Rasih Yilmaz

Variables Affecting Patient Satisfaction in Breast Surgery: A Cross-Sectional Sample of Turkish Women with Breast Cancer

Objective: In Turkey, despite the fact that breast cancer accounts for 24.1% of all cancer in women, a very small number of these patients receive breast reconstruction. This low percentage would seem to indicate that there are several factors affecting the decision of which surgical procedure should be selected. The aim of this study was to establish the demographical, medical, and psychological factors associated with the breast cancer patients decision-making process, and assess their satisfaction with the type of surgery received. Method: We assessed long-term satisfaction with the type of surgery received; satisfaction with the information process by which the surgery decision is taken; feelings of ambivalence or regret regarding the type of surgery received in both mastectomy (n = 50) and breast reconstruction patients (n = 25). Additionally, breast cancer survivors were compared with age-matched healthy control volunteers (n = 50) in terms of demographics, body image and self-esteem, which could be expected to affect their preferences. We administered a demographical and medical information form, Structured Clinical Interview for DSM-IV, Clinical Version (SCID-I), the Body Cathexis Scale (BCS); and the Rosenberg Self-Esteem Scale (RSE). Results: In both groups, women with a low income and less education were more likely to experience decision regret or low satisfaction. Moreover, total mastectomy-alone patients had lower self-esteem compared to reconstructive surgery patients and healthy women. Conclusion: Early stage breast cancer is a chronic disease and patients have to live with the consequences of their decision for many years. At the same time, the type of surgery is decided on when patients are in an acute phase and under intense pressure. Therefore, the decision making process needs to be explored more, especially breast cancer patients with less education and low income need better assistance and more detailed explanation of their options.

Superior Mesenteric Artery Aneurysm

A 38-year old woman with mid-epigastric pain, diarrhea, and weight loss, underwent resection of a superior mesenteric artery aneurysm and primary repair of the artery. Pathological examination showed degenerative atherosclerotic changes, marked medial and intimal thickening, and vegetations. Microbiological studies demon-strated Streptococcus viridans as the infecting organism of this mycotic aneurysm. The patient made a good recovery and remained well after 3 years.

Dermatofibrosarcoma Protuberans of the Breast: Dermatofibrosarcoma Protuberans of the Breast

A48 years old female patient was performed excisional biopsy 5 years ago due to breast mass. Approximately 18 months after first excision, second excision was performed due to mass development in the same area. The patient presented to our clinic, there was an inflammatory mass in the breast which was underwent excisional biopsy previously. The tumor was growing gradually for 1 year and had intermittent bleeding. On physical examination the left breast had lost its normal form and there was an approximately 10 cm lobulated and protruding lesion, which held nearly whole of the breast (Fig. 1). There was no axillary lymphadenopathy and the other breast was normal. Breast ultrasonography revealed thick walled cystic lesion with dense content located in the middle outer quadrant of the left breast. Histogical essay of the excisional biopsy specimen revealed Dermatofibrosarcoma protuberans (DFSP). No sign of distant metastasis was found in thorax CT and abdominal ultrasonography. Patient underwent left total mastectomy and axillary dissection. On pathologic examination the mass was nodular, protuberant, and white in color. The mass size was 10 · 7 · 6 cm, infiltrating cutis and had 0.2 cm distance to pectoral fascia. On microscopic examination tumor infiltrated dermis diffusely beginning from just underneath the epidermis. In deep regions, the tumor spreaded along the breast connective tissue and interdigitated with lobules of the breast fat. Tumor was composed of uniform slender fibroblasts arranged in a distinct monotonous storiform pattern. There was low mitotic activity and no obvious pleomorphism. MIB-1 proliferating index was about 5%. Immunohistochemistry demonstrated diffuse CD34 positivity. With these findings, tumor was diagnosed as DFSP (Fig. 2). Metastasis was not detected in the 12 lymph nodes that were dissected from the left axilla. Patient was evaluated in the breast tumor council and was decided to be applied adjuvant radiotherapy. Dermatofibrosarcoma protuberans is a relatively uncommon neoplasm of the deep dermis and subcutaneous tissue with low-grade malignant potential. Growth rate is variable and increases after recurrence. As tumor can remain stable for years, it may show slow growth pattern accompanied by periods of rapid growth. The differential diagnosis should include dermatofibroma, epidermal inclusion cyst, neurogenic tumor, malign melanoma, fibrosarcoma, and malign fibrous histiocytoma. Characteristic protrusion of the skin is a very important sign and without the presence of protrusion the differential diagnosis may be challenging. Skin biopsy is golden standard for certain diagnosis. Local recurrence occurs in 20–55% of patients with DFSP. This ratio reaches as high as 73% in cases with fibrosarcomatous changes which worsens prognosis. Local recurrence after conservative surgery is reported to be 43%, however, this ratio drops to 1, 6% when Mohs micrographic surgery (MMS) and to 0% when extensive surgical excision (surgical borders >5 cm) is applied. Most of the recurrences occur within first 3 years of primary excision and, however, this period can be longer. Despite its local aggressiveness, DFSP rarely causes distant metastases. The rare distant metastases of DFSP which usually occur after multiple local recurrences are reported to be related to insufficient excision of vascular structures involved by the tumor and usually occur after multiple efforts to resect local recurrences. As an uncommon soft tissue tumor with a low rate of metastasis, we found our case of DFSP patient worth reporting as, in discordance with the literature, she had lung metastasis without the presence of local recurrence after a long period of 7 years Address correspondence and reprints request to: Levent Yeniay, MD, Ege Universitesi Tip Fakultesi Hastanesi Genel Cerrahi AD 35100 Bornova/ Izmir/Turkiye or e-mail: levent. yeniay@ege.edu.tr.

