Erin L. Doren

U.s. Epidemiology of Breast Implant–associated Anaplastic Large Cell Lymphoma

Background: Breast implant–associated anaplastic large cell lymphoma (ALCL) is a distinctive type of T-cell lymphoma that arises around breast implants. Although rare, all cases with adequate history have involved a textured breast implant. The objective of this study was to determine the U.S. incidence and lifetime prevalence of breast implant–associated ALCL in women with textured breast implants. Methods: This is a retrospective review of documented cases of breast implant–associated ALCL in the United States from 1996 to 2015. The incidence and prevalence were determined based on a literature and institutional database review of breast implant–associated ALCL cases and textured breast implant sales figures from implant manufacturers’ annualized data. Results: One hundred pathologically confirmed breast implant–associated ALCL cases were identified in the United States. Mean age at diagnosis was 53.2 ± 12.3 years. Mean interval from implant placement to diagnosis was 10.7 ± 4.6 years. Forty-nine patients had breast implants placed for cosmetic reasons, 44 for mastectomy reconstruction, and seven for unknown reasons. Assuming that breast implant–associated ALCL occurs only in textured breast implants, the incidence rate is 2.03 per 1 million person-years (203 per 100 million person-years), which is 67.6 times higher than that of primary ALCL of the breast in the general population (three per 100 million per year; p < 0.001). Lifetime prevalence was 33 per 1 million persons with textured breast implants. Conclusions: This study demonstrates a statistically significant association between textured breast implants and breast implant–associated ALCL. Although women with a textured breast implant have a low risk of developing breast implant–associated ALCL, the current U.S. incidence is significantly higher than that of primary ALCL of the breast in the general population.

Predicting cancer on excision of atypical ductal hyperplasia

BACKGROUND There are no specific histopathologic factors that allow identification of patients with atypical ductal hyperplasia (ADH) who will have cancer on final excision. METHODS This was a retrospective study of all patients who had ADH on biopsy followed by excision from 1999 to 2006. RESULTS Fifty-one patients were found to have ADH on core biopsy. Eight (15.7%) patients had invasive carcinoma on surgical excision, 9 (17.5%) had ductal carcinoma-in-situ (DCIS), 21 (41.5%) had ADH, 4 (8%) patients had atypical lobular hyperplasia, and 9 (17.5%) had benign tumors. The grade of atypia on the core biopsy was mild in 13 (25%) patients, moderate in 22 (43%), and marked in 16 (32%). On multivariate analysis of histopathologic factors, the grade of atypia was the only significant variable that predicted a diagnosis of cancer on final surgical excision (P = .001). CONCLUSIONS The grade of atypia correlated with the presence of cancer on surgical excision.

Differentiating fat necrosis from recurrent malignancy in fat-grafted breasts: an imaging classification system to guide management.

Background: In breast reconstruction with autologous fat grafting, concerns persist about the ability to differentiate palpable masses representing fat necrosis from recurrent cancer. The authors’ objective was to develop standardized imaging classifications to distinguish benign from malignant lesions after fat grafting. Methods: A database of 286 breast reconstruction patients undergoing fat grafting from 2006 to 2011 was retrospectively reviewed to identify patients with imaging of clinically palpable masses. All images were reviewed independently by a radiologist blinded to prior results. Lesions were classified, using the American College of Radiology Breast Imaging Reporting and Data System ultrasound lexicon, as follows: A, solid mass, hypoechoic; B, solid mass, isoechoic; C, solid mass, hyperechoic; D, solid mass, complex echogenicity; E, anechoic mass with posterior acoustic enhancement; F, cystic mass with internal echoes; and G, negative. Evolutions in lesions on follow-up ultrasound were recorded. Images were correlated with histopathologic results. Results: On ultrasound, 66 lesions were visualized in 37 patients with palpable masses. Twenty-two lesions (33 percent) were Breast Imaging Reporting and Data System category 4 lesions; biopsies were performed on all of them. Histopathologic results revealed that 85.7 percent (six of seven) with classification D and 100 percent with classifications A, B, C, E, F, and G were fat necrosis. The one malignant lesion (classification D) exhibited vascularity and angular margins on ultrasound and was not in the location of fat injection. Negative predictive value of avascularity and circumscribed margins for malignancy was 100 percent. Follow-up ultrasound of 29 lesions at a median of 6.5 months revealed that no masses increased in size or developed vascularity. Conclusion: Ultrasound analysis, with a standardized classification system, is reliable at differentiating benign from malignant lesions after fat grafting in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon's 10-Year Experience.

