. Therefore, many studies analyzed the expression and function of microRNA in human breast cancer, the most frequent malignancy in females. However, nothing is known so far about microRNA expression in male breast cancer, accounting for approximately 1% of all breast cancer cases. METHODS: The expression of 319 microRNAs was analyzed in 9 primary human male breast tumors and in epithelial cells from 15 male gynecomastia specimens using fluorescence-labeled bead technology. For identification of differentially expressed microRNAs data were analyzed by cluster analysis and selected statistical methods.Expression levels were validated for the most up- or down-regulated microRNAs in this training cohort using real-time PCR methodology as well as in an independent test cohort comprising 12 cases of human male breast cancer. RESULTS: Unsupervised cluster analysis separated very well male breast cancer samples and control specimens according to their microRNA expression pattern indicating cancer-specific alterations of microRNA expression in human male breast cancer. miR-21, miR519d, miR-183, miR-197, and miR-493-5p were identified as most prominently up-regulated, miR-145 and miR-497 as most prominently down-regulated in male breast cancer. CONCLUSIONS: Male breast cancer displays several differentially expressed microRNAs. Not all of them are shared with breast cancer biopsies from female patients indicating male breast cancer specific alterations of microRNA expression.

Association between women's self-diagnosis of labor and labor duration after admission.

AIMS: To examine the association between women's perception of onset and the duration of labor after hospital admission. METHODS: Women whose labor started spontaneously at term, delivering at the Hannover Medical School Hospital, Germany, between 2001 and 2004 were asked when and how labor had started. Answers were analyzed using structured content analysis. Women's symptoms were grouped in eight predefined categories; inter-rater agreement was assessed (kappa=0.93). Associations between women's symptoms and labor duration after admission were also analyzed. RESULTS: Duration of labor after admission was longer in nulliparas (n=347) than in multiparas (n=304, P<0.001). Nulliparas experienced shorter labor in association with recurrent pain, advanced cervical dilatation at admission and spontaneous rupture of membranes. Oxytocin augmentation and epidural analgesia were associated with a longer duration. In multiparas, advanced cervical dilatation at admission, spontaneously ruptured membranes, blood-tinged mucus or emotional upheaval perceived by women were associated with a shorter interval from admission until birth. CONCLUSIONS: How women diagnose their onset of labor relates to some extent with labor duration after admission. Recognized symptoms and their association with labor duration differed between nulliparas and multiparas.

Quality of life and satisfaction after breast cancer operation.

PURPOSE: To investigate the quality of life and satisfaction after different operations in patients with breast cancer, which are breast conserving therapy (BCT), mastectomy and reconstruction after breast BCT or mastectomy. MATERIALS AND METHODS: 180 patients with breast cancer who were operated from January 2005 to October 2006 were chosen. They presented without local or distant metastasis in this period of time and were asked to complete the EORTC quality of life questionnaire (QLQ-C30), the EORTC breast cancer module questionnaire (QLQ-BR23) and a specific questionnaire regarding satisfaction of postoperative results designed by ourselves. RESULTS: Of 112 (62.2%) patients who responded there were 76, 20 and 16 patients in the group of BCT, mastectomy and reconstruction, respectively. Compared with the mastectomy group and reconstruction group, the patients in BCT group had better body image (BI) (P = 0.004, P = 0.003), the patients in the group of reconstruction had more financial difficulties (FD) and more future perspective (FP) than the BCT group (P = 0.006, P = 0.039). Compared with the group of mastectomy and reconstruction, the patients in the group of BCT had a better self-assessment of postoperative results (P = 0.001, P < 0.001) and less visible postoperative scars (P = 0.003, P = 0.019). Patients in the reconstruction group thought that the difference in shape of the bilateral breast was more visible than in the BCT group (P = 0.005). Regarding visible differences in size of the breasts and satisfaction with the position and form of nipple-areolar complex, there were no differences between the two groups (P = 0.077, P = 0.272). CONCLUSION: Patients with BCT have a better quality of life and higher satisfaction rate with their postoperative breasts compared to patients undergoing mastectomy or reconstructive surgery.

Organ-preserving and reconstructive microsurgery of the fallopian tubes in tubal infertility: still an alternative to in vitro fertilization (IVF).

Tubal infertility mostly results from infections. Conception only is possible through complex treatments (in vitro fertilization or surgery). Success cannot be guaranteed, even after repeated treatments. Unfortunately, many couples are not informed about the prospect for success of tubal reconstruction. Problems of in vitro fertilization are low pregnancy and birth rates of 28.4% and <20% respectively (Germany) and the high number of multiple pregnancies (21%). In this retrospective study 462 women with acquired tubal infertility and further 127 women after previous sterilization underwent microsurgical treatment (microsurgical adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization due to former sterilization). The main outcome measures are the pregnancy and birth rates following the microsurgical procedure. Pregnancy and birth rates of 43.4% and 29.2%, respectively, were higher than the outcomes post-single in vitro fertilization (abortion: 6.4%, extrauterine pregnancy: 7.9%). When reversal of sterilization was performed, pregnancy and birth rates were higher at 73% and 50.6%, respectively (abortion: 15.7%, extrauterine pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of woman's ability to conceive naturally (repeated pregnancies are possible without further therapy), a high postoperative birth rate overall, and avoidance of multiple births. It is advisable to inform the patient about the objective possibility of reconstructive tubal surgery.

The cost efficiency of HPV vaccines is significantly underestimated due to omission of conisation-associated prematurity with neonatal mortality and morbidity.

