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The purpose of this study was to determine whether breast cancer patients who had prior breast augmentation presented at a more advanced stage than nonaugmented breast cancer patients, and to determine the mode of presentation and effectiveness of lymphatic mapping and sentinel lymph node biopsy in this same group of patients. A total of 4186 breast cancer patients from 1987 to 2002 were reviewed. Patients who had augmentation before their diagnosis of breast cancer were compared with a control group of nonaugmented breast cancer patients. The Wilcoxon rank sum test was used to compare tumor size, node positivity, and stage. The patient's age at presentation was also compared by the two-sided pooled t test. Seventy-six patients who previously underwent augmentation were identified with 78 breast cancers. Seventy percent (48 of 69) were initially detected by palpation, whereas 30 percent (21 of 69) were initially identified mammographically. Fifty-three percent (n = 41) underwent mastectomy and 47 percent (n = 37) underwent a lumpectomy. This compares with a 63.6 percent (2615 of 4110) breast conservation rate in the nonaugmented population during the same time period. The two groups did not differ regarding (tumor) size (p = 0.77), nodal positivity (p = 0.32), or stage (p = 0.34). The mean time between implant placement and a diagnosis of breast cancer was 14 years. The average age of the patients who had previously undergone augmentation at breast cancer diagnosis was 49.5 years (SD, 9.0 years) versus 57.1 years (SD, 13.5 years) for the nonaugmented patients (p < 0.0001). Forty-nine of the patients underwent lymphatic mapping, with a 100 percent success rate in identifying the sentinel lymph node. There have been no clinically detected axillary recurrences in the patients who had a negative sentinel lymph node biopsy. Breast cancer patients who have undergone previous augmentation are more likely to present with a palpable mass. This initial mode of detection does not appear to translate into a larger tumor size or worse prognosis. Breast conservation and lymphatic mapping can be performed successfully in previously augmented patients.

Background: Wire localization (WL) is the current standard for surgical diagnosis of nonpalpable breast lesions. Many disadvantages inherent to WL are solved with radioactive seed localization (RSL). This trial investigated the ability of RSL to reduce the need for specimen radiographs and operating room delays associated with WL. Methods: A total of 134 women were entered onto an institutional review board–approved study. RSL was performed by placing a titanium seed containing .29 to 20 mCi of iodine-125 to within 1 cm of the suggestive breast lesion. The surgeon used a handheld gamma detector to locate and excise the iodine-125 seed and the lesion. Results: Specimen radiographs were eliminated in 98 (79%) of 124 patients. Surgical seed retrieval was 100% in 124 patients. No seed migration occurred after correct radiographical placement. A total of 26 (21%) of 124 patients required a specimen radiograph; 22 (85%) of these 26 were performed for microcalcifications. Conclusions: After surgical removal, RSL can eliminate specimen radiographs when the radiologist accurately places the seed and the pathologist grossly identifies the lesion. If small microcalcifications are noted before surgery, then specimen radiographs may be necessary. RSL reduced requirements for specimen radiographs, decreased OR time, improved incision placement, and improved resections to clear margins.

Objective: To document the incidence of metastatic disease in complete axillary lymph node dissections (CALND) of patients with invasive carcinoma after a sentinel lymph node (SLN) biopsy, positive only by immunohistochemical staining for cytokeratin (CK-IHC). Methods: Sections of all SLNs, negative by routine histology, were immunostained and examined for cytokeratin positive cells. Sections of lymph nodes from CALND specimens were interpreted using routine hematoxylin and eosin (H&E) staining. Results: A total of 409 patients (29.6%) had metastatic disease in at least one sentinel lymph node on H&E examination. Of 971 H&E negative patients, 78 (8.0%) were positive only by CK-IHC. Sixty-two of the CK-IHC positive only patients underwent CALND. Nine of these 62 patients (14.5%) had metastases identified in the CALND specimen. Conclusions: Because 14.5% of patients with invasive breast cancer and SLNs positive only by CK-IHC were found to have H&E positive lymph nodes on CALND, we conclude first, that CK-IHC should be used to evaluate SLNs, and second, that CALND should be considered when SLNs are positive by CK-IHC only. This approach will result in an absolute reduction of the false negative rate (absolute false negative rate reduced by 2.6% in our series).

