Annalisa Curcio

Improved sub-areolar breast tissue removal in nipple-sparing mastectomy using hydrodissection

We report on a new technique of dissection of the nipple-areola-complex (NAC) in nipple-sparing mastectomy (NSM). NACs removed due to the presence of tumor cells beneath them were histologically examined for the presence of normal breast glandular tissue. Cases were divided into cohort 1, where NACs were dissected by sharp isolation, coring the nipple, and cohort 2, where the same procedure was preceded by hydrodissection of the areola. In 20 (17.4%) cases the planned NSM was converted to skin-sparing mastectomy (SSM) because of intraoperative findings of cancer in retro-areolar tissue. Histological examination of 20 NSMs converted to SSM showed the presence of glandular tissue in 12 out of 13 cohort 1 cases (92%) and in 1 out of 7 cohort 2 cases (14%). We conclude that hydrodissection creates a subdermal plane facilitating NAC dissection and permitting a more complete removal of breast tissue in NSM. Such radicality could prove important in the treatment of breast cancer and in BRCA 1-2 mutation carriers because of its potential for reducing the risk of relapse.

Nipple-sparing mastectomy: an alternative technique for large ptotic breasts.

The concept of “breast conservative surgery” originally referred to the preservation of the mammary gland itself, but in the last few years it has been extended to include radical breast procedures as mastectomy, shifting the conservative target from the gland to the skin. Such change took place as sparing the skin envelope proved to be oncologically safe in selected groups of patients. Among the so-called “conservative mastectomies,” nipple-areola sparing mastectomy (NSM) allows the surgeon to spare the skin envelope of the breast in its entirety, minimizing the disfiguring impact and allowing for a reconstruction with good cosmetic outcomes. However, besides the condition-related contraindications, the procedure comes with technical limitations due to patients’ anatomic features. In large and ptotic breasts, the skin envelope may be redundant and its preservation may result in nipple necrosis or dislocation, chronic edema of the skin flaps, and double profile of the inferior poledall conditions associated with a likely poor cosmetic outcome. We report a technical modification of NSM designed to allow nipple preservation in large/ptotic breasts and to overcome the drawbacks of maintaining the whole skin envelope in anatomically unsuitable breasts.

Nipple areola complex sparing mastectomy

Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forlì. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.

Role of androgen and estrogen receptors as prognostic and potential predictive markers of ductal carcinoma in situ of the breast.

Background Ductal carcinoma in situ (DCIS) is a heterogeneous disease that has not been investigated as widely as invasive breast cancer. Thus, the search for biomarkers capable of identifying DCIS lesions that may recur or progress to invasive cancer is ongoing. Although conventional steroid hormone receptors, cell proliferation and other important tumor markers have been extensively studied in invasive tumors, little is known about the role played by androgen receptors (ARs), widely expressed in breast cancer, in DCIS. Methods We performed a retrospective study in a series of 43 DCIS patients treated with quadrantectomy only and followed up for a period ranging from 5 to 13 years, to evaluate the prognostic relevance of conventional biomarkers (estrogen receptor [ER], progesterone receptor [PgR], Ki67, human epidermal growth factor receptor 2 [HER2]) and AR. Results Our findings showed that AR and ER were not independent prognostic variables and that an AR/ER ratio cutoff of 1.13 showed a sensitivity of 75% and a specificity of 94% in predicting in situ relapse or progression to the invasive phenotype. Moreover, while the variables considered singly showed area under the curve (AUC) values ranging from 0.52% to 0.77%, the AR/ER ratio reached a very high AUC (0.92%). Conclusions These preliminary results highlight the potentially important role of AR and ER and, in particular, of their ratio, as prognostic indicators of DCIS evolution.

A rare case of primary necrotising fasciitis of the breast: combined use of hyperbaric oxygen and negative pressure wound therapy to conserve the breast. Review of literature

Necrotising fasciitis is a rare but potentially fatal disease. It is even more unusual as a primary disease of the breast. Surgical treatment is required in order to gain control over the spreading infection and mastectomy is reported to be the most common procedure. We report the first case of an otherwise healthy woman exhibiting a primary necrotising fasciitis of the breast, which was treated combining conservative surgery with hyperbaric oxygen (HO) and negative pressure wound therapy (NPWT). A 39‐year‐old woman presented to the emergency room with fever and swelling of her right breast. The physical examination showed oedema and erythema of the breast, with bluish blisters on the lower quadrant. Ultrasound and CT scans showed diffuse oedema of the entire right breast, with subdermal gas bubbles extending to the fascial planes. Few hours later the necrotic area extended regardless an IV antibiotic therapy; a selective debridement of all breast necrotic tissue was performed and repeated 7 days later. The HO was started immediately after the first surgery and repeated daily (2·8 Bar, 120 min) for 18 days and then a NPWT (120–135 mmHg) was applied. Forty‐five days after the last debridement, the breast wound was covered with a full‐thickness skin graft. Several months later, an excellent cosmetic result was observed. This is the first case of primary necrotising fasciitis of the breast treated associating HO and NPWT to surgical debridement only; this combination resulted in a complete recovery with the additional benefit of breast conservation. Such result is discussed in light of the available literature on the treatment of primary necrotising fasciitis of the breast.

