Parto Forouhi

Titanium clip placement to allow accurate tumour bed localisation following breast conserving surgery – Audit on behalf of the IMPORT Trial Management Group

INTRODUCTION Accurate tumour bed (TB) localisation is a key requirement for the UK IMPORT (Intensity Modulated Partial Organ Radiotherapy) trial. We audited the value of titanium clips for TB localisation following breast conserving surgery (BCS) in breast radiotherapy (RT) planning. PATIENTS AND METHODS At surgery, paired clips were positioned around the TB as follows: 1. Medial, lateral, superior and inferior: half-way between skin and fascia; 2. Posterior: at the pectoral fascia; 3. Anterior: close to the suture line. Thirty consecutive patients with clips inserted were audited at the time of RT planning. Audit standards were set as follows: (i) 5/6 pairs of clips identified on RT planning computed tomography (CT) scan - 100%; (ii) possible clip migration: <10%; (iii) TB localisation improved with clips: >50%. Inter- and intra-observer variability in clinician outlining of the TB was studied in a subset of 12 randomly selected patients to see if this impacted on positioning of radiotherapy field borders. RESULTS Five or six pairs of clips were identified in all 30 cases. The TB could be successfully identified using CT seroma alone in only 8/30 (27%) patients. Clips were essential for the TB localisation of the other 22/30 (73%) patients. There was no evidence of clip migration. TB localisation led to modified RT field borders in 18/30 (60%) patients. Five of these patients had highly visible seromas, so the addition of clips modified field borders in 13/30 (43%) patients. Both inter- and intra-observer variability was reasonable and did not impact on positioning of radiotherapy field borders. CONCLUSION Titanium clips provide an accurate and reliable method of TB localisation following BCS. We anticipate that the audit results will lead to clips being adopted as best practice by the Association of Breast Surgeons (ABS) at BASO (British Association of Surgical Oncology).

Erdheim-chester disease presenting as bilateral clinically malignant breast masses.

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis of unknown etiology, the commonest sites of involvement being the long bones, skin, orbit, pituitary and retroperitoneum. Breast involvement is rare, with only four reported cases in the English literature. We present a case of a 78-year-old female presenting with bilateral clinically malignant breast masses, with mammographic and ultrasound findings suggestive of locally advanced bilateral breast cancer. Core biopsies from both breasts showed identical features, with a diffuse xanthomatous infiltrate with scattered Touton-type giant cells and a patchy lymphocytic infiltrate. The cells were CD68 positive, and negative for S100, CD1a and a broad panel of cytokeratins. The patient has a background history of cerebrovascular disease with carotid artery stenosis, and subsequently developed rapid restenosis after carotid endarterectomy. With the combined clinical history and classic histological findings in the breast, a diagnosis of Erdheim-Chester disease was made. This is the fifth case report of Erdheim-Chester disease involving the breast, and only the second case with breast lesions as the presenting symptom. Perivascular infiltration is also a rare but recognized presentation of Erdheim-Chester disease. Histiocytic proliferations including ECD can mimic breast carcinoma clinically, radiologically, and histologically, and should be considered in the differential diagnosis of breast mass lesions.

An evaluation of incidental metastases to internal mammary lymph nodes detected during microvascular abdominal free flap breast reconstruction.

BACKGROUND The significance of internal mammary lymph nodes (IMLNs) encountered during dissection of internal mammary vessels (IMVs) for microvascular free flap breast reconstruction (FFBR) remains uncertain. We report our experience with the opportunistic harvest of IMLNs during FFBR. Therapeutic implications and patient outcomes are explored. METHODS All IMV anastomoses for delayed (DBR) or immediate breast reconstruction (IBR), between 1997 and 2009 were recorded. Opportunistic IMLN harvests were identified and patient characteristics and outcomes recorded from review of case records. RESULTS Of the 293 FFBRs, 43 patients had 46 IMLNs harvested during 20 immediate and 26 delayed FFBRs. Six patients had positive nodes (4 IBR and 2 DBR), and were offered post operative chemotherapy. Four received radiotherapy to the internal mammary chain. Three of the four IMLN+ve IBR patients have died of metastatic disease at 23, 33 and 55 months after reconstruction. The two IMLN+ve DBR patients were alive at 4 and 20 months. DISCUSSION AND CONCLUSION Although routine biopsy of IMLNs for staging in breast cancer is not standard practice, if identified during IMV recipient site preparation for microvascular anastomosis, opportunistic biopsy should be performed due to the additional staging information provided and subsequent effect upon the predicted prognosis.