A new and simple predictive formula for non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph nodes, and validation of 3 different nomograms in Turkish breast cancer patients.

Background: Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement. Patients and Methods: Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement. Results: The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64–0.8), 0.665 (95% CI 0.59–0.73), and 0.696 (95% CI 0.59–0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63–0.81). Conclusion: The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.

Precipitating Factors for Lymphedema Following Surgical Treatment of Breast Cancer: Implications for Patients Undergoing Axillary Lymph Node Dissection

To the Editor: Axillary lymph node dissection (ALND) remains the standard of care in the management of invasive breast carcinoma (1,2). However, questions have been raised about the routine performance of this procedure due to relatively high morbidity rate (3,4). Lymphedema is the most common complication of ALND resulting in chronic and debilitating arm swelling. This retrospective analysis was performed to identify the predisposing factors that significantly impact on the likelihood of lymphedema following breast cancer surgery. Between January 1990 and December 2000, 1,155 breast cancer patients were treated surgically at Ege University Medical Faculty. All patients had invasive carcinomas and underwent ALND, with either mastectomy (with or without adjuvant radiotherapy [RT]) or breast conserving surgery [BCS] with adjuvant RT. A total of 681 patients (59%) were given postoperative RT to the breast with 50 Gy over 4 weeks with a boost to the tumor side. A group of 327 patients with gross residual or N2 disease, or having ‡4 positive ALNs received axillary RT. None of the patients received neoadjuvant treatment and there were no immediate reconstructions. The patients were observed for a minimum of 36 months. The occurrence of lymphedema was determined by means of the difference in circumferential arm measurement (10 cm below and 10 cm above the lateral epicondyl) between the treated side and the contra-lateral side. Arm swelling involving a difference >2 cm was accepted as lymphedema. Statistical analysis was performed using SPSS 14.0 for Windows. Statistical methods for univariate analysis included the chi-squared test applied to categorical data and analysis of variants, and the Student t-test for continuous variables. Statistically significant variables were entered into multivariate regression analysis using logistic regression. With an average follow-up of 66.7 ± 27 months, 538 patients developed lymphedema (46.6%, LE [+] group). At time of initial diagnosis, the presence of locally advanced disease (p < 0.001, RR = 2.06, 95% CI, 1.42–3.00), and clinically positive lymph nodes (p = 0.002, RR = 1.44, 95% CI, 1.14–1.82) were significant factors contributing to the risk of lymphedema. The number of lymph nodes removed during ALND (range, 7–52 nodes) showed a statistically significant difference between LE [+] and LE [)] groups (17.9 ± 6.4 versus 16.2 ± 5.7, respectively, p < 0.001). The lymphedema rates corresponding to axillary clearance with £10, 11–15, 16–20, and >20 lymph nodes removed were 34.0%, 44.4%, 47.2%, and 54.9%, respectively (p < 0.001). ALN involvement was also found to contribute to the occurrence of lymphedema, with a significantly increased risk noted in node positive (55.7%) versus node negative (35.5%) patients (p < 0.001, RR = 2.28, 95% CI, 1.79–2.89). The corresponding rates in patients with axillary metastasis involving 1–3, 4–9, and ‡10 nodes were 47.9%, 61.0%, and 73.5%, respectively (p < 0.001). The incidence of lymphedema was found to increase in patients undergoing mastectomy (49.2%) versus BCS (32.0%) (RR = 2.05, 95% CI, 1.47–2.88). Furthermore, adjuvant RT of the breast appeared to increase the lymphedema rate significantly. The development of lymphedema was more frequent in irradiated (52.7%) versus nonirradiated (37.8%) patients (RR = 1.53, 95% CI, 1.20–1.95). The patients treated with axillary RT (n = 66) had the highest risk of lymphedema (RR = 34.5, 95% CI, 8.3–142.5). However, despite the fact that all patients undergoing BCS were irradiated, they were found to have a lower incidence of lymphedema (32%) than the patients undergoing mastectomy without irradiation (37.6%) (RR = 1.70, 95% CI, 1.47–1.97). The risk of lymphedema was found to be unrelated to chemotherapy. Multivariant Address correspondence and reprint requests to: Dr. Murat Dayangac, MD, Florence Nightingale Hastanesi, Abide-I Hurriyet Cad. No: 290, 34381 Sisli ⁄ Istanbul, Turkey, or e-mail: dayangac@mail.ege.edu.tr.

