Surgical Reconstruction, Locally Recurrent Breast Cancer and Angiosarcoma

Background: Local recurrence (LR) of breast cancer is defined as any recurrence of tumour in the ipsilateral thoracic wall and locoregional recurrence (LRR) as any recurrence in the ipsilateral thoracic wall or regional lymph nodes following surgery for primary breast cancer. The standard of care for LRR has not been established but surgery forms a key part of most accepted strategies. The oncological safety of immediate breast reconstruction for primary breast cancer has been addressed in numerous studies but only a few have considered the oncological safety of delayed autologous breast reconstruction. Radiotherapy-induced breast angiosarcoma is now increasingly being recognized in the medical literature and is an aggressive tumour with a poor prognosis. Patients and methods The first study consisted of 60 consecutive patients treated by skin sparing mastectomy and immediate breast reconstruction for an ipsilateral breast tumour recurrence. Study II consisted of 40 consecutively operated patients who were treated with wide soft tissue resection and immediate flap reconstruction for an extensive chest wall recurrent breast cancer. In both studies I and II hospital records were analysed for surgical complications and oncological outcome. Study III was based on 522 consecutive patients who underwent mastectomy with or without breast reconstruction between January 2000 and December 2003. Data on cancer recurrence and survival were collected from hospital records and the files of the Finnish Cancer Registry. Study IV consisted of 10 patients treated surgically between 1999 and 2010 for a breast angiosarcoma following earlier radiotherapy for primary breast cancer. Surgical notes and pathology reports were reviewed for resection margins. Hospital records were analysed for oncological outcome. Results Study I After a median follow-up of 84 months, 11 (18%) patients developed disease relapse (6 local re-recurrences (10%), 3 cases of regional lymph node metastasis and 2 cases of distant metastasis). 5 year overall survival (OS) was 94% and 5 year disease-free survival (DFS) was 83%. Study II After a median follow-up of 31 months, the median DFS was 31 months and the median OS was 52 months. The 2 and 5 year OS rates were 71% and 32% respectively. Multivariate cox regression analysis revealed that resection size was an independent prognostic factor with a threefold increased risk of mortality for resections of more than 150 cm². Study III After a median follow-up of 102 months, the 8-year LRR rate was 5.4% (n=21) in the mastectomy only group, 0.8% (n=1) in the delayed reconstruction group and 23.1% (n=3) in the immediate reconstruction group. Cox multivariate analysis revealed immediate reconstruction to be an independent risk factor for LRR. However Cox multivariate analysis revealed no reconstruction to be an independent risk factor for distant metastasis (DM), poor breast cancer specific survival (BCSS) and poor overall survival (OS). Study IV Marked lateral macroscopic margins were at least 3 cm in 9/10 cases and clear histological margins were achieved in all cases. Defect coverage involved direct closure in 2 cases, reconstruction with a pedicled latissimus dorsi flap in 4 cases and skin grafting in 4 cases. After a median follow-up of 81 months, 3 patients suffered a recurrence and 5 year OS was 70%. Conclusions Skin-sparing mastectomy and immediate breast reconstruction is a possible treatment option for selected patients who develop an ipsilateral breast tumour recurrence. In selected patients autologous flap reconstruction enables the resection of extensive chest wall recurrent breast tumours with acceptable morbidity and reasonable local control and survival. Palliative surgery can also be invaluable to improve the quality of life in patients with extensive symptomatic recurrences. In comparison to mastectomy only breast reconstruction does not appear to worsen the prognosis following treatment for primary breast cancer. Increased awareness of radiation-associated angiosarcoma, with no delay in diagnosis and ultimately excision with wide macroscopic margins, is vital in improving