The purpose of this study was to evaluate the oncologic and aesthetic results of patients undergoing breast-conserving therapy with 0.5 cm surgical margins and determine the factors that influence the need for reconstruction. One hundred consecutive patients who underwent breast-conserving surgery with 0.5 cm surgical margins followed by radiotherapy for invasive cancer and ductal carcinoma in situ (DCIS) were followed prospectively and evaluated for recurrence and aesthetic result. Thirteen patients underwent reexcision to achieve a 0.5 cm margin. Factors including breast size, location of the tumor, specimen size and volume, tumor size and volume, and TNM stage, if axillary dissection or reexcision were required, were included in the analysis. Aesthetic evaluation consisted of both patient rating and an independent observer rating on a 10-point scale that assessed volume, shape, symmetry, areola/nipple, and scar. Of the 100 patients that underwent breast-conserving therapy, the overall aesthetic results revealed that 8% of the patients scored themselves seven or less, another 8% were scored seven or less by the independent observer, and another 7% were scored seven or less by both the patient and the observer. Of these patients, only one proceeded to have a reconstructive procedure. Analysis of variance revealed a significant correlation between tumor size (cm(2)) and an aesthetic score of seven or less (p = 0.023), and specimen volume (cm(3)) and an aesthetic score of seven or less (p = 0.039). Chi-squared analysis revealed a significant difference (chi(2) = 4.39, p < 0.5) in the aesthetic result in patients with stage IIA disease. Other independent factors such as age, breast size, location of the tumor, axillary dissection, and reexcision did not influence the overall aesthetic result. A Pearson correlation of patient and independent observer ratings showed a positive correlation (r = 0.4; 95% confidence interval [CI] 0.19-0.57) between the two groups. There were zero local recurrences of breast cancer during the study period. Our results demonstrate that following breast-conserving therapy with a minimum of 0.5 cm resection margins, it is possible to achieve excellent oncologic and aesthetic results. Patients with large tumors that require a large volume of resection or with stage IIA disease should be considered for reconstructive evaluation.
IntroductionVideo-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness.Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound.As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.Case descriptionThis paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.MethodsIn two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule.The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.ResultsThree lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.ConclusionVATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.
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