Description of Event or Problem · 1
PATIENT #2 FROM LITERATURE: BOVA, D., COOPER, R.A., HENKEL, A., WARD, K., AND YAO, K. (2008). MALIGNANT-APPEARING MICROCALCIFICATIONS AT THE LUMPECTOMY SITE WITH THE USE OF FLOSEAL HEMOSTATIC SEALANT. AMERICAN ROENTGEN RAY SOCIETY, AJR 2008; 191:W1371-W1373. SUMMARY OF PUBLICATION FROM AJR WOMEN'S IMAGING: RECENTLY AT A MEDICAL CENTER, FLOSEAL WAS USED FOR HEMOSTASIS DURING SEVEN LUMPECTOMIES PERFORMED FOR TREATMENT OF BREAST CANCER. FOLLOW-UP MAMMOGRAMS FOR ALL SEVEN PATIENTS IN WHOM FLOSEAL WAS USED SHOWED INNUMERABLE PUNCTUATE RADIOPAQUE DENSITIES THROUGHOUT THE LUMPECTOMY SITE THAT MIMICKED THE APPEARANCE OF MALIGNANT MICROCALCIFICATIONS. THESE MICROCALCIFICATIONS WERE OBSERVED ON THE 6-MONTH FOLLOW-UP MAMMOGRAM IN SIX PATIENTS. IN ANOTHER CASE, THE CALCIFICATIONS WERE SLIGHTLY FEWER IN NUMBER ON THE MAMMOGRAM 1 YEAR AFTER LUMPECTOMY THAN ON THE INITIAL 6-MONTH POSTOPERATIVE STUDY, SUGGESTING THAT THEY MAY EVENTUALLY BE REABSORBED. HOWEVER, THE RISK FOR RECURRENT DISEASE AFTER TREATMENT OF BREAST CANCER IS HIGHEST IN THE FIRST 5 YEARS AFTER SURGERY. FLOSEAL WAS APPLIED TO AN EXCISED BREAST SPECIMEN, BUT SAW NO MICROCALCIFIC DENSITIES WHEN THE SPECIMEN UNDERWENT BOTH ANALOG AND DIGITAL EXAMINATION. THEREFORE, THE DEVELOPMENT OF CALCIFICATIONS IS A RESPONSE TO FLOSEAL THAT REQUIRES A LIVING HOST. THE GELATIN MATRIX AND THROMBIN-BASED HEMOSTATIC AGENT FLOSEAL APPLIED AT A LUMPECTOMY SITE MIMICS THE APPEARANCE OF MALIGNANT MICROCALCIFICATIONS ON MAMMOGRAPHY, THUS LIMITING EVALUATION FOR RESIDUAL OR RECURRENT DISEASE AND IS NOT RECOMMENDED FOR USE ON BREAST TISSUE. ADDITIONAL INFORMATION RECEIVED ON 11/10/2008: REPORTER, THE OPERATING SURGEON IN THE SEVEN FLOSEAL CASES STATED THAT AFTER COMPLETING THE LUMPECTOMY, SHE OBTAINED HEMOSTASIS USING CAUTERY. SHE THEN LOCATED THE RESECTION BED WITH FLOSEAL, CLOSED THE INCISION AND APPLIED A COMPRESSION BRA AS PART OF THE ROUTINE WOUND DRESSING. NO IRRIGATION WAS USED. PERFORMING A ONE MONTH POST OPERATIVE MAMMOGRAM WAS NOT THEIR ROUTINE, HOWEVER, THE ONE PATIENT (MRN# 2954761-2008-00057) REQUIRED THIS PRIOR TO INITIATING RADIATION THERAPY. IT WAS THIS PATIENT WHO DEMONSTRATED THE MOST MICROCALCIFICATIONS. THE OTHER SIX PATIENTS WHO RECEIVED FLOSEAL IN THIS MANNER HAD ROUTINE SIX MONTH POST OPERATIVE MAMMOGRAMS, AND SHOWED LESS IMPRESSIVE MICROCALCIFICATIONS, BUT ONES THAT WERE CLEARLY QUESTIONED IF THEY WERE RECURRENCES OF THE TUMOR OR FLOSEAL. REPORTER AND THE RADIOLOGY TEAM LOOKED AT THE CONTENTS OF FLOSEAL AND SAW IT DID CONTAIN CALCIUM CHLORIDE, WHICH THEY THOUGHT CONTRIBUTED TO THE MICROCALCIFICATIONS. GIVEN THE IMPORTANCE OF MAMMOGRAPHY IN BREAST CANCER THERAPY, SHE FELT THIS WAS A REMARKABLE FINDING AND WANTED TO INFORM HER COLLEAGUES VIA THE PUBLICATION. THE INDICATION FOR USE OF FLOSEAL AND THE REQUIREMENT TO APPLY THE PRODUCT ONLY ONTO SITES THAT WERE VISIBLY BLEEDING WAS EXPLAINED TO REPORTER. MATRIX THAT IS INCORPORATED IN THE HEMOSTATIC CLOT IS LEFT IN SITU, WHILE ALL EXCESS MATRIX IS REMOVED WITH GENTLE IRRIGATION. THE FLOSEAL CLOT IS BROKEN DOWN AND RESORBED WITHIN 6-8 WEEKS, WHEN EXCESS MATERIAL IS REMOVED. WITHOUT THE REMOVAL OF EXCESS MATRIX, THE EXCESS MATERIAL IS NOT BROKEN DOWN DURING THE FIBRINOLYSIS OF THE HEMOSTATIC CLOT. THE BREAKDOWN AND RESORPTION OF LOOSE MATRIX HAS NOT BEEN STUDIED. REPORTER STATED THAT SHE THOUGHT SHE COULD USE FLOSEAL TO PREVENT HEMATOMA FORMATION IF THE PATIENT WAS TO BLEEP POST-OPERATIVELY, BUT NOW CLEARLY UNDERSTANDS THAT IT HAS NO PLACE AS A PROPHYLACTIC AGENT. ALSO INDICATED THAT DR(REPORTER) HAS LEFT THIS USER FACILITY AND CANNOT OBTAIN THE PATIENTS' CHART DATA.