Background The techniques of breast reconstruction have evolved and matured over the past 25 years. Recent studies have proven the benefit of breast reconstruction for breast cancer patients. Methods The authors reviewed the recent literature on the techniques of breast reconstruction and the effects of reconstruction on patients following surgery for breast cancer. The findings in recent studies are correlated with the experience of the authors. Results A better understanding has been gained regarding surgical techniques of breast reconstruction as well as the proper indications for the various methods. The criteria of patient benefit have been defined by recent long-term studies. Conclusions Breast reconstruction following mastectomy has been proven to be a safe and beneficial procedure.

Background Postmastectomy pain syndrome (PMPS) has been reported following procedures involving complete lymph node dissection (CLND). Since the triggering event is probably related to nerve injury, sentinel lymph node dissection (SLND) should decrease the incidence of PMPS. The purpose of this report is to determine the impact of SLND on the number of patients referred to the pain clinic for PMPS treatment. Methods The records of all breast surgical patients with a diagnosis of PMPS referred to the Moffitt Cancer Center pain clinic were reviewed. The criterion for diagnosis of PMPS was a history of postoperative pain in the upper anterior chest wall, upper extremity, axilla, and/or shoulder in the absence of recurrent disease. Results A total of 55 patients with a diagnosis of PMPS were seen in the pain clinic since 1991. Treatments included local anesthetics/corticosteroid injection, stellate ganglion block, and tricyclic antidepressants. A decrease from 15 patients in 1991 to 3 in 1998 was observed. All but one of the 55 patients with PMPS had CLND, and none referred to the pain clinic had undergone SLND. Conclusions PMPS is a complication of CLND. The increased use of SLND in our center has reduced the number of referrals to the pain clinic for treatment of PMPS. This benefit of SLND reduces suffering in the postoperative breast patient.

The University of South Florida has established a 3-year plastic surgery residency that includes a 4-month formal clinical rotation in aesthetic surgery with the Division of Plastic Surgery clinical faculty and a 4-month rotation as a chief resident who oversees the resident aesthetic surgery clinic. This report introduces the University of South Florida resident aesthetic training model and reviews the operative experience of each chief resident who completed the residency program. The total number of aesthetic surgery cases involving the 5 chief residents who completed the program in 1997 and 1998 was obtained from the Residency Review Committee operative logs. Each chief resident who completed the program first-assisted with 201 ± 97 (mean ± SD) aesthetic surgery cases, mainly during the 4-month clinical rotation, and then performed 114 ± 21 aesthetic surgery cases as a primary surgeon, mainly during the chief-resident rotation. The program’s 2 rotations—both the clinical faculty and the aesthetic surgery clinic experiences—provided complementary and intensive training opportunities in aesthetic surgery.

This article reviews the literature on psychoneuroimmunology and its theoretical underpinnings. It also reviews research related to the immune-system-link of stress, chronic stress, depression and health behaviors to breast cancer. Although the relationship between psychological characteristics and the immune system have been documented repeatedly, the significance of these effects has not been demonstrated in many studies empirically. The question whether the use of alternative therapies contributes to decreasing the progression of the diseased is often asked. Research in the area of psychoneuroimmunology can provide the answer to this question.

Plastic surgery residency programs often rely on a residents' aesthetic clinic to help train residents in aesthetic surgery. The television media may be used to help boost interest in such clinics. We report our experience with a local television station in helping to produce a "health segment" broadcast that chronicled the experience of an aesthetic patient in the residents' aesthetic clinic. As a result of this broadcast, approximately 150 people responded by telephone and subsequently attended a series of seminars designed to screen patients and educate the audience about the aesthetic clinic. A total of 121 patients (112 women and 9 men) signed up for personal consultations. The age distribution and requested procedures are presented. From the data, we conclude that there is a healthy demand for reduced-fee plastic surgery procedures performed by residents in plastic surgery. The number and variety of cases generated are sufficiently diverse to provide a well-rounded operative experience. The pursuit of media coverage of a not-for-profit clinic has the potential for generating large patient volume. Such efforts, although very attractive, are not without their own risks, which must be taken into consideration before engaging the media in the public interest arena.

Background Axillary node dissection is considered a standard staging procedure in patients with breast cancer. The procedure is associated with significant morbidity and provides pathologists with many lymph nodes to evaluate. Methods A total of 174 women participated in a trial that included preoperative lymphoscintigraphy and intraoperative lymphatic mapping using a combination of a vital blue dye and radiocolloid mapping. Results The intraoperative lymphatic mapping correctly identified a sentinel lymph node (SLN) in 160 (92%) of 174 patients. One skip metastasis (0.7%) occurred in 136 women who had a subsequent complete node dissection. Conclusions Lymphatic mapping and SLN biopsy using a combination of mapping techniques provide accurate nodal staging for women with breast cancer. With this technique, approximately 70% to 80% of women with no axillary metastases could be spared the morbidity of a complete node dissection.