survival of this poorly known tumour.Tausta: Rintasyöpä voi uusiutua paikallisesti (primaarileikkauksen alueelle) tai regionaalisesti (kainaloon). Syövän paikallinen uusiutuma rinnan poiston jälkeen ilmaantuu rintakehän iholle tai pehmytkudoksiin. Rinnan säästävän leikkauksen jälkeen paikallinen uusiutuma ilmaantuu samaan rintaan. Optimaalista uusiutumien hoitoa ei ole selvästi määritelty, mutta kirurgia on aina osa hoitoa, kuten mastektomia säästävän leikkauksen jälkeisen uusiutuman hoitona. Myöhäisrekonstruktion jälkeen ilmaantuvista paikallisista uusiutumista on vain muutamia julkaisuja. Välittömän rintarekonstruktion jälkeen ilmaantuvista paikallisista uusiutumista on enemmän raportteja, joissa uusiutumien määrä on 2-7.5% 5 vuoden sisällä. Angiosarkooma on harvinainen tuumori joka voi esintyy rintaseinämässä primaaririntasyövän sädehoidon jälkeen. Se on aggressiivinen ja huonoennusteinen syöpä. Potilaat ja menetelmät Tutkimuksen ensimmäinen osa sisälsi 60 potilasta, jotka oli hoidettu skin-sparing mastektomialla ja joille oli tehty välitön rintarekonstruktio paikallisen uusiuman vuoksi. Tutkimuksen toinen osa sisälsi 40 potilasta, joille oli tehty laaja pehmytkudosresektio ja rekonstruktio kielekkeellä laajan rintaseinämän uusiuman vuoksi. Tutkimuksen kolmas osa käsitti 522 potilasta, joille oli tehty pelkkä rinnan poisto tai rinnan poisto ja rekonstruktio vuosina 2000-2003. Retrospektiivinen tutkimus toteutettiin keräämällä arkisto- ja seurantatiedot näistä potilaista.Sairauskertomuksista kerättiin tiedot kirurgisista ja onkologisista hoidoista, sekä tietoja seuranta-ajalta. Tutkimuksen neljäs osa sisälsi 10 potilasta, jotka oli hoidettu kirurgisesti sädehoidon jälkeisen rinnan angiosarkooman vuoksi. Sairauskertomuksista kerättiin tiedot kirurgisista ja onkologisista hoidoista ja analysoitiin patologin lausunnot resektiomarginaaleista. Tulokset I Mediaaniseuranta-aika oli 84 kk. Yhdellätoista potilaalla (18%) todettiin taudin uusiuma (6 paikallista (10%), 3 regionaalisten imusolmukeiden (?%) ja 2 systeemistä uusiumaa (?%)). Viiden vuoden elossaolo-osuus (OS) oli 94% ja 5 vuoden tautivapaa osuus (DFS) oli 83%. II Mediaaniseuranta aika oli 31 kk. Kahden ja 5 vuoden OS olivat 71% ja 32%. DFS oli 31 kk ja mediaani OS 52 kk. Cox-regressioanalyysissä resektiopinnan laajuus oli itsenäinen ennustetekijä; yli 150 cm² resektiopinta-alue lisäsi kuolleisuutta kolminkertaiseksi. III Mediaaniseuranta aika oli 102 kk. Kahdeksan vuoden paikallis- ja regionaalinen uusiumaosuus oli 5.4% pelkän mastektomian jälkeen, 0.8% myöhäisrekonstruktion jälkeen ja 23.1% välittömän rekonstruktion jälkeen. Cox-regressioanalyysissä välitön rekonstruktio oli itsenäinen riskitekijä paikalliselle- ja regionaaliselle uusiumalle. Samassa analyysissä potilailla, joille oli tehty mastektomia ilman rekonstruktiota oli kohonnut riski systeemiselle uusimalle, sekä alentunut rintasyöpäspesifinen eloonjäämisosuus (BCSS) ja yleinen elossaolo-osuus (OS). IV Leikkauksissa makroskoopiset tervekudosmarginaalit olivat vähintään 3 cm 9/10 tapauksista ja histologiset tervekudosmarginaalit saavutettiin kaikissa tapauksissa. Kudospuutoksen korjaaminen onnistui suoralla sululla 2 potilaalla, varrellisella latissimus dorsi -kielekkeellä 4 potilaalla ja ihonsiirteellä 4 potilaalla. Mediaaniseuranta-aika oli 81 kk. Seuranta-aikana 3 potilaalla todettiin uusiuma ja 5 vuoden OS oli 7%. Johtopäätokset Skin-sparing mastektomia ja välitön rekonstruktio on mahdollinen hoitovaihtoehto niillä hyväennusteisilla potilailla, joille on ilmaantunut paikallisuusiuma rintaa säästävän leikkauksen jälkeen. Valikoiduilla potilailla joilla on uusiuma, kielekerekonstruktio mahdollistaa laajan rintaseinämän resektion tyydyttävällä morbiditeetilla ja onkologisella lopputuloksella. Palliatiivisella kirurgialla voi olla tärkeä elämänlaatua parantava merkitys potilaille, joilla on hankalia oireita syövän uusitumisen vuoksi. Pelkkään mastektomiaan verrattuna rintarekonstruktio ei huononna ennustetta primaaririntasyövän hoidon jälkeen. Sädehoitoon liittyvä angiosarkooma on harvinainen tuumori, jonka hoidossa nopea diagnostiikka ja laaja resektio suurella marginaalilla ovat tärkeitä, jotta tämän huonosti tunnetun syövän hoidon ennuste paranisi

