Tara L. Huston

Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma

BACKGROUND Sentinel‐lymph‐node biopsy is associated with increased melanoma‐specific survival (i.e., survival until death from melanoma) among patients with node‐positive intermediate‐thickness melanomas (1.2 to 3.5 mm). The value of completion lymph‐node dissection for patients with sentinel‐node metastases is not clear. METHODS In an international trial, we randomly assigned patients with sentinel‐node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph‐node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma‐specific survival. Secondary end points included disease‐free survival and the cumulative rate of nonsentinel‐node metastasis. RESULTS Immediate completion lymph‐node dissection was not associated with increased melanoma‐specific survival among 1934 patients with data that could be evaluated in an intention‐to‐treat analysis or among 1755 patients in the per‐protocol analysis. In the per‐protocol analysis, the mean (±SE) 3‐year rate of melanoma‐specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log‐rank test) at a median follow‐up of 43 months. The rate of disease‐free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log‐rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log‐rank test); these results must be interpreted with caution. Nonsentinel‐node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. CONCLUSIONS Immediate completion lymph‐node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma‐specific survival among patients with melanoma and sentinel‐node metastases. (Funded by the National Cancer Institute and others; MSLT‐II ClinicalTrials.gov number, NCT00297895.)

The Presentation of Contralateral Axillary Lymph Node Metastases from Breast Carcinoma: A Clinical Management Dilemma

Abstract:  Metastases to the contralateral axillary lymph nodes in breast cancer patients are uncommon. Involvement of the contralateral axilla is a manifestation of systemic disease (stage IV) or a regional metastasis from a new occult primary (T0N1, stage II). The uncertain laterality of the cancer responsible for these metastases complicates overall disease staging and is a management dilemma for clinicians. Seven women who developed contralateral axillary metastases (CAM), but did not have evidence of systemic disease were identified. Patient demographics, histopathologic tumor characteristics, treatment and outcome were examined. The median age was 49 years. A family history of breast cancer was present in six (86%). The initial breast cancers were located in all quadrants. They were generally hormone receptor negative, HER‐2/neu overexpressing and associated with lymphovascular invasion. There was a median interval of 71 months between initial breast cancer diagnosis and CAM presentation. Surgical management of the CAM included simple excision in one (14%) and axillary lymph node dissection in five (71%). Adjuvant treatment consisted of chemotherapy in seven (100%) and hormonal therapy in one (14%). The median follow‐up from the diagnosis of CAM was 35 months and three women were alive without disease, two were alive with disease and two had died of disease. With surgical treatment, there were no axillary recurrences in this series. When patients present with CAM and no evidence of systemic disease or a new primary in the contralateral breast, surgical treatment should be considered for local control and possibly improved relapse‐free survival.

Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.

BackgroundNipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability. MethodsA retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy. ResultsThe overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7–1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%). ConclusionsPatients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.

Oncoplastic Breast Reduction: Maximizing Aesthetics and Surgical Margins

Oncoplastic breast reduction combines oncologically sound concepts of cancer removal with aesthetically maximized approaches for breast reduction. Numerous incision patterns and types of pedicles can be used for purposes of oncoplastic reduction, each tailored for size and location of tumor. A team approach between reconstructive and breast surgeons produces positive long-term oncologic results as well as satisfactory cosmetic and functional outcomes, rendering oncoplastic breast reduction a favorable treatment option for certain patients with breast cancer.

