Jason D. Keune

Accuracy of ultrasonography and mammography in predicting pathologic response after neoadjuvant chemotherapy for breast cancer.

BACKGROUND Neoadjuvant chemotherapy reduces tumor size before surgery in women with breast cancer. The aim of this study was to assess the ability of mammography and ultrasound to predict residual tumor size following neoadjuvant chemotherapy. METHODS In a retrospective review of consecutive breast cancer patients treated with neoadjuvant chemotherapy, residual tumor size estimated by diagnostic imaging was compared with residual tumor size determined by surgical pathology. RESULTS One hundred ninety-two patients with 196 primary breast cancers were studied. Of 104 tumors evaluated by both imaging modalities, ultrasound was able to size 91.3%, and mammography was able to size only 51.9% (chi(2)P < .001). Ultrasound also was more accurate than mammography in estimating residual tumor size (62 of 104 [59.6%] vs 33 of 104 [31.7%], P < .001). There was little difference in the ability of mammography and ultrasound to predict pathologic complete response (receiver operating characteristic, 0.741 vs 0.784). CONCLUSIONS Breast ultrasound was more accurate than mammography in predicting residual tumor size following neoadjuvant chemotherapy. The likelihood of a complete pathologic response was 80% when both imaging modalities demonstrated no residual disease.

Shared management of a rare necrotizing soft tissue infection of the breast.

To the Editor: Necrotizing soft tissue infections encompass a clinically diverse subset of manifestations. They are characterized according to the tissues affected: skin, subcutaneous tissue, fascia, or muscle. Patients with diabetes, chronic alcoholism, advanced age, vascular disease, and those who are immunosuppressed are predisposed to necrotizing infections of soft tissue. These infections are commonly caused by mixed aerobic and anaerobic organisms acting synergistically. The condition is rare. One recent study estimated 0.04 necrotizing infections per 1,000 person-years (1). Necrotizing soft tissue infections are associated with significant mortality, especially when early surgical intervention is delayed and patients have significant comorbidities (2). In one pooled analysis, overall mortality from all-cause necrotizing soft tissue infection was 34% (3). Early signs include: edema, dark reddish discoloration of skin, and tenderness in the area of infection which progresses to angiothrombotic phenomena, and liquefactive necrosis. Late presentation can also include systemic symptoms including shock and multiorgan dysfunction syndrome. Treatment is aggressive operative debridement and comprehensive medical care. The goals of surgical treatment include the removal of all necrotic material, visualization of deep structures and the obtaining of sufficient specimens for Gram stain and culture. We describe a patient treated for a rare necrotizing soft tissue infection of the breast, managed via a comprehensive multidisciplinary team approach. Her urgent care was managed initially by our Acute Care Surgical Service, with continued and definitive management by our Breast Service. This represents effective implementation of a new paradigm in the surgical staffing of a tertiary care center. This unique presentation of a relatively common and serious soft tissue infection is as an example of not only our surgical care goals, but also the advantages of our twentyfour ⁄ seven multidisciplinary care model. A 47-year-old female presented to our emergency department with complaints of a large black, malodorous, and painful area of the left breast. She described first having noticed a tender ‘‘knot’’ in the same area approximately 14 days prior to presentation. The patient was seen at a local urgent care center seven days prior to presentation where she was prescribed a course of trimethoprim–sulphamethoxazole. The patient noted that over the following several days, the ‘‘knot’’ increased in size and became extremely tender, indurated, and erythematous. Three days before presentation, the patient developed subjective fever, chills, and night sweats. One day prior to presentation, she noticed that the skin overlying the infected area had become black and had taken on a foul odor. The patient denied any trauma to the breast. She had no history of breast cancer and never had a mammogram. She had no significant past medical history and was taking no medications. On initial examination, her left breast had a black, necrotic-appearing 20 · 10 cm area in the left inner quadrant. The area was edematous, fluctuant, and subcutaneous emphysema was present. There was an area of liquefactive necrosis caudal to the area of blackened skin. Copious purulent material could be expressed from a 1 cm opening under the breast fold (Fig. 1). The patient was afebrile, and did not appear septic. Her white blood cell count was 16,700 ⁄ mm (3). A computed tomography scan of the chest revealed skin thickening and a large amount of subcutaneous gas tracking just beneath the skin surface and into the deep tissues of the breast, to a depth of 5 cm. There was a large amount of fat stranding, some of which extended to the pectoralis major muscle. Vessel thrombosis was not seen. There were prominent left axillary lymph nodes, the largest of which measured 1.7 · 0.9 cm (Fig. 2). Because she had presented to our emergency department late in the evening over a weekend, our Acute and Critical Care Surgical Service was initially Address correspondence and reprint requests to: Rebecca L. Aft, MD, PhD, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA, or e-mail: aftr@wustl.edu.

