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BACKGROUND: We hypothesized that disconcerting lymphedema rates in both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) may be because of unrecognized vunerable variations in arm lymphatic drainage within the axilla. Axillary reverse mapping (ARM) facilitates identification and avoidance of arm lymphatics within the axilla and its use may reduce lymphedema. METHODS: This institutional review board-approved study from June 2007 to December 2013 involved patients undergoing SLNB with or without ALND, or ALND alone. Technetium is injected subareolarly for localization of the breast SLN and isosulfan blue dye (5 mL) is injected in the ipsilateral upper arm for localization of nonbreast lymphatics. Data were collected on identification and preservation of arm lymphatics, crossover rates, blue node metastases, axillary recurrence, and lymphedema as measured by volume displacement. RESULTS: A total of 654 patients prospectively underwent 685 ARM procedures with a SLNB and/or ALND. Objective lymphedema rates for SLNB and ALND were 0.8% and 6.5% respectively, with 26-month median follow up. Blue lymphatics were identified in 29.2% (138/472) of SLNB and 71.8% (153/213) of ALND. Crossover was seen in 3.8% (18/472) of SLNB and 5.6% (12/213) of ALND. Blue node metastases rate was 4.5% (2/44). Axillary recurrence rate was 0.2% and 1.4% for SLNB and ALND, respectively. CONCLUSIONS: ARM allows frequent identification of arm lymphatics in the axilla, which would have been transected during routine surgery. Rates of metastases in noncrossover nodes and axillary recurrences are low. Lymphedema rates are dramatically reduced using ARM when compared with accepted standards.

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BACKGROUND: Skin graft donor sites are notoriously painful, with potential complications of fluid loss, delayed healing, infection, and hypertrophic scarring, particularly in patients with burns or traumatic injury. In this population, rapid epithelialization is critical to reducing morbidity and cost. STUDY DESIGN: This prospective, randomized controlled trial compared the effects of 40-kHz noncontact low-frequency ultrasound (NLFU) in addition to standard care (SC) with SC alone in subjects with split-thickness donor sites of 20 to 200 cm(2). Standard care consisted of cleansing and moist wound dressings. Outcomes measured were time to healing, defined as absence of drainage and full epithelialization; pain and itching scores; and recidivism rates. RESULTS: Of 33 patients enrolled; 27 were randomized and received a minimum of 4 study treatments. Median age was 49 years, 69% were male, and 84% were burn patients. Comorbidities included hypertension (31%), coronary artery disease (22%), pulmonary disease (38%), anemia (31%), and diabetes (16%). Median donor site area was 136.0 cm(2). Noncontact low-frequency ultrasound and SC compared with SC demonstrated a mean time to heal of 12.1 days vs 21.3 days (p = 0.04). All NLFU+SC subjects had epithelialized by 4 weeks compared with only 71% in SC. Recidivism rates were 8% for NLFU+SC compared with 45% for SC. Pain scores were reduced and significant differences in itching were observed. CONCLUSIONS: Noncontact low-frequency ultrasound and SC compared with SC alone in the treatment of split-thickness donor sites demonstrated significant accelerated healing and reduced pain and itching. Noncontact low-frequency ultrasound subjects experienced a better quality of healing with less incidence of infection and recidivism.

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BACKGROUND: Health care reform goals involve more cost-effective methods of delivering health care. The cost-effectiveness of axillary ultrasound-guided core needle biopsy (AUS-CNB) was compared with sentinel lymph node biopsy (SLNB) when evaluating the status of the axilla in operable invasive breast cancer. STUDY DESIGN: We performed an IRB-approved retrospective review of patients undergoing ultrasound of the axilla plus core needle biopsy at our institution from 2007 to 2012. An accuracy of technique and cost analysis (TreeAge Pro 2009) of AUS-CNB vs SLNB was conducted. RESULTS: The cohort of 95 patients was divided into 2 groups: clinically positive (CP) (32%) and negative (CN) (68%) axilla. In the CP group, 83% had a suspicious AUS, of which 90% were positive. In the CN group, AUS was suspicious in 70%, with a positive biopsy in 59%. The sensitivity and specificity of AUS-CNB were 90% (95% CI 84.8% to 98.8%) and 100% (95% CI 27% to 59.1%), respectively. Cost estimates comparing AUS-CNB with SLNB demonstrated a cost saving of $236,517 in the CP axilla and $248,490 in the CN axilla, for a total cost savings of $485,007. CONCLUSIONS: Axillary ultrasound-guided core needle biopsy is a sensitive, diagnostic, surgeon-performed procedure. It is time-saving, cost-efficient, and less invasive, making it a viable option when evaluating the status of the axilla in invasive breast cancer or staging before neoadjuvant chemotherapy.

