Positive margins, fibroproliferation in the surrounding breast tissue, and necrosis are associated with a marked increase in LR rates. Efforts should be made to achieve negative surgical margins to reduce risk of LR. Death from PT is rare (2%), and only PT that demonstrate uniformly aggressive pathologic features seem to be associated with mortality.

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Most acute skin toxicities were mild. Our infection rate was higher than in prior studies that used interstitial brachytherapy. Cosmesis was good to excellent in most patients. Breast brachytherapy with the MammoSite catheter was well tolerated; further investigations of breast brachytherapy with this system are warranted.

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with focal areas of necrosis (Fig. 1a). Microscopically the tumor cells were arranged in sheets separated by fibrous septae (Fig. 1b). The cells were polygonal to ovoid cells had moderate amount of clear cytoplasm, oval nuclei with moderate pleomorphism, inconspicuous nucleoli, and 4-6 mitosis per high power field with areas of necrosis (Fig. 1c). The tumor involved the overlying skin and was fungating through it; however the nipple and areola were uninvolved. No areas suggestive of adenomyoepithelioma were seen. The cells were negative for glycogen, mucin, and lipid. On immunohistochemistry the cells expressed smooth muscle actin (SMA) and S-100 ( Fig. 2a, b) and weekly expressed Her 2 Neu and were negative for estrogen and progesterone receptor. Thus a final diagnosis of myoepithelial carcinoma was made.Malignant myoepithelioma (MM) can be seen in association with adenomyoepithelioma, but only rare cases of pure MM have been reported. It is commonly seen in 53-81 years of age, as a firm, rubbery, painless palpable tumor, which may rarely fungate. Microscopically shows solid proliferation of spindle cells. Immunoreactivity for myoepithelial markers, such as SMA, S-100 protein, CK14 calponin, and caldesmon aids in definitive diagnosis. Differential diagnosis includes other clear cell tumors such as glycogen-rich, lipid-rich, and secretory carcinoma. Glycogen-rich carcinomas show abundant clear cytoplasm that is periodic acid-schiff (PAS)-positive diastase-labile material, and are negative for SMA and S-100. Lipid-rich carcinomas show clear cells, containing lipid, demonstrated by oil red O or Sudan IV methods and are negative for glycogen and mucin. Secretory carcinomas are mainly seen in children; the tumor consists of glands and microcystic spaces that contain abundant pink, foamy secretions with clear or vacuolated cytoplasm. Apocrine and mucinous carcinomas can rarely show clear cell change. Apocrine carcinomas have dense homogenous or granular eosinophilic cytoplasm with apical snouts. Mucinous carcinoma is characterized by malignant cells floating in lakes of mucin. MM of the breast with fungating mass are uncommon tumors and often present a diagnostic challenge, these should also be considered in the differential diagnosis of clear cell tumors of the breast.

A replication-deficient recombinant vaccinia virus, NYVAC, was developed by deleting 18 open reading frames in the vaccinia virus genome. Recombinant NYVAC, encoding the murine T cell co-stimulatory gene B7.1 (CD 80) (NYVAC-B7.1) and the murine interleukin-2 gene (NYVAC-IL-2), were prepared and the expression of B7.1 and the secretion of IL-2 were respectively confirmed in vitro. The use of these viruses to prepare a potent tumor cell vaccine was studied in a syngeneic murine CC-36 colon adenocarcinoma model. Mice were immunized on days 1 and 8 with 10(6) irradiated CC-36 cells that were infected with 10(7) plaque-forming units of either NYVAC-B7.1, NYVAC-IL-2 or a control virus, NYVAC-HR, which encodes a vaccinia virus host-range gene. These mice were then challenged with 10(8) viable CC-36 tumor cells on day 15. All mice (10/10) in a group that had received no vaccination and all mice (20/20) in a group that had received a control vaccine of CC-36/NYVAC-HR developed tumor 4-weeks after tumor cell challenge. Interestingly, only 16/20 mice in a group that had received CC-36/ NYVAC-B7.1 showed the development of tumor after the same interval. The protection against tumor development and the reduction in tumor burden (as mean tumor diameter, 4 weeks after tumor challenge) were significant in this group when compared to groups that were either unvaccinated or vaccinated with CC-36/NYVAC-HR (mean tumor diameter = 6.51+/-3.2 mm compared to 26.5+/-0.9 mm or 26.2+/-1.8 mm respectively) (P = < 0.05). The protection against tumor in a group of mice that received CC-36/ NYVAC-IL-2 vaccination was similar to that in the unvaccinated group or the group receiving a CC-36/NYVAC-HR control vaccination. However, in a survival experiment, mice that received either CC36/NYVAC-B7.1 or CC-36/ NYVAC-IL-2 vaccination on the day of tumor transplantation survived significantly longer than mice that had not been vaccinated (median survival 60+ days, 60+ days or 23.5 days respectively) (P = < 0.05). Interestingly, when a therapeutic tumor vaccination was performed on day 4 after tumor transplantation, mice that had been vaccinated with either CC36/NYVAC-B7.1 or CC-36/NYVAC-IL-2 did not show an improved survival when compared to mice in the control that had not been vaccinated (median survival 28 days compared to 26 days or 25 days respectively). However, mice that had received a therapeutic vaccination with CC-36 cells infected with both NYVAC-B7.1 and NYVAC-IL-2, 4 days after tumor transplantation, survived significantly longer than control mice that had not received any vaccination (median survival 29.5 days compared to 25 days respectively) (P<0.05). These results suggest that a replication-deficient recombinant NYVAC encoding the B7.1 gene and NYVAC encoding the IL-2 gene can be used to produce an effective vaccinia-virus-augmented tumor cell vaccine.

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Background: Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction. Methods: A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed. Results: A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups. Conclusions: This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.