Once individuals are diagnosed with malignant melanoma, they are at an increased risk of developing another melanoma when compared with the normal population.To determine the impact of an intensive follow-up protocol on the stage of disease at diagnosis of subsequent primary melanomas, a retrospective query was performed of an electronic medical record database of 2,600 consecutively registered melanoma patients.Sixty-seven patients (2.6%) had another melanoma diagnosed at the time of presentation to the clinic or within 2 months (synchronous) and another 44 patients (1.7%) developed a second primary melanoma during the follow-up period (metachronous). For the 44 patients diagnosed with metachronous lesions, the Breslow mean tumor thickness for the first invasive melanoma was 2.27 mm compared with 0.90 mm for the second melanoma. The first melanomas diagnosed are thicker by an average of 3.8 mm (p = 0.008). The mean Clark level for the initial melanoma was greater than the mean level for subsequently diagnosed melanomas (p = 0.002). Twenty-three percent of the initial melanomas were ulcerated, whereas only one of the second primary lesions showed this adverse prognostic factor (p = 0.002).Once individuals are diagnosed with melanoma, they are in a high-risk population for having other primary site melanomas diagnosed and should be placed in an intensive follow-up protocol consisting of a complete skin examination.

Silicone was originally regarded as inert in the human body. Silicone medical devices have been associated with various complications that may involve an immune reaction to silicone or a silicone organic complex. There have been more than 80 cases reported in the medical literature of a varied systemic autoimmune illness in patients who have had various foreign materials placed in the breast. Controversy exists as to which complications have a cause and effect relationship, and which represent coincidental findings. It is difficult to distinguish between nonspecific local reactions and reactions that have an immunological basis. Approximately 1,000,000 to 2,000,000 women in the United States have had silicone breast implants inserted for reconstruction or augmentation mammaplasty; 28 of those patients have been reported to have developed a systemic autoimmune disease. Data on the 28 reported cases do not in any way prove a causal relationship between breast implants and immune disease. Given the natural incidence of autoimmune diseases, we would expect a coincidental occurrence in the United States of more than 1,000 cases of autoimmune disease in women who had undergone breast implant surgery. Additional information must be obtained to resolve the question. The true incidence of autoimmune disease in patients with implants needs to be determined. A prospective registry of implant patients should be established and comprehensive retrospective information obtained on the implant patient population. Further experimental work is necessary on the bioreactivity of silicone. Patients with implants and autoimmune disease, once identified, must be carefully evaluated by physicians who are experienced in the treatment of autoimmune disease.

6. Oberman HA, Holtz F, Sheffer LA, et al: Chemodectomas (nonchromaffin paragangliomas) of the head and neck. A clinicopathologic study. Cancer 21:838, 1968 7. Bertogalli D, Calearo C, Pignataro 0: Les paragangliomes non chromatophiles a siege rare. Ann Otol (Paris) 76688. 1959 8. Burman SO: The chemoreceptor system and its tumourThe chemodectoma. Int Abstr Surg 102:330. 1956 9. Lack EE, Mercer L: A modified Grimelius argyrtophil technique for neurosecretory granules. Am J Surg Path01 1~275, 1977 10. Batsakis JG: Tumors of the Head and Neck. Clinical and Pathological Considerations (ed 2). Baltimore, Williams & Wilkins, 1979, pp 369-380

In this study, the prevalence of additional positive lymph nodes in subsequent complete lymphadenectomy specimens for patients with early-stage melanoma of the head and neck, after positive sentinel lymphadenectomy results, was retrospectively analyzed. In the past 5 years at the authors' institution, 23 consecutive patients with clinical stage I or stage II melanoma of the head and neck underwent complete lymphadenectomies after positive sentinel lymph node biopsies and wide local excisions of the primary lesions. Sentinel lymph nodes were identified with intraoperative lymphatic mapping techniques (radiolymphoscintigraphy and vital blue dye injection) and were examined with routine histological methods and immunohistochemical staining for S-100. All lymph nodes harvested in complete lymphadenectomies were examined with routine histological techniques. Twenty-one patients (91.3 percent) demonstrated no additional positive lymph nodes in subsequent complete lymphadenectomy specimens; two patients (8.7 percent) each demonstrated one additional positive lymph node in the complete lymphadenectomy specimens. Both patients had ulcerated primary lesions more than 5 mm in depth. No patient developed a regional nodal recurrence during a mean follow-up period of 23.7 months (range, 2 to 56 months). The low prevalence of additional positive lymph nodes in complete lymphadenectomy specimens suggests that when microscopic metastases exist in the regional nodal basin, most of the time they are confined to the sentinel lymph nodes of patients with early-stage melanoma of the head and neck. Nevertheless, the question of whether subsequent complete lymphadenectomy is still necessary for this subgroup of patients warrants further study.

