Daniele Tosi

Oestrogen receptor-alpha and -beta expression in breast implant capsules: Experimental findings and clinical correlates

Myofibroblasts provide a force to decrease the surface area of breast implant capsules as the collagen matrix matures. 17-β-Oestradiol promotes myofibroblast differentiation and contraction. The aim of the study was to investigate the expression of oestrogen receptors α and β in capsular tissue. The study enrolled 70 women (80 capsules) who underwent expander or implant removal, following breast reconstruction. Specimens were stained with haematoxylin/eosin, Masson trichrome and immunohistochemistry and immunofluorescence stainings for alpha-smooth muscle actin (α-SMA), oestrogen receptor-alpha (ER-α) and oestrogen receptor-beta (ER-β). The relationship between anti-oestrogenic therapy and capsular severity was evaluated. A retrospective analysis of 233 cases of breast reconstruction was conducted. Myofibroblasts expressed ER-α, ER-β or both. In the whole sample, α-SMA score positively correlated with ER-α (p = 0.022) and ER-β expression (p < 0.004). ER-β expression negatively correlated with capsular thickness (p < 0.019). In capsules surrounding expanders α-SMA and ER-α, expressions negatively correlated with time from implantation (p = 0.002 and p = 0.016, respectively). The incidence of grade III-IV contracture was higher in patients who did not have anti-oestrogenic therapy (p < 0.036); retrospective analysis of 233 cases confirmed this finding (p < 0.0001). This study demonstrates the expression of oestrogen receptors in myofibroblasts of capsular tissue. A lower contracture severity was found in patients who underwent anti-oestrogenic therapy.

Increased carotid thickness in subjects with recently-diagnosed diabetes from rural Cameroon.

Background We have recently shown a high prevalence of diabetes and obesity in rural Cameroon, despite an improved lifestyle. Diabetes in rural Africa remains underdiagnosed and its role in increasing risk of atherosclerosis in these populations is unknown. We investigated the prevalence of carotid atherosclerosis and cardiovascular risk factors in a population of subjects with recently-diagnosed diabetes from rural Cameroon. Methodology/Principal Findings In a case-control study, carotid intima-media thickness (IMT) was measured in 74 subjects with diabetes (diagnosed <2 years), aged 47–85 and 109 controls comparable for age and sex. Subjects were recruited during a health campaign conducted in April 2009. Blood glucose control (HbA1c, fasting blood glucose) and major cardiovascular risk factors (complete lipid panel, blood pressure) were also measured. Mean carotid IMT was higher in subjects with diabetes than healthy controls at each scanned segment (common, internal carotid and bulb) (P<0.05), except the near wall of the left bulb. Vascular stiffness tended to be higher and pressure-strain elastic modulus of the left carotid was increased in subjects with diabetes than controls (P<0.05), but distensibility was similar between the two groups. At least one plaque >0.9 mm was found in 4%, 45.9% and 20% of diabetic subjects at the common, bulb or internal carotid, respectively. Only 25% of patients had an HbA1c<7%, while over 41.6% presented with marked hyperglycemia (HbA1c>9%). The prevalence of diabetic subjects with abnormal levels of LDL-cholesterol, triglycerides, HDL-cholesterol or blood pressure was 45%, 16.6%, 15% and 65.7%, respectively. Conclusions Carotid thickness is increased in subjects with diabetes from a rural area of Cameroon, despite the relatively recent diagnosis. These findings and the high rate of uncontrolled diabetes in this population support the increasing concern of diabetes and cardiovascular diseases in African countries and indicate the need for multifaceted health interventions in urban and rural settings.

Toll-Like Receptor 4 Expression in Human Breast Implant Capsules: Localization and Correlation with Estrogen Receptors.

Background: Capsular contracture is the most common complication following breast augmentation and reconstruction. Myofibroblasts, which are specialized fibroblasts with contractile activity, are involved in its pathogenesis. Toll-like receptor 4 stimulation in fibroblasts induces transcription of genes involved in extracellular matrix remodeling and tissue repair; furthermore, it enhances sensitivity to transforming growth factor-&bgr;1 and promotes transition to myofibroblasts. 17&bgr;-Estradiol, by binding to its main receptors, &agr; and/or &bgr;, increases the expression of toll-like receptor 4 and the production of proinflammatory mediators by macrophages; moreover, it promotes extracellular matrix production and myofibroblasts contraction and differentiation. The aim of the study was to investigate the expression of toll-like receptor 4 in breast implant capsules and its relationship with estrogen receptors. Methods: The study enrolled 30 women who underwent expander removal following breast reconstruction. Specimens were stained with hematoxylin and eosin, Masson trichrome, immunohistochemistry, and immunofluorescence for toll-like receptor 4, &agr;-smooth muscle actin (a marker of myofibroblasts), estrogen receptor-&agr;, and estrogen receptor-&bgr;. Results: Toll-like receptor 4 was expressed by fibroblasts and myofibroblasts of capsular tissue. Its expression positively correlated with estrogen receptor-&bgr; expression (p = 0.012). A positive correlation was found between estrogen receptor-&bgr; and &agr;-smooth muscle actin expression (p = 0.037). Conclusions: This study demonstrates the expression of toll-like receptor 4 in myofibroblasts of capsular tissue and its correlation with estrogen receptor-&bgr; positivity. Activation of toll-like receptor 4 and estrogen receptor-&bgr;, and their interplay, may be involved in myofibroblast differentiation and in the profibrotic pathogenic process underlying capsular contracture.