Resuscitated unconscious male : Lichtenberg's sign lighting the way

Non peer reviewe

The fractal lightning burn results from a positively charged strike

Non peer reviewe

Validation of the Finnish FACE-Q for use in patients undergoing surgery for functional problems or malignancy

The aim of this study was to produce a Finnish version of the FACE-Q scales Satisfaction with Forehead and Eyebrows, Adverse effects: Forehead, Eyebrows and Scalp, and Adverse effects: Cheeks, Lower face and Neck, and assess the performance of these scales and the Satisfaction with Facial Appearance, Satisfaction with Outcome and Appearance-related Psychosocial Distress in patients who had undergone surgery for functional problems or malignancy affecting the forehead or cheeks. The general health-related outcomes instrument 15 D was used as a reference. Patients who had undergone a frontal lift, a direct brow lift, a facelift or an excision of a facial tumor in Helsinki University Hospital plastic surgery department in 2009-2019 were identified. A postal survey study was conducted with 305 patients, of whom 135 (44%) responded. Diagnoses included facial nerve dysfunction (53%), brow ptosis (21%) and skin, mucosal or salivary gland tumor (20%). The FACE-Q scales displayed high internal consistency (Cronbach's alphas >= 0.80) and good reliability on repeat administration. The exploratory factor analysis revealed unifactorial influences for all scales except the Adverse effects: Forehead, Eyebrows and Scalp. Weak correlations with 15 D dimensions were detected. The FACE-Q scales evaluated here are suitable for use in patients with functional problems or malignancy.Peer reviewe

Case Report: Unravelling the Mysterious Lichtenberg Figure Skin Response in a Patient With a High-Voltage Electrical Injury

cited By 0We describe a case of Lichtenberg Figures (LFs) following an electrical injury from a high-voltage switchgear in a 47 year-old electrician. LFs, also known as ferning pattern or keraunographic markings, are a pathognomonic skin sign for lightning strike injuries. Their true pathophysiology has remained a mystery and only once before described following an electical injury. The aim was to characterise the tissue response of LFs by performing untargeted non-labelled proteomics and immunohistochemistry on paraffin-embedded sections of skin biopsies taken from the area of LFs at presentation and at 3 months follow-up. Our results demonstrated an increase in dermal T-cells and greatly increased expression of the iron-binding glycoprotein lactoferrin by keratinocytes and lymphocytes. These changes in the LF-affected skin were associated with extravasation of red blood cells from dermal vessels. Our results provide an initial molecular and cellular insight into the tissue response associated with LFs.Peer reviewe

Application of the FACE-Q rhinoplasty module in a mixed reconstructive and corrective rhinoplasty population in Finland

The FACE-Q Rhinoplasty module is a patient-reported outcome instrument developed for the assessment of primarily aesthetic outcomes of rhinoplasty. The aim of our study was to produce a Finnish version of the instrument and validate it for use in patients undergoing nasal reconstruction as well as those treated with a rhinoplasty. Finnish versions of the FACE-Q scales Satisfaction with Nose, Satisfaction with Nostrils and Adverse Effects: Nose, were translated following established guidelines. Patients undergoing nasal resection, reconstruction or rhinoplasty in Helsinki University Hospital plastic surgery department in 2009-2019 were identified using theatre records. A total of 240 Finnish-speaking patients 18-85 years old were approached with a postal survey questionnaire. The questionnaire included the translated FACE-Q modules and those for Satisfaction with Facial Appearance, Appearance-Related Psychosocial Distress and Satisfaction with Outcome, as well as the general health-related quality of life instrument 15 D. The FACE-Q scales translated readily to Finnish. Eighty-three patients (35%) responded to the survey. Most FACE-Q scales performed well with high internal consistency (Cronbach's alphas 0.87-0.92) and repeatability. Only the Adverse Effects: Nose scale displayed poor consistency and a floor effect with 18% of the patients reporting no adverse outcomes. Answers to the Appearance-Related Psychosocial Distress scale were skewed towards no experienced stress. Answers to the other scales were normally distributed with weak correlation with 15 D dimensions. The Finnish translations of the FACE-Q Rhinoplasty scales perform well at assessing a diverse group of patients including those undergoing nasal reconstruction as well as those undergoing rhinoplasty.Peer reviewe