Objective To investigate the incidence of nodal metastasis in a consecutive series of patients treated at the authors' institution with highly selective criteria, and to determine the impact that lymphatic mapping and sentinel node biopsy have on the detection of nodal metastases in this carefully selected patient population. Methods Study patients were selected from the 7,750 breast cancer patients entered into the authors' database from April 1989 to August 2001, based on the following criteria: nonpalpable, T1 a and T1 b, non-high nuclear grade tumors, without lymphovascular invasion. Results Of the 7,750 patients in the database 1,327 (17%) were found to have T1 a and T1 b lesions. Three hundred eighty-nine patients were confirmed to meet all four selection criteria. This represents 5% (389/7,750) of the authors' breast cancer patients and 29.3% (389/1,327) of the authors' T1a/T1 b tumors. One hundred sixty patients were diagnosed before routine use of lymphatic mapping, and only one patient had a positive axillary lymph node. Two hundred twenty-nine patients underwent lymphatic mapping and sentinel lymph node biopsy, and 10 had a positive axillary lymph node. The difference in proportions of nodal positivity between the mapped and unmapped patients was significant. Conclusions This study clearly demonstrates the ability of lymphatic mapping and a more detailed examination of the sentinel node to increase the accuracy of axillary staging. It has been argued that this highly selected group of breast cancer patients possessing retrospectively identified favorable characteristics does not require axillary staging. This select population represents only 5% of breast cancer patients in this series, and the authors do not believe they can be accurately identified preoperatively. Therefore, the authors strongly argue for evaluation of the axillary nodal status by lymphatic mapping.

Sentinel lymph node (SLN) mapping is an effective and accurate method of axillary nodal evaluation for metastatic disease. Cytokeratin (CK) immunohistochemical (IHC) staining of the SLN has found micrometastatic disease previously undetected by routine hematoxylin and eosin (HE) stains. The purpose of this study is to determine the number of patients who were upstaged or microstaged, i.e., detected to have micrometastatic disease only by combined lymphatic mapping with CK IHC.Two hundred and ten patients with newly diagnosed breast cancer underwent intraoperative lymphatic mapping using a combination of vital blue dye and technetium-labeled sulfur colloid. The excised sentinel lymph nodes were examined grossly, by imprint cytology, by standard HE histology, and by IHC stains for CK. SLNs that were only CK positive were confirmed to be malignant by histologic examination.CK IHC staining was performed on 381 SLNs in 210 breast cancer patients. Forty-seven of 210 patients (22.4%) had positive nodes. Thirty of these 47 patients (63.8%) had both HE- and CK-positive SLNs, and an additional 17 of the 47 positive patients (36.2%) had only CK-positive SLNs. Seventeen of the 180 patients (9.4%) who were negative on HE staining were upstaged by CK IHC staining of malignant cells in the SLN. Comparison of tumor size with the total number of node-positive patients demonstrated that 16 of 30 node-positive T0 and T1 patients (53.5%) and 22 of 39 nodes (56.4%) were upstaged by CK IHC staining. T2 and T3 patients were less frequently upstaged by cytokeratin analysis of lymph nodes. Only one of 17 node-positive patients (5.9%) and seven of 34 nodes (20.6%) in patients with T2 and T3 tumors were upstaged.CK IHC staining of SLNs shifted 9.4% of patients from stage I to stage II. There was a significant upstaging influence noted in patients with tumor sizes under 2 cm. This microstaging shift or upstaging may account for the significant proportion of stage I breast cancer treatment failures. Microstaging of the SLNs using more sensitive assays may help identify a subgroup of patients with invasive breast cancer who would benefit from systemic adjuvant treatment, while sparing a disease-free subset of patients the additional risks of toxic adjuvant chemotherapy.

