Surgery News - April 2008 - (Page 16)

BREAST, SKIN & SOF T TISSUE SURGERY NEWS • A P R I L 2 0 0 8 MRI Helps Identify Candidates for Breast Conservation B Y J E F F E VA N S H O T S P R I N G S , VA . — Routine use of bilateral breast MRI before surgery may change the management of nearly 20% of candidates for breast conservation, lowering reexcision rates to achieve clear surgical margins, according to a retrospective study. The ability to perform MRI-directed biopsies is a “critical component” of a program that uses preoperative MRI to locate breast cancer lesions, said Dr. William G. Cance at the annual meeting of the Southern Surgical Association. Dr. Cance and his coinvestigators evaluated the ability of preoperative MRI scans to improve candidate selection for breastconserving therapy, plan multimodality treatments more precisely, and improve cancer-related outcomes by identifying occult sites of disease at an earlier stage. They reviewed a series of 79 consecutive candidates for breast conservation who underwent preoperative MRI scanning. The median age of the women was 57 years. Each patient received a physical exam, mammogram, ultrasound, and MRI during an 18-month period in 2006-2007, said Dr. Cance, chairman of the surgery department at the University of Florida, Gainesville, and an ACS Fellow. Patients who had lesions that were suspicious for cancer on an MRI and confirmed on an ultrasound had an ultra- Magnetic resonance imaging of a primary breast cancer lesion in white (left) corresponded to mammography, but MRI also detected a second invasive lesion (right) not revealed by mammography. patients for neoadjuvant chemotherapy, the selection of patients for partial versus total mastectomy, and the planning of the extent of partial mastectomy. Patient selection is crucial for the best oncologic outcomes and cosmesis with breast-conserving therapy, he said. But even after efforts are made to characterize the tumor, locate it radiographically, and then excise it with clear surgical margins, “reexcision rates to achieve clear margins still remain high,” he said. “The only prognostic factor that we as surgeons can affect is margin status,” Dr. V. Suzanne Klimberg, an ACS Fellow at the University of Arkansas, Little Rock, said in a scheduled discussion of the study. “This paper demonstrates that preopera- tive MRI may help us select out those patients in which we would be unlikely to obtain negative margins.” Although the investigators did not evaluate the costs of MRI scanning, Dr. Stephen R. Grobmyer, an ACS Fellow and Dr. Cance’s colleague at the University of Florida, suggested that the scans may save money in the long term by decreasing reexcision rates and recurrent disease. MRI scans and MRI-guided biopsies cost about $1,500 at the University of Florida, according to Dr. Grobmyer. MRI-directed biopsy has been shown to improve preoperative staging. It may be used in conjunction with second-look ultrasound to confirm the extent of the disease seen on MRI, said Dr. Cance. Novel Approaches Look Promising for Gynecomastia BY BRUCE JANCIN Else vier Global Medical Ne ws S A N A N T O N I O — Electrosurgical excision of gynecomastia results in markedly fewer hematomas and less need for early reoperation than the popular technique of excision by sharp dissection accompanied by saline infiltration of epinephrine, Dr. Prasad Ramachandran reported at the annual San Antonio Breast Cancer Symposium. Cosmetic outcomes with the two techniques are similar, added Dr. Ramachandran of the department of breast surgery at Royal Albert Edward Infirmary in Wigan (England). In a separate presentation, Dr. Omar Qutob outlined a novel minimally invasive surgical technique for gynecomastia excision in which the vacuum-assisted biopsy device known as the Mammotome is used with liposuction. Dr. Ramachandran explained that men’s breast tissue is more fibrous and bleeds much more during dissection than a woman’s breast. For this reason, saline epinephrine infiltration is often used to reduce bleeding during subcutaneous mastectomy by sharp dissection for gynecomastia. Postoperative bleeding, however, can be a problem using this technique. He and his coinvestigators sought to compare the results of electrosurgery only and saline epinephrine infiltration followed by sharp dissection by arbitrarily assigning 75 young men with gynecomastia to one technique or the other. A total of 121 breasts were operated upon. Hematoma occurred in 4% of patients in the electrosurgery group and in 24% of those who underwent sharp dissection. The rates of other complications, including infection, seroma, and nipple paresthesia, were similar in the two groups. The early reoperation rate was 7% in the electrocautery group, compared with 28% for sharp dissection. Early