Giant gastrointestinal stromal tumour of the oesophagus presenting with atypic symptom.

kayak, 6 months of nausea and occasional vomiting while scrubbing in theatre, with 4 months of stress incontinence. She also suffered dizziness on bending over. She had some mild upper abdominal discomfort. A gastroscopy was normal, but an ultrasound scan (to exclude gallstones) showed the large septated abdominal cyst. A CT scan confirmed a cyst measuring 24 ¥ 15 ¥ 8 cm. It appeared to be within the lesser sac of the abdomen and was thought not originate from the liver. No definitive preoperative diagnosis was made despite consultation with both surgical and radiological colleagues. She proceeded to a laparotomy when the large cyst originating from the lesser curve of the stomach was defined. The lesser omentum was stretched over the cyst. This was incised and the cyst delivered out of the abdomen (Fig. 1) and dissected free, without significant difficulty. The histology defined the diagnosis. She made a straightforward recovery with no evidence of recurrence to date.

DIAGNOSTIC RELIABILITY OF COMBINED APPROACH OF PHYSICAL EXAMINATION, MAMMOGRAPHY AND FINE-NEEDLE ASPIRATION BIOPSY IN PATIENTS WITH BREAST CANCER

Breast cancer is a common malignancy in females. For that reason the disease has to be suspected when one encounters a solid mass in the breast. Until recently in order to find out the actual nature of the lump both excisional biopsy and histopathologic examination were thought to be essential. Nowadays fine-needle aspiration biopsy (FNAB) is performed to evaluate the solid mass in the breast and by using this technique individual characteristics of each cell can lead to diagnosis. But it is reported that erroneous diagnosis is more common with FNAB than with excisional biopsy and histopathologic examination. Despite the recent advances in diagnostic techniques physical examination is still the first step in breast cancer diagnosis and it is the most widely used method. Mammography and FNAB should follow. However the accuracy rate of mammography alone is especially low for the evaluation of small masses. Therefore FNAB has become of use as an important adjunctive diagnostic procedure and it is used along with physical and mammographic examinations. Some authors report that the rate of correct diagnosis rises sometimes up to 100% when these three methods are applied together. The aim of the present study is to detect the diagnostic reliability of a combined approach with physical examination mammography and FNAB in patients with breast cancer. (excerpt)