The impact of physical activity on promoter-specific methylation of genes involved in the redox-status and disease progression: A longitudinal study on post-surgery female breast cancer patients undergoing medical treatment

Most anticancer treatments act on oxidative-stress pathways by producing reactive oxygen species (ROS) to kill cancer cells, commonly resulting in consequential drug-induced systemic cytotoxicity. Physical activity (PA) has arisen as an integrative cancer therapy, having positive health effects, including in redox-homeostasis. Here, we investigated the impact of an online supervised PA program on promoter-specific DNA methylation, and corresponding gene expression/activity, in 3 antioxidants- (SOD1, SOD2, and CAT) and 3 breast cancer (BC)-related genes (BRCA1, L3MBTL1 and RASSF1A) in a population-based sample of women diagnosed with primary BC, undergoing medical treatment. We further examined mechanisms involved in methylating and demethylating pathways, predicted biological pathways and interactions of exercise-modulated molecules, and the functional relevance of modulated antioxidant markers on parameters related to aerobic capacity/endurance, physical fatigue and quality of life (QoL). PA maintained levels of SOD activity in blood plasma, and at the cellular level significantly increased SOD2 mRNA (≈+77 %), contrary to their depletion due to medical treatment. This change was inversely correlated with DNA methylation in SOD2 promoter (≈-20 %). Similarly, we found a significant effect of PA only on L3MBTL1 promoter methylation (≈-25 %), which was inversely correlated with its mRNA (≈+43 %). Finally, PA increased TET1 mRNA levels (≈+15 %) and decreased expression of DNMT3B mRNA (≈-28 %). Our results suggest that PA-modulated DNA methylation affects several signalling pathways/biological activities involved in the cellular oxidative stress response, chromatin organization/regulation, antioxidant activity and DNA/protein binding. These changes may positively impact clinical outcomes and improve the response to cancer treatment in post-surgery BC patients.

An Integrated Care Approach to Improve Well-Being in Breast Cancer Patients

BACKGROUND

Breast cancer (BC) treatment has recently been revolutionized by the introduction of newer targeted agents, that helped tailoring therapies around the single patient. Along with increased survival rates, a careful evaluation of diet, lifestyle habits, physical activity, emotional and psychological experiences linked to the treatment journey, is now mandatory. However, a true proposal for an omnicomprehensive and "integrative" approach is still lacking in literature.

METHODS

A scientific board of internationally recognized specialists throughout different disciplines designed a shared proposal of holistic approach for BC patients.

RESULTS

A narrative review, containing information on BC treatment, endocrinological and diet aspects, physical activity, rehabilitation, integrative medicine, and digital narrative medicine, was developed.

CONCLUSIONS

In the context of a patient-centered care, BC treatment cannot be separated from a patient's long-term follow-up and care, and an organized interdisciplinary collaboration is the future in this disease's cure, to make sure that our patients will live longer and better.

TRIAL REGISTRATION

NCT05893368: New Model for Integrating Person-based Care (PbC) in the Treatment of Advanced HER2-negative Breast Cancer (PERGIQUAL). Registration date: 29th May 2023.

Serum levels of adiponectin differentiate generalized lipodystrophies from anorexia nervosa

PURPOSE

The differential diagnosis of lipodystrophy involves other disorders characterized by severe fat loss and may be sometimes challenging. Owing to the rarity of lipodystrophy, it is relevant to search for tools and assays that differentiate it from other diseases that may mimic it. We conducted a study on leptin and high molecular weight (HMW) adiponectin serum concentrations in a series of patients diagnosed with lipodystrophy and compared them with those found in anorexia nervosa, one of the illnesses that may be cause of a missed diagnosis of lipodystrophy.

METHODS

Leptin and HMW adiponectin serum concentrations were measured in six patients diagnosed with generalized lipodystrophy (GL), six with progeroid syndromes (PS), 13 with familial partial lipodystrophy type 1 (FPLD1, Kobberling syndrome), 10 with familial partial lipodystrophy type 2 (FPLD2, Dunnigan syndrome), 18 with acquired partial lipodystrophy (APL) and 12 affected by anorexia nervosa (AN). Measurements were compared to those obtained in 12 normal weight healthy subjects.

