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Magnetic resonance mammography in the evaluation of recurrence at the prior lumpectomy site after conservative surgery and radiotherapy
Lorenzo Preda, Gaetano Villa, Stefania Rizzo, Luca Bazzi, Daniela Origgi, Enrico Cassano, Massimo Bellomi
Breast Cancer Research , 2006, DOI: 10.1186/bcr1600
Abstract: Between April 1999 and July 2003, 93 consecutive patients with breast cancer treated with conservative surgery and radiotherapy underwent MRM, when a malignant lesion on the site of lumpectomy was suspected by ultrasound and/or mammography. MRM scans were evaluated by morphological and dynamic characteristics. MRM diagnosis was compared with histology or with a 36-month imaging follow-up. Enhancing areas independent of the prior lumpectomy site, incidentally detected during the MRM, were also evaluated.MRM findings were compared with histology in 29 patients and with a 36-month follow-up in 64 patients. MRM showed 90% sensitivity, 91.6% specificity, 56.3% positive predictive value and 98.7% negative predictive value for detection of recurrence on the surgical scar. MRM detected 13 lesions remote from the scar. The overall sensitivity, specificity, positive predictive value and negative predictive value of MRM for detection of breast malignancy were 93.8%, 90%, 62.5% and 98.8%, respectively.MRM is a sensitive method to differentiate recurrence from post-treatment changes at the prior lumpectomy site after conservative surgery and radiation therapy. The high negative predictive value of this technique can avoid unnecessary biopsies or surgical treatments.Recurrence of breast cancer lesions on the surgical scar after conservative surgery and radiation therapy have been reported to occur in at least 1–2% of cases per year [1,2]. The proper follow-up of these patients usually includes periodic clinical examination, mammography and ultrasonography [3]. Detection of recurrence on the prior lumpectomy site still represents a challenge because of changes in breast tissue after treatment. Clinical examination, mammography or ultrasonography can raise a suspicion but an additional evaluation is frequently mandatory to avoid unnecessary biopsy or surgery.Several recent studies have shown the important role of breast magnetic resonance imaging (MRI) imaging for detection of recu
A New Technique for Mastopexy and Reduction Mammaplasty: The Rolling Bilateral Flap Technique  [PDF]
Stefano A. Karoschitz
Advances in Breast Cancer Research (ABCR) , 2016, DOI: 10.4236/abcr.2016.52008
Abstract: Background: Numerous techniques have been proposed as “gold standard” for mastopexy, as for reduction mammaplasty. The quality of the breast parenchyma should be a primary factor in selecting the most appropriate technique for an individual case. Objective: The article describes a simple technique that can be used either for mastopexy or for reduction mammaplasty, giving optimal breast shape and position. It is appropriate for patients having some degree of ptosis, and especially for those in whom the glandular component of the breast predominates. Methods: The technique entails elevating the entire dome of the breast, rolling it under, and then stitching the two halves of the breast parenchyma together (lateral and medial dermoglandular flaps), while the upper pedicle (a third dermoglandular flap) bearing the nipple areolar complex (NAC) severed from the two inferior flaps is attached as a cap. The result is a new and attractive shape of the underlying supporting “barrel”. The technique can be performed with the T scar or the vertical scar approach. Results: The procedure was applied for various indications on 45 patients aged 20 - 62 years. Good results were only achieved in 36 women with predominant glandular component. Nine patients with fatty breasts achieved unsatisfactory results (6 with T scar, 3 with vertical scar) and very poor breast projection. Conclusions: The best-suited candidates for the proposed technique for mastopexy or reduction mammaplasty are women in whom the glandular component of the breast predominates. This simple technique, applicable with either inverted T scar or vertical scar approaches, carries very low morbidity, affording an attractive profile, long-lasting results, and conserving the patient’s ability to breast feed.