INTRODUCTION: Cervical intraepithelial neoplasia (CIN) represents the precursor of invasive cervical cancer and is associated with human papillomavirus infection (HPV) against which two vaccines have been approved in the last years. Standard treatments of high-grade CIN are conisation procedures, which are associated with an increased risk of subsequent pregnancy complications like premature delivery and possible subsequent life-long disability. HPV vaccination has therefore the potential to decrease neonatal morbidity and mortality. This has not been taken into account in published cost-effectiveness models. MATERIAL AND METHODS: We calculated the possible reduction rate of conisations for different vaccination strategies for Germany. Using this rate, we computed the reduction of conisation-associated preterm deliveries, life-long disability and neonatal death due to prematurity. The number of life-years saved (LYS) and gain in quality-adjusted life-years (QALYs) was estimated. The incremental costs per LYS / additional QALY were calculated. RESULTS: The reduction of conisation procedures was highest in scenario I (vaccination coverage 90% prior to HPV exposition) with about 50%. The costs per LYS or additional QALY were lowest in scenario I, II and III with 45,101 € or 43,505-47,855 € and rose up to 60,544 € or 58,401-64,240 € in scenario V (50% vaccinated prior to sexual activity + additional 20% catch-up at a mean age of 20 y). CONCLUSION: Regarding the HPV 16 / 18 vaccines as "vaccines against conisation-related neonatal morbidity and mortality" alone, they already have the potential to be cost-effective. This effect adds up to reduction of cervical cancer cases and decreased costs of screening for CIN. Further studies on cost-effectiveness of HPV vaccination should take the significant amount of neonatal morbidity and mortality into account.

Optimizing breast cancer follow-up: diagnostic value and costs of additional routine breast ultrasound.

A total of 2,546,325 breast cancer survivors are estimated to live in the United States. The organized breast cancer follow-up programs do not generally include breast ultrasound in asymptomatic women. The purpose of our prospective study was to investigate the efficacy of breast ultrasound in detecting previously occult recurrences. A total of 735 eligible patients with a history of breast cancer were recruited. We assessed the same patient population before (routine follow-up program) and after (study follow-up program) the introduction of an additional ultrasound examination. In the routine follow-up program 245 of 735 patients (33.3% [95% confidence-interval (CI): 29.9-36.7]) had an ultrasound due to abnormal local or mammographic findings. 490 of 735 patients (66.7% [95% CI: 63.3-70.1]) were initially considered asymptomatic and received an additional ultrasound exclusively within the study follow-up program. All positive examination results were followed by accelerated core needle biopsy. The routine follow-up program led to a biopsy in 66 of 735 patients (9.0%) revealing a recurrent cancer in 27 cases (3.7%). The study follow-up program with the additional ultrasound led to another 21 biopsies raising the total number of patients who had to undergo a biopsy from 9.0% (95% CI: 6.9-11.1) to 11.8% (95% CI: 9.5-14.2). Finally, we diagnosed a previously occult malignant lesion in an additional six patients following this protocol. Therefore, the rate of detected recurrences rose from 3.7% (95% CI: 2.3-5.0) in the routine follow-up program to 4.5% (95% CI: 3.0-6.0) in the study follow-up program (p = 0.041). Negative side effects were the additional costs (the costs per detected malignancy in the routine follow-up program were $2455.69; the costs for each additionally detected malignancy in the study follow-up program were $7580.30), the higher overall biopsy rate (9.0 vs. 11.8%) and the elevated benign biopsies rate (59.1% vs. 71.4%). Regarding these results, the advantages and disadvantages of additional breast ultrasound must be discussed for every follow-up patient individually even today, as we can detect a significantly higher number of previously occult malignancies.

The Automated Breast Volume Scanner (ABVS): initial experiences in lesion detection compared with conventional handheld B-mode ultrasound: a pilot study of 50 cases.

The idea of an automated whole breast ultrasound was developed three decades ago. We present our initial experiences with the latest technical advance in this technique, the automated breast volume scanner (ABVS) ACUSON S2000(™). Volume data sets were collected from 50 patients and a database containing 23 women with no detectable lesions in conventional ultrasound (BI-RADS(®)-US 1), 13 women with clearly benign lesions (BI-RADS(®)-US 2), and 14 women with known breast cancer (BI-RADS(®)-US 5) was created. An independent examiner evaluated the ABVS data on a separate workstation without any prior knowledge of the patients' histories. The diagnostic accuracy for the experimental ABVS was 66.0% (95% confidence interval [CI]: 52.9-79.1). The independent examiner detected all breast cancers in the volume data resulting in a calculated sensitivity of 100% in the described setting (95% CI: 73.2%-100%). After the ABVS examination, there were a high number of requests for second-look ultrasounds in 47% (95% CI: 30.9-63.5) of the healthy women (with either a clearly benign lesion or no breast lesions at all in conventional handheld ultrasound). Therefore, the specificity remained at 52.8% (95% CI: 35.7-69.2). When comparing the concordance of the ABVS with the gold standard (conventional handheld ultrasound), Cohen's Kappa value as an estimation of the inter-rater reliability was κ = 0.37, indicating fair agreement. In conclusion, the ABVS must still be regarded as an experimental technique for breast ultrasound, which definitely needs to undergo further evaluation studies.

Reconstructive, organ-preserving microsurgery in tubal infertility: still an alternative to in vitro fertilization.

In this retrospective study, we observed a total of 553 patients with tubal infertility who underwent microsurgical reconstructive surgery of the fallopian tubes (including adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization after former sterilization). The pregnancy (43.4%) and birth (29.2%) rates after microsurgery for acquired tubal damages (abortion: 6.4%; ectopic pregnancy: 7.9%) were higher than after single in vitro fertilization (28.4% and <20%, respectively; data from German IVF register). The pregnancy (73%) and birth (50.6%) rates after the reversal of sterilization also were higher (abortion: 15.7%; ectopic pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of a woman's ability to conceive naturally in every cycle that she ovulates, a high postoperative birth rate overall, and avoidance of multiple births.