Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach (LYMPHA) is a technique used to prevent BCRL at the time of axillary lymph node dissection (ALND). We report the 5-year experience of a breast surgeon trained in LYMPHA and investigate the outcomes of patients who underwent LYMPHA following ALND for treatment of cT1–4N1–3M0 breast cancer. A retrospective review of patients with cT1–4N1–3M0 breast cancer was performed in patients who underwent ALND with and without LYMPHA. Diagnosis of BCRL was made by certified lymphedema therapists. Descriptive statistics and lymphedema surveillance data were analyzed using results of Fisher’s exact or Wilcoxon rank-sum tests. Logistic regression and propensity matching were performed to assess the reduction of BCRL occurrence following LYMPHA. In a 5-year period, 132 patients met inclusion criteria with 76 patients undergoing LYMPHA at the time of ALND and 56 patients undergoing ALND alone. Patients who underwent LYMPHA at the time of ALND were significantly less likely to develop BCRL than those who underwent ALND alone (p = 0.045). Risk factors associated with BCRL development were increased patient age (p = 0.007), body mass index (BMI) (p = 0.003), and, in patients undergoing LYMPHA, number of positive nodes (p = 0.026). LYMPHA may be successfully employed by breast surgeons trained in lymphatic–venous anastomosis at the time of ALND. While research efforts should continue to focus on prevention and surveillance of BCRL, LYMPHA remains an option to reduce BCRL and improve patient quality of life.

Objectives Knowledge of women's health is important for physicians in various specialties, but training often is inadequate. The objective of this project was to develop, implement, and evaluate a women's health curriculum for medical students at the University of Florida College of Medicine in Gainesville. Methods After reviewing previous pertinent literature and assessing institutional factors, we developed an interdisciplinary women's health elective for medical students. We present the curricular design for the course. The 2-week elective explores women's health topics such as disease prevention, screening, breast health, osteoporosis, and cardiovascular health. Teaching methodology includes case-based lectures, reading assignments, and clinic sessions at multiple sites. Results Senior medical students worked in a variety of clinical settings and were assigned a women's health project, a pretest before starting the elective, and a posttest after completion of the course. A statistically significant increase was seen in the students' mean posttest (98.8%) versus pretest (85.6%) scores (difference 13.1%; 95% confidence interval 7.3-19.0, P < 0.0001). Conclusions Designing curricula that promote lifelong professional competency in the field of women's health can be challenging. At the University of Florida, we have successfully created and implemented a medical student elective in women's health using local resources and expertise. This elective satisfies important women's health training requirements, has been well received by our students, and has resulted in increased women's health-specific knowledge. The experience at our institution may be useful for other programs interested in developing a women's health curriculum geared toward medical students utilizing minimal resources.

Wire localization is currently the most widely used localization strategy for excision of nonpalpable breast lesions. Its disadvantages include patient discomfort, wire-related complications such as wire displacement/fracture, and operating room delays related to difficulties during wire placement. We have implemented the technique of intraoperative ultrasound-guided excision using hydrogel-encapsulated (HydroMARK) biopsy clips for lesion localization. We hypothesize that this method is as effective as wire localization for breast conserving therapy.

We present a pilot clinical study for breast cancer diagnosis and neoadjuvant chemotherapy monitoring using quantitative multispectral photoacoustic tomography. Absolute total hemoglobin concentration and oxygen saturation maps from several breast cancer patients are obtained for the first time and compared with the MR images and biopsy reports.