Cuadrantectomía con mastopexia tipo "donut" versus cuadrantectomía estándar en cáncer de seno: un estudio comparativo prospectivo Doughnut type quadrantectomy with mastopexy versus standard quadrantectomy in breast cancer: a prospective comparative study
María Clara López,Nouredine El Gareh,Olivier Dubon,Jean Pierre Daurés
Revista Colombiana de Cirugía , 2006,
Abstract: Este fue un estudio comparativo prospectivo de 104 pacientes con cáncer de seno, a quienes se ofreció la elección entre dos tratamientos quirúrgicos conservadores: cuadrantectomía con mastopexia tipo donut (Grupo CMD, n=39) o cuadrantectomía estándar (Grupo CE, n=75). Los grupos fueron similares en tama o radiológico del tumor, localización del tumor en el seno, tama o histológico, y la distribución por estadios pT. En el grupo CMD, la incisión de piel fue tres veces más grande que en el grupo CE, pero con ella se obtuvo al final, una cicatriz alrededor del complejo areola-pezón, sin complicaciones posoperatorias posteriores. El volumen promedio del espécimen quirúrgico y los márgenes de sección, fueron mayores en el grupo CMD comparados con el grupo CE. Se obtuvieron márgenes libres de tumor con mayor frecuencia en el grupo CMD que en el grupo CE, pero la diferencia no fue significativa. Estos datos indican fuertemente que la técnica CMD puede ser más eficiente que la técnica CE, en términos de precisión en la resección del tejido mamario. This is a prospective comparative study comprising 104 patients with breast cancer to which two modalities of conservative therapy were offered: quadrantectomy with mastopexy doughnut type (group QMD, n = 39) or standard quadrantectomy (group QS, n = 75). The two groups had similar tumor size, location of the tumor, histology size and PT distribution. In the QMD group the skin incision was three times greater than in the QS group, but a good healing around the areola-nipple complex was achieved without postoperative complications. Both the size of the surgical specimen and the free margins were greater in the QMD group. Free section margins were more frequently achieved in the QMD group, but the difference was not significant. Our date strongly indicate that the QMD technique can be more efficient that the QS in terms of precision of mammary tissue resection.
Frozen Section Analysis of Breast Lumpectomy Margins  [PDF]
Fatma Khinaifis Althoubaity, Adnan Merdad, Nouf Yahya Akeel, Nisar Haider Zaidi, Abdullah Omar Sultan
Surgical Science (SS) , 2017, DOI: 10.4236/ss.2017.86029
Abstract: Objectives: To evaluate breast lumpectomy margins by frozen section in breast conservation surgery. Methods: A retrospective study of frozen section of lumpectomy margins of one hundred ten patients was done at King Abdulaziz University Hospital from June 2007 to June 2013. All patients underwent lumpectomy + Sentinel lymph node biopsy. Patient records were studied for location of mass in breast, size of mass, site of breast, pre or postmenopausal, frozen section margins, new frozen section margins, permanent margins, reoperation. Complications like skin necrosis, numbness, and wound infection were studied. Result: Majority were Saudis (64.5%). Left breast was involved in 60%. Upper outer quadrant was involved in majority (51.9%). Size of mass was less than 1 cm in 14.8% cases, 1 - 2.9 cm in 43.5%, 3 - 4 cm in 13%, more than 4 cm in 10.2%. Lumpectomy plus sentinel lymph node biopsy was done in 96.4% and lumpectomy and axillary lymph node dissection was done in 1.8% cases. Gross margins were positive in 17.3% and frozen margins were positive in 28.2%. New margin on frozen section were positive in 3.6% and negative in 79.1%. Permanent section histology showed positive margins in 5.5% and negative in 94.5% cases. Re-operation was done in 7.3%. Lympho-vascular margins were positive in 20.9%. Skin necrosis was found in 2.2%, numbness was found in 4.4%, wound infection was in 2.2%. Conclusion: Lumpectomy margins with frozen section reduce re-operation and recurrence.
