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Kim SH, Park S, Lee DW, Park HS, Lew DH, Song SY. Early Experience of Direct-to-Implant Breast Reconstruction Using Acellular Dermal Matrix after Robot-Assisted Nipple-Sparing Mastectomy. Plast Reconstr Surg 2024; 154:512-520. [PMID: 37797243 DOI: 10.1097/prs.0000000000011105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND The authors performed a retrospective review to analyze operative outcomes of breast mound reconstruction after robot-assisted mastectomy. METHODS Patients who underwent nipple-sparing mastectomy (NSM) with a robotic device (Da Vinci Xi) and immediate prepectoral prosthetic reconstruction by lateral incision from June of 2018 to July of 2019 were enrolled. Patient characteristics, complications, and satisfaction rates as assessed by BREAST-Q were analyzed. The surgical technique was described in detail. RESULTS Thirty-nine cases, including 7 bilateral cases (total 46 breasts), underwent robot-assisted NSM followed by immediate prepectoral prosthetic implant reconstruction. The median patient age was 46.63 years (range, 21 to 63 years). The mean operation time for each prepectoral breast mound reconstruction using the direct-to-implant technique was 126.55 minutes. Robot-assisted reconstruction resulted in superior BREAST-Q scores compared with the conventional reconstruction method. Major infection occurred in 7 cases (15.2%), and complete nipple loss occurred in 3 cases (6.6%). Severe complications requiring breast implant removal occurred in 4 breasts (8.7%). Two cases were due to the coexistence of infection and skin necrosis; in 1 case, the skin flap became congested on postoperative day 3 and required additional surgery to change the expander. Other complications were resolved with conservative care or minor revision. CONCLUSIONS This report is the first concerning robot-assisted NSM followed by prepectoral acellular dermal matrix-wrapped prosthetic reconstruction. This procedure was not inferior to other methods. Further prospective research to evaluate oncologic outcomes is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Shin Hyun Kim
- From the Departments of Plastic and Reconstructive Surgery
- Institute for Human Tissue Restoration
| | - Seonghyuk Park
- From the Departments of Plastic and Reconstructive Surgery
- Institute for Human Tissue Restoration
| | - Dong Won Lee
- From the Departments of Plastic and Reconstructive Surgery
- Institute for Human Tissue Restoration
| | - Hyung Seok Park
- Surgery, Severance Hospital, Yonsei University College of Medicine
| | - Dae Hyun Lew
- From the Departments of Plastic and Reconstructive Surgery
- Institute for Human Tissue Restoration
| | - Seung Yong Song
- From the Departments of Plastic and Reconstructive Surgery
- Institute for Human Tissue Restoration
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2
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Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
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Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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Burns HR, McCarter JH, King BW, Yu JZ, Hwang RF. Robotic-Assisted Nipple Sparing Mastectomy. Semin Plast Surg 2023; 37:176-183. [PMID: 38444956 PMCID: PMC10911906 DOI: 10.1055/s-0043-1771047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Minimally invasive approaches to breast surgery have evolved from endoscopic techniques to recent developments in robotic-assisted mastectomies. Initial studies on robotic-assisted nipple-sparing mastectomy (RNSM) have shown improved patient satisfaction and aesthetic outcomes with similar complication rates and oncological outcomes in selected patients. This chapter reviews techniques used and available data on complications and clinical outcomes for RNSM. Currently, RNSM is an investigational technique in the United States and should be performed in clinical trials with U.S. Food & Drug Administration approval to rigorously evaluate the safety and effectiveness of this approach.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jacob H. McCarter
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Brody W. King
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rosa F. Hwang
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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4
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Wu WP, Lai HW, Liao CY, Lin J, Huang HI, Chen ST, Chou CT, Chen DR. Use of Magnetic Resonance Imaging for Evaluating Residual Breast Tissue After Robotic-Assisted Nipple-Sparing Mastectomy in Women With Early Breast Cancer. Korean J Radiol 2023; 24:640-646. [PMID: 37404106 DOI: 10.3348/kjr.2022.0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 04/03/2023] [Accepted: 05/17/2023] [Indexed: 07/06/2023] Open
Abstract
OBJECTIVE Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer. MATERIALS AND METHODS In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence. RESULTS RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free. CONCLUSION R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.
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Affiliation(s)
- Wen-Pei Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Wen Lai
- Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan
- Minimally Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
- Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chiung-Ying Liao
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Joseph Lin
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsin-I Huang
- Department of Information Management, National Sun Yat-sen University, Kaohsiung, Taiwan
- We-Sing Breast Hospital, Kaohsiung, Taiwan
| | - Shou-Tung Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chen-Te Chou
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dar-Ren Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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Park KU, Cha C, Pozzi G, Kang YJ, Gregorc V, Sapino A, Gazzetta G, Marrazzo E, Toesca A. Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies. CURRENT BREAST CANCER REPORTS 2023; 15:127-134. [PMID: 37293274 PMCID: PMC10133895 DOI: 10.1007/s12609-023-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/10/2023]
Abstract
Purpose of review The purpose of this review is to summarize the recent technical advancements in RNSM, describe the ongoing teaching programs, and discuss the ongoing controversies. Recent findings Robot-assisted nipple sparing mastectomy (RNSM) is the newest addition to the armamentarium of surgical techniques for patients who require a mastectomy. The potential benefits of using the da Vinci® Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) are the small 3D camera and lighting offering superior visualization, the Endowrist robotic instruments offering greater range of motion, and surgeon being at a seated position at the console rendering a more ergonomic operating position. Summary RNSM can potentially help overcome the technical difficulties of performing a conventional NSM. Further studies are needed to elucidate the oncologic safety and cost-effectiveness of RNSM.
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Affiliation(s)
- Ko Un Park
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215 USA
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH USA
| | - Chihwan Cha
- Department of Surgery, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Giada Pozzi
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Young-Joon Kang
- Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Vanesa Gregorc
- Department of Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Anna Sapino
- Unit of Pathology, Candiolo Cancer Institute, FPO-IRCCS, Department of Medical Science, University of Turin, Turin, Italy
| | - Guglielmo Gazzetta
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Emilia Marrazzo
- Breast Unit, Department of Surgery, Ospedale Maggiore Di Lodi, Lodi, Italy
| | - Antonio Toesca
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
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Egan KG, Selber JC. Modern Innovations in Breast Surgery: Robotic Breast Surgery and Robotic Breast Reconstruction. Clin Plast Surg 2023; 50:357-366. [PMID: 36813413 DOI: 10.1016/j.cps.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Robotic surgery has a history of applications in multiple surgical areas and has been applied in plastic surgery over the past decade. Robotic surgery allows for minimal access incisions and decreased donor site morbidity in breast extirpative surgery, breast reconstruction, and lymphedema surgery. Although a learning curve exists for the use of this technology, it can be safely applied with careful preoperative planning. Robotic nipple-sparing mastectomy may be combined with either robotic alloplastic or robotic autologous reconstruction in the appropriate patient.