The Effects of Negative Pressure on Blood Supply and the Adipogenic Role of Edema

Sir:We read with great interest the recent article by Heit et al. entitled “External Volume Expansion Increases Subcutaneous Thickness, Cell Proliferation, and Vascular Remodeling in a Murine Model,”1 in which the authors accurately described the effect of vacuum-assisted closure in mice. Neverthele

The role of angiogenesis, inflammation and estrogen receptors in breast implant capsules development and remodeling

BACKGROUND Capsular contracture is the most common complication following breast implant placement. The multiple factors unbalancing the physiological response to the foreign body have not been fully elucidated. The aim of this study was to investigate the role of neo-angiogenesis, inflammation and estrogen receptors in peri-prosthetic tissue development and remodeling. METHODS The study enrolled 31 women who underwent expander substitution with definitive implant. Specimens were stained with hematoxylin/eosin, Masson trichrome, immunohistochemistry and immunofluorescence for alpha-smooth muscle actin, estrogen receptor-α (ER-α), estrogen receptor-β (ER-β), Collagen type I and III, CD31 (as a marker of neo-angiogenesis) and vascular endothelial growth factor (VEGF). Inflammatory infiltration was quantified and analyzed. Transmission electron microscopy was performed for ultrastructural evaluation. RESULTS Myofibroblasts, mainly localized in the middle layer of capsular tissue, expressed VEGF, ER-α and ER-β. ER-β expression positively correlated with Collagen type I deposition (p= 0.025). Neo-angiogenesis was predominant in the middle layer. CD31 expression positively correlated with Collagen type I expression (p=0.009) and inflammatory infiltration grade (p= 0.004). The degree of inflammatory infiltration negatively correlated with the time from implantation (p = 0.022). DISCUSSION The middle layer is key in the development and remodeling of capsular tissue. Myofibroblasts produce VEGF, that induces neo-angiogenesis. New vessels formation is also correlated to the inflammatory response. Collagen deposition is associated with ER-β expression and neo-angiogenesis. These findings may prelude to targeted pharmacologic therapies able to control such interactions, thus hampering the self-sustaining loop promoting the progression of physiologic fibrosis toward pathologic contracture.

Thromboprophylaxis in Abdominoplasty: Efficacy and Safety of a Complete Perioperative Protocol.

Background Venous thromboembolism, a spectrum of diseases ranging from deep venous thrombosis to pulmonary embolism, is a major source of morbidity and mortality. The majority of cases described in plastic surgery involve abdominoplasty. Risk assessment and prophylaxis are paramount in such patients. General recommendations were recently developed, but the evidence in the literature was insufficient to prepare exhaustive guidelines regarding the medication, dosage, timing, or length of the prophylaxis. Methods A thromboprophylaxis protocol was developed for patients undergoing abdominoplasty. The protocol consisted of preoperative, intraoperative, and postoperative measures. Enoxaparin was administered as chemoprophylaxis in selected patients. The study involved 253 patients. The patients were analyzed for age, body mass index, enoxaparin dosage, risk factors, and complications. Results Deep venous thrombosis was documented in two cases (0.8%). No pulmonary embolism occurred. Three patients (1.2%) presented mild subcutaneous abdominal hematoma within the first postoperative week that spontaneously resorbed with neither aesthetic nor functional complications. Two patients (0.8%) presented severe hematoma requiring surgical re-intervention for drainage and hemostasis revision. Statistical analysis showed no significant correlation between enoxaparin dosage and hematoma (P=0.18) or deep venous thrombosis (P=0.61). Conclusions The described thromboprophylaxis protocol proved to be effective in the prevention of thrombotic events, with an acceptable risk of hemorrhagic complications. Furthermore, it provides new evidence regarding the currently debated variables of chemoprophylaxis, namely type, dosage, timing, and length.

Abstract 159: CAPSULAR CONTRACTURE

Methods: 32 peri-expander capsules were examined for estrogen receptors Œ± and Œ and Œ±-SMA expression. Contracture severity was valuated with Bakers score. Specimens were stained with Hematoxylin and Eosin, Masson trichrome, immunohistochemistry and immuno uorescence for Œ±-Smooth Muscle Actin, Estrogen receptor-Œ±, Estrogen receptor Œ , Collagen type I and type III, CD31 (as angiogenic marker) and evaluated at Transmission electron microscopy. A retrospective analysis of 263 cases of breast reconstruction was performed to evaluate the relationship between anti-estrogenic therapy and severity of capsule contracture.