Lymphatic mapping techniques have the potential of changing the standard of surgical care of breast cancer patients. This paper reports a prospective study documenting the safety and efficacy of sentinel lymph node biopsy in 167 breast cancer patients and reviews the world literature on the procedure.One hundred sixty-seven patients with newly diagnosed breast cancers underwent a prospective trial of intra-operative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or "hot" node with a 10/1 ex-vivo gamma-probe ratio of SLN to non-SLN. All SLN were bi-valved, step-sectioned, and examined with routine HE stains and immunohistochemical stains for cytokeratin. Cytokeratin-positive SLN were defined as any SLN with a defined cluster of positive staining cells which could be confirmed histologically on HE sections. Finally, a review of the worldwide data was undertaken using a uniform analytical method to compare the rates of sensitivity, diagnostic accuracy, and false negatives of SLN mapping.In 167 patients, 337 SLN were harvested, for an average of 2.01 SLN/patient. Fifty-two (31.1%) of the patients had metastasis in the SLN. In the 115 patients with negative SLN, 1 was found to have tumor in higher axillary nodes, for a false negative rate of 0.88%. Fifty-nine (37.8%) of the patients were diagnosed by fine-needle aspiration, 89 (53.3%) by excisional biopsy, and 19 (11.4%) by core biopsy. Positive SLN were identified in 1/17 (5.9%) patients with DCIS. Metastasis was found in 33/115 (28.7%) of the patients with infiltrating ductal tumors and in 11/19 (57.9%) of the patients with infiltrating lobular tumors. Positive SLN were identified in 7/16 (43.7%) of the patients with mixed cellularity tumors. Metastasis in the SLN was detected in 7/55 (12.7%) of the 59 patients with T1a-T1b tumors and in 21/58 (36.2%) of the patients with T1c tumors. Positive SLN were found in 17/30 (56.7%) of the patients with T2 tumors and in 6/7 (85.7%) of the patients with T3 tumors. A literature review of 731 patients (including this study) demonstrates a sensitivity rate of 95% and a diagnostic accuracy rate of 98%. The overall false negative rate is 3.1%.This study demonstrates that SLN biopsy is a highly sensitive and accurate method of predicting axillary nodal status. It is a reproducible technique that is easily learned. The future addition of more sensitive methods such as PCR evaluation of nodal involvement may reduce the need for widespread use of adjuvant chemotherapy with its high cost and attendant morbidity and mortality. We believe that this technique will eventually become the standard of care in the treatment of breast cancer, particularly for T1 and T2 lesions and perhaps also for high-grade DCIS tumors.

Developed initially for the treatment of malignant melanoma, lymphatic mapping and sentinel lymph node biopsy have recently been introduced into the treatment of early breast cancer. In breast cancer patients, harvested sentinel lymph nodes are evaluated more thoroughly by detailed pathologic examination using serial sectioning, immunohistochemistry, and reverse transcriptase-polymerase chain reaction (RT-PCR) techniques. This allows for the detection of smaller tumor volumes and leads to more accurate staging. Lymphatic mapping has a 68% to 98% success rate in identifying the sentinel lymph node. The false-negative rate (defined as a negative sentinel lymph node while a higher node or nodes in the axilla are positive) is between 0% and 2%. The morbidity associated with this procedure is minimal. We believe that lymphatic mapping and sentinel lymph node biopsy will ultimately lead to more conservative treatment of patients with breast cancer. This article describes the historical background and technical aspects of the procedure. This is followed by updated, prospectively collected outcomes data from 466 consecutive breast cancer patients who underwent lymphatic mapping at the H. Lee Moffitt Cancer Center, as well as an up-to-date review of the literature.