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Affiliation(s)
- Katie G Egan
- The University of Texas M.D. Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX 77030, USA
| | - Jesse C Selber
- The University of Texas M.D. Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX 77030, USA.
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Lee J, Park HS, Lee DW, Song SY, Yu J, Ryu JM, Bae SJ, Lew DH, Kim SI, Toesca A. From cadaveric and animal studies to the clinical reality of robotic mastectomy: a feasibility report of training program. Sci Rep 2021; 11:21032. [PMID: 34702866 PMCID: PMC8548531 DOI: 10.1038/s41598-021-00278-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 09/28/2021] [Indexed: 11/27/2022] Open
Abstract
Robotic nipple-sparing mastectomy (RNSM) provides better cosmetic outcomes and improves the quality of life of women with breast cancer. However, this has not been widely adapted due to the lack of well-structured training programs. The present study aimed to report the establishment of cadaveric and animal skill laboratory training programs for RNSM and the participants’ perception on the training programs. We performed 24 RNSMs using 11 cadavers and one porcine model. Then, the skill laboratory characteristics were reviewed. Five trainers and 10 trainees participated in the programs. The first four cadaveric RNSMs with latissimus dorsi flaps and implants were performed using the da Vinci Si® system. We performed 14 and six RNSMs using the Xi® and SP® systems, respectively. The scores for questionnaires on the satisfaction with the training consisted of the trainees’ perceived goals in attending the course, teaching/learning environment, and teaching staff performance. The scores were excellent. Cadaveric or porcine RNSM skill laboratory training may be essential programs that can provide safe and efficient training.
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Affiliation(s)
- Jeea Lee
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Dong Won Lee
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Yong Song
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jonghan Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jai Min Ryu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dea Hyun Lew
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Il Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
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8
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Single-port robot-assisted prosthetic breast reconstruction with the da Vinci SP Surgical System: first clinical report. Arch Plast Surg 2021; 48:194-198. [PMID: 33765738 PMCID: PMC8007454 DOI: 10.5999/aps.2020.01557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/10/2020] [Indexed: 11/15/2022] Open
Abstract
Robot-assisted nipple-sparing mastectomy with immediate reconstruction is currently performed in an attempt to seek smaller and indistinct incisions. Robotic surgery system has been evolving under the concept of minimal invasive technique which is a recent trend in surgery. One of the latest version is the da Vinci SP Surgical System (Intuitive Surgical). In this report, we will share our experiences. Two patients underwent robot-assisted nipple-sparing mastectomy, each followed by immediate robot-assisted expander insertion and prepectoral direct-to-implant breast reconstruction, respectively. There was no open conversion or major postoperative complication. One patient experienced mild infection, which was resolved by intravenous antibiotic treatment. Simple docking process, multi-joint instruments, and third-arm functionality are among the new surgical system’s advantages. The present cases suggest that robot-assisted nipple-sparing mastectomy with immediate reconstruction using the da Vinci SP Surgical System is feasible and safe. The promising features and potential application of da Vinci SP in breast reconstruction need further study.
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Houvenaeghel G, Barrou J, Jauffret C, Rua S, Sabiani L, Van Troy A, Buttarelli M, Blache G, Lambaudie E, Cohen M, Bannier M. Robotic Versus Conventional Nipple-Sparing Mastectomy With Immediate Breast Reconstruction. Front Oncol 2021; 11:637049. [PMID: 33747960 PMCID: PMC7971115 DOI: 10.3389/fonc.2021.637049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background Several studies reported the feasibility and safety of robotic-NSM (R-NSM). The aim of our prospective study was to compare R-NSM and conventional-NSM (C-NSM). Methods We analyzed patients who were operated on with and without robotic assistance (R-NSM or C-NSM) and who received immediate breast reconstruction (IBR) with implant or latissimus dorsi-flap (LDF). The main objective was complication rate and secondary aims were post-operative length of hospitalization (POLH), duration of surgery, and cost. Results We analyzed 87 R-NSM and 142 C-NSM with implant-IBR in 50 and 135 patients, with LDF-IBR in 37 and 7 patients, respectively. Higher durations of surgery and costs were observed for R-NSM, without a difference in POLH and interval time to adjuvant therapy between R-NSM and C-NSM. In the multivariate analysis, R-NSM was not associated with a higher breast complication rate (OR=0.608) and significant factors were breast cup-size, LDF combined with implant-IBR, tobacco and inversed-T incision. Grade 2-3 breast complications rate were 13% for R-NSM and 17.3% for C-NSM, significantly higher for LDF combined with implant-IBR, areolar/radial incisions and BMI>=30. A predictive score was calculated (AUC=0.754). In logistic regression, patient's satisfaction between C-NSM and R-NSM were not significantly different, with unfavorable results for BMI >=25 (OR=2.139), NSM for recurrence (OR=5.371) and primary breast cancer with radiotherapy (OR=4.533). A predictive score was calculated. In conclusion, our study confirms the comparable clinical outcome between C- NSM and R-NSM, in the price of longer surgery and higher cost for R-NSM. Predictive scores of breast complications and satisfaction were significantly associated with factors known in the pre-operative period.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Julien Barrou
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Camille Jauffret
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Laura Sabiani
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Aurore Van Troy
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Max Buttarelli
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Guillaume Blache
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Marie Bannier
- CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
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Park KU, Tozbikian GH, Ferry D, Tsung A, Chetta M, Schulz S, Skoracki R. Residual breast tissue after robot-assisted nipple sparing mastectomy. Breast 2020; 55:25-29. [PMID: 33310481 PMCID: PMC7726449 DOI: 10.1016/j.breast.2020.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction While the long-term oncologic safety of robot-assisted nipple sparing mastectomy (RNSM) remains to be elucidated, histologically detected residual breast tissue (RBT) can be a surrogate for oncologically sound mastectomy. The objective of this study is to determine the presence of RBT after RNSM. Methods Between August 2019–January 2020, we completed 5 cadaveric RNSMs. Full thickness biopsies from the mastectomy skin flap were obtained from predefined locations radially around the mastectomy skin envelop and nipple areolar complex to histologically evaluate for RBT. Results The first case was not technically feasible due to inability to obtain adequate insufflation. Five mastectomy flaps were analyzable. The average mastectomy flap thickness was 2.3 mm (range 2–3 mm) and the average specimen weight was 382.72 g (range 146.9–558.3 g). Of 70 total biopsies, RBT was detected in 11 (15.7%) biopsies. Most common location for RBT was in the nipple-areolar complex, with no RBT detected from the peripheral skin flaps. Conclusions In this cadaveric study, RNSM is feasible leaving minimal RBT on the mastectomy flap. The most common location for RBT is in the periareolar location consistent with previous published findings after open NSM. Clinical studies are underway to evaluate the safety of RNSM. Robot-assisted nipple sparing mastectomy (RNSM) is technically feasible. Residual breast tissue after RNSM is histologically detected only from the periareolar location. Further clinical trials are underway to determine oncologic safety of RNSM.
