Alfonso Fausto

Subcutaneous Direct-to-Implant Breast Reconstruction: Surgical, Functional, and Aesthetic Results after Long-Term Follow-Up

Background: Direct-to-implant breast reconstruction can be achieved more easily by means of soft-tissue replacement devices such as dermal matrices and synthetic meshes. The feasibility of a subcutaneous approach has been recently investigated by some studies with different devices functioning as implant support. Aim of this study is to analyze the long-term results, both objective and subjective, of a previous nonrandomized trial comparing prepectoral (subcutaneous) and retropectoral breast reconstructions. Methods: Patients enrolled in a nonrandomized prospective trial, comparing the standard retropectoral reconstruction and the prepectoral subcutaneous approach, using a titanium-coated mesh in both techniques, were followed up and evaluated for long-term results. Cases were compared in terms of the causes and rate of reinterventions, of the postoperative BREAST-Q questionnaire results, and of an objective surgical evaluation. Results: The subcutaneous group had a rate of implant failure and removal of 5.1% when compared with 0% in the retropectoral group. Aesthetic outcome was significantly better for the subcutaneous group both at a subjective and at an objective evaluation. Capsular contracture rate was 0% in the subcutaneous group. Conclusions: A higher rate of implant failure and removal, although not significant, always because of skin flaps and wound problems, should be taken into account for a careful patients selection. The subcutaneous breast reconstruction shows good long-term results. A coherent subjective and objective cosmetic advantage of this approach emerges. Moreover, no capsular contracture is evident, albeit in a relatively limited number of cases.

A new method to combine contrast-enhanced magnetic resonance imaging during live ultrasound of the breast using volume navigation technique: a study for evaluating feasibility, accuracy and reproducibility in healthy volunteers.

OBJECTIVES To evaluate feasibility, accuracy and reproducibility of combined US-MR of the breast using volume navigation technique. SUBJECTS AND METHODS Five healthy females underwent bilateral contrast-enhanced MR (CE-MR) of the breast in supine position, after positioning three couples of markers on the breast. After CE-MR data uploading in the ultrasound (US) database, manual co-registration was obtained during live US of the breast by means of an electromagnetic transmitter positioned near the subject under examination and two electromagnetic sensors were mounted on the transducer bracket. Transmitter and sensors were connected to a position-sensing unit embedded in the US equipment allowing to track probe position and orientation within the electromagnetic field. Live US image were co-registered to the previously loaded breast CE-MR volume by coupling markers. For each subject, two independent radiologists recorded the examination time and verified twice image alignment using five fixed checkpoints. Pair t Student test and Wilcoxon test were used for statistical analysis. RESULTS In all subjects US and CE-MR images were successfully combined. The examination time was 10±2 vs. 9±4 min, respectively (p=0.642; NS). A total of one hundred measurements of images misalignment were performed: the measurements recorded between the two operators were 0.42±0.32 cm and 0.58±0.41 cm (p=0.161; NS), and 0.50±0.32 cm and 0.56±0.52 cm (p=0.928; NS), respectively. DISCUSSION In our preliminary experience, volume navigation technique appears to be a accurate and reproducible method to combine CE-MR image during unilateral US of the breast.

Clinical value of second-look ultrasound: Is there a way to make it objective?

Breast second-look ultrasound is a technique widely used in clinical practice aimed to re-evaluate a previous ultrasound examination after the acquired knowledge of additional lesion, suspicious or indeterminate, previously undetected showed by contrast enhanced MR imaging [1,2]. The additional lesion, now subject to ultrasound, has to be correlated to MR result because it is well known that conventional imaging is not able to detect all breast cancers in the screened population [3–5]. However MR imaging, thanks to its higher sensitivity, is able to show many aspects of the breast glands but in two-thirds of cases those only MR detected aspects will be probably benign at pathology [6]. The resulted unbalance of costeffectiveness is much more important when an MR-guided biopsy is needed [6]. False negative values of conventional imaging and false positive of MR imaging depend mainly by two different reasons. An ‘objective’ or technical reason: the type of energy used to enhance breast lesions. A ‘subjective’ or human reason: the skill of the operator to detect the lesion reconstructing its different spatial position in all breast imaging techniques. Nowadays these biases could be overcome in clinical practice by using a new technique able to combine live breast ultrasound and MR imaging with high reproducibility and low values of misalignment [7]. Aim of this paper is to review the literature on second-look ultrasound, show how MR volume navigation is able to make it more objective and evaluate the clinical value of second-look ultrasound with volume navigation in a consecutive series of examinations.