OBJECTIVE: To define preliminary guidelines for the use of lymphatic mapping techniques in patients with breast cancer. SUMMARY BACKGROUND DATA: Lymphatic mapping techniques have the potential of changing the standard of surgical care of patients with breast cancer. METHODS: Four hundred sixty-six consecutive patients with newly diagnosed breast cancer underwent a prospective trial of intraoperative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or a hot node with a 10:1 ex vivo gamma probe ratio of SLN to non-SLN. All SLNs were bivalved, step-sectioned, and examined with routine hematoxylin and eosin (H&E) stains and immunohistochemical stains for cytokeratin. A cytokeratin-positive SLN was defined as any SLN with a defined cluster of positive-staining cells that could be confirmed histologically on H&E sections. RESULTS: Fine-needle aspiration (FNA) or stereotactic core biopsy was used to diagnose 195 of the 422 patients (46.2%) with breast cancer; 227 of 422 patients (53.8%) were diagnosed by excisional biopsy. The SLN was successfully identified in 440 of 466 patients (94.4%). Failure to identify an SLN to the axilla intraoperatively occurred in 26 of 466 patients (5.6%). In all patients who failed lymphatic mappings, a complete axillary dissection was performed, and metastatic disease was documented in 4 of 26 (15.4%) of these patients. Of the 26 patients who failed lymphatic mapping, 11 of 227 (4.8%) were diagnosed by excisional biopsy and 15 of 195 (7.7%) were diagnosed by FNA or stereotactic core biopsy. Of interest, there was only one skip metastasis (defined as a negative SLN with higher nodes in the chain being positive) in a patient with prior excisional biopsy. A mean of 1.92 SLNs were harvested per patient. Twenty percent of the SLNs removed were positive for metastatic disease in 105 of 440 (23.8%) of the patients. Descriptive information on 844 SLNs was evaluated: 339 of 844 (40.2%) were hot, 272 of 844 (32.2%) were blue, and 233 of 844 (27.6%) were both hot and blue. At least one positive SLN was found in 4 of 87 patients (4.6%) with noninvasive (ductal carcinoma in situ) tumors. A greater incidence of positive SLNs was found in patients who had invasive tumors of increasing size: 18 of 112 patients (16%) with tumor size between 0.1 mm and 1 cm had positive SLNs. However, a significantly greater percentage of patients (43 of 131 [32.8%] with tumor size between 1 and 2 cm and 31 of 76 [40.8%] with tumor size between 2 and 5 cm) had positive SLNs. The highest incidence of positive SLNs was seen with patients of tumor size greater than 5 cm; in this group, 9 of 12 (75%) had a positive SLN (p < 0.001). CONCLUSIONS: This study demonstrates that accurate SLN identification was obtained when all blue and hot lymph nodes were harvested as SLNs. Therefore, lymphatic mapping and SLN biopsy is most effective when a combination of vital blue dye and radiolabeled sulfur colloid is used. Furthermore, these data demonstrate that patients with ductal carcinoma in situ or small tumors exhibit a low but significant incidence of metastatic disease to the axillary lymph nodes and may benefit most from selective lymphadenectomy, avoiding the unnecessary complications of a complete axillary lymph node dissection.

The surgical evolution of breast cancer treatment over the past century from Halsted through Haagensen and Urban has demonstrated the utility of radical and ultra-radical surgery. Patey, Meyer, and subsequently Fisher’s studies have initiated the movement toward surgical breast conservation. The continued progress toward lesser surgery has brought the value of axillary lymph node dissection (ALND) under close scrutiny (Frazier et al. 1977; Silverstein et al. 1987; Balch et al. 1993).

The purpose of this case report is to illustrate the utility of radio-guided mapping of sentinel lymph nodes (SLN's) as demonstrated by the technique's successful identification of nodes containing metastatic disease that would have been left behind if only the visual-oriented vital blue dye mapping technique had been used.The patient underwent preoperative lymphoscintigraphy and intra-operative lymphatic mapping using vital blue dye and radiolymphoscintigraphy using the Neoprobe (handheld gamma probe). Nodes which were blue and/or "hot" (i.e., radioactive counts were three times the background count) were considered SLN's.Four SLN's were harvested, all of which were "hot" but only one of which was both "hot" and blue. Pathology revealed that the two SLN's positive for metastatic disease were not blue.While the blue dye lymphatic mapping technique provides the surgeon with a visual road map in the identification of SLN's, the Neoprobe increases the success rate of localization when compared to vital blue dye mapping due to the reliable migration of radiocolloid to the SLN's in the regional basin. Radiolymphoscintigraphy also increases the accuracy and efficiency of the SLN harvest by providing a directed dissection to the level of the nodes in the basin. The Neoprobe increases the yield of SLN's, some of which are clinically relevant since they contain metastatic disease.