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Affiliation(s)
- Ko Un Park
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Gary H Tozbikian
- Department of Pathology, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - David Ferry
- Robotic Surgery Program, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Mathew Chetta
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Steven Schulz
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Roman Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
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11
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Loh ZJ, Wu TY, Cheng FTF. Evaluation of the Learning Curve in Robotic Nipple-sparing Mastectomy for Breast Cancer. Clin Breast Cancer 2020; 21:e279-e284. [PMID: 33189563 DOI: 10.1016/j.clbc.2020.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study discusses the preliminary results of robotic nipple sparing mastectomy (R-NSM) in patients with breast cancer and analyzes the learning curve of the same surgeon in a single medical center. PATIENTS AND METHOD Patients with breast cancer from a single center who received R-NSM between 2018 to 2020 were recruited for clinical and pathologic tumor characteristics including family history, grade, type of tumor, treatment, and outcome. The learning curve for R-NSM was analyzed by using cumulative sum (CUSUM). RESULTS A total of 85 R-NSM procedures from 78 patients were evaluated. In the CUSUM plot analysis of the learning curve, a significant decrease in time for mastectomy, reconstruction, and total operation appeared in the 22nd, 23rd, and 26th procedures, respectively. Patients' body weight, gel implant size, and specimen weight had significant correlations with the time for mastectomy. Four (5.6%) patients had nipple partial ischemia, and 1 (1.4%) had total nipple necrosis. The mean follow-up was 11.4 ± 6.2 months; only 1 patient showed recurrence. CONCLUSION Robotic breast surgery is a feasible method with good cosmetic outcome under suitable patient selection. Oncologic safety is not a reason to stop its development.
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Affiliation(s)
- Zhu-Jun Loh
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Yi Wu
- Department of Occupational Therapy, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Fiona Tsui-Fen Cheng
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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12
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Uras C, Enes Arıkan A, Kara H, Dülgeroğlu O, Avşar Y. Robotic nipple sparing mastectomy through a single incision: Advantages of starting with posterior dissection. Turk J Surg 2020; 36:303-309. [PMID: 33778387 DOI: 10.47717/turkjsurg.2020.4771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/24/2020] [Indexed: 11/23/2022]
Abstract
Objectives Loss of breast, which is an important body marking of women, causes a huge decrease in quality of life (QoL) after treatment. In order to overcome this morbidity and increase QoL, nipple sparing mastectomy (NSM) has been developed. Even though the demand for better cosmetic results has yielded endoscopic nipple sparing mastectomy, limitations like unsuitable optical window and limited manual control of rigid-tip instruments, and struggling to keep dissection space have led robotic nipple sparing mastectomy (rNSM) to be developed. Material and Methods Records of three patients who underwent to rNSM for invasive breast carcinoma with DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) in affiliated hospitals of xxxxx xxxxx xxx xxxx University, Research Institute of xxxxx in 2018 were investigated retrospectively. In all breasts (n=4), dissection was started from the posterior side of breast. Results In the unit, 738 breast cancer patients underwent surgery between 2018 and 2019 with an NSM ratio of 31.4% (n=232). Of these patients, three underwent rNSM with DaVinci Xi robotic system. The operation was performed on the left breast in one patient, right in one, and bilateral in one patient. Only in patient #2, who was a neoadjuvant chemotherapy recipient, seroma was observed six weeks after surgery (3 weeks after removal of drains) and spontaneously resolved in 4 weeks. No other complication was seen in all patients. In the follow-up period of median 21 months, no loco-regional recurrence or distant metastasis was seen. Conclusion A single incision robotic mastectomy can be performed easily and safely when the dissection starts from the pre-pectoral plane rather than the subcutaneous plane.
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Affiliation(s)
- Cihan Uras
- Acibadem Mehmet Ali Aydinlar University, Research Institute Of Senology, Istanbul, Turkey
| | - Akif Enes Arıkan
- Acibadem Mehmet Ali Aydinlar University, School Of Medicine, Department Of General Surgery, Istanbul, Turkey
| | - Halil Kara
- Acibadem Mehmet Ali Aydinlar University, Vocational School Of Health Sciences, Istanbul, Turkey
| | - Onur Dülgeroğlu
- Acibadem Mehmet Ali Aydinlar University, Vocational School Of Health Sciences, Istanbul, Turkey
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13
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Consensus Statement on Robotic Mastectomy-Expert Panel From International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019. Ann Surg 2020; 271:1005-1012. [PMID: 31977514 DOI: 10.1097/sla.0000000000003789] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To achieve a consensus statement on robotic mastectomy. BACKGROUND Robotic-assisted surgery has gained much attention especially the results of few case series reporting on the technical feasibility, safety and early oncologic outcomes of robotic-assisted mastectomy in a few centers worldwide. The aim of this consensus statement was to develop and provide standardized guidelines on robotic mastectomy based on consensus statement by a panel of experts from indications to outcome measures and indicators, thereby providing a valuable guide for breast surgeons worldwide. METHODOLOGY An internationally representative expert panel of 10 surgeons was invited to participate in the generation of a consensus statement. 52 statements were created in 6 domains: indications, contraindications, technical considerations, patient counseling, outcome measures and indicators, training and learning curve assessment. Experts were asked to vote if they agree, disagree or of the opinion that the statement should be rephrased. Two electronic rounds via online survey of iterative rating and feedback were anonymously completed, followed by a final round of in-person meeting during the inaugural International Endoscopic and Robotic Breast Surgery Symposium 2019 from May 24 to 25, 2019. Consensus was reached when there was at least 80% agreement on each statement. RESULTS A total of 53 statements with at least 80% agreement were generated after 3 rounds of voting; 21 statements from first round of voting, 20 statements from second round of voting and 12 statements from the final round of in-person meeting. All experts agreed that the consensus statement served as expert recommendations but not mandatory for a successful and safe practice of robotic mastectomy. CONCLUSION Robotic mastectomy is a promising technique and could well be the future of minimally invasive breast surgery whereas proving to be safe and feasible. The first consensus statement on robotic mastectomy from an international panel of experts serves as an extremely important milestone and provides recommendations for breast surgeons keen to embark on this technique.