Abstract 153: ESTROGEN RECEPTORS ALPHA AND BETA EXPRESSION IN BREAST IMPLANT CAPSULES

Background: Capsular contracture is a common complication of breast heterologous reconstruction and augmentation; pregnancy has been reported to be a risk factor. Myo broblasts provide a force to decrease the surface area of the capsule as the collagen matrix matures. In other tissues, seventeen-β-estradiol has been shown to promote myo broblasts contraction and differentiation by mean of TGF-β. Inversely, tamoxifen reduces TGF-β production and myo broblast contraction. The aim of the study was to investigate the expression of Estrogen Receptors α and β in capsular tissue.

Hidden Sentinel Node in Cutaneous Melanoma

Sentinel lymph node (SLN) biopsy is a well-established staging method for melanomas. Several techniques have been described to identify the first lymph node receiving lymphatic flow from the primary tumor. Injection of 99mTc-nanocolloid into the tumor bed followed by lymphoscintigraphy provides a road map for the surgeon. However, in a variable percentage of cases, the sentinel node may remain undiscovered during this procedure [1]. This problem is well-known with regard to the identification of lymph nodes in the head and neck, where the complex anatomy as well as the presence of vital structures renders lymphatic mapping a challenging procedure [2]. Hence, we would like to share our experience in this field by describing the case of a 40-year-old woman who was referred to our department for a 1.33-mm-thick melanoma of the upper external quadrant of the left breast (Fig. 1). Previous surgical excision had been followed by histopathologic analysis reporting an infiltrating cutaneous melanoma with vertical growth and a mitotic index=2, and without ulceration. Fig. 1 Melanoma of the upper external quadrant of the left breast. As a consequence, the patient underwent lymphoscintigraphy (Fig. 2). Planar imaging of the thorax was performed 10 minutes, 30 minutes, and 2 hours and 4 hours after the injection of the radiopharmaceutical. No hot spot could be identified as a sentinel lymph node. Hence, lymphoscintigraphy was postponed for two weeks but, again, neither lymphatic drainage nor a sentinel lymph node was shown. One day later, intraoperatively, a γ-ray detection probe (Navigator, USSC, Norwalk, CT, USA) was used through the intact skin to check the axilla. No radioactivity was found and, in consultation with our institutions oncologists, axillary lymphadenectomy was planned. Widening of the margins was performed, and the hand-held gamma probe was subsequently inserted into the resulting defect (Fig. 3). Radioactivity was found on the deep upper portion of the defect. An accurate dissection, guided by a gamma probe, was performed, and one radioactive node was removed. After removal of the sentinel node, the wound showed no further radioactivity. As a consequence, lymphadenectomy was not performed. Histological analysis of the sentinel node showed the presence of metastatic cells. Fig. 2 Lymphoscintigraphy of the patient with an image at 10 minutes after the injection of the radiopharmaceutical. No hot spot could be identified as a sentinel lymph node. Fig. 3 Preoperative image of the patient undergoing widening of the margins of the previous melanoma excision. Left oblique view of the breast with the scar of the previous melanoma excision. Sentinel node biopsy was first introduced in melanoma patients in 1992 [1]. Since this initial experience, several techniques have been described to identify the first node receiving lymphatic flow from the primary tumor. Preoperative mapping by mean of lymphoscintigraphy has become of paramount importance in melanoma patients due to the unpredictability of lymphatic drainage patterns [3]. However, there are some reports in the literature describing its failure in identifying the SLN. Jansen and colleagues showed that the predicted number of sentinel nodes detected with lymphoscintigraphy was accurate in only 81% of lymph node fields and that its limited discriminating power was the most frequent reason for discrepancies with surgical findings [1]. Hidden sentinel nodes have also been reported in breast cancer patients. Several techniques have been suggested to address this problem, such as delayed imaging, re-injection of the radiopharmaceutical, post-injection massage, injection of saline around the tumor, and hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) scan. In our patient, no sentinel node was shown by lymphoscintigraphy. Two reasons were hypothesized to be responsible for this finding: disruption of the lymphatic drainage induced by surgical excision or concealment of the axillary sentinel node behind the injected radioactivity. Intraoperatively, the latter proved to be true, thus overcoming the need for primary lymphadenectomy. Lymphoscintigraphy is an important guide for sentinel node biopsy, but it may sometimes fail to provide an adequate road map for the surgeon, as in our patient. In such cases, multi-directional scintigraphic views must be considered, in order to detect hot nodes concealed by the injection site, as described for axillary nodes in breast cancer of the upper lateral quadrant [4]. The intraoperative use of blue dye and/or a gamma probe is of paramount importance to compensate for the limitations of scintigraphy, thus allowing the surgeon to perform an oncologically adequate procedure and to spare the patient primary or wrong-site lymphadenectomy. However, the use of blue dye may produce adverse effects, such as urticaria, hypotension, and bronchospasm, and may have marginal benefits, as described by Lingam et al. [5]. As a consequence, intraoperative gamma probing remains a mainstay in cases of hidden nodes or false-negative scintigraphic findings.