Sentinel Node Positivity Rates With and Without Frozen Section for Breast Cancer

BackgroundSentinel lymph node biopsy (SLNB) is used to detect breast cancer axillary metastases. Some surgeons send the sentinel lymph node (SLN) for intraoperative frozen section (FS) to minimize delayed axillary dissections. There has been concern that FS may discard nodal tissue and thus underdiagnose small metastases. This study examines whether evaluation of SLN by FS increases the false-negative rate of SLNB.MethodsA retrospective analysis of SLNB from 659 patients was conducted to determine the frequency of node positivity among SLNB subjected to both FS and permanent section (PS) versus PS alone. Statistical analysis was performed by the χ2 square test, and a logistic regression model was applied to estimate the effect of final node positivity between the two groups.ResultsFS was performed in 327 patients and PS was performed in all 659 patients. Among patients undergoing both FS and PS (n = 327), the final node positivity rate was 33.0% compared with 19.6% among patients undergoing PS alone (n = 332). After adjustment for patient age, tumor diameter, grade, and hormone receptor status in a multivariate logistic regression model, there remained an increased likelihood of final node positivity for patients undergoing both procedures relative to PS alone (adjusted odds ratio, 2.1; 95% confidence interval, 1.3–3.6; P = .005).ConclusionsThere was a higher rate of SLN positivity in specimens evaluated by both FS and PS. Therefore, evaluating SLN by FS does not underdiagnose small metastases nor produce a higher false-negative rate. Intraoperative FS offers the advantage of less delayed axillary dissections.

Abdominal wall gossypiboma

A 71-year-old woman, one year following a fleur-de-lis abdominoplasty and incisional hernia repair, presented with two chronic, draining peri-umbilical sinuses. Her immediate postoperative course was complicated by a superficial surgical site infection with central skin breakdown that was treated with vacuum assisted closure (VAC). After the wound had closed completely, two midline sinus tracts developed. A CT scan demonstrated an 8x3x1.6cm thick-walled collection along the anterior abdominal wall containing numerous air bubbles. Surgical debridement revealed a cavity containing an 8x3x1.6cm block of well incorporated VAC foam. With the increasing clinical use of VAC wound therapy, this image serves as an important reminder to include gossypiboma in the differential diagnosis for patients with chronic wound problems who have previously received VAC treatment.

Merkel Cell Carcinoma With Gastric Metastasis and Review of Literature

Background: Merkel cell carcinoma (MCC) is a rare, highly aggressive cutaneous neoplasm, with a propensity for recurrence and metastasis. Very few cases of metastases to the gastrointestinal tract have been reported in the medical literature. Objectives: The aim of this study was to report a case of MCC metastasizing to the stomach, its clinical presentation, and its management. Methods: A PubMed search was made using the following search terms: “Merkel cell carcinoma,” “gastric,” and “metastasis.” Results: The investigators report a case of MCC metastatic to the stomach presenting with melena, syncope, early satiety, increasing fatigue, and unintentional weight loss. The other known cases of gastrointestinal metastasis of MCC are summarized and critically reviewed. Conclusions: Although MCC spreading to the stomach is exceedingly rare, because of MCC’s high recurrence rate and metastatic potential, it should be considered in patients with histories of MCC presenting with recent weight loss, early satiety, and gastrointestinal bleeding.

Hematoma mimicking local recurrence of breast cancer.

A n 84-year-old woman who underwent breastconserving therapy (BCT) at an outside institution for right breast ductal carcinoma in situ (DCIS) in 2002 presented with right nipple retraction and spontaneous bloody nipple discharge. Her medical history was significant for daily aspirin use. On examination, a palpable 2.5 cm mass in the lower outer quadrant, adherent to the chest wall, was identified (Fig. 1). Mammogram revealed a 2.8 cm Breast Imaging Reporting and Data System (BIRADS) 5 spiculated mass (Fig. 2). Ultrasound demonstrated a 2.9 cm heterogeneously, hypoechoic, slightly lobulated complex cystic mass with enhanced posterior through-transmission (Fig. 3). Fine-needle aspiration of the lesion revealed only blood. For further evaluation of this suspicious mass, a surgical incisional biopsy was performed that showed breast tissue with an organizing blood clot, fibrosis, and radiation change (Fig. 4). Blood was present in a large duct to explain the nipple discharge. There was no evidence of malignancy. An organized hematoma may present as a mass following BCT. It is the result of extravasated blood which diffusely infiltrates the mammary parenchyma forming a focal collection, usually following surgery, radiation, or trauma. On mammogram, hematomas or seromas appear as round or oval masses at the lumpectomy site. Hematomas often resolve slowly and can be replaced by scar tissue forming a spiculated mass. These masses can mimic carcinoma clinically and radiographically. Ultrasound may be useful in a time-dependent fashion. In the early phase, hematomas appear as complex cystic lobular or irregular masses with ill-defined margins. In the late phase, they appear regularly hypoechoic. This case highlights the importance of obtaining adequate tissue for pathologic examination prior to definitive management. In this case, carcinoma was number one in the differential diagnosis following clinical and radiologic examination. Treatment in the event of a recurrent cancer would have been mastectomy. Therefore a thorough examination in this patient resulted in breast salvage.