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14
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Houvenaeghel G, Cohen M, Ribeiro SR, Barrou J, Heinemann M, Frayret C, Lambaudie E, Bannier M. Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With Robotic Latissimus Dorsi Flap Harvest: Technique and Results. Surg Innov 2020; 27:481-491. [PMID: 32418492 DOI: 10.1177/1553350620917916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. Only few cases of robotic latissimus dorsi flap reconstruction (RLDFR) have been reported in indication of reconstruction for breast cancer (BC). We report our experience of combined robotic nipple-sparing mastectomy (R-NSM) and RLDFR, and analyze technique, indications, and reproducibility. Methods. All patients with R-NSM and RLDFR from November 2016 to August 2, 2018, were analyzed, and technics have been described. Complication rate with Clavien-Dindo grading and postoperative hospitalization length (days) are reported. Results. Thirty-five R-NSM with RLDFR were performed in 22 cases for primitive BC and 13 for local recurrence. In 12 patients, another surgical procedure was performed during the same time (axillary lymph node dissection or contralateral breast surgery). R-NSM was realized through a short axillar incision, with inside-only installation for 12 patients (34.3%): 18 nonautologous and 17 autologous RLDFR associated with implant in 9 patients. In logistic regression, mastectomy weight >330 g was significantly associated with the use of implant (odds ratio [OR] = 17, P = .015), and significant factor of the time of anesthesia ≥380 minutes was 2 installations (OR = 10.4, P = .049). The median duration of hospitalization stay was 4 days. Complications rates were 51.4% (18/35; 9 grade-1, 2 grade-2, and 7 grade-3). In logistic regression, associated other surgical procedure was predictive of grade-3 complications (OR = 6.87, P = .053). Conclusion. We confirmed the reproducibility and safety of R-NSM and RLDFR with a decreased complication rate. NSM was performed in 42.8% of our patients after previous radiotherapy. We observed an increase of grade-3 complications when R-NSM and RLDFR was combined to another surgical procedure.
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Affiliation(s)
- Gilles Houvenaeghel
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Monique Cohen
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Sandrine Rua Ribeiro
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Julien Barrou
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Mellie Heinemann
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Christine Frayret
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Eric Lambaudie
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Marie Bannier
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
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15
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Sarfati B, Toesca A, Roulot A, Invento A. Transumbilical Single-port Robotically Assisted Nipple-sparing Mastectomy: A Cadaveric Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2778. [PMID: 33133886 PMCID: PMC7572180 DOI: 10.1097/gox.0000000000002778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022]
Abstract
The authors performed a transumbilical, single-port robotically assisted, nipple-sparing mastectomy on a cadaveric model to assess technical feasibility. Surgeon-controlled, robotic-wristed instrumentation, as well as 3-dimensional high definition (HD) vision allowed the entire dissection to be performed through a single incision placed in the umbilicus. The technique warrants further exploration and development before any application in clinical applied research.
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Affiliation(s)
- Benjamin Sarfati
- From the Department of Plastic Surgery, Gustave Roussy, Villejuif, France
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Aurélie Roulot
- From the Department of Plastic Surgery, Gustave Roussy, Villejuif, France
| | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
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16
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Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple‐sparing mastectomy. J Surg Oncol 2020; 122:29-35. [DOI: 10.1002/jso.25909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Kopkash
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Mark Sisco
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Elizabeth Poli
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | - Akhil Seth
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Catherine Pesce
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
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17
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Lai HW, Chen ST, Mok CW, Lin YJ, Wu HK, Lin SL, Chen DR, Kuo SJ. Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results. J Plast Reconstr Aesthet Surg 2020; 73:1514-1525. [PMID: 32238306 DOI: 10.1016/j.bjps.2020.02.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/01/2020] [Accepted: 02/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Robotic nipple sparing mastectomy (R-NSM), which uses the da Vinci surgical platform, could perform NSM and immediate breast reconstruction through a small and inconspicuous extra-mammary axillary or lateral chest incision. R-NSM was reported with extremely low nipple areolar complex (NAC) necrosis rate, good cosmetic results, and high patient satisfaction. However, there was little evidence available comparing the effectiveness and safety of R-NSM and conventional NSM (C-NSM) in the management of breast cancer. METHODS A case control comparison study was conducted for patients with breast cancer who underwent R-NSM or C-NSM with immediate gel implant breast reconstruction (IGBR) from July 2011 to September 2019 at a single institution to compare the clinical outcomes, patient-reported esthetic results, and medical cost. RESULTS According to the study design, 54 procedures of R-NSM were compared with 62 procedures of C-NSM in the surgical management of breast cancer combined with IGBR. Compared with C-NSM, R-NSM was associated with higher overall satisfaction (92% excellent and 8% good versus 75.6% excellent and 24.4% good, P = 0.046), and wound/scar related outcome in patient-reported esthetic results. The NAC ischemia/necrosis risk, overall complication rate, and blood loss were not significantly different between R-NSM and C-NSM groups. However, longer operation time and higher overall medical cost (10,877 ± 796 versus 5,702 ± 661 US Dollars, P<0.01) was observed in R-NSM group. CONCLUSION Compared with C-NSM, R-NSM showed comparable clinical outcomes and favorable patients' satisfaction with the esthetic results, but at the price of longer operation time and higher cost.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan; Minimal invasive surgery research center, Changhua Christian Hospital, Changhua, Taiwan; Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Chang Gung University College of Medicine, Taoyuan City, Taiwan; Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore; Singhealth Duke-NUS Breast Centre, Singapore.
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Hwa-Koon Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan.
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
| | - Dar-Ren Chen
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Shou-Jen Kuo
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
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18
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Corso G, Magnoni F, Provenzano E, Girardi A, Iorfida M, De Scalzi AM, Invento A, Colleoni M, Cassano E, Trentin C, Gullo RL, Pravettoni G, Gilardi L, Grana CM, Intra M, Galimberti V, Veronesi P, De Lorenzi F, Leonardi MC. Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review. Future Oncol 2020; 16:395-412. [PMID: 32026709 DOI: 10.2217/fon-2019-0540] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.
