Immediate Breast Reconstructions in the Treatment of Breast Cancer

Breast cancer is the most common form of potentially fatal cancer in women in the Western world. Better understanding of the breast cancer disease process together with developments in treatments have led to improved survival and reduced risk of recurrence, significantly influencing the acceptance of breast reconstructions as part of breast cancer treatment. Skin-sparing mastectomy followed by immediate breast reconstruction has proved superior to other forms of breast reconstruction in terms of aesthetic outcome. However, due to the relatively recent introduction of skin-sparing mastectomy concerns on the surgical and oncological safety of the operation persist. The aim of the present study is to evaluate the surgical and oncological safety of skin-sparing mastectomy and immediate breast reconstruction in a consecutive patient series with ensuing follow-up. Subsequent aims of the study are to examine possibilities of reducing surgical complications of the operation and to assess the feasibility of sentinel node biopsy together with immediate breast reconstruction. The study population comprises a consecutive series of patients having undergone skin-sparing mastectomy followed by immediate breast reconstruction at the Helsinki University Central Hospital between 1992 and 2006. In Study I, the hospital records of 207 patients, operated between 1992 and 2001, were analyzed for surgical complications and recurrences of breast cancer during follow-up. In Study II, 60 consecutive patients were randomized into either conventional diathermy or radiofrequency coagulation groups to examine possibilities of reducing skin-flap complications. Study III consists of 62 consecutive breast cancer patients evaluated for the feasibility of sentinel node biopsy simultaneously with immediate breast reconstruction. In Study IV, hospital records were analyzed to examine local recurrence of breast cancer in a consecutive series of 146 patients with Stage I or II disease. Post-operative complications in Study I included native skin-flap necrosis (10.1%), hematoma (10.1%), anastomose thrombosis (5.3%), infection (3.4%), hernia (2.6%) and loss of one microvascular flap (0.7%). The Stage I and II patients in Study IV had a local recurrence rate of 2.7%, an isolated regional lymph node recurrence rate of 2.1% and a systemic recurrence rate of 2.7%, during a mean follow-up time of 51 months. The Stage III patients in study I had a locoregional recurrence rate of 31.3% during follow-up. Radiofrequency coagulation in Study II did not decrease skin-flap complications when compared with conventional diathermy. An increased skin-flap complication rate in Study II was associated with smoking and the type of skin incision used. In Study III, eleven patients had tumor positive sentinel nodes, nine of which were detected intraoperatively. Skin-sparing mastectomy followed by immediate breast reconstruction is a safe procedure both surgically and oncologically, especially for early stage breast cancer. Tennis racket type incision is associated with an increased skin-flap complication rate. Sentinel node biopsy with intraoperative assessment of sentinel node metastases is feasible in patients undergoing immediate breast reconstruction.

Suokasvillisuuden vaste muuttuvaan ilmastoon: kokeellinen tutkimus kuivumisen vaikutuksesta