RESULTS

Serum leptin concentrations were reduced to a similar degree in GL, PS and AN, proportionally to the extent of fat loss. Serum concentrations of HMW adiponectin were found extremely low in patients with GL and PS, while comparable to normal weight subjects in patients with AN.

CONCLUSION

Serum HMW adiponectin can be regarded as a useful tool to discriminate between generalized lipodystrophy syndromes (including PS) and AN.

The Breaking Point and Post-Traumatic Growth in Breast Cancer Survivors

Advancements in breast cancer survival rates make the issues of quality of life and psycho-physical wellbeing in survivors central goals of comprehensive care [...].

Local Treatment of Triple-Negative Breast Cancer: Is Mastectomy Superior to Breast-Conserving Surgery?

Triple-negative breast cancer (TNBC) is an aggressive type of breast cancer that lacks the expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2). TNBC accounts for about 15% of breast cancers and has a poorer prognosis as compared with other subtypes of breast cancer. The more rapid onset of this cancer and its aggressiveness have often convinced breast surgeons that mastectomy could provide better oncological results. However, there is no relevant clinical trial that has assessed differences between breast-conserving surgery (BCS) and mastectomy (M) in these patients. This population-based study aimed to investigate the distinct outcomes between conservative treatment and M in a case series of 289 patients with TNBC treated over a 9-year period. This monocentric study retrospectively evaluated patients with TNBC who underwent upfront surgery at Fondazione Policlinico Agostino Gemelli IRCCS, in Rome, between 1 January 2013 and 31 December 2021. First, the patients were divided in two groups according to the surgical treatment received: BCS vs. M. Then, the patients were stratified into four risk subclasses based on combined T and N pathological staging (T1N0, T1N+, T2-4N0 and T2-4N+). The primary endpoint of the study was to evaluate locoregional disease-free survival (LR-DFS), distant disease-free survival (DDFS) and overall survival (OS) in the different subclasses. We analyzed 289 patients that underwent either breast-conserving surgery (247/289, 85.5%) or mastectomy (42/289, 14.5%). After a median follow-up of 43.2 months (49.7, 22.2-74.3), 28 patients (9.6%) developed a locoregional recurrence, 27 patients (9.0%) showed systemic recurrence and 19 patients (6.5%) died. No significant differences due to type of surgical treatment were observed in the different risk subclasses in terms of locoregional disease-free survival, distant disease-free survival and overall survival. With the limits of a retrospective, single-center study, our data seem to indicate similar efficacy in terms of locoregional control, distant metastasis and overall survival with the use of upfront breast-conserving surgery as compared with radical surgery in the treatment of TNBC. Therefore, TNBC should not be considered to be a contraindication for breast conservation.

Endocrine Disruptors in Food, Estrobolome and Breast Cancer

The microbiota is now recognized as one of the major players in human health and diseases, including cancer. Regarding breast cancer (BC), a clear link between microbiota and oncogenesis still needs to be confirmed. Yet, part of the bacterial gene mass inside the gut, constituting the so called "estrobolome", influences sexual hormonal balance and, since the increased exposure to estrogens is associated with an increased risk, may impact on the onset, progression, and treatment of hormonal dependent cancers (which account for more than 70% of all BCs). The hormonal dependent BCs are also affected by environmental and dietary endocrine disruptors and phytoestrogens which interact with microbiota in a bidirectional way: on the one side disruptors can alter the composition and functions of the estrobolome, ad on the other the gut microbiota influences the metabolism of endocrine active food components. This review highlights the current evidence about the complex interplay between endocrine disruptors, phytoestrogens, microbiome, and BC, within the frames of a new "oncobiotic" perspective.