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Affiliation(s)
- Giovanni Corso
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Monica Iorfida
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Trentin
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Lo Gullo
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Faculty of Medicine, University of Milan, Milan, Italy.,Applied Research Division for Cognitive & Psychological Science, European Institute of Oncology, IRCCS, Milan, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic & Reconstructive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
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19
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Lai HW, Chen ST, Tai CM, Lin SL, Lin YJ, Huang RH, Mok CW, Chen DR, Kuo SJ. Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost. Ann Surg Oncol 2020; 27:2255-2268. [PMID: 32016631 DOI: 10.1245/s10434-020-08223-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND New surgical innovations of nipple-sparing mastectomy (NSM), such as endoscopic NSM (E-NSM) or robotic NSM (R-NSM), were emerging. However, there was a lack of evidence comparing the effectiveness and safety in the management of breast cancer. METHODS A case-control comparison study was conducted for patients with breast cancer underwent E-NSM or R-NSM with immediate prosthesis breast reconstruction (IPBR) from July 2010 to February 2019 at a single institution to compare the clinical outcomes, learning curve, patient-reported cosmetic results, and medical cost. RESULTS A total of 91 E-NSM and 40 R-NSM procedures were retrieved and analyzed. The surgical margin involvement rate in both R-NSM (2.5%) and E-NSM (4.4%) procedures were relatively low (P = 0.52). The R-NSM group was associated with higher satisfaction rates in terms of scar appearance, scar length, and surgical wound position compared with the E-NSM group. Compared with E-NSM, the R-NSM operation time took longer (241 ± 61 vs. 215 ± 70 min, P = 0.01), less blood loss (32 ± 29 vs. 79 ± 62 ml, P < 0.01), and higher medical cost (10,587 ± 554 vs. 6855 ± 936 U.S. dollars, P < 0.01). There was no statistically significant difference in nipple ischemia/necrosis or overall complication between R-NSM and E-NSM. In the learning curve analysis, it took the 27th procedure in E-NSM and 10th procedure in R-NSM to decrease operation time significantly. CONCLUSIONS R-NSM was associated with higher wound-related satisfaction, lesser blood loss, and shorter learning curve compared with E-NSM, however, at the price of longer operation time and higher medical cost.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,School of Medicine, National Yang Ming University, Taipei, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan. .,Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chin-Mei Tai
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ren-Hung Huang
- Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore.,Singhealth Duke-NUS Breast Center, Singapore, Singapore
| | - Dar-Ren Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Jen Kuo
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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20
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Donnely E, Griffin MF, Butler PE. Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2578. [PMID: 32095394 PMCID: PMC7015621 DOI: 10.1097/gox.0000000000002578] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Breast cancer is the most prevalent cancer and second leading cause of cancer-related deaths in both the US and UK female population, a prominent cause of morbidity and cost to both health services. All surgically fit patients are offered breast reconstruction following the initial surgery, and this is traditionally an open approach: either implant-based or an autologous tissue flap. Both lead to scarring that is difficult to conceal. This paper aims to evaluate the novel minimally invasive technique of robotic-assisted surgery. Methods: A systematic review was conducted using Medline (OvidSP) and Embase (OvidSP) to evaluate the current application of robotic-assisted surgery in breast surgery and reconstruction. Results: Twenty-one articles were identified and discussed, composing of level 4 and 5 evidence comparing different surgeons' experiences, techniques, and outcomes. To date, the robotic system has been utilized to harvest the latissimus dorsi muscle for use as a tissue flap (total harvest time of 92 minutes), to perform nipple-sparing mastectomy with immediate breast reconstruction (total operation time 85 minutes) and lately to harvest a deep inferior epigastric perforator flap via an intraabdominal approach. Conclusions: Robotic-assisted surgery can successfully and reproducibly perform a nipple-sparing mastectomy with breast reconstruction. It can minimize the size of scarring and is superior to the laparoscopic technique, with improved 3-dimensional visualization, dexterity, and range of motion able to guide around the curvature of the breast. The main limiting factors are the lack of the US Food and Drug Administration approval, cost of the robot, and specialized skills required.
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Affiliation(s)
- Edward Donnely
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
| | - Michelle F Griffin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
| | - Peter E Butler
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
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21
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Rathat G, Herlin C, Bonnel C, Captier G, Duraes M. Endoscopic Nipple-Sparing Mastectomy with Immediate Prepectoral Implant-Based Reconstruction: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1812-1816. [PMID: 31801936 PMCID: PMC6913238 DOI: 10.12659/ajcr.919669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Female, 45-year-old Final Diagnosis: Prophylactic mastectomy Symptoms: — Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology
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Affiliation(s)
- Gauthier Rathat
- Department of Oncological Breast Surgery, Montpellier University Hospital, Montpellier, France
| | - Christian Herlin
- Department of Plastic Surgery, Montpellier University Hospital, Montpellier, France
| | - Christophe Bonnel
- Innovation Extractor Department, Montpellier Hospital, University of Montpellier, Montpellier, France
| | - Guillaume Captier
- Laboratory of Anatomy, University of Montpellier, Montpellier, France
| | - Martha Duraes
- Department of Oncological Breast Surgery, Montpellier University Hospital, Montpellier, France
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22
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Robot-assisted Mastectomy Followed by Immediate Autologous Microsurgical Free Flap Reconstruction: Techniques and Feasibility in Three Different Breast Cancer Surgical Scenarios. Clin Breast Cancer 2019; 20:e1-e8. [PMID: 31780382 DOI: 10.1016/j.clbc.2019.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/21/2019] [Accepted: 06/23/2019] [Indexed: 11/23/2022]
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23
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Park HS, Lee J, Lee H, Lee K, Song SY, Toesca A. Development of Robotic Mastectomy Using a Single-Port Surgical Robot System. J Breast Cancer 2019; 23:107-112. [PMID: 32140275 PMCID: PMC7043949 DOI: 10.4048/jbc.2020.23.e3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022] Open
Abstract
Minimal invasive surgical technique has been increasingly applied to breast surgery. Since the first robot-assisted nipple-sparing mastectomy was introduced, we have been performing nipple-sparing mastectomy using multi-port robotic surgical system. Last year, the new robotic surgical system with single port was introduced. We report the development of a robotic nipple-sparing mastectomy with immediate reconstruction through a single incision using the updated single-port surgical robot system for a patient with ductal carcinoma in situ (DCIS). Breast reconstruction was performed using implants. Postoperative pathological examination revealed DCIS in both breasts. There were no major immediate complications, except for a minor skin burn on the right breast. Overall, the initial operation using the updated platform was safely performed.