We are concerned over the conclusions made by Levin et al [ 1 Levin D.C. Parker L. Schwarz G.F. Rao V.M. Percutaneous needle vs surgical breast biopsy: previous allegations of overuse of surgery are in error. J Am Coll Radiol. 2012; 9: 137-140 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar ] on the basis of their analysis of breast biopsies within a Medicare population only. Most patients undergoing breast biopsy are <60 years of age [ 2 Gur D. Wallace L.P. Klym A.H. et al. Trends in recall, biopsy, and positive biopsy rates for screening mammography in an academic practice. Radiology. 2005; 235: 396-401 Crossref PubMed Scopus (34) Google Scholar , 3 Williams R.T. Yao K. Stewart A.K. et al. Needle versus excisional biopsy for noninvasive and invasive breast cancer: report from the National Cancer Data Base 2003-2008. Ann Surg Oncol. 2011; 18: 3802-3810 Crossref PubMed Scopus (25) Google Scholar , 4 Gutwein L.G. Ang D.N. Liu H. et al. Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions. Am J Surg. 2011; 202: 127-132 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar ]. Therefore, the findings of Levin et al are not broadly applicable. The investigators' claim that open biopsy (OB) is “not being overused” conflicts with the evidence that has accumulated to date [ 3 Williams R.T. Yao K. Stewart A.K. et al. Needle versus excisional biopsy for noninvasive and invasive breast cancer: report from the National Cancer Data Base 2003-2008. Ann Surg Oncol. 2011; 18: 3802-3810 Crossref PubMed Scopus (25) Google Scholar , 4 Gutwein L.G. Ang D.N. Liu H. et al. Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions. Am J Surg. 2011; 202: 127-132 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar , 5 Wilke L.G. Ballman K.V. McCall L.M. et al. Adherence to the National Quality Forum (NQF) breast cancer measures within cancer clinical trials: a review from ACOSOG Z0010. Ann Surg Oncol. 2010; 17: 1989-1994 Crossref PubMed Scopus (15) Google Scholar , 6 Edge S.B. Ottesen R.A. Lepisto E.M. et al. Surgical biopsy to diagnose breast cancer adversely affects outcomes of breast cancer care: finding from the National Comprehensive Cancer Network. in: Presented at: San Antonio Breast Cancer Symposium, San Antonio, Tex2005 Google Scholar , 7 Clarke-Pearson E.M. Jacobson A.F. Boolbol S.K. et al. Quality assurance initiative at one institution for minimally invasive breast biopsy as the initial diagnostic technique. J Am Coll Surg. 2009; 208: 75-78 Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar , 8 Breslin T.M. Caughran J. Pettinga J. et al. Improving breast cancer care through a regional quality collaborative. Surgery. 2011; 150: 635-642 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar ]. A comprehensive survey of the medical literature makes this point clear. Percutaneous Needle vs Surgical Breast Biopsy: Previous Allegations of Overuse of Surgery Are in ErrorJournal of the American College of RadiologyVol. 9Issue 2PreviewA recent paper in the American Journal of Surgery reported that surgery is used for 30% of breast biopsies, an excessive number. The investigators' stated biopsy volume included Current Procedural Terminology® code 19125 (“excision of breast lesion identified by preoperative placement of radiological marker, open”). However, this code may often be used when a surgeon's primary intention is not biopsy but rather excision of a lesion. Therefore, the reported results may overstate the percentage of biopsies performed as surgical procedures. Full-Text PDF Authors' ReplyJournal of the American College of RadiologyVol. 9Issue 5PreviewWe appreciate the comments of Grobmyer et al, the authors of the paper in the American Journal of Surgery [1] that we critiqued in our recent paper [2]. On the basis of the results of our research, we concluded that the rate of use of surgical breast biopsy was significantly less than the 30% stated by Dr Grobmyer and his colleagues in their earlier study. We believe they erred by including all cases with the procedure code 19125 (“excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion”) as biopsies, especially considering that the word “biopsy” does not appear in the descriptor. Full-Text PDF

BACKGROUND: Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy. METHODS: The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008. RESULTS: Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (similar to 30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year. CONCLUSIONS: The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs. (C) 2011 Elsevier Inc. All rights reserved.

To determine the utility of MRI for assessing axillary lymph node status in patients with breast cancer.

I n late 2006, an outpatient imaging center began its conversion to digital mammography (DM). Part of this transition was a plan to purchase software for computer-aided detection (CAD) to assist in analysis of the digital mammography images. The preparation to purchase one of two systems included a comparison of several specifications, including DICOM compatibility and the ability of the systems to fit well into the digital mammography program of the imaging center. A small study was designed to determine whether one of the two different commercially available systems being considered [R2 ImageChecker (version 8.3.17) and iCAD Second Look (version 7.2-H)] was superior to the other for assisting in interpretation of digital mammography images from screening mammograms obtained with the newly installed General Electric Senographe DS unit. Patient images included in this study were given retrospective approval from the Institutional Review Board with waiver of informed consent for publication of the study results.