Objective. —To identify the sentinel lymph node(s) (SLN[s]) (the first node[s] draining the primary tumor in the regional lymphatic basin) in patients with invasive breast cancer and to test the hypothesis that the histologic characteristics of the SLN predict the histologic characteristics of the remaining lymph nodes in the axilla. Design. —A prospective trial. Participants. —Sixty-two patients with newly diagnosed invasive breast cancers. Intervention. —Patients underwent intraoperative lymphatic mapping using a combination of a vital blue dye and filtered technetium-labeled sulfur colloid. The SLN was identified and removed, followed by a definitive cancer operation, including a complete axillary node dissection. Main Outcome Measure. —The metastatic distribution in the axilla was determined in patients with occult nodal disease. Results. —The SLN was successfully identified in 57 (92%) of 62 patients using the 2 lymphatic mapping procedures. After localization, 18 patients (32%) were found to have metastatic disease, and the SLN tested positive in all 18 patients. There were no "skip" metastases, defined as an SLN that tested negative with higher nodes that tested positive. In 12 (67%) of 18 patients with metastatic disease, the SLN was the only site of disease. The metastatic distribution significantly favored SLN involvement. Among subjects with discordant nodal involvement, the probability of observing the distribution of SLN involvement by chance is very small (P Conclusions. —This study confirms that lymphatic mapping is technically possible in the patient with breast cancer and that the histologic characteristics of the SLN probably reflect the histologic characteristics of the rest of the axillary lymph nodes. The procedure also allows the pathologist to focus the histologic examination on 1 or 2 nodes, potentially increasing the yield of positive dissections and the accuracy of staging.

The development of surgery using high magnification has allowed reconstructive surgeons to operate on the small blood vessels of the distal extremity which previously were beyond technical limits. Using this new technology reconstructive surgeons are able to replant amputated upper extremities with a high degree of survival and functional success.The world's first successful clinical replantation was performed by Malt and McKhann1in 1962. They replaced the arm of a 12 year old boy who had been amputated at the mid-humeral level. In 1965, Komatsu and Tamai2used the surgical microscope to replant a thumb amputated at the metacarpophalangeal level.This first successful microsurgical replantation was preceded by considerable ex perimental work. Jacobson and Suarez3using an operating microscope reported a 100 percent patency rate in arteries 1.4 mm in diameter. Harry Buncke, a plastic surgeon continued development of the microsurgical technique, instruments, and sutures, that would result in successful replantation surgery. In 19634Buncke successfully replanted a rabbit ear anastomosing an artery less than 1 mm. Next he replanted monkey digits5and even performed a toe to hand transfer with primary arterial and venous anas tomoses.6

Twenty-two of 90 patients with carcinoma of the anterior oral cavity treated at the Minneapolis Veterans Administration Hospital from 1965 through 1973 had advanced lesions - tumors attached to the mandible and/or more than 3 cm in size. These patients were treated by primary radical neck dissection, en bloc excision, and segmental mandibulectomy. A cervical-pectoral flap combination was used for reconstruction. The functional and cosmetic results were excellent. Patient survival and cure rate compare favorably with other series. We emphasize the need for wide initial resection with immediate reconstruction.

We have employed a two-stage operative approach to the correction of Crouzon's/Apert's deformity. Extensive use of methyl methacrylate in cranioplasty and frontal bone advancement is employed to obtain finely detailed contours with excellent stability. By adhering to principles of separation of oral contamination and the methyl methacrylate, as well as the provision of adequate soft tissue coverage of the methyl methacrylate, the problems of infection and soft tissue breakdown can be minimized.

We report the variability of the rejection process among the several tissues of a limb allograft. We used a rat hind limb allograft model transplanting across a well-defined minor histocompatibility barrier (Fischer RT-1(1v1)), donor animals, and Lewis (RT-1(1)) recipient animals. Continuous cyclosporin and prednisone immunosuppression was used. Four immunosuppressive regimens all produced extended limb survival. The rejection process was most severe and difficult to control in the skin. Nonskin tissues reverted to a nearly normal appearance after a period of cellular infiltration 2 to 3 weeks posttransplantation. Clinical and electromyographic evidence of nerve regeneration and end-organ reinnervation was demonstrated in long-term surviving animals.

In summary, the surgical techniques described can provide substantial benefit to selected patients who have sustained massive weight loss. As in all cosmetic surgery, patient selection must be meticulous. The expectations of the patient must be realistic, and the very real risks of the operative procedures must be understood. Patients who have sustained massive weight loss should be informed of the possibilities of reconstructive plastic surgery.

A rigid transparent face mask of cellulose acetate butyrate was developed for the control of scar hypertrophy in the burned face. Excellent patient acceptance has been found in a six-year series of 97 patients. Use of the device for at least twenty hours a day for an average of one and a half years per patient has enabled preservation of normal facial contours.

Peripheral blood leukocytes, isolated by continuous flow leukapheresis and purification, are an excellent source of HL-A antigen. 3M KCI extraction releases the HL-A antigenic mosaic with good yield and specificity. This technique will allow a selective choice of HL-A representation in source material for studies of biochemical characteristics of the HL-A antigens. The technique would allow preparation of antigen from a proposed allograft donor and the pretreatment of the recipient in attempts to induce specific immunoIogic unresponsiveness.