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Affiliation(s)
- Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeea Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Haemin Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kwanbum Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yong Song
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
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24
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Park HS, Lee J, Lee DW, Song SY, Lew DH, Kim SI, Cho YU. Robot-assisted Nipple-sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience. Sci Rep 2019; 9:15669. [PMID: 31666551 PMCID: PMC6821761 DOI: 10.1038/s41598-019-51744-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/02/2019] [Indexed: 01/10/2023] Open
Abstract
Seeking smaller and indistinct incisions, physicians have attempted endoscopic breast surgery in breast cancer patients. Unfortunately, there are some limitations in the range of movement and visualization of the operation field. Potentially addressing these limitations, we investigated the outcomes of gas and gasless robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR). Ten patients underwent 12 RANSM with IBR between November 2016 and April 2018. Patients with tumors measuring >5 cm in diameter, tumor invasion of the skin or nipple-areolar complex, proven metastatic lymph nodes, or planned radiotherapy were excluded. Age, breast weight, diagnosis, tumor size, hormone receptor status, and operation time were retrospectively collected. Postoperative outcomes including postoperative complications and final margin status of resected were analyzed. The median total operation time and console time were 351 min (267–480 min) and 51 min (18–143 min), respectively. The learning curve presented as a cumulative sum graph showed that the console time decreased and then stabilized at the eighth case. There was no open conversion or major postoperative complication. One patient had self-resolved partial nipple ischemia, and two patients experienced partial skin ischemia. We deemed that RANSM with IBR is safe and feasible for early breast cancer, benign disease of the breast, and BRCA 1/2 mutation carriers. RANSM is an advanced surgical method with a short learning curve.
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Affiliation(s)
- Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Jeea Lee
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dong Won Lee
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yong Song
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstruction Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Il Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Up Cho
- Department of Surgery, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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25
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Toesca A, Invento A, Massari G, Girardi A, Peradze N, Lissidini G, Sangalli C, Maisonneuve P, Manconi A, Gottardi A, Baker JL, Bottiglieri L, Naninato P, Farante G, Magnoni F, De Scalzi A, Corso G, Colleoni M, De Lorenzi F, Sacchini V, Galimberti V, Intra M, Rietjens M, Veronesi P. Update on the Feasibility and Progress on Robotic Breast Surgery. Ann Surg Oncol 2019; 26:3046-3051. [PMID: 31342391 DOI: 10.1245/s10434-019-07590-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Robotic nipple-sparing mastectomy (RNSM) may allow for more precise anatomic dissection and improved cosmetic outcomes over conventional open nipple-sparing mastectomy; however, data regarding the feasibility and safety of the procedure are limited. OBJECTIVE The aim of this study was to present and discuss perioperative surgical outcomes and early oncologic follow-up data on consecutive patients undergoing RNSM from June 2014 to January 2019. METHODS Patients underwent RNSM and immediate robotic breast reconstruction through an axillary incision at a single institution. Perioperative data, complications at 3 months postoperatively, pathological data, and adjuvant therapies were recorded. Local recurrence-free, disease-free, and overall survival were analyzed. RESULTS Overall, 73 women underwent 94 RNSM procedures. Indications were invasive breast cancer in 39 patients, ductal carcinoma in situ in 17 patients, and BRCA mutation in 17 patients. Mean surgery time was 3 h and 32 min. One-step reconstruction with implant occurred in 89.4% of procedures. The rate of complications requiring reoperation was 4.3%, and the rate of flap or nipple necrosis was 1.1%. Median follow-up was 19 months (range 3.1-44.8). No local recurrences occurred. Overall survival at 12, 24, or 60 months was 98% (95% confidence interval 86-100%). CONCLUSION We observed a low complication rate in 94 consecutive RNSM procedures, demonstrating the procedure is technically feasible and safe. We found no early local failures at 19 months follow-up. Long-term follow-up is needed to confirm oncologic safety. Future clinical trials to study the advantages and disadvantages of RNSM are warranted.
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Affiliation(s)
- Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.
| | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Massari
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Nickolas Peradze
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Germana Lissidini
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Claudia Sangalli
- Data Management, European Institute of Oncology IRCCS, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, European Institute of Oncology IRCCS, Milan, Italy
| | - Andrea Manconi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Alessandra Gottardi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Jennifer L Baker
- Breast Surgery Division, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Luca Bottiglieri
- Division of Pathology, European Institute of Oncology IRCC, Milan, Italy
| | - Paola Naninato
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriel Farante
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Virgilio Sacchini
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.,Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,University of Milan School of Medicine, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.,University of Milan School of Medicine, Milan, Italy
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26
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Houvenaeghel G, Bannier M, Rua S, Barrou J, Heinemann M, Van Troy A, Lambaudie E, Cohen M. Breast cancer robotic nipple sparing mastectomy: evaluation of several surgical procedures and learning curve. World J Surg Oncol 2019; 17:27. [PMID: 30728011 PMCID: PMC6366058 DOI: 10.1186/s12957-019-1567-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies of robotic nipple sparing mastectomy (NSM) were reported. We report feasibility of robotic NSM and determine standard surgical procedure and learning curve threefold. METHODS A cohort of patients with robotic NSM for breast cancer was analyzed. Complications and post-operative hospitalization stay were reported. The same technic was used for all patients except for skin and nipple areolar complex (NAC) dissection. Differences between three surgical procedures of NAC dissection were analyzed: group 1, dissection with robotic scissors using coagulation; group 2, dissection with robotic scissors without coagulation; and group 3, dissection with non-robotic scissors and then robotic dissection. We explored possible effect of learning curve among patients from group 1 with the same surgical procedure. RESULTS Twenty-seven NSM with immediate breast reconstruction for breast cancers, 22 invasive and 5 in situ, were performed, with robotic latissimus dorsi-flap (RLDF) only in 17 cases, RLDF and breast implant in 6 cases, and implant alone in 4 cases. Repartition according to 3 surgical procedure groups was 16, 5, and 6 patients. Mean time of surgery and anesthesia decrease according to groups 1 to 3. Among 16 patients from group 1, time of surgery and anesthesia decreased with learning curve. Post-operative hospitalization decreased from group 1 to 3. We reported a total of 11 complications, with significant difference between groups (10 for group 1). Skin complications were higher for group 1 in comparison with groups 2-3 (p = 0.02). CONCLUSION Robotic NSM can be performed with a brief learning. Standardized technique is proposed with non-robotic scissors superficial dissection and then dissection with robot.
