Alexander Swistel

Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies.

BACKGROUND Skin-sparing mastectomies (SSMs) are being used more frequently to treat many cases of breast cancer. This type of surgery maximizes breast skin preservation and facilitates immediate reconstruction, resulting in a superior cosmetic appearance after mastectomy and a more satisfied patient. Although SSMs are becoming more common, there are few data regarding the local and distant recurrence rates. METHODS A total of 231 patients treated with mastectomies from 1990 to 1998 were studied, including 77 SSM and 154 non-skin-sparing (NSSM) mastectomy patients. RESULTS The local recurrence rates for SSM and NSSM were 3.90% (3 of 77 patients) and 3.25% (5 of 154 patients), respectively. The local recurrence-free survival at 5 years was 95.3% for SSM patients and 95.2% for NSSM patients (P = .28). The distant recurrence rates of SSM and NSSM were 3.9% (3 of 77 patients) and 3.9% (6 of 154 patients), respectively. The distant recurrence-free actuarial survival at 5 years was 90.2% for SSM patients and 92% for NSSM patients (P = .07). CONCLUSIONS Mastectomies using the skin-sparing technique do not appear to result in any increase in local or distant recurrence and improve aesthetic results of the immediate reconstruction.

Effectiveness of a noninvasive digital infrared thermal imaging system in the detection of breast cancer

BACKGROUND Digital infrared thermal imaging (DITI) has resurfaced in this era of modernized computer technology. Its role in the detection of breast cancer is evaluated. METHODS In this prospective clinical trial, 92 patients for whom a breast biopsy was recommended based on prior mammogram or ultrasound underwent DITI. Three scores were generated: an overall risk score in the screening mode, a clinical score based on patient information, and a third assessment by artificial neural network. RESULTS Sixty of 94 biopsies were malignant and 34 were benign. DITI identified 58 of 60 malignancies, with 97% sensitivity, 44% specificity, and 82% negative predictive value depending on the mode used. Compared to an overall risk score of 0, a score of 3 or greater was significantly more likely to be associated with malignancy (30% vs 90%, P < .03). CONCLUSION DITI is a valuable adjunct to mammography and ultrasound, especially in women with dense breast parenchyma.

Pathological evaluation of nipple-sparing mastectomies with emphasis on occult nipple involvement: the Weill-Cornell experience with 325 cases.

Nipple‐sparing mastectomy (NSM) is an increasingly utilized surgical option in managing breast carcinoma; however, data on malignant involvement of a separately submitted nipple margin are scant. Consecutive NSM, including those performed for therapeutic and prophylactic purposes, over a 4‐year period (2007–2011), were studied. A separately submitted nipple margin was evaluated by permanent H&E preparations and via frozen section evaluation whenever requested. 325 consecutive NSM specimens, 208 (64%) therapeutic‐NSM, and 117 (36%) prophylactic‐NSM were studied. All nipples were clinically unremarkable. 86% (179/208) of nipple margins from therapeutic‐NSM and 100% (117/117) from prophylactic‐NSM showed no histopathologic abnormality. 14% (29/208) of nipple margins from therapeutic‐NSM and no nipple margin from prophylactic‐NSM showed malignancy. Frozen section evaluation was performed in 188/325 NSM (58%) with a sensitivity of 64% and specificity of 99%. Central tumor location and stage N2/N3 lymph node status were significantly associated with nipple margin positivity (χ2 ≤ 0.05). Subsequent nipple resection was performed in 69% (20/29) of nipple margin‐positive cases with residual malignancy found in 40% (8/20, including three cases of invasive carcinoma). In a mean follow‐up of 33 months, one invasive carcinoma recurred in the “saved” nipple, 36 months after therapeutic‐NSM. 14% (29/208) of nipple margins in therapeutic‐NSM and no nipple margin (0/117) in prophylactic‐NSM showed malignancy. Central tumor location and N2/N3 stage were significantly associated with nipple margin positivity (χ2 ≤ 0.05).

Secretory Carcinoma in the Axilla: Probable Origin From Axillary Skin Appendage Glands in a Young Girl

Invasive carcinoma in the axilla may arise from skin appendage glands or ectopic breast tissue or it may be a metastasis. Carcinomas of the skin adnexal glands and breast can be difficult to distinguish from each other as they often display the same patterns of growth. Tubular, cribriform, papillary, apocrine, mucinous, and adenoid cystic are histologic types of carcinoma seen in the breast and skin appendage glands. To our knowledge, secretory carcinoma, the most common form of mammary carcinoma in children, has not yet been described as a morphologic pattern of skin adnexal carcinoma, although we cannot exclude the possibility that such a case was reported with a different diagnosis. We report a case of a young girl with secretory carcinoma that seems to have arisen from skin appendage glands in the skin of the axilla in the absence of demonstrable ectopic breast tissue.