The preexisting humoral immunity of four normal human beings to nine species of lower animals was assayed by conventional hemagglutination, leukoagglutination and cytotoxicity techniques. The specific

An axillofemoral bypass was used to preserve a functioning renal allograft after excision of a mycotic abdominal aortic aneurysm in a diabetic patient. In the presence of continued immunosuppression the aortic wall infection progressed and the patient expired after rupture of the proximal aortic closure.

We have presented a technic of excision and primary closure for the treatment of pilonidal disease. It has been shown that pilonidal disease is probably an acquired condition. A limited excision with primary closure done under local anesthesia will correct the problem in most patients. Technics of open packing and wide mobilization of tissues can lead to prolonged convalescence and are unwarranted in most cases.

A prophylactic bilateral subcutaneous mastectomy, following a preoperative mammogram revealed clustered small calcifications in the left breast. In order to investigate the merits of thermorphythmometry, the patient self-measured surface temperature of each breast, above and below the nipple, while awake. In the case here presented, bilateral subcutaneous mastectomy followed by extensive histologic scrutiny of both breasts revealed no indication of malignancy. Bilateral fibrocystic disease with calcification and lobular hyperplasia was found. As compared to the contralateral sites, the atypical epithelial proliferation was more abundant in the mammographically and thermorhythmometrically 'abnormal' area of the left breast.

A number of physiologic derangements have been observed resulting from the management of head and neck cancer with resection and simultaneous bilateral neck dissection. A protocol evolved to minimize morbidity from these complications was used on seventeen patients. Eleven are alive and free of disease and there was no mortality.

Summary Thirty-five of 186 recipients of renal transplants in a twenty-one month period were Australia antigen positive at the time of transplantation. The Au antigen positive group was compared with an Au antigen negative control group of recipients matched for source of kidney, age, sex, and date of transplantation. The follow-up period averaged twenty-one months post transplantation. Among twenty Au antigen positive recipients of related kidneys, there were eight rejection episodes but only two kidney losses and one death. Among twenty matched related Au antigen negative controls there were thirteen rejection episodes, no kidney losses, and two deaths. Of fifteen Au antigen positive cadaver recipients there were eighteen rejection episodes, eight kidney losses, and six deaths. Of the fifteen matched Au antigen negative recipients of cadaver kidneys, there were four rejection episodes, one kidney loss, and four deaths. In only one of the Au antigen positive recipients did clinically significant liver abnormalities develop one year after removal of the transplant, which eventually led to death from hepatitis. Au antigenemia in recipients does not seem to be associated with increased risk except perhaps in recipients of cadaver donor kidneys in whom the apparent increased risk may be coincidental.

In this paper we advocate secondary healing for closure of large perineal wounds following full thickness skin excision for the treatment of Hailey-Hailey disease.

• Fifty-three consecutive unrandomized patients with squamous cell cancer of the oral tongue were retrospectively studied to compare the results of an aggressive surgical approach performed as primary therapy or as salvage after irradiation failure. Twenty-five patients underwent surgery primarily, while 23 of 28 patients treated with curative irradiation required surgical salvage. Tumor staging was equivalent between the two groups. Local recurrences at the site of origin of the tumor within two years postoperatively were significantly more frequent in salvage patients (10.0%) than in primary surgical patients (5.5%). Cervical lymph node recurrences within five years were more frequent in the salvage surgery group (74.8% V 36.7%). Systemic metastases developed in a similar proportion in both groups. Determinate fiveyear survivals were nearly identical (55.2% v 55.5%). Although recurrence rates were significantly higher after irradiation and salvage surgery, an aggressive surgical effort in patients who are irradiation failures can result in five-year survival rates matching those of surgical patients. (Arch Surg1984;119:394-399)

Thirty-one earlobe keloids in 20 patients were treated by complete surgical excision and three postoperative injections of .1 to .2 ml of 40 mg per milliliter of triamcinolone solution at four-week intervals beginning three weeks postoperation. Only 1 recurrence developed in a follow-up of twelve to sixty-two months.

Early serial histologic changes in replanted extremities have not been well defined; their contribution to a suboptimal functional result is unknown. With the use of a rat hind limb replantation model to address this question, we studied tissues of the replanted legs by light microscopy from 1 to 60 days after replantation. Although early lesions were consistent with ischemic injury, the chronic preparations were remarkably normal, and the lesions were more consistent with denervation. Poor function in clinical replantations may be a reflection of more pronounced versions of these pathologic lesions.