Application of mastopexy technique using Klein’s solution. A 40 cases experience. Aplicación de técnicas de Mastopexia con solución de Klein. Experiencia de 40 casos.  [cached]
Heriberto Chávez Sánchez,Liliana Espinosa Chang,Dagmaris Losa Pérez
MediSur , 2009,
Abstract: Background: Breasts has always played an important role in female image. Breast ptosis is a disease which is frequently consulted to plastic surgeons. A correction was performed applying mastopexy in a minor outpatient surgery using modified Klein′s solution in minimal concentrations of lidocaine which avoid bleeding. Objectives: To describe the aesthetic results in the usage of mastopexy with Klein′s solution specifying: behavior of pain, bleeding during the surgery process, presence of complications and the satisfaction exploration in surgical operated patients. Method: A series of cases consisted of 40 patients who came to the plastic surgery consultation at the University Hospital “Dr. Gustavo Aldereguía Lima” in Cienfuegos city with breast ptosis from January 2005 to January 2006, using three mastopexy techniques (pedicle fixation, periareolar fixation, and dermal fixation). Pain was assessed during the operation and after the operation, as well as the satisfaction level of the patients and the aesthetic results obtained. Results: 75 per cent of the studied patients were among 20 and 39 years old. Klein′s solution modified with an anesthetic method was administered. 87.5 per cent stated no not feel pain showing the efficacy of the solution. Complications were minimal, only in two of the patients who presented partial wound dehiscence without any other surgical intervention. Conclusions: It was evidenced the efficacy of the Klein′s solution in the breast ptosis correction. It is recommended the usage of this solution due to the advantages it offers. It is also very economic in its usage. Fundamento: La mama ha tenido un papel importante en la imagen femenina, la ptosis mamaria es una enfermedad por la cual son consultados con frecuencia los cirujanos plásticos. Nos propusimos realizar la corrección aplicando la Mastopexia, en cirugía menor ambulatoria, con solución de Klein modificada, utilizando concentraciones mínimas de lidocaina, que evita sangramientos. Objetivos: Describir los resultados estéticos con la utilización de las técnicas de Mastopexia con solución de Klein precisando: comportamiento del dolor, sangramientos transoperatorio, presencia de complicaciones y exploración de satisfacción en pacientes operadas. Método: Consistió en serie de casos constituida por 40 pacientes, que acudieron a consulta de cirugía plástica en el Hospital Universitario Gustavo Aldereguía Lima, de Cienfuegos, con ptosis mamaria, en el período comprendido de enero del 2005 a enero del 2006, utilizamos tres técnicas de Mastopexia (Fijación de pedículo, Periareolar
Mastopexia de aumento, técnica de quinta generación Augmentation mastopexy, fifth generation technique  [cached]
R. Navarro,L. Torreblanca,A. Enríquez
Cirugía Plástica Ibero-Latinoamericana , 2008,
Abstract: Presentamos una nueva técnica de mastopexia, más sencilla, que evita recidivas además de disminuir el riesgo de carcinoma mamario. El estudio se realiza sobre 25 pacientes femeninas de 25 a 50 a os de edad, con ptosis mamaria. Con las pacientes de pie realizó el marcaje tradicional; si las mamas son peque as se colocan implantes en el plano submuscular, y si son grandes, en retroglandular. Para evitar recidivas se colocaron dos tirantes internos con suturas irreabsorbibles. Si el complejo resultante glándula-implante es grande y pesado, se fija un tirante de mama al periostio hemiclavicular y otro al periostio de la tercera costilla; si es peque o o mediano, únicamente se fija a la costilla. Realizamos controles entre 1 mes y 3 a os tras la intervención. Conseguimos corregir ptosis de entre 5 a 12cm., sin recidiva en ninguno de los controles, ni pseudo-ptosis postoperatoria. El ejercicio físico fue posible a los 15 días de la cirugía con el apoyo de un sujetador elástico. La cicatrización fue altamente satisfactoria. Las únicas complicaciones presentadas fueron dehiscencias parciales en 2 pacientes y sensación de ardor, tirantez y elongación de la areola en pacientes cuya ptosis excedía los 12cm y con areolas grandes. La facilidad de ejecución de la técnica y su seguridad, permiten que la cirugía sea ambulatoria. Proponemos esta técnica, que denominamos de quinta generación, que evita la cicatriz periareolar, la inframamaria, la vertical y la "T" invertida; además, elimina parte de ambos cuadrantes superiores de la mama, lo que disminuye notablemente la posibilidad de desarrollar ulteriores casos de carcinoma mamario y evita recidivas con el uso del tirante clavicular. We present a new mastopexy technique, simpler, which precludes the recidivism and reduces the risk of breast cancer. The study was based on 25 female patients between 25 to 50 years old with breast ptosis. With the patients standing up, was realized the traditional marks. If breasts were small, implants were positioned by submuscular way, and if bigger, the way was retroglandular. For recidivism prevention, it was positioned 2 internal straps; if the gland-implant was bigger and heavier an immobile strap from the breast to the clavicle periostium and to the 3rd rib, was realized; if it would result smaller or median size only were fixed to the third ribs with a dermal flap. Controls were realized between 1 month to 3 years. Ptosis was corrected between 5 to 12cm without any recidivism, neither post surgery pseudo-ptosis. With the support of an elastic brassier, physical exercise is recomm