Intraarterial versus intravenous adriamycin in the rabbit Vx‐2 tumor system

Intraarterial (IA) chemotherapy can theoretically result in a high tissue level of the drug with reduced systemic toxicity compared with intravenous (IV) administration. The authors compared these two modes of therapy using Adriamycin (doxorubicin) in the rabbit Vx‐2 tumor system. Vx‐2 was implanted in hind limb muscle, and silastic catheters were placed in the jugular vein and femoral artery. Nuclear imaging of technetium‐99m‐labeled autologous erythrocytes in nine animals was used to measure the kinetics of tumor blood flow. Presence of tumor increased flow through the involved limb up to threefold. One minute following injection there was no difference in concentration of 99mTc in tumor whether labeled cells were introduced IA or IV. Twelve rabbits received IA (N = 6) or IV (N = 6) Adriamycin (3 mg/ kg), while eight animals received normal saline IA or IV as controls. Tumor progressed in all control rabbits, whereas there was an objective or complete response in 83% of animals receiving Adriamycin. One hundred percent of those treated IA responded compared with 67% for IV (P = 0.04). Median time to initial response in animals treated IA was 7 days versus 21 days for those treated IV (P = 0.02). Thus, IA Adriamycin achieves a more complete and more rapid response than the drug given IV. This occurs despite a large tumor blood flow and rapid equilibration using both methods. Cancer 53:1397‐1404, 1984.

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Detection of recurrent breast cancer after TRAM flap reconstruction.

Breast cancer remains a significant cause of morbidity and mortality among women today. The transverse rectus abdominis myocutaneous (TRAM) flap has played a substantial role in the reconstruction of defects secondary to mastectomy. Although such reconstruction has not been shown to adversely affect survival or local recurrence, specific screening modalities for recurrence in this population of patients have not been delineated. Three patients were examined retrospectively at the authors’ institution. They presented with local recurrences of breast cancer after mastectomy and TRAM flap reconstruction. All patients’ recurrences were detected on physical examination, and all had the diagnosis of recurrent carcinoma made on biopsy of the mass. A review of the literature demonstrates that mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), scintimammography, and biopsy have all been used as adjuncts to clinical examination in detecting recurrence. Subsequent treatment of recurrent breast cancer is determined by the results of a metastatic workup and the receptor status of the tumor. The most reliable form of diagnosis of recurrent breast cancer after TRAM flap reconstruction remains fine-needle, core, or open biopsy if indicated.

Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction.

Background: This article discusses the senior author’s (M.T.) experience with nipple-areola complex malposition following nipple-sparing mastectomy, surgical options for treatment, and an analysis of risk factors. Methods: A retrospective review was conducted on a prospectively collected institutional review board–approved database of nipple-sparing mastectomy cases with immediate device-based reconstruction performed between July of 2006 and October of 2012. Malposition was graded as mild (1 cm), moderate (2 cm), or severe (>3 cm) displacement. Results: Three hundred nineteen nipple-sparing mastectomies were reviewed. Malposition occurred in 44 (13.79 percent). Significant factors were age (p < 0.0001), diabetes mellitus (p = 0.0025), body mass index (p = 0.0093), preoperative sternal notch–to-nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), periareolar mastectomy incision with lateral extension (p < 0.0001), prior radiation (p = 0.0004), prior lumpectomy (p = 0.0125), unilateral nipple-sparing mastectomy (p = 0.0004), and postoperative nipple-areola complex ischemia (p = 0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant. Nineteen patients were satisfied. Eight were not offered surgical correction because of an inadequate skin envelope. Eight had crescent mastopexy, three had implant exchange and pocket revision, four had free nipple grafts, and two had pedicled nipple transposition. There were no incidences of necrosis or malposition after surgical correction. Conclusions: Nipple-sparing mastectomy followed by immediate device-based reconstruction has a risk of nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in certain populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Levofloxacin-Induced Radiation Recall Dermatitis: A Case Report and a Review of the Literature

Radiation recall dermatitis (RRD) is a rare phenomenon. There are a few reports in the literature reporting RRD triggered by quinolones administration after external beam radiation therapy (EBRT). We present an unusual case of RRD induced by levofloxacin 7 months after completion of EBRT. A 56-year-old Caucasian female was treated with EBRT for stage I carcinoma of the right breast with whole breast irradiation followed by the boost to the tumor bed to a total dose of 6080 cGy. Seven months post completion of EBRT, levofloxacin was administered for an upper respiratory tract infection. On day 8 of levofloxacin, the patient developed a blistering RRD in the skin overlying the area of previous radiation portals. Discontinuation of the RRD-inducing antibiotic and appropriate therapy led to the resolution of the condition. We review literature emphasizing this quinolone antibiotic as a causative of RRD.

Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.

BackgroundNipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability. MethodsA retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy. ResultsThe overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7–1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%). ConclusionsPatients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.