Repair of the deflated nipple following nipple-sparing mastectomy utilizing the skate flap technique

To the Editor: The esthetic outcome of the nipple-areola complex (NAC) is a critical aspect of reconstruction after oncologic surgery. Multiple techniques for creation of an NAC that looks and feels like the native NAC have been proposed but all suffer from loss of projection over time, with some studies quoting 50-70% over the first year. Skate, C-V, star and bell flaps, and the utilization of cartilage or bioprosthetic implants to achieve nipple projection have been described. The skate flap is popular because it provides better longterm projection compared to other methodologies. Shestak et al. found a statistically significant loss of projection when the bell flap was compared to the star or skate flaps at 3, 6, or 12 months. Between 12-24 months, both bell and star flaps had increased loss of projection while the skate flaps remained essentially unchanged from the 6 month period onwards. The skate flap lost a mean of 42% 14% initial projection by 24 months, compared to 71% 24% for the bell flap. Garramone et al. use an AlloDerm core supporting a modified star flap, allowing maintenance of projection of 56% at 1 year in patients with autologous reconstructions and 47% with tissue-expanders. Craft inserts a disc of Surgimend at the time of initial mastectomy and allows it to integrate into the remaining tissues for several months to provide a thicker substrate for a delayed skate flap which demonstrated only a 25% loss of projection at 6 months. Guerra et al. use an arrow-style flap supported by cartilage, which is routinely resected from the sternochondral joint of the third rib during autologous flap reconstruction when accessing the vessels for microvascular anastomosis. The authors note excellent maintenance of projection over 7 years of follow-up. Nipple-sparing mastectomy (NSM) has emerged as an alternative for patients who wish to remove all of the breast tissue but want to preserve the esthetic appearance of the natural nipple. Although large series with long-term follow-up are not yet available, several studies have indicated that NSM can be safe and oncologically sound. Preservation of the nipple is predicated on the ability to ensure that there is no cancer remaining in the NAC. Some surgeons choose to send an intraoperative frozen section of a biopsy from the areolar disc but preserve some amount of ductal tissue, while others choose to “core” the nipple in its entirety. Removal of the ductal tissue contributes to postoperative loss of projection due to loss of connective tissue support for the skin. This has prompted the need for reconstructive procedures to augment postoperative projection of the native NAC. We propose an adaptation of the skate flap incorporating the native NAC to address flattening of the nipple after NSM. This procedure is performed first by marking out a circular area centered on the deflated NAC. One half is thinly de-epithelialized. On the other half, consisting of the native flattened nipple and the remainder of the areola, two complementary skin flaps are raised and sutured together to create a mound which projects from the surface of the breast. The de-epithelialized area is covered with a skin graft to

Abstract 10: ARE POSTOPERATIVE ANTIBIOTICS FOR IMMEDIATE BREAST RECONSTRUCTION NECESSARY? RESULTS OF A PROSPECTIVE RANDOMIZED CLINICAL TRIAL

Background: Antibiotics and closed suction drains are routinely used in postoperative tissue expander based immediate breast reconstruction (TE-IBR). Prophylactic postoperative antibiotics are prescribed due to the presence of implants, drains, and a high associated infection rate. CDC guidelines for antibiotic prophylaxis are recommended for only 24-hours. There are no randomized controlled trials suggesting that extended antibiotic prophylaxis is bene cial to these patients. This study evaluates the difference in surgical site infection (SSI) between perioperative and postoperative antibiotics.