A Cost-Utility Analysis Comparing Oncoplastic Breast Surgery to Standard Lumpectomy in Large Breasted Women  [PDF]
Abhishek Chatterjee, Anaeze C. Offodile II, Ammar Asban, Raquel A. Minasian, Albert Losken, Roger Graham, Lilian Chen, Brian J. Czerniecki, Carla Fisher
Advances in Breast Cancer Research (ABCR) , 2018, DOI: 10.4236/abcr.2018.72011
Abstract: Purpose: Ablative options, beyond mastectomy, for large breasted patients with breast cancer include oncoplastic resection via reduction pattern and standard lumpectomy. Oncoplastic resection also entails a contralateral procedure for symmetry and the potential benefit of a superior cosmetic outcome. Our aim was to examine the cost-effectiveness of this treatment strategy comparing it to standard lumpectomy in treating breast cancer patients. Methods: A literature review was performed of the probabilities and outcomes related to treatment of unilateral breast cancer via oncoplastic resection or unilateral lumpectomy. Utility score surveys were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure, additional margins excision and post-operative complications. A decision analysis tree was developed to highlight the more cost-effective strategy. An Incremental Cost-Utility Ratio (ICUR) was calculated. Sensitivity analysis was performed to check the robustness of our data. Results: Oncoplastic resection was associated with fewer positive margins relative to standard lumpectomy (10.0% versus 18%). In cases with positive margins, a greater percentage of oncoplastic resection patients chose a mastectomy compared to the lumpectomy patients (72% versus 19%). Utility scores for a successful operation favored oncoplastic resection (92.6 versus 86.55), but in instances of positive margins, favored the lumpectomy patients (74.2 versus 70.2). Decision tree analysis revealed that oncoplastic resection was more cost-effective with an ICUR of $2609.66/QALY gained. Conclusion: Oncoplastic resection represents a cost-effective strategy for the large breasted patient and provides the surgical team yet another reasonable option for the appropriate patient.
3D-conformal Accelerated Partial Breast Irradiation treatment planning: the value of surgical clips in the delineation of the lumpectomy cavity
Maia Dzhugashvili, Elodie Tournay, Charlotte Pichenot, Ariane Dunant, Eduardo Pessoa, Adel Khallel, Sébastien Gouy, Catherine Uzan, Jean-Rémy Garbay, Fran?oise Rimareix, Marc Spielmann, Philippe Vielh, Hugo Marsiglia, Céline Bourgier
Radiation Oncology , 2009, DOI: 10.1186/1748-717x-4-70
Abstract: Forty CT-based 3D-APBI plans were retrieved on which a total of 4 radiation oncologists, two trainee and two experienced physicians, outlined the lumpectomy cavity. The inter-observer variability of LC contouring was assessed when the CTV was defined as the delineation that encompassed both surgical clips and remodelled breast tissue.The conformity index of tumour bed delineation was significantly improved by the placement of surgical clips within the LC (median at 0.65). Furthermore, a better conformity index of LC was observed according to the experience of the physicians (median CI = 0.55 for trainee physicians vs 0.65 for experienced physicians).The placement of surgical clips improved the accuracy of lumpectomy cavity delineation in 3D-APBI. However, a learning curve is needed to improve the conformity index of the lumpectomy cavity.Accelerated Partial Breast Irradiation (APBI) is still under investigation to demonstrate equivalence to whole breast irradiation in terms of local control. Among the different APBI techniques (invasive or non-invasive), 3D-conformal APBI is widely used given its accessibility in radiotherapy centres [1]. However, several issues related to this technique still warrant investigation: e.g. the identification and contouring of the lumpectomy cavity (LC), the patient's set-up and optimal dose determination. The definition of the lumpectomy cavity is an essential part of 3D-conformal APBI treatment planning as the irradiation is confined to a limited volume of breast tissue adjacent to the lumpectomy cavity. Unlike intra-operative partial breast irradiation, LC determination is critical as treatment delivery is delayed after breast surgery. In 3D-APBI, the GTV (Gross Tumour Volume) and CTV (Clinical Target Volume) are generally defined as the contouring of a seroma within the lumpectomy cavity, expanded by a 1 cm margin [2,3]. However, the delineation of the seroma could vary among different observers and even among experienced ones[4].I
Image-Based Treatment Planning of the Post-Lumpectomy Breast Utilizing CT and 3TMRI  [PDF]
Geraldine Jacobson,Gideon Zamba,Vicki Betts,M. Muruganandham,Joni Buechler-Price
International Journal of Breast Cancer , 2011, DOI: 10.4061/2011/246265