reoperation was performed most often for hematoma, and in a few cases to correct a nipple deformity or for residual gynecomastia. Electrosurgical excision was performed using a handheld device set on spray mode. Mean operative time was 32 min- utes in the electrosurgery group and 44 minutes with sharp dissection. The hospital stay averaged 1 day in both groups, Dr. Ramachandran said. Three months after surgery, men in the electrosurgery arm rated their satisfaction with the results at 7 on a 0-10 scale; those in the sharp dissection group scored their results as a 6, he said. Dr. Qutob of Castle Hill Hospital in Cottingham, England, reported on 46 men with gynecomastia who underwent excision of hypertrophic breast tissue using the Mammotome device plus liposuction. Twenty-seven had bilateral procedures. The technique involved inserting the 8-gauge Mammotome probe through a 4-mm anterior axillary incision and Hematoma and Early Reoperation Rates for advancing it toward Gynecomastia Excision at 3-Month Follow-Up the target breast tissue, which was reSaline epinephrine infiltration Electrosurgery only moved sequentially followed by sharp dissection with no need to take out the probe 28% until the surgeon 24% was finished with the device. At that point the area was infused with Hartmann’s solution 7% with epinephrine to 4% facilitate liposucHematoma Early reoperation tion, he explained. Liposuction was Note: Based on a randomized study of 121 breasts in 75 young men. performed in stanSource: Dr. Ramachandran dard fashion. It was ELSEVIER GLOBAL MEDICAL NEWS also applied below the inframammary fold as needed. After the incision was closed, a corset and an inflatable device were used to apply a pressure dressing over the wound to minimize hematomas. The inflatable device was removed in the recovery room; the corset was worn for 6 weeks. The average procedure time was 53 minutes. Thirty-four patients were discharged on the day of surgery, the other 12 on the next day. Three patients developed small hematomas that resolved spontaneously, Dr. Qutob said. After 6-8 weeks, 42 men rated their results as excellent. The other four had residual gynecomastia and underwent reoperation. The operating surgeons rated cosmetic outcome as a mean 7.9 on a scale of 0-10. This minimally invasive approach has the potential to become the surgical treatment of choice for gynecomastia. Before it can assume that mantle, however, it needs to be evaluated in a randomized trial against an open surgical technique, he said. The Mammotome was developed as a device for obtaining radiographically guided breast biopsies. Dr. Qutob cautioned that in using it in men to excise hypertrophic breast tissue it’s essential to always point the probe away from the skin in order to avoid inadvertently suctioning skin into the cutting chamber. One patient in the series had a small area of his areola accidentally excised in just this way. Dr. Ramachandran and Dr. Qutob had no relevant conflicts to disclose. PHOTOS COURTESY DR. STEPHEN R. GROBMYER Else vier Global Medical Ne ws sound-guided core biopsy. The lesions that were detected by MRI but not by ultrasound were biopsied under MRI guidance. The results obtained on the initial MRI scan prompted an additional 25 biopsies in 21 patients. Positive results for cancer or ductal carcinoma in situ were detected in 3 of 6 ultrasound-guided biopsies and in 8 of 19 MRI-guided biopsies. Changes in treatment plans were necessary for 15 (19%) of the 79 patients, because of multicentric disease (7 patients), greater extent of the primary tumor (6), or contralateral breast cancer (2). Breast-conserving therapy was contraindicated in patients with multicentric tumors in multiple quadrants of the breast or solitary tumors that were large relative to breast size. In all, breast-conserving therapy was possible for 60 of the 79 patients. Of 61 lumpectomies performed in those 60 patients, 6 patients (10%) required reexcision for close or positive margins. These results compare favorably with other series, Dr. Cance said. Receipt of an MRI did not significantly delay treatment. A median of 2 days passed between the initial surgical consult and the receipt of a bilateral breast MRI, while a median of 8 days occurred between the initial surgical consult and an MRI-directed biopsy. Dr. Cance speculated that MRI scanning may lower reexcision rates for close or positive margins by improving the selection of

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Surgery News - April 2008 Contents Comorbidities Sway Bariatric Outcomes Database Finds Gap in Dissection For Melanoma Future Surgeon Shortage Predicted Dexterity Demo Best for Bile? Health Policy Scan Plan

Surgery News - April 2008

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