Opportunistic internal mammary lymph node biopsy during microvascular free flap breast reconstruction: A useful technique?

Internal mammary lymph node (IMLN) biopsy for staging breast cancer is not standard practice. The significance of IMLNs encountered incidentally during dissection of internal mammary vessels (IMVs) for microvascular free flap breast reconstruction (FFBR) remains obscure. Since our last study,1 we now routinely harvest incidental IMLNs during FFBR. We present our 15-year experience with the opportunistic harvest of IMLNs during FFBR. All IMV anastomoses performed between 1997 and 2011 for delayed (DBR) or immediate breast reconstruction (IBR) at Addenbrooke’s University Hospital, Cambridge were identified from our audit database. All IMLN harvests were analysed from our histology database by retrospectively correlating them with patient and tumour characteristics and oncological outcomes. Patients with breast tumours that were large (T3), locally advanced (T4) or had involvement of more than four axillary lymph nodes underwent preoperative staging. This was performed with CT chest, abdomen and pelvis with bone windows to include the upper femurs. Axillary staging prior to 2006 involved level 2 axillary lymph node dissection for invasive cancers and since then, sentinel lymph node biopsy has been used. A total of 503 FFBRs were performed in 474 patients. Of these, 86 patients (18%) had 95 IMLNs harvested during 54 immediate and 41 delayed FFBRs. Eleven patients (13%) had tumour-positive nodes (Table 1, Fig. 1). In the IBR group, 7 of 44 patients were confirmed to have IMLN metastases histologically (16%) compared to 4 of 42 patients (10%) in the DBR group. The mean patient agewas 47 years with no significant age difference between the IBR and DBR groups. Therewere also no significantmacroscopic differences between the metastatic and non-involved nodes. In the DBR group, the median time between mastectomy and reconstruction was 30 months (range 11–154). All patients with positive IMLNs were offered chemotherapy and eight received radiotherapy to the internal mammary chain. Three of the seven IMLN positive IBR patients (43%) have died of

Marking clips for tumour-bed localization as a cause of chronic sinus formation and pain after breast conservation surgery for cancer: A case series of 4 patients.

The Association of Breast Surgeons recommends the intra-operative placement of six paired surgical vessel ligation clips to allow accurate tumour bed localization during breast conserving surgery (BCS) to facilitate delivery of adjuvant radiotherapy. Little has been published regarding wound complications secondary to foreign-body reaction to titanium clips used for this purpose. We describe a series of four patients who developed delayed chronic wound complications following BCS, including non-healing ulcers, sinus formation and chronic pain. In all cases, clinical examination and radiographic imaging suggested subcutaneous migration of clips. Symptoms resolved following excision of affected breast tissue and associated clips. Pathology assessment of the excised tissue demonstrated a giant cell foreign-body reaction accompanying the marking clips. We advise the use of the smallest available clips, ensuring these are not placed too superficially. A high index of clinical suspicion is warranted to assess and manage this uncommon complication which sometimes presents to the reconstructive plastic surgeon.

Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus

Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.

Novel use of LigaSure Impact™ electrosurgical bipolar vessel sealing system in skin-sparing mastectomy

http://dx.doi.org/10.1016/j.bjps.2015.01.005 1748-6815/a 2015 British Association of Plastic, Reconstructive and Aestheti report its use in skin-sparing mastectomies (SSM) for invasive cancer, DCIS or risk reduction. We modified the traditional method of SSM by incorporating LigaSure Impact LF4218 for dissection of breast tissue. The skin incision is planned taking into account the previous biopsy scar, tumour location and depth, and reconstructive approach. The SSM incision is made and mastectomy plane infiltrated with Hartmann’s solution containing 1 mg/L adrenaline. The mastectomy plane is identified by blunt dissection using Metzenbaum scissors (Figure 1) and a few centimetres of skin flap elevated using monopolar diathermy (on blend setting), while the breast skin is retracted using a Kilner (“cat’s paw”) retractor. LigaSure Impact is then inserted, held parallel to the skin, using palpation on the skin surface to ensure it is kept approximately 5 mm in thickness to prevent skin necrosis (Figure 2). The tissue is then divided and the instrument