Ethics in Surgery

This monograph is designed to provide surgeons with a broad overview of the common ethical problems that they are likely to encounter in their daily practice. It also demonstrates a method for approaching these problems. Finally, it presents cases that illustrate some of these problems and provides guidance to finding rational solutions. Professional responsibilities have been a concern of surgeons since antiquity. However, the last 25 years have witnessed a dramatic growth of both professional and societal attention to moral and ethical issues involved in the delivery of health care. Increased interest in medical ethics has been fueled by factors such as improved technology in modern medicine, the assignment of social ills to the responsibility of medicine, a growing sophistication of patients and the information available to them, efforts to protect the civil rights of the increasingly disadvantaged groups in society, and the rapidly escalating costs of health care. All of these factors contribute to the urgency of identifying and addressing ethical issues involved in the delivery of modern surgical care. Surgeons live and practice an intense form of applied ethics. They deliver bad news; guide patients and their families through complicated decisions; live a code of trust with colleagues, patients, and trainees; and frequently address end-of-life issues. Moreover, surgeons must go to bed at night knowing that in the morning they will spend hours with someone’s life literally in their hands. In recent decades, surgeons have developed the capability to do more for patients than ever before. At the same time, personal, trusting relationships with patients are often not as strong as they have been in the past. Medicine has become a business, guided in many cases by the financial bottom line rather than by an uncompromising concern for the sick patient. Within this now fastmoving corporate system, surgeons see too many patients, do too many operations, and do not have time to develop a close mentoring relationship with trainees. These factors adversely affect relationships with patients, as well as the training of the next generation of surgeons. Surgery in this era of exciting scientific and technologic advancement is complicated by the demands of limited financial resources, limited time, and the constraints of managed care and extensive bureaucracy. Surgeons are forced to deliver care to patients in a manner and timeframe that many never contemplated when they entered medicine. In addition, surgeons have a different, more personal level of responsibility for patient care when compared to other healthcare providers. They are responsible for the operative procedure itself, the postoperative care, and the long-term follow-up and management of postoperative complications. Often, this intense relationship is established very quickly and under stressful circumstances. Contents lists available at SciVerse ScienceDirect

The Ethics of Conducting Graduate Medical Education Research on Residents

The field of graduate medical education (GME) research is attracting increased attention and broader participation. The authors review the special ethical and methodological considerations pertaining to medical education research. Because residents are at once a convenient and captive study population, a risk of coercion exists, making the provision of consent important. The role of the institutional review board (IRB) is often difficult to discern because GME activities can have multiple simultaneous purposes, educational activities may go forward with or without a research component, and the subjects of educational research studies are not patients. The authors provide a road map for researchers with regard to research oversight by the IRB and also address issues related to research quality. The matters of whether educational research studies should have educational value for the study subject and whether to use individual information obtained when residents participate as research subjects are explored.

The Importance of an Ethics Curriculum in Surgical Education

The nature of surgical work provides fertile ground in which ethical problems can grow. The concept of what it means to be a “good surgeon” includes the ability to reason and deliberate about how the surgeon’s unique technical capabilities integrate with larger society. Ethics education at the resident level is important for several reasons. It can ensure that care is delivered in a socially and ethically responsible manner through global and emergent effects on institutions and traditions. It will prepare residents for leadership positions. It can allow residents to confront issues, such as the scientific underdetermination of surgical practice, the application of new technologies to trusting patients that have been developed by for-profit companies, and a surgical environment that is becoming increasingly institutionalized. Resident ethics education provides the opportunity for a model of collective deliberation to be developed that can be used to make sense of ethical problems as they arise.

Conflicts of interest concerning the use of implants in the operating room.

ordance with ACCME regulations, the American College of ns, as the accredited provider of this journal CME, must that anyone in a position to control the content of the tional activity has disclosed all relevant financial relationships ny commercial interest. The editor and author(s) of this article were required to complete disclosures and any reported conflicts have been managed to our satisfaction. However, if you perceive a bias within the article, please advise us of the circumstances on the evaluation form.

Medicolegal and Ethical Dilemmas

The ethical and legal challenges that face colorectal surgeons are the same challenges that have faced all physicians throughout history. The contemporary legal environment presents special challenges to the practicing physician. In this chapter, we consider those medicolegal and ethical challenges that colorectal surgeons in practice are most likely to face.

A Nonlinear View of Scientific Progression: A Reevaluation of Kaposy's Supposed Obligation

overall sense for what morally ought to be done, then perhaps the same can be, and is, done concerning generic, plain “oughts” too.) A complete defense of Kaposy’s argument would require a more detailed examination of these issues concerning value conflicts. These conflicts are common: For example, some argue that rejecting certain religious beliefs is morally or prudentially troubling and so they should be retained; others argue that accepting certain religious beliefs is morally or prudentially troubling and so they should be rejected; some find some scientific theories depressing, others find them uplifting, and both cite this as reasons to accept or reject; and finally, some (neuro)scientific experiments are morally dubious, but are sometimes defended by appealing to their epistemic value, i.e., the knowledge and understanding they produce. These are just a few common examples of value conflicts (which are not yet disambiguated into different kinds of values), to add to those potentially raised by neuroscience. If these conflicts can be understood and resolved in a principled, non-ad hoc manner, this would be of great moral, epistemic, and prudential value. Kaposy’s paper effectively raises these important and broad-reaching issues and, if this is possible, we ought to attend to their resolution, all things considered.