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BACKGROUND: Margin negativity is a critical endpoint in breast-conserving surgery. Despite advances in technology, there is up to a 40 % positive margin rate in lumpectomy specimens, which results in a twofold increase in ipsilateral breast tumor recurrence. We have developed a new method for lumpectomy that could improve margin negativity. METHODS: A novel method for partial mastectomy was developed using ultrasound to perform dissection of breast specimens in real time. Continuous ultrasound-guided breast excision (CUBE) was first tested on gel models and subsequently implemented in vivo. The step-by-step method for this technique was performed on 12 successive patients who had ultrasound-detectable lesions. RESULTS: Twelve patients underwent lumpectomy for cancer using the CUBE technique. All patients had negative margins on final pathology. Three patients who had close margins on ex vivo ultrasound evaluation had additional shave margins taken, resulting in negative final margins. CONCLUSIONS: The CUBE technique is a novel technique that allows for dissection of breast lesions with continuous visualization of margins. This facilitates real-time adjustments to ensure margin negativity. Preliminary data is promising, but further research is needed for confirmation.

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BACKGROUND: Excision followed by radiofrequency ablation (eRFA) is an intraoperative method that uses intracavitary hyperthermia to create an additional tumor-free zone around the lumpectomy cavity in breast cancer patients. We hypothesized that eRFA after lumpectomy for invasive breast cancer could reduce the need for re-excision for close margins as well as potentially maintain local control without the need for radiation. STUDY DESIGN: This prospective phase II institutional review board-approved study was conducted from March 2004 to April 2010. A standard lumpectomy was performed, then the RFA probe was deployed 1 cm circumferentially into the walls of the lumpectomy cavity and maintained at 100 °C for 15 minutes. Validated Doppler sonography was used to intraoperatively determine adequacy of ablation. RESULTS: One hundred patients were accrued to the trial, with an average age of 65.02 years ± 10.0 years. The stages were Tis (n = 30); T1mic (n = 1); T1a (n = 9); T1b (n = 27); T1c (n = 22); T2 (n = 10) ; and T3 (n = 1). Grades were I (n = 48); II (n = 29); and III (n = 23). Seventy-eight subjects had margins >2 mm (negative), 22 patients had margins ≤ 2 mm, of which 12 were close and 3 focally positive, which, at our institution, would have required re-excision (only 1 patient in this group had re-excision). There were 6% postoperative complications, and 24 patients received radiation therapy (XRT). During the study mean follow-up period of 62 months ± 24 months (68-month median follow-up) in patients not treated with XRT, there were 2 in-site tumor recurrences treated with aromitase inhibitor, 3 biopsy entrance site recurrences treated with excision and XRT to conserve the breast, and 2 recurrences elsewhere and 1 contralateral recurrence; all 3 treated with mastectomy. CONCLUSIONS: Long-term follow-up suggests that eRFA may reduce the need for re-excision for close or focally positive margins in breast cancer patients, and eRFA may be a valuable tool for treating favorable patients who desire lumpectomy and either cannot or do not want radiation. A multicenter trial has been initiated based on these results.

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Advertisements targeted at the elderly population suggest that antioxidant therapy will reduce free radicals and promote wound healing, yet few scientific studies substantiate these claims. To better understand the potential utility of supplemental antioxidant therapy for wound healing, we tested the hypothesis that age and tissue ischemia alter the balance of endogenous antioxidant enzymes. Using a bipedicled skin flap model, ischemic and non-ischemic wounds were created on young and aged rats. Wound closure and the balance of the critical antioxidants superoxide dismutase and glutathione in the wound bed were determined. Ischemia delayed wound closure significantly more in aged rats. Lower superoxide dismutase 2 and glutathione in non-ischemic wounds of aged rats indicate a basal deficit due to age alone. Ischemic wounds from aged rats had lower superoxide dismutase 2 protein and activity initially, coupled with decreased ratios of reduced/oxidized glutathione and lower glutathione peroxidase activity. De novo glutathione synthesis, to restore redox balance in aged ischemic wounds, was initiated as evidenced by increased glutamate cysteine ligase. Results demonstrate deficiencies in two antioxidant pathways in aged rats that become exaggerated in ischemic tissue, culminating in profoundly impaired wound healing and prolonged inflammation.

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