Clinical value of relative quantification ultrasound elastography in characterizing breast tumors

OBJECTIVES To evaluate ultrasound elastography (USE) using strain ratio (SR), a relative quantification approach for breast lesions characterization. METHODS One hundred forty-seven consecutive patients with a total of 156 breast lesions underwent USE. Technical accuracy was assessed automatically. For SR evaluation a rounded ROI was depicted inside fat (F), glandular tissue (G) and inside the lesion (L), preferably at the same depth. R1, mean value of the G and F ratio, stands for in background tissue composition elasticity. R2; mean value of L/F stands for in lesion elasticity, both evaluated in arbitrary unit (au). Two-years follow-up and pathology results were standard of reference. Mann-Whitney test, ROC analysis and Chi-square with Yates correction were used. RESULTS With the exception of 27 cysts, 17 malignant and 112 benign lesions were found. R1 values were 1.6±0.7au and 1.2±0.9au (p=0.015 NS); R2 values were 6.1±2.5au and 1.9±1.3au (p<0.001) for malignant and benign lesions, respectively. A threshold of 3.3au showed a sensitivity and specificity of 88% and 87%, respectively with an AUC of 93%. Fifteen false positive and two false negative were detected. CONCLUSION Relative quantification of ultrasound elastography allows to find high levels of diagnostic accuracy in characterizing breast tumors above all in downgrading BI-RADS 3 and 4 lesions.

Brachial plexopathy due to breast cancer metastases: electrophysiological and imaging findings

Dear Editor, Radiation fibrosis, primary and metastatic lung cancer, and metastatic breast cancer account for almost threefourths of the causes of atraumatic brachial plexopathy [1]. Brachial plexopathy-associated breast cancer can occur by radiation injury or metastatic spread of the tumor [2]. Breast cancer is the most likely to metastasize because major lymphatic drainage routes for the breast course through the apex of the axilla [1]. The diagnosis of recurrent breast carcinoma with brachial plexus involvement is often delayed, and misinterpretation with a radiationor chemotherapy-induced brachial plexopathy is common. Since electrophysiological evaluation, magnetic resonance imaging (MRI), and ultrasound (US) are cardinal investigations to detect a metastatic involvement of the brachial plexus, reporting this case, we aim at underlying the importance of an early recognition of a treatable brachial plexopathy. A 58-year-old woman was hospitalized for a 6-month history of progressive motor weakness in the upper left limb. Twelve years before, she was diagnosed with an invasive ductal carcinoma at the inner upper quadrant of the left breast, treated with neoadjuvant chemotherapy, breastconserving surgery (ypT1c; y pN3a; G3; negative hormone receptors; Herceptest: 3+), and subsequent adjuvant chemotherapy (adriamycin and paclitaxel) and radiotherapy. Six years later, chemotherapic treatment with trastuzumab and vinorelbine was started for left axillary supraand infraclavear recurrence; complete remission was obtained, but the patient developed cardiac toxicity, so a second-line therapy with capecitabine was preferred. After 4 years, a total-body computed tomography (CT scan) revealed lung recurrence; therapeutic response to the association of trastuzumab and vinorelbine was significant, even if the latter had to be stopped for liver toxicity. One month later, the patient developed progressive motor weakness in the upper left limb, in absence of pain. Clinical examination revealed marked muscular weakness and atrophy of deltoid and moderate weakness of biceps, triceps, and extensors of forearm and fingers, as well as absence of biceps and triceps tendon reflex. Electrophysiological findings were strongly suggestive of a left brachial plexus damage with involvement of the lateral and posterior cords (Table 1); stimulation from Erb’s point of left musculocutaneous motor nerve, left radial motor nerve (registered at brachial triceps), and left axillary motor nerve showed that compound muscle action potential (CMAP) was absent (musculocutaneous, radial) or markedly decreased in amplitude with prolonged latency (axillary), and left radial sensory nerve was unexcitable, while left suprascapular, median (registered at abductor brevis pollicis), and ulnar nerves did not show abnormalities in motor and sensory conduction; needle electromyography revealed marked abundant fibrillation potentials and positive sharp waves in left deltoid, biceps, triceps, brachioradialis, extensor carpi radialis, and extensor digitorum communis muscles, while left supraspinatus, infraspinatus, flexor digitorum superficialis, abductor brevis pollicis, and first dorsal interosseous muscles were spared. MRI of the left brachial plexus and a contrast-enhanced bilateral breast MRI were performed to assess the supraand infraclavicular fossa, to verify the left brachial plexus, and to exclude a recurrence of breast disease. The former immediately showed an extensive involvement of the supraand infraclavicular soft * Andrea Mignarri andrea.mignarri@teletu.it