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Affiliation(s)
- G Houvenaeghel
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
| | - M Bannier
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - S Rua
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - J Barrou
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - M Heinemann
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - A Van Troy
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - E Lambaudie
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - M Cohen
- Department of Surgical Oncology, Institut Paoli Calmettes and CRCM and Aix-Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
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27
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Park HS, Kim JH, Lee DW, Song SY, Park S, Kim SI, Ryu DH, Cho YU. Gasless Robot-Assisted Nipple-Sparing Mastectomy: A Case Report. J Breast Cancer 2018; 21:334-338. [PMID: 30275863 PMCID: PMC6158155 DOI: 10.4048/jbc.2018.21.e45] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/14/2018] [Indexed: 01/30/2023] Open
Abstract
Robotic surgical systems enhance surgical accuracy and efficiency by applying advanced technologies such as artificial arm joints to provide higher degrees of freedom of movement and high-quality three-dimensional images. However, the application of robotic surgical systems to breast surgery has not been widely attempted. The robotic system would improve cosmesis by enabling surgery using a single small incision. We report the first case of a gasless robot-assisted nipple-sparing mastectomy and immediate reconstruction in a patient with early breast cancer.
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Affiliation(s)
- Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Heung Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seho Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Ryu
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Young Up Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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28
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Oncoplastic Breast Consortium consensus conference on nipple-sparing mastectomy. Breast Cancer Res Treat 2018; 172:523-537. [PMID: 30182349 PMCID: PMC6245050 DOI: 10.1007/s10549-018-4937-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/22/2018] [Indexed: 11/24/2022]
Abstract
Purpose Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion. Methods The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology. Results Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference. Conclusions In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques. Electronic supplementary material The online version of this article (10.1007/s10549-018-4937-1) contains supplementary material, which is available to authorized users.
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29
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Rimareix F, Sarfati B, Leymarie N, Alkhashnam H, Honart JF, Tran De Frémicourt K, Conversano A, Struk S, Schaff JB, Bennis Y, Mazouni C, Delaloge S, Rivera S, Kolb F. [Mastectomy and immediate reconstruction: Indications, techniques and decision algorithm]. ANN CHIR PLAST ESTH 2018; 63:542-544. [PMID: 30144962 DOI: 10.1016/j.anplas.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 01/22/2023]
Abstract
Immediate breast reconstruction indications extend to infiltrating carcinomas, due to new matrix implant coverage techniques and the development of perforator flaps. These techniques allow adjuvant treatments. However, the decision of immediate reconstruction must be discussed with the oncological multidisciplinary team and the benefits/risks must also be evaluated in relation to the morphology of the patients and their co-morbidities. The chosen type of mastectomy: conventional or skin sparing and/or nipple sparing depends on the shape and volume of the breast, the localization of the tumor in the breast and the distance from the nipple areola complex (NAC). We describe an algorithm to allow, in the case of therapeutic mastectomy with or without adjuvant radiotherapy, an immediate reconstruction with implants or free or pedicled flaps.
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Affiliation(s)
- F Rimareix
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - B Sarfati
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - N Leymarie
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - H Alkhashnam
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - J F Honart
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - K Tran De Frémicourt
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - A Conversano
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - S Struk
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - J-B Schaff
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - Y Bennis
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - C Mazouni
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - S Delaloge
- Département d'oncologie médicale, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - S Rivera
- Département de radiothérapie, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
| | - F Kolb
- Département de chirurgie plastique, Gustave-Roussy, 114, rue Edouard-Vaillant, 94800 Villejuif, France.
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30
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van Mulken TJM, Schols RM, Qiu SS, Brouwers K, Hoekstra LT, Booi DI, Cau R, Schoenmakers F, Scharmga AMJ, van der Hulst RRWJ. Robotic (super) microsurgery: Feasibility of a new master-slave platform in an in vivo animal model and future directions. J Surg Oncol 2018; 118:826-831. [PMID: 30114335 PMCID: PMC6221079 DOI: 10.1002/jso.25195] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
Advanced microsurgical procedures are currently limited by human precision and manual dexterity. The potential of robotics in microsurgery is highlighted, including a general overview of applications of robotic assistance in microsurgery and its introduction in different surgical specialties. A new robotic platform especially designed for (super) microsurgery is presented. Results of an in vivo animal study underline its feasibility and encourage further development toward clinical studies. Future directions of robotic microsurgery are proposed.
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Affiliation(s)
- Tom J M van Mulken
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kaj Brouwers
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lisette T Hoekstra
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Darren I Booi
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Raimondo Cau
- Department of Medical Robotics Technologies, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Ferry Schoenmakers
- Department of Medical Robotics Technologies, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Andrea M J Scharmga
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rene R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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31
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Lai HW, Chen ST, Lin SL, Chen CJ, Lin YL, Pai SH, Chen DR, Kuo SJ. Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant: Technique, Preliminary Results and Patient-Reported Cosmetic Outcome. Ann Surg Oncol 2018; 26:42-52. [PMID: 30109537 DOI: 10.1245/s10434-018-6704-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Experience with application of a robotic surgery platform in the management of breast cancer is limited. The preliminary results of the robotic nipple-sparing mastectomy (R-NSM) and immediate breast reconstruction (IBR) with Gel implant procedure are reported. METHODS The medical records of patients from a single institution who underwent an R-NSM and IBR with Gel implant procedure for breast cancer during the period March 2017 to February 2018 were assessed. Data on clinicopathologic characteristics, type of surgery, complications, and recurrence were analyzed to determine the effectiveness and oncologic safety of R-NSM. Patient-reported cosmetic outcome results were obtained. RESULTS A total of 22 patients who received 23 R-NSM and IBR with Gel implant procedures were analyzed. The mean operation time for R-NSM was 118.8 ± 50.6 min, and 74.5 ± 26.6 min for Gel implant reconstruction. Docking time quickly dropped from 20 to 6-8 min, and the time needed to complete R-NSM was usually completed within 100 min after accumulation of case experience. Mean blood loss was 37 ± 38.2 mL, and the positive surgical margin rate was 0%. Three (13%) patients had transit nipple ischemia change, and no total nipple-areolar complex necrosis cases were observed. No local recurrence or mortality was found during a mean 6.9 ± 3.5 months of follow-up. All 22 patients were satisfied with the postoperative aesthetic outcome. CONCLUSION From our preliminary experience, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan. .,School of Medicine, National Yang Ming University, Taipei, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,Minimally Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Jung Chen