Intra-operative radiological margins assessment in conservative treatment for non-palpable DCIS: correlation to pathological examination and re-excision rate

What constitutes an adequate surgical margin in partial mastectomy is still controversial: intra-operative specimen radiogram is commonly used during partial mastectomy for nonpalpable lesions in order verify the adequacy of the resection but what margin is to be considered “adequate” is still debatable.An intraoperative specimen mammogram was performed during all consecutive conservative resections for nonpalpable DCIS and a 15-mm radiological margin was considered “adequate”. Margins were pathologically assessed and classified as “negative”, “close” or “positive” and the rate of margin involvement constitued the main outcome of the study.Among 272 conservative interventions, 80.51% had negative margins at final pathology, 3.31% had close margins and 16.18% had positive margins.An intraoperative “adequate” margin of 15 mm as defined on intraoperative specimen mammogram granted a high rate of histologically negative margin at primary surgery; this finding was paralleled by confirmation of the treatment as conservative in 95% of cases.

Iatrogenic Arteriovenous Fistula of the Breast: A Rare Complication Following Ultrasound-guided Core Biopsy of Fibroadenoma

A 27-year-old Caucasian female presented to a Private Radiologic Centre with a 1-week history of node palpation in the upper outer quadrant (UOQ) of the left breast. Targeted ultrasound showed a 1 cm 9 0.7 cm regular hypoechoic mass at 2 cm from the pectoralis fascia. Ultrasound core biopsy of the mass was subsequently performed; a modest amount of bleeding was noted after the procedure and controlled with manual compression. The Pathology reports indicated a diagnosis of Fibroadenoma. After 6 months, the patient presented to our Radiologic Department with a swelling within the UOQ of the left breast and she was quite anxious about that. Patient’s history revealed no previous trauma or other comorbidities. She was nonobese and nonsmoker. She had never undergone surgery, or any other invasive procedure of the breast. Clinical examination revealed slight breast asymmetry with a thrill and pulsatile mass in correspondence of the UOQ.

Multicentric/Multifocal Breast Cancer: Overview, Biology, and Therapy

Multiple breast cancers may present with different clinical and biological characteristics as compared with unicentric disease, and in certain instances this may have implications as far as treatment is concerned. Multiple tumors may have increased lymph node involvement compared with unifocal tumors, and some available data suggest that multifocal/multicentric breast cancer is actually more aggressive and carries worse overall outcomes than unifocal disease. In other studies, multifocality itself does not appear to be a contributing factor for worse outcome; more aggressive systemic disease or decreased response to systemic therapies, instead, seem to play a role. It has been suggested that multi- and unifocal tumors do not share the same biology since factors other than those currently employed for staging and prognostic purposes have been shown to affect behavior. In fact, the prognostic impact of multiple breast cancer has been poorly studied, and the necessity for specific adjuvant treatment in order to counteract the potentially unfavorable effect of multifocality is still subject to investigation.

DCIS: The Problem of Recurrence

The term “ductal carcinoma in situ” (DCIS) of the breast represents a heterogeneous group of neoplastic lesions histologically confined to the breast ducts.

A New Human-Derived Acellular Dermal Matrix for Breast Reconstruction Available for the European Market: Preliminary Results

IntroductionThe introduction of acellular dermal matrices (ADMs) contributed to the growing diffusion of direct-to-implant breast reconstruction (DTI-BR) following mastectomy for breast cancer. According to specific legislations, European specialists could not benefit from the use of human-derived ADMs, even though most evidence in the literature are available for this kind of device, showed optimal outcomes in breast reconstruction. The Skin Bank of the Bufalini Hospital (Cesena, Italy) obtained in 2009 the approval for the production and distribution of a new human cadaver-donor-derived ADM (named with the Italian acronym, MODA, for matrice omologa dermica acellulata) from the Italian National Transplant Center and National Health Institute. We report preliminary results of MODA application in direct-to-implant breast reconstruction following nipple–areola complex (NAC)-sparing mastectomy for breast cancer treatment.Materials and MethodsWe prospectively enrolled all women undergoing NAC-sparing mastectomy for breast cancer and DTI-BR in our breast surgical unit from June 2015 to January 2017. We enrolled a selected population without previous chest wall irradiation, not being heavy tobacco smokers or diabetic, with a BMIxa0<xa030xa0kg/m2 and requiring less than 550xa0cc silicone implants. We assessed short-term outcomes, defined as postoperative complications presenting in the first 30 postoperative days and long-term outcomes at 6 and 12xa0months.ResultsFrom June 2015 to January 2017, we treated 56 breasts. At a mean follow-up of 14xa0months, we observed only two minor complications described as limited wound dehiscences, conservatively managed with complete resolution without implant exposure or re-intervention.ConclusionsOur preliminary results show very good performance of MODA in direct-to-implant breast reconstruction following NAC-sparing mastectomy for breast cancer treatment. This is particularly relevant for the European market, where no other human-derived devices are available for breast reconstruction due to regulatory restrictions.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.