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Recurrence or new breast cancer after mastectomy and autologous breast reconstruction is a rare occurrence. We present a case series of four patients with this rare phenomenon and describe their presentation, workup, and surgical and adjuvant therapy. We discuss the possible physiologic mechanisms leading to tumor recurrence in a reconstructed breast along with literature review. A new palpable mass in a reconstructed breast mound warrants tissue diagnosis to avoid delay in treatment. The surgical options for breast cancer in tissue reconstructions depend on the location and extent of the tumor, involvement of the vascular pedicle, stage of disease, and adjuvant therapy options.

Background Little data address outcome in patients with sentinel lymph node (SN) metastases without completion axillary lymph node dissection (CALND). This study was designed to assess locoregional recurrence in patients with positive SNs who did not undergo CALND. Methods An IRB-approved, retrospective chart review was conducted on breast cancer patients with a positive SN. Follow-up information on outcomes was obtained via mailed questionnaires and chart review. Comparative analyses were performed between patients who did and did not undergo CALND after a positive sentinel lymph node biopsy. Results From November 1998 to June 2004, 625 breast cancer patients had a positive sentinel lymph node biopsy. One-hundred and eighteen patients with ≤0.2 mm nodal metastases (N0i+) were excluded from the study. Of the remaining 507 patients, 421 underwent CALND and 86 did not. In comparison to patients who had CALND, patients who did not undergo CALND had smaller primary tumors (2 vs 2.6 cm, P = .0007) and were more likely to have a single positive sentinel node (92% vs 77%, P = .002). The metastasis size of the sentinel node was smaller compared to patients who underwent axillary dissection (1.7 vs 6.4 mm, P < .0001). Mean predicted probability of nonsentinel node metastasis in patients who did not undergo CALND was 20% compared to 47% in patients who did (P < .0001). During a median follow-up of 30 months, there were no axillary recurrences. Conclusions These data confirm that patients who have a positive sentinel node biopsy and do not undergo CALND have a lower risk profile for axillary disease. In this lower risk subset, axillary treatment may not be necessary.

Background The accurate prediction of nonsentinel node (NSN) metastasis in breast cancer patients remains uncertain. Methods The medical records of 574 breast cancer patients from 2 different institutions (Mayo Clinic and University of Michigan) with sentinel lymph node biopsy examination and completion axillary lymph node dissection were reviewed for multiple clinicopathologic variables. The Memorial Sloan Kettering Cancer Center nomogram performance for prediction of NSN metastases was assessed. A new model was developed with clinically relevant variables and possible advantages. Results The Memorial Sloan Kettering Cancer Center nomogram predicted the likelihood of NSN metastasis with an area under the receiver operating characteristic curve of .72 and .86. For predicted probability cut-off points of 5% and 10%, the false-negative rates were 0% and 14% (Mayo), and 17% and 11% (Michigan). A new model was developed with similar area under the curve but lower false-negative rates for low-probability subgroups. Conclusions Predictive models for NSN tumor burden are imperfect.

Although all three Vav family members are expressed in T lymphocytes, the role that Vav3 plays in T cell activation is poorly defined. Here we show that, like Vav1, Vav3 undergoes rapid tyrosine phosphorylation after T cell receptor (TCR) cross-linkage and interacts with the adaptor molecules SLP76 and 3BP2 in a SH2-dependent manner. However, depletion of Vav1 but not Vav3 protein by RNA interference affects TCR-mediated IL-2 promoter activity. In contrast, Vav3 function is specifically required for coupling TCR stimulation to serum response element–mediated gene transcription. These data indicate that, although both Vav proteins are biochemically coupled to the TCR, they regulate distinct molecular pathways leading to defined gene transcriptional events.

treatment. 3 We hypothesized that seromas occur more frequently in extensive surgical procedures or in those that require a drainage tube. In addition, we theorized that seroma and surgical site infection (SSI) were directly correlated.The aims of this study were to evaluate the frequency of seromas that require intervention, to assess variation based on the extent of the breast or axillary surgical procedure, and to evaluate the incidence of SSI in relation to seroma occurrence.

