Jill R. Dietz

Hospital-Associated Costs Due to Surgical Site Infection After Breast Surgery

OBJECTIVE To determine the attributable costs associated with surgical site infection (SSI) following breast surgery. DESIGN AND SETTING Cost analysis of a retrospective cohort in a tertiary care university hospital. PATIENTS All persons who underwent breast surgery other than breast-conserving surgery from July 1, 1999, through June 30, 2002. MAIN OUTCOME MEASURES Surgical site infection and hospital costs. Costs included all those incurred in the original surgical admission and any readmission(s) within 1 year of surgery, inflation adjusted to US dollars in 2004. RESULTS Surgical site infection was identified in 50 women during the original surgical admission or at readmission to the hospital within 1 year of surgery (N = 949). The incidence of SSI was 12.4% following mastectomy with immediate implant reconstruction, 6.2% following mastectomy with immediate reconstruction using a transverse rectus abdominis myocutaneous flap, 4.4% following mastectomy only, and 1.1% following breast reduction surgery. Of the SSI cases, 96.0% were identified at readmission to the hospital. Patients with SSI had crude median costs of

Risk Factors for Surgical Site Infection after Major Breast Operation

16 882 compared with

Recognition of HLA-A2-restricted mammaglobin-A-derived epitopes by CD8+ cytotoxic T lymphocytes from breast cancer patients.

6123 for uninfected patients. After adjusting for the type of surgical procedure(s), breast cancer stage, and other variables associated with significantly increased costs using feasible generalized least squares, the attributable cost of SSI after breast surgery was

Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: Data on CPM Outcomes and Risks.

4091 (95% confidence interval,

Generation of CD8+ cytotoxic T lymphocytes against breast cancer cells by stimulation with mammaglobin-A-pulsed dendritic cells

2839-

Nipple-Sparing Mastectomy: Indications, Contraindications, Risks, Benefits, and Techniques

5533). CONCLUSIONS Surgical site infection after breast cancer surgical procedures was more common than expected for clean surgery and more common than SSI after non-cancer-related breast surgical procedures. Knowledge of the attributable costs of SSI in this patient population can be used to justify infection control interventions to reduce the risk of infection.

Skin Reduction Nipple-Sparing Mastectomy.

BACKGROUND Understanding surgical site infection (SSI) risk factors after breast operation is essential to develop infection-prevention strategies and improve surgical outcomes. METHODS We performed a retrospective case-control study with subjects selected from a cohort of mastectomy, breast reconstruction, and reduction surgical patients between January 1998 and June 2002 at a university-affiliated hospital. SSI cases within 1 year after operation were identified using ICD-9-CM diagnosis codes for wound infection and complication or positive wound cultures, or both. Medical records of 57 patients with breast SSI and 268 randomly selected uninfected control patients were reviewed. Multivariate logistic regression was used to identify independent risk factors for SSI. RESULTS Significant independent risk factors for breast incisional SSI included insertion of a breast implant or tissue expander (odds ratio [OR] = 5.3; 95% CI, 2.5 to 11.1), suboptimal prophylactic antibiotic dosing (OR = 5.1; 95% CI, 2.5 to 10.2), transfusion (OR = 3.4; 95% CI, 1.3 to 9.0), mastectomy (OR = 3.3; 95% CI, 1.4 to 7.7), previous chest irradiation (OR = 2.8; 95% CI, 1.2 to 6.5), and current or recent smoking (OR = 2.1; 95% CI, 0.9 to 4.9). Local infiltration of an anesthetic agent was associated with substantially reduced odds of SSI (OR = 0.4; 95% CI, 0.1 to 0.9). CONCLUSIONS Suboptimal prophylactic antibiotic dosing is a potentially modifiable risk factor for SSI after breast operation. SSI risk was increased in patients undergoing mastectomy and in patients who had an implant or tissue expander placed during operation. This information can be used to develop a specific risk stratification index to predict SSI and infection-preventive strategies tailored for breast surgery patients.

Editorial: Management Based on Risk: Individualizing the Care of the Breast Cancer Patient

A breast cancer-associated antigen, mammaglobin-A, is specifically expressed in 80% of primary breast tumors. The definition of immune responses against this highly expressed breast cancer-specific antigen should be of great value in the development of new therapeutic strategies for breast cancer. Thus, the purpose of this study was to identify HLA-A2-restricted mammaglobin-A-derived epitopes recognized by CD8+ cytotoxic T lymphocytes (CTL). We identified seven mammaglobin-A-derived candidate epitopes that bind the HLA-A2 molecule (Mam-A2.1-7) by means of a HLA class I-peptide binding computer algorithm from the Bioinformatics & Molecular Analysis Section of the National Institutes of Health. Subsequently, we determined that CD8+ CTLs from breast cancer patients reacted to the Mam-A2.1 (83–92, LIYDSSLCDL), Mam-A2.2 (2–10, KLLMVLMLA), Mam-A2.3 (4–12, LMVLMLAAL), Mam-A2.4 (66–74, FLNQTDETL), and Mam-A2.7 (32–40, TINPQVSKT) epitopes using an IFN-c ELISPOT assay. Interestingly, healthy individuals also showed high reactivity to the Mam-A2.2 epitope. Two CD8+ CTL lines generated in vitro against TAP-deficient T2 cells loaded with the candidate epitopes showed significant cytotoxic activity against the Mam-A2.1-4 epitopes. These CD8+CTL lines recognized a HLA-A2+breast cancer cell line expressing the Mam-A2.1 epitope. In addition, DNA vaccination of HLA-A2+/human CD8+ double-transgenic mice with a DNA construct encoding the Mam-A2.1 epitope and the HLA-A2 molecule induced a significant expansion of epitope-specific CD8+ CTLs that recognize the same HLA- A2+/Mam-A2.1+ breast cancer cell line. In conclusion, these results demonstrate the immunotherapeutic potential of mammaglobin-A for the treatment and prevention of breast cancer.

Breast Cancer Management Updates: Young and Older, Pregnant, or Male

The American Society of Breast Surgeons (ASBrS) endorses the American Board of Internal Medicine’s Choosing Wisely campaign statement: “Don’t routinely perform a double mastectomy in patients who have a single breast with cancer.”1 However, women with a newly diagnosed unilateral breast cancer are increasingly opting for bilateral mastectomy. This has been seen in patients who are candidates for breast conservation who elect mastectomy as well as those requiring mastectomy for their index breast cancer.2 National rates of contralateral prophylactic mastectomy (CPM) in the United States have been increasing and this trend is continuing.2–4

Providing the Best Care for Patients with Breast Cancer Through Use of the Multidisciplinary Team

Mammaglobin-A is exclusively expressed by breast cancer cells. Thus, mammaglobin-A-specific T cell immune responses may be useful for the design of new breast cancer-specific immunotherapies. We show herein that CD8+ T cells generated against recombinant mammaglobin-A-pulsed dendritic cells display a marked cytotoxic activity against mammaglobin-A-positive breast cancer cell lines. This study indicates the immunotherapeutic potential of this novel antigen for the treatment of breast cancer.