Background: Contoured cohesive gel breast implants have been recently approved in the United States. These implants have been available for premarket approval studies for selected surgeons. The purpose of this study was to assess a single surgeon’s outcomes in three specific clinical situations—breast augmentation, secondary augmentation, and breast reconstruction—using implants of all three contoured cohesive gel implant manufacturers (Allergan, Mentor, and Sientra) over a 10-year period. Methods: The authors performed a prospective study of contoured cohesive silicone gel breast implants. Demographic and outcomes data were recorded. Complication rates were compared among the three implant manufacturers. Results: From 2001 to 2013, 695 patients were included from U.S. Food and Drug Administration clinical trials. Mean age at implantation was 42.7 years (range, 18 to 82 years), and mean time enrolled was 5.3 years (range, <1 to 10 years). One hundred sixty-four patients (24 percent) received Allergan implants, 245 (35 percent) received Mentor implants, and 286 (41 percent) received Sientra implants. Three hundred eighty-four patients (55 percent) underwent primary augmentation, 198 (29 percent) underwent secondary augmentation, and 113 (16 percent) underwent breast reconstruction. The total complication rate was the lowest for primary augmentation of the Mentor group compared with the Allergan and Sientra groups (p < 0.05). There were no significant differences in complication rates when used for secondary augmentation and reconstruction. There was no statistically significant difference between implant group reoperation, explantation, or capsular contracture rates. Overall implant rupture and rotation rates were low (0.7 percent and 1.3 percent, respectively). Patient and surgeon satisfaction was high. Conclusions: Contoured cohesive gel breast implants overall have low complication rates and high patient and surgeon satisfaction. The authors believe these implants to be safe and effective in breast augmentation and reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Neuronal Bursting Properties in Focal and Parafocal Regions in Pediatric Neocortical Epilepsy Stratified by Histology

To test the hypothesis that focal and parafocal neocortical tissue from pediatric patients with intractable epilepsy exhibits cellular and synaptic differences, the authors characterized the propensity of these neurons to generate (a) voltage-dependent bursting and (b) synaptically driven paroxysmal depolarization shifts. Neocortical slices were prepared from tissue resected from patients with intractable epilepsy. Multiunit network activity and simultaneous whole-cell patch recordings were made from neurons from three patient groups: (1) those with normal histology; (2) those with mild and severe cortical dysplasia; and (3) those with abnormal pathology but without cortical dysplasia. Seizure-like activity was characterized by population bursting with concomitant bursting in intracellularly recorded cortical neurons (n = 59). The authors found significantly more N-methyl-d-aspartic acid-driven voltage-dependent bursting neurons in focal versus parafocal tissue in patients with severe cortical dysplasia (P < 0.01). Occurrence of paroxysmal depolarization shifts and burst amplitude and burst duration were significantly related to tissue type: focal or parafocal (P < 0.05). The authors show that functional differences between focal and parafocal tissue in patients with severe cortical dysplasia exist. There are functional differences between patient groups with different histology, and bursting properties can be significantly associated with the distinction between focal and parafocal tissue.

Pyoderma Gangrenosum Following Breast Reduction: Treatment With Topical Tacrolimus and Steroids

UNLABELLED Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids. LEVEL OF EVIDENCE 5.

Biplanar flap reconstruction for pressure ulcers: experience in patients with immobility from chronic spinal cord injuries

BACKGROUND Surgical therapy for advanced-stage pressure ulcers recalcitrant to healing is a widely accepted practice. The present study examined the incidence of wound recurrence after reconstruction with fasciocutaneous versus combined (biplanar) muscle and fasciocutaneous flaps. METHODS A retrospective review identified 90 nonambulatory patients with spinal cord injury who underwent reconstruction for persistent decubitus ulcers from 2002 to 2008. Electronic medical records were surveyed for patient comorbidities and postoperative complications. Statistical methods included the Fisher exact test and the Mann-Whitney U test with a 2-sided P value of less than .05. RESULTS Among 90 patients reviewed, 33% (n = 30) received fasciocutaneous flaps and 66% (n = 60) underwent biplanar reconstruction. Comorbidities were the same between cohorts with the exception of a greater prevalence of diabetes in the biplanar group (27% vs 50%; P < .05). The incidence of recurrence for biplanar flaps (25%) was significantly lower than for fasciocutaneous reconstruction (53%; P < .01). CONCLUSIONS Biplanar flap reconstruction should be considered for chronically immobilized patients at high risk for recurrent decubitus ulceration.