Systemaattiset kriteerit potilasvalintaan kasvojensiirtoa varten

Kasvoilla on useita tehtäviä vuorovaikutuksesta tärkeiden elintoimintojen ylläpitoon. Perinteisten plastiikkakirurgisten menetelmien lisäksi kasvojensiirto aivokuolleelta luovuttajalta on vakiinnuttamassa paikkaansa vaikeasti kasvoistaan vammautuneiden potilaiden hoitomuotona. Toimenpiteeseen ja elinikäiseen hyljinnänestolääkitykseen liittyvät haitat rajoittavat kasvojensiirtoon soveltuvia potilaita. Toistaiseksi potilasvalinta on tehty tapauskohtaisesti, ja systemaattiset potilasvalintakriteerit puuttuvat. Esittelemme vaikeasti kasvoiltaan vammautuneita potilaita, ja arvioimme systemaattisesti heidän soveltuvuuttaan kasvojensiirtoa varten. Kymmenen vaikean kasvovamman vuoksi hoidetuista potilaista vuosilta 1995-2017 valittiin tutkimukseen. Tietoa kerättiin potilasasiakirjoista sekä kliinisistä tutkimuksista. Vammojen laajuus jaettiin osa-alueisiin: anatominen laajuus (10), toiminnallinen haitta, esteettinen haitta (asteikko 0-9), elämänlaatuarvio (15D-lomake) ja sosiaalinen hyvinvointi. Lisäksi arvioitiin kunkin potilaan immunologinen tila ja vasta-aiheet toimenpiteelle. Vammojen etiologioita olivat palovammat (4), ampuma-asevammat (3), tylpän esineen aiheuttama vamma (1), räjähdysvamma (1) ja neurofibromatoosi (1). Kaikilla potilailla esiintyi keskikasvojen vaurioita, ja kuudella potilaalla oli vähintään 8/10 kasvojen osa-alueista vaurioitunut. Kaikilla potilailla ilmeni jonkin asteinen toiminnallinen vajaus. Arvioitu esteettinen vajaus oli mediaaniltaan 7/9. Elämänlaadun laskun mediaani oli -0.107. Immunologisia vasta-aineita ei havaittu, mutta viidellä potilaalla ilmeni muita vasta-aiheita toimenpiteeseen. Kuudesta vaikeasti vammautuneesta potilaasta kolme todettiin soveltuvaksi kasvojensiirtoleikkaukseen. Vaikeasti kasvoistaan vammautuneet potilaat muodostavat monimuotoisen potilasryhmän. Aiemmin käytetyt potilasvalintakriteerit ovat epätarkkoja, eivätkä ne sisällä painotuksia eri kasvojen toimintojen välillä tai elämänlaadullista arviota. Esittelemme systemaattisen arviointimenetelmän vaikeasti kasvoiltaan vammautuneiden arvioon. Arviointimenetelmä on hyödyllinen myös toimenpiteen onnistumisen ja potilaiden toipumisen seurannassa.Aim. There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Materials and Methods. Ten patients with severe facial defects treated between 1995-2017 formed the study group. Data was collected from patient charts and examinations. Facial deficiencies were subdivided into different categories: anatomical region (10 regions), facial function, aesthetic defect (range 0-9-worst), impact on health-related quality of life (HRQoL) (15D questionnaire, range 0-1) and social well-being. Immunological status and contraindications were also evaluated. Results. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 or more injured regions. All patients had at least partial loss of facial function. The median aesthetic disfigurement score was 7. The median lowering of 15D score was -0.107. None were significantly sensitized although 5 patients had significant contraindications for FT. Three of the 6 patients with a severe overall facial deficiency, were considered as potential FT candidates. Conclusions. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of anatomical regions affected, facial function, aesthetics, social well-being and HRQoL

Olfactory and gustatory functions after free flap reconstruction and radiotherapy for oral and pharyngeal cancer : a prospective follow-up study

The senses of smell and taste can be adversely affected by both tumour- and treatment-related factors amongst head and neck cancer patients. The consequences may negatively impact nutritional status as well as quality of life in this patient population. This prospective longitudinal follow-up study is consisted of 44 patients treated for oral cavity, oropharyngeal or hypopharyngeal cancer with tumour resection and microvascular free tissue transfer reconstruction at the Helsinki University Hospital, Helsinki, Finland. Thirty-nine (89%) of them also received radiotherapy. The senses of smell (odour detection, identification and threshold test) and taste (electrogustometry) and quality of life (UW-QOL) were evaluated preoperatively, and at 6 weeks, 3 months, 6 months and 12 months, postoperatively. There were higher scores in the odour detection values in the 6-week and 3-month tests compared with preoperative values for the tumour side. Other detection scores did not differ statistically from the preoperative values neither in the tumour nor the contralateral side. However, in the odour identification test, all posttreatment values were statistically significantly higher than pretreatment ones. In the olfactory threshold test, no statistically significant differences were found between pre- and posttreatment values. Electrogustometry values for the taste on the tumour side were statistically significantly impaired at 6 weeks (p <0.05) and at 3 months (p <0.01) compared with the pretreatment results. They were also impaired at 6 months and at 12 months, although the differences were not statistically significant. The quality of life was impaired after treatment in this patient series. However, the correlation between quality of life and sense of taste was found only at one time point (3 months) and only with contralateral side measurements. We conclude that in oral and pharyngeal cancer patients the postoperative taste problems are related to the impairment on the taste sensation in the tongue but not with the sense of smell. Moreover, the impairment in the quality of life is not clearly related to the impaired sense of taste.Peer reviewe