Breast cancer most often presents as a palpable mass or with an abnormal mammogram. Much less commonly, breast cancer may present as a paraneoplastic syndrome. Dermatomyositis (DM) is a rare disease most often considered a complement-mediated idiopathic inflammatory myopathy manifested by classic skin findings and proximal muscle weakness. However, DM may also be due to a paraneoplastic syndrome associated with an underlying malignancy. The authors present a case report of a woman with presumed contact dermatitis who was diagnosed with breast cancer in the setting of progressive fatigue and muscle weakness. DM was subsequently diagnosed. Treatment of DM simultaneous with treatment of the breast cancer led to regression of DM. The diagnosis of DM in an adult should raise suspicion of an underlying malignancy. Breast cancer is a common disease that may rarely present with uncommon features that may divert attention from the underlying malignancy.

Completion axillary lymph node dissection (CALND) is controversial in patients with sentinel lymph node (SLN) metastases ≤ 0.2 mm [N0(i+)]. Our goal was to characterize patients with SLN isolated tumor cells regarding surgical management and axillary recurrence.An Institutional Review Board (IRB)-approved retrospective chart review identified 677 consecutive patients with positive SLN biopsy for breast cancer between October 1997 and June 2004, and N0(i+) patients were identified. Clinicopathologic characteristics, predicted probability of nonsentinel node disease, axillary surgery, and recurrences were recorded.Of 81 patients with SLN N0(i+) metastasis, 31 underwent CALND and 50 did not. The two groups of patients showed no statistical differences in tumor size, stage, grade, number of SLNs removed, and number of positive SLNs. Predicted probability of additional axillary metastasis was somewhat higher among those who underwent CALND compared with those who did not. Patients undergoing CALND were significantly younger than those who did not (mean age 50 vs. 57, P = 0.01). Of the 31 patients with CALND, 4 (12.9%) had additional nodal metastases. Radiation to nodal fields was administered to 8 patients in the CALND group (25.8%) and to 7 in the group without axillary dissection (14.0%, P = 0.44). No axillary recurrences were noted at a median follow-up of 38 months.Among breast cancer patients with SLN isolated tumor cells, a small percentage have additional metastasis in other axillary nodes. However, the risk of axillary recurrence appears low in those who do not undergo CALND.

To identify operative morbidity, mortality, and long-term outcome after operative treatment for symptomatic polycystic liver disease (PLD) and develop a treatment algorithm for patients with PLD.PLD represents a challenging clinical problem that can result in massive hepatomegaly and various complications, leading to significant decline in health status and quality of life. The optimal surgical treatment for this disease is still evolving.All patients who underwent hepatic resection, cyst fenestration, or liver transplantation for PLD from 1985 to 2006 were identified retrospectively. Long-term outcomes were evaluated by patient survey. Mean follow-up was 8 +/- 0.5 years.Of 141 patients (122 women; age: 51 +/- 1 years) with PLD, 117 had concomitant polycystic kidney disease. All patients suffered from symptomatic hepatomegaly with 85% being functionally impaired (Eastern Cooperative Oncology Group Performance Status: 1-3). Despite significant inferior vena cava or hepatic venous compression in 65%, hepatic function was commonly preserved. A total of 124 patients underwent partial hepatectomy with cyst fenestration, 10 underwent cyst fenestration alone, and 7 underwent liver transplantation for primary treatment of PLD. Overall operative morbidity and mortality was 58% and 4%, respectively, with major complications (Clavien grade: III-V) in 30%. Five- and 10-year survival was 90% and 78%, respectively. Eastern Cooperative Oncology Group Performance Status performance status normalized or improved in 75% of patients and 73% returned to work full-time. At follow-up, health survey scores were similar to the general population despite subsequent recurrence of symptoms in 73% of patients.Selective patients with massive hepatomegaly from PLD benefit from operative intervention. The type of operation performed is mainly dependent on the distribution of the cysts, coincident sectoral vascular patency and parenchymal preservation, and hepatic reserve. Hepatic resection can be performed with acceptable morbidity and mortality, prompt and durable relief of symptoms, and maintenance of liver function. Cyst fenestration and liver transplantation, though effective in selected patients, are less broadly applicable.