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Ya-Ling Lin
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan.,Minimally Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shu-Hsin Pai
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan.,Minimally Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Jen Kuo
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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32
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Lai HW, Chen ST, Lin SL, Lin YL, Wu HK, Pai SH, Chen DR, Kuo SJ. Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report. Medicine (Baltimore) 2018; 97:e11373. [PMID: 29979425 PMCID: PMC6076135 DOI: 10.1097/md.0000000000011373] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/05/2018] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The clinical application of robotic surgery in breast conserving surgery or volume replacement with robotic latissimus dorsi flap harvest (RLDFH) has been rarely reported. In this study, we report the preliminary experience and clinical outcome of robotic assisted quadrantectomy (RAQ) and immediate partial breast reconstruction (IPBR) with RLDFH. PATIENT CONCERN Decreasing and avoid back scar length after latissimus dorsi flap harvest. DIAGNOSES One 28 years old female with left breast cancer underwent RAQ and IPBR with RLDFH. Initially, she was diagnosed with left breast infiltrating carcinoma that was clinical stage T3N1M0 and triple negative. INTERVENTIONS Neoadjuvant chemotherapy consisting of 4 cycles of epirubicin and cyclophosphamide followed by 4 cycles of docetaxel was performed. Breast magnetic resonance imaging showed residual breast cancer about 4.5 cm over the left upper outer quadrant of the breast. Sentinel lymph node biopsy showed no lymph node metastasis. RAQ, which took 82 minutes, was performed first, and the resected breast specimen's weight was 203 gm. She received IPBR with RLDFH, which took 97 minutes. OUTCOMES The overall blood loss was 40 mL. The final pathology result was ypT2 (4.2 cm)N0 (sn0/3)M0 and stage IIA. The resection margin was free of tumors. The post-operative recovery was smooth except for seroma formation over the back, which was relieved after repeated aspiration at an outpatient clinic. The patient was satisfied with the post-operative scar and aesthetic outcome. No local recurrence, distant metastasis or case mortality was found during 5 months of follow-up. LESSONS RAQ and IPBR with RLDFH is a safe alternative for small-to-medium-breast-size women with breast cancer who desire breast conservation and are indicated for volume replacement with autologous latissimus dorsi flap.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center
- Division of General Surgery
- Comprehensive Breast Cancer Center
- School of Medicine, National Yang Ming University, Taipei
- Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin
- Minimal Invasive Surgery Research Center
- Kaohsiung Medical University, Kaohsiung
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center
- Division of General Surgery
- Comprehensive Breast Cancer Center
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery
| | - Ya-Ling Lin
- Endoscopic and Oncoplastic Breast Surgery Center
- Minimal Invasive Surgery Research Center
| | - Hwa-Koon Wu
- Department of Radiology, Changhua Christian Hospital, Changhua
| | - Shu-Hsin Pai
- Endoscopic and Oncoplastic Breast Surgery Center
- Minimal Invasive Surgery Research Center
| | - Dar-Ren Chen
- Endoscopic and Oncoplastic Breast Surgery Center
- Division of General Surgery
- Comprehensive Breast Cancer Center
| | - Shou-Jen Kuo
- Division of General Surgery
- Comprehensive Breast Cancer Center
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Corso G, Figueiredo J, La Vecchia C, Veronesi P, Pravettoni G, Macis D, Karam R, Lo Gullo R, Provenzano E, Toesca A, Mazzocco K, Carneiro F, Seruca R, Melo S, Schmitt F, Roviello F, De Scalzi AM, Intra M, Feroce I, De Camilli E, Villardita MG, Trentin C, De Lorenzi F, Bonanni B, Galimberti V. Hereditary lobular breast cancer with an emphasis on E-cadherin genetic defect. J Med Genet 2018; 55:431-441. [PMID: 29929997 DOI: 10.1136/jmedgenet-2018-105337] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/25/2018] [Accepted: 06/05/2018] [Indexed: 12/22/2022]
Abstract
Recent studies have reported germline CDH1 mutations in cases of lobular breast cancer (LBC) not associated with the classical hereditary diffuse gastric cancer syndrome. A multidisciplinary workgroup discussed genetic susceptibility, pathophysiology and clinical management of hereditary LBC (HLBC). The team has established the clinical criteria for CDH1 screening and results' interpretation, and created consensus guidelines regarding genetic counselling, breast surveillance and imaging techniques, clinicopathological findings, psychological and decisional support, as well as prophylactic surgery and plastic reconstruction. Based on a review of current evidence for the identification of HLBC cases/families, CDH1 genetic testing is recommended in patients fulfilling the following criteria: (A) bilateral LBC with or without family history of LBC, with age at onset <50 years, and (B) unilateral LBC with family history of LBC, with age at onset <45 years. In CDH1 asymptomatic mutant carriers, breast surveillance with clinical examination, yearly mammography, contrast-enhanced breast MRI and breast ultrasonography (US) with 6-month interval between the US and the MRI should be implemented as a first approach. In selected cases with personal history, family history of LBC and CDH1 mutations, prophylactic mastectomy could be discussed with an integrative group of clinical experts. Psychodecisional support also plays a pivotal role in the management of individuals with or without CDH1 germline alterations. Ultimately, the definition of a specific protocol for CDH1 genetic screening and ongoing coordinated management of patients with HLBC is crucial for the effective surveillance and early detection of LBC.
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Affiliation(s)
- Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology, Milano, Italy
| | - Joana Figueiredo
- EPIC Lab, Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto (IPATIMUP), Porto, Portugal
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology, Milano, Italy.,Oncology and Hematology, University of Milan, Milan, Italy
| | - Gabriella Pravettoni
- Oncology and Hematology, University of Milan, Milan, Italy.,Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology, Milan, Italy
| | - Debora Macis
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | | | - Roberto Lo Gullo
- Division of Breast Imaging, European Institute of Oncology, Milan, Italy
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK.,Cambridge Breast Cancer Research Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology, Milano, Italy
| | - Ketti Mazzocco
- Oncology and Hematology, University of Milan, Milan, Italy.,Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology, Milan, Italy
| | - Fátima Carneiro
- Institute of Molecular Pathology and Immunology, University of Porto (IPATIMUP), Porto, Portugal.,Division of Pathology, Hospital São Joao, Porto, Portugal
| | - Raquel Seruca
- EPIC Lab, Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto (IPATIMUP), Porto, Portugal.,Medical Faculty of the University of Porto, Porto, Portugal
| | - Soraia Melo
- EPIC Lab, Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto (IPATIMUP), Porto, Portugal.,Medical Faculty of the University of Porto, Porto, Portugal
| | - Fernando Schmitt
- EPIC Lab, Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto (IPATIMUP), Porto, Portugal.,Medical Faculty of the University of Porto, Porto, Portugal
| | - Franco Roviello
- Departments of Surgery and Pathology, Le Scotte Hospital, University of Siena, Siena, Italy
| | | | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, Milano, Italy
| | - Irene Feroce
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Elisa De Camilli
- Division of Pathology, European Institute of Oncology, Milan, Italy
| | | | - Chiara Trentin
- Division of Breast Imaging, European Institute of Oncology, Milan, Italy
| | | | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology, Milano, Italy
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