Abstract: Accurate lumpectomy cavity definition is critical in breast treatment planning. We compared contouring lumpectomy cavity volume and cavity visualization score (CVS) with CT versus 3T MRI. 29 patients were imaged with CT and 3T MRI. Seven additional boost planning sets were obtained for 36 image sets total. Three observers contoured the lumpectomy cavity on all images, assigning a cavity visualization score (CVS ) of 1 to 5. Measures of consistency and agreement for CT volumes were 98.84% and 98.62%, for T1 MRI were 95.65% and 95.55%, and for T2 MRI were 97.63% and 97.71%. The mean CT, T1 MRI, and T2 MRI CVS scores were 3.28, 3.38, and 4.32, respectively. There was a highly significant difference between CT and T2 scores ( ) and between T1 and T2 scores ( ). Interobserver consistency and agreement regarding volumes were high for all three modalities with T2 MRI CVS the highest. MRI may contribute to target definition in selected patients. 1. Introduction Definition of the lumpectomy cavity is a critical step in treatment planning for irradiation of the intact breast, breast boost, and for partial breast irradiation. Multiple studies have shown the limitations of single modality imaging with interobserver differences in lumpectomy cavity definition [1–4]. CT-based imaging is commonly used for breast treatment planning; but the limited soft tissue contrast of CT can result in poor visualization of the lumpectomy site in patients with dense breast parenchyma, small lumpectomy cavities, or a prolonged delay between surgery and treatment planning [2, 3]. MR imaging provides superior soft tissue contrast and may provide clearer visualization of the lumpectomy cavity. Although the diagnostic role of MRI in breast cancer management is expanding, MRI is rarely used as an imaging modality in post-lumpectomy radiation therapy planning. We compared contouring of the lumpectomy cavity volume and cavity visualization score (CVS) based on CT imaging compared to 3 Tesla magnetic resonance imaging, (3T MRI). 2. Methods and Materials This is an IRB-approved retrospective review of treatment planning imaging obtained for breast cancer patients following breast conserving surgery. From September 2008 to July 2009, 29 patients referred for intact breast irradiation had breast imaging performed using both CT and noncontrast 3T MRI. Of these, seven patients had repeat CT and MRI performed at the time of boost planning, providing 36 image sets. Sixteen patients did not receive chemotherapy. The average interval between surgery and image acquisition for this group was 28 days
Redefining Lumpectomy Using a Modification of the “Sick Lobe” Hypothesis and Ductal Anatomy  [PDF]
W. Dooley,J. Bong,J. Parker
International Journal of Breast Cancer , 2011, DOI: 10.4061/2011/726384
Abstract: Objectives. The “Sick Lobe” hypothesis states that breast cancers evolve from entire lobes or portions of lobes of the breast where initiation events have occurred early in development. The implication is that some cancers are isolated events and others are truly multi-focal but limited to single lobar-ductal units. Methods. This is a single surgeon retrospective review of early stage breast cancer lumpectomy patients treated from 1/2000 to 2/2005. Ductal endoscopy was used direct lumpectomy surgical margins by defining ductal anatomy and mapping proliferative changes within the sick lobe for complete excision. Results. Breast conservation surgery for stage 0–2 breast cancer with an attempt to perform endoscopy in association with therapeutic lumpectomy was performed in 554 patients (successful endoscopy in 465 cases). With an average followup of >5 years for the entire group, annual hazard rate for local failure in traditional lumpectomy without ductal mapping was 0.97%/yr. and for lumpectomy with ductal mapping and excision of entire sick lobe was 0.18%/yr. With endoscopy, 42% of patients were found to have extensive disease within their “sick lobe.” Conclusions. Targeting breast cancer lumpectomy using endoscopy and excision of regional associated proliferation seems associated with lower recurrence in this non-randomized series. 1. Introduction The “Sick Lobe” hypothesis was proposed by Tibor Tot in 2005 [1]. His work was really a culmination of collecting relevant clinical and pathologic observations of the last century and a half. His first observations and predictions were based upon DCIS. The breast is defined as a single organ made of multiple lobes. Each lobe is identified by a single orifice on the nipple papilla connecting to branching tree of ducts and hundreds to thousands of individual lobules in the periphery. He proposed that for many cases of DCIS (especially extensive ones) the initiating events of carcinogenesis occurred perhaps as early as in the womb. Then throughout life as the lobe both grew and contracted from hormonal and other influences progression would occur at varying rates in different regions of the ductal tree. This led to the situation of apparent multifocality within the ductal tree and pathologic “skips” between DCIS patches. With further whole mount examination, extensive dissection of extensive intraductal component small invasive cancer cases, and multifocal invasive cancers, the findings support this theory [2–7]. Further molecular studies would seem to indicate that serious adverse genetic events are present
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