The high sensitivity and lower specificity of breast MRI for detecting breast cancer are well documented in the literature. As the use of breast MRI continues to grow, medical controversy persists over the appropriate use of this test. However, patients' perceptions of breast MRI are unknown. The aim of this study was to determine patients' perception of the impact of breast MRI on their care and to compare patients' perception with objective assessments.Patients undergoing breast MRI between January 2004 and December 2005 for cancer staging or high-risk surveillance were surveyed regarding comfort during, satisfaction with, and perception of MRI's impact on their clinical care. The respondents' perceptions of the impact of MRI on their care were compared with objective assessments based on retrospective chart review for breast cancer patients.Of 300 patients, the survey was completed by 227 (76%). Ninety-one percent (203/224) reported mild or no discomfort during the examination, and 91% (206/226) perceived the breast MRI examination as having a positive impact on their care. Breast cancer patients were significantly more likely to perceive the impact of MRI as beneficial in comparison with the objective assessment (91% vs 35%, respectively; p0.001).Most women undergoing breast MRI for cancer staging and screening found it to be a comfortable test and perceived it to have a positive impact on their care. Breast cancer patients perceived the clinical impact of their breast MRI examination to be significantly more positive than when assessed objectively.

Introduction: Sentinel lymph node (SLN) biopsy using blue dye and radioisotope often results in the removal of multiple SLNs. We sought to determinewhether there is a point where the surgeon can terminate the procedure without sacrificing accuracy. Methods: One thousand one hundred ninety-seven patients from University of Michigan and the Mayo Clinic undergoing SLN biopsy formed the study population. Surgeons removed all SLNs until counts within the axilla were less than 10% of the highest node ex vivo and recorded the order in which they were removed. Results: The mean number of SLNs removed per patient was 2.5 (range 1‐9). Approximately 42% of patients had three or more lymph nodes removed, while 19% had four or more lymph nodes removed. Eighteen percent of patients (132/725) at University of Michigan and 22% (103/472) at Mayo Clinic had a positive SLN. Ninety-eight percent (231/235) of patients with lymph node metastases were identified by the 3rd SLN while 100% were identified by the 4th SLN. Conclusion: Among patients undergoing SLN biopsy for breast cancer, the only positive SLN is rarely identified in the 4th or higher node. Terminating the procedure at the 4th node may lower the cost of the procedure and reduce morbidity. J. Surg. Oncol. 2007;96:554–559. 2007 Wiley-Liss, Inc.

Introduction: Predictors of outcome in patients with metastatic colorectal cancer remain inconsistent. We aimed to identify predictors of outcome in these patients, to develop a prognostic scoring system, and to assess the general applicability of the current major risk scoring systems. Materials and Methods: Following IRB approval, medical records of 662 consecutive patients undergoing resection of colorectal metastases to the liver during 1960 to 1995 were reviewed. Clinicopathologic and outcome data were assessed from records and mailed questionnaire. Clinicopathologic variables were tested using univariate and multivariate analyses; best-fit models were then generated to study the effect of each independent risk factor on outcome. To validate existing scoring models, our independent data set was applied to those scores. The relative concordance probability estimates were calculated for these models and compared with that of the proposed Mayo model. Results: The overall and disease-specific 5-year survival rates were 37% and 42%, respectively. The probability of recurrence at any site was 65% at 5 years. Perioperative blood transfusion and positive hepatoduodenal nodes were the major determinants of survival and recurrence. To assess the general applicability of the proposed risk scoring systems, we imported the data from our patient population into 3 other scoring systems. Neither survival nor recurrence among our patients was stratified discretely by any of the scoring systems. Based on probability estimates, all models were only marginally better than chance alone in predicting outcome. Conclusion: Broad application of risk scoring systems for patients with metastatic colorectal cancer has limited clinical value and refinement and external validation should be undertaken before utilization.