BACKGROUND:The role of preoperative bilateral breast MRI in breast cancer patients being considered for breast-conserving therapy has been controversial. We hypothesized that preoperative MRI, along with an active program in MRI-directed biopsies, would lead to a change in multidisciplinary treatment planning for patients being considered for breast-conserving cancer therapy, and it would be associated with reduced rates of margin-positive partial mastectomies. STUDY DESIGN:A retrospective review of a consecutive series of patients who were treated for breast cancer at a single center between January 2005 and July 2007 was conducted. Patients in the study were candidates for breast-conserving cancer therapy based on physical examination, mammography, and ultrasonography. All patients were evaluated by a preoperative breast MRI. Analysis included number and result of MRI-directed biopsies, impact of MRI on treatment planning, and incidence of margin-positive partial mastectomy within the series of patients. RESULTS:Seventy-nine female patients were analyzed. Median age was 57 years. MRI led to the performance of 25 MRI-directed biopsies for previously unrecognized suspicious lesions in 21 patients. Forty-four percent of MRI-directed biopsies were positive for cancer. MRI was associated with a change in management in 15 patients (19%) for multicentric ipsilateral cancer (n = 7), a more extensive primary lesion size (n = 6), or contralateral breast cancer (n = 2). Incidence of margin-positive partial mastectomy requiring additional resective operation was very low in this series (10%). CONCLUSIONS:Bilateral breast MRI, when used in conjunction with MRI-directed biopsy procedures, can be helpful in planning multidisciplinary treatment of candidates for breast-conserving cancer therapy. By allowing more accurate local staging of tumors, MRI is a tool that can be used to help reduce high reexcision rates for margin-positive partial mastectomies.

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.

PURPOSE:Scarring in the tumor bed may mask or mimic local recurrence of tumor on surveillance mammography. Type of surgical closure technique used during lumpectomy may impact the pattern or density of scar tissue apparent in the tumor bed on mammography. This study sought to determine whether surgical closure type affects tumor-bed scar formation and impacts interpretation of surveillance mammography in women treated with breast-conserving therapy for early-stage breast cancer.MATERIALS AND METHODS:One hundred women who received breast-conserving therapy were selected; 99 of them had 2-year post-treatment mammograms for the treated breast. Craniocaudal and mediolateral oblique views were reviewed by 3 subspecialty radiologists who routinely read mammograms. The mammograms were scored on 5-point scales for overall breast density and scarring within the tumor bed.RESULTS:The analyses did not demonstrate greater scarring or density in breast status post superficial closure compared with breast status post full-thickness closure, or vice versa (P > 0.05 for scarring and density). There were no detectable differences between the 2 closure techniques either within the data from individual reviewers, within the composite data for the entire group of reviewers, or in instances where 2 of 3 reviewers agreed (P > 0.05). There was significant interobserver variability in scoring among the mammographers for both scarring (P = 0.001) and density (P < 0.0001).CONCLUSION:Based on our study of the 2-year post-treatment mammograms, there was no evidence that closure technique impacts degree of scarring in the tumor bed. However, striking interobserver variability in scoring density and scarring was noted.

Idiopathic granulomatous mastitis, also known as idiopathic granulomatous lobular mastitis, is a benign breast lesion that represents both a diagnostic and therapeutic dilemma. We report two cases of granulomatous mastitis recently evaluated and managed at our institution. To better understand this rare disease, we analyzed treatment outcomes in reported cases of granulomatous mastitis. One hundred sixteen cases were subsequently analyzed. Primary management strategies included observation (n = 9), steroids (n = 29), partial mastectomy (n = 75), and mastectomy (n = 3). Success rates with each treatment were observation, 56 per cent; steroids, 42 per cent; partial mastectomy, 79 per cent; and mastectomy, 100 per cent. Based on this analysis, we propose a clinically useful algorithm for both workup and management of these challenging cases.

Several possible functions have been proposed for antiphonal duetting in birds, including pair-bond maintenance, cooperative territorial defence and acoustic mate guarding. Previous work has suggested that duetting in magpie-larks was consistent with both defence of the territory and guarding the mate against usurpation. We conducted playback experiments designed to distinguish between these two functions. Responses of males and females to simulated intrusion (broadcasts of unfamiliar solo songs) suggested functional differences for solo songs and duets. Both sexes initiated more songs in response to same-sex conspecific song, suggesting that solo songs are used to deter same-sex rivals in the context of territory defence. Contrary to predictions of the mate-guarding and pair-bond maintenance hypotheses, the sex of playback song had no effect on the likelihood of either sex answering their partner's song to form a duet. Thus, duets are most likely to be performed for the purpose of cooperative territorial defence.