Soilla on merkittävä rooli ilmastonmuutoksen hillitsemisessä suuren hiilivarastonsa sekä ekosysteemin ja ilmakehän välisen kaasunvaihdon ansiosta. Ilmastonmuutoksen ennustetaan vaikuttavan suokasvillisuuteen ja suon toimintaan epäsuorasti. Vedenpinnan ennustetaan laskevan 14–21 cm johtuen kasveista ja avoimilta pinnoilta tapahtuvan haihdunnan lisääntymisestä lämpötilan noustessa, mikäli sadanta ei lisäänny. Aiemmat vedenpinnan laskun jälkeistä kasvillisuutta seuranneet tutkimukset ovat osoittaneet, että putkilokasvit hyötyvät alhaisemmasta vedenpinnan tasosta ja että kuljuun sopeutuneet rahkasammalet kärsivät kuivuneista oloista. Kasvillisuuden runsaussuhteiden muuttumisen lisäksi kasviyhteisöjen monimuotoisuus vähenee. Erityisen herkkiä vedenpinnan laskulle ovat olleet välipinta- ja kuljurahkasammalet ja sarat. Funktionaalisten kasviryhmien vasteiden selvittämiksesi käytettiin BACI (before-after-control-impact) –tutkimusotetta. Tutkimuksessa oli kolme verrokkialaa ja kolme käsittelyalaa, joissa vedenpintaa oli laskettu 14–21 senttimetriin. Lisäksi vertailukohdaksi tutkimuksessa oli mukana kolme alaa, joissa oli tehty metsäojitus n. 50 vuotta sitten. Nämä toistot sijaitsivat meso-, oligo ombrotrofisilla suotyypeillä Oriveden Lakkasuolla. Kasvillisuus kartoitettiin ja vedenpinnat mitattiin aloilta ennen käsittelyä vuonna 2000 sekä vuosina 2001–2003 ja 2009. Aineisto analysoitiin TWINSPAN- (PC-Ord), PRC ja DCA (CANOCO)-monimuuttujamenetelmillä. Tulokset osoittivat, että verrokki- ja käsittelyalat olivat samanlaisia lähtökohdiltaan, joten niitä voitiin käsittelyn jälkeen verrata toisiinsa. Kasvillisuuden rakenne vaihteli vuosien välillä myös verrokkialoilla, mikä osoittaa kasvien sopeutumiskyvyn muuttuviin sääoloihin (lämpötila, sademäärä). Vuosi 2003 erottui tutkimuksessa alhaisella vedenpinnantasolla, mutta toisaalta myös ainavihantien varpujen suuren peittävyyden osalta. Vuoteen 2009 mennessä kasvillisuuden erityisesti sarojen peittävyys väheni. Ravinteikkaimmilla toistoilla kasvillisuuden vasteet vaikuttivat olevan vahvemmat kuin vähäravinteisilla toistoilla. Kasviryhmistä kulju- ja välipintasammalilla oli vahvimmat vasteetvedenpinnan laskuun ja mätäslajeilla heikoimmat. Tulosten mukaan kasviryhmien vasteet vaihtelevat riippuen tarkasteltavasta aikajaksosta: ensimmäiset kolme vuotta käsittelyn jälkeen suo oli häiriötilassa ja vasta sen jälkeen kasvillisuus sopeutui muuttuneisiin oloihin.

Use of wetland buffer areas to reduce nitrogen transport from forested catchments: Retention capacity, emissions of N2O and CH4 and vegetation composition dynamics

The use of buffer areas in forested catchments has been actively researched during the last 15 years; but until now, the research has mainly concentrated on the reduction of sediment and phosphorus loads, instead of nitrogen (N). The aim of this thesis was to examine the use of wetland buffer areas to reduce the nitrogen transport in forested catchments and to investigate the environmental impacts involved in their use. Besides the retention capacity, particular attention was paid to the main factors contributing to the N retention, the potential for increased N2O emissions after large N loading, the effects of peatland restoration for use as buffer areas on CH4 emissions, as well as the vegetation composition dynamics induced by the use of peatlands as buffer areas. To study the capacity of buffer areas to reduce N transport in forested catchments, we first used large artificial loadings of N, and then studied the capacity of buffer areas to reduce ammonium (NH4-N) export originating from ditch network maintenance areas in forested catchments. The potential for increased N2O emissions were studied using the closed chamber technique and a large artificial N loading at five buffer areas. Sampling for CH4 emissions and methane-cycling microbial populations were done on three restored buffer areas and on three buffers constructed on natural peatlands. Vegetation composition dynamics was studied at three buffer areas between 1996 and 2009. Wetland buffer areas were efficient in retaining inorganic N from inflow. The key factors contributing to the retention were the size and the length of the buffer, the hydrological loading and the rate of nutrient loading. Our results show that although the N2O emissions may increase temporarily to very high levels after a large N loading into the buffer area, the buffer areas in forested catchments should be viewed as insignificant sources of N2O. CH4 fluxes were substantially higher from buffers constructed on natural peatlands than from the restored buffer areas, probably because of the slow recovery of methanogens after restoration. The use of peatlands as buffer areas was followed by clear changes in plant species composition and the largest changes occurred in the upstream parts of the buffer areas and the wet lawn-level surfaces, where the contact between the vegetation and the through-flow waters was closer than for the downstream parts and dry hummock sites. The changes in the plant species composition may be an undesired phenomenon especially in the case of the mires representing endangered mire site types, and therefore the construction of new buffer areas should be primarily directed into drained peatland areas.