With availability of genetic testing and development of statistical models for risk stratification, more women are being identified as having increased risk for breast cancer. A number of risk-reducing treatment options with varying efficacy exist for them, including frequent surveillance, chemoprevention, prophylactic salpingo-oophorectomy (PSO), and prophylactic mastectomy (PM). Those most likely to benefit from PM are BRCA gene carriers and those who have a strong family history of breast cancer. Prevetive PM remains controversial, however. There are no randomized controlled trials to substantiate the potential benefit or harms of PM. This article describes the high-risk women in whom PM may be considered, and summarizes data on the efficacy of PM as a treatment for the prevention of breast cancer.

Context Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence. Design We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy. Conclusion Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.

Background We aimed to evaluate the safety and efficacy of methylene blue dye (MBD) for sentinel lymph node (SLN) mapping in breast cancer. Methods A total of 398 patients undergoing 401 SLN biopsy procedures with MBD were retrospectively reviewed and divided into 3 groups based on dye concentration and location of dye injection. Technical success and complication rates were compared. Results Overall technical success of SLN biopsy was 99.7%. Technical success of SLN mapping with MBD was lowest in the group receiving full strength dye in a peritumoral location (74%) and highest in the group that received very dilute MBD (1.25 mg/mL) in the subareolar location (92%, P = .004). The complication rate was highest in the first group (21%) and lowest in the latter (2%, P = .0003). Conclusions Dilute MBD (1.25 mg/mL) successfully maps SLNs with very few complications.

Routine preoperative assessment may not accurately assess the extent of underlying cancer in patients with Paget's disease (PD) of the breast. We performed this study to correlate findings on clinical examination and mammography with pathologic results and outcomes in women with PD.An IRB-approved retrospective review identified all patients with PD between 1975 and 2000. Clinical exam and mammographic findings were recorded, and information on recurrence and survival was obtained from medical records.Univariate analyses identified palpable mass and suspicious mammogram as risk factors significantly associated with a worse outcome. Patients were therefore categorized by combinations of these two preoperative factors. All patients with a palpable mass and a suspicious mammogram had invasive cancer. In the subgroup of 40 women with a benign mammogram and no palpable mass, invasive cancer occurred in 5% and the majority (68%) had ductal carcinoma in situ which extended beyond the nipple. Women with a palpable mass and a suspicious mammogram had significantly worse survival compared to those with a benign mammogram and no palpable mass (P = 0.008). With a median follow-up of 6.4 years, five local recurrences occurred in patients with invasive cancer who underwent mastectomy.In women with PD, a palpable mass or suspicious mammogram portends a high likelihood of invasive cancer. Underlying cancer is common even in women with a benign mammogram and no palpable mass. Although breast conservation is an attractive option in patients with PD, mammography and physical exam may significantly underestimate the presence and extent of underlying disease.

Transcription factors are proteins that regulate gene expression by modulating the synthesis of messenger RNA. Since this process, known as gene transcription, is often the dominant control point in the production of many proteins, transcription factors are key regulators of numerous cellular functions, including secretion, proliferation, differentiation, and apoptosis. Most transcription factors are also the final effectors of signaling pathways that transduce signals from the cell membrane to the nucleus. Therefore alterations in the activity or expression of some transcription factors have a significant impact on the biology of human cells and may lead to the development of diseases. In this article we review this field of research with a particular emphasis on the role of transcription factors in pancreatic development and cancer.