Efficacy of Second-Look Ultrasound with MR Coregistration for Evaluating Additional Enhancing Lesions of the Breast: Review of the Literature

Contrast enhanced magnetic resonance imaging (CE-MRI) has acquired a central role in the field of diagnosis and evaluation of breast cancer due to its high sensitivity; on the other hand, MRI has shown a variable specificity because of the wide overlap between the imaging features of benign and malignant lesions. Therefore, when an additional breast lesion is identified at CE-MRI, a second look with targeted US is generally performed because it provides additional information to further characterise the target lesion and makes it possible to perform US-guided biopsies which are costless and more comfortable for patients compared with MRI-guided ones. Nevertheless, there is not always a correspondence between CE-MR findings and targeted US due to several factors including different operators experience and position of patients. A new technique has recently been developed in order to overcome these limitations: US with MR coregistration, which can synchronise a sonography image and the MR image with multiplanar reconstruction (MPR) of the same section in real time. The aim of our study is to review the literature concerning the second look performed with this emerging and promising technique, showing both advantages and limitations in comparison with conventional targeted US.

Hough transform for clustered microcalcifications detection in full-field digital mammograms

Many screening programs use mammography as principal diagnostic tool for detecting breast cancer at a very early stage. Despite the efficacy of the mammograms in highlighting breast diseases, the detection of some lesions is still doubtless for radiologists. In particular, the extremely minute and elongated salt-like particles of microcalcifications are sometimes no larger than 0.1 mm and represent approximately half of all cancer detected by means of mammograms. Hence the need for automatic tools able to support radiologists in their work. Here, we propose a computer assisted diagnostic tool to support radiologists in identifying microcalcifications in full (native) digital mammographic images. The proposed CAD system consists of a pre-processing step, that improves contrast and reduces noise by applying Sobel edge detection algorithm and Gaussian filter, followed by a microcalcification detection step performed by exploiting the circular Hough transform. The procedure performance was tested on 200 images coming from the Breast Cancer Digital Repository (BCDR), a publicly available database. The automatically detected clusters of microcalcifications were evaluated by skilled radiologists which asses the validity of the correctly identified regions of interest as well as the system error in case of missed clustered microcalcifications. The system performance was evaluated in terms of Sensitivity and False Positives per images (FPi) rate resulting comparable to the state-of-art approaches. The proposed model was able to accurately predict the microcalcification clusters obtaining performances (sensibility = 91.78% and FPi rate = 3.99) which favorably compare to other state-of-the-art approaches.