Identification of a minimum number of genes to predict triple-negative breast cancer subgroups from gene expression profiles

BACKGROUND

Triple-negative breast cancer (TNBC) is a very heterogeneous disease. Several gene expression and mutation profiling approaches were used to classify it, and all converged to the identification of distinct molecular subtypes, with some overlapping across different approaches. However, a standardised tool to routinely classify TNBC in the clinics and guide personalised treatment is lacking. We aimed at defining a specific gene signature for each of the six TNBC subtypes proposed by Lehman et al. in 2011 (basal-like 1 (BL1); basal-like 2 (BL2); mesenchymal (M); immunomodulatory (IM); mesenchymal stem-like (MSL); and luminal androgen receptor (LAR)), to be able to accurately predict them.

METHODS

Lehman's TNBCtype subtyping tool was applied to RNA-sequencing data from 482 TNBC (GSE164458), and a minimal subtype-specific gene signature was defined by combining two class comparison techniques with seven attribute selection methods. Several machine learning algorithms for subtype prediction were used, and the best classifier was applied on microarray data from 72 Italian TNBC and on the TNBC subset of the BRCA-TCGA data set.

RESULTS

We identified two signatures with the 120 and 81 top up- and downregulated genes that define the six TNBC subtypes, with prediction accuracy ranging from 88.6 to 89.4%, and even improving after removal of the least important genes. Network analysis was used to identify highly interconnected genes within each subgroup. Two druggable matrix metalloproteinases were found in the BL1 and BL2 subsets, and several druggable targets were complementary to androgen receptor or aromatase in the LAR subset. Several secondary drug-target interactions were found among the upregulated genes in the M, IM and MSL subsets.

CONCLUSIONS

Our study took full advantage of available TNBC data sets to stratify samples and genes into distinct subtypes, according to gene expression profiles. The development of a data mining approach to acquire a large amount of information from several data sets has allowed us to identify a well-determined minimal number of genes that may help in the recognition of TNBC subtypes. These genes, most of which have been previously found to be associated with breast cancer, have the potential to become novel diagnostic markers and/or therapeutic targets for specific TNBC subsets.

Screening for Physical Activity Levels in Non-Metastatic Breast Cancer Patients Undergoing Surgery: An Observational Study

BACKGROUND

Physical activity (PA) can play a role in lowering the risk of breast cancer (BC), but also in reducing perioperative complications and treatments related side effects, improving the quality of life and decreasing mortality in BC survivors. PA and nutritional screening are not offered to patients after cancer diagnosis as standard of care, even in high quality breast units.

METHODS

From February 2019 to March 2020, we performed a preoperative physical and nutritional screening in 504 consecutive BC patients waiting for surgery. The screening included an IPAQ questionnaire to evaluate the level of physical activity; nutritional screening with measurement of anthropometric parameters (weight, height, waist and hips circumference, BMI, and waist hip ratio) and evaluation of body composition using Bioelectrical Impedance Analysis (BIA).

RESULTS

The majority of patients in our series resulted physically inactive: clustering the IPAQ scores, 47% of patients proved to be physically inactive (MET score <700), 34% moderately active (MET score 700-2520), and only 19% physically active (MET score > 2520). In addition, approximately half of the patients (49.01%) resulted overweight or obese, and more than half (55.2%) had a percentage of fatty tissue over the recommended cut off for adult women.

CONCLUSIONS

Our data confirm that assessment of PA levels should become part of the standard preoperative evaluation of BC patients and behavioral interventions should be offered to them, in order to pre-habilitate for surgery and improve outcomes. IPAQ Questionnaire and body composition analysis could be quick and easy screening tools in order to identify which patients may need more support in being active during and after anticancer treatments.

Paget’s disease of the breast: Our 20 years’ experience

Introduction

Paget’s disease (PD) represents 1%–3% of all breast cancers and mostly occurs in postmenopausal women. Multiple studies have confirmed that breast-conserving surgery (BCS) followed by radiotherapy is a safe option for patients with in situ or invasive PD, ensuring local control and survival rates similar to those achieved with mastectomy.

Materials and methods

We retrospectively analyzed 115 patients affected by PD treated in our institution between January 2000 and May 2021. Median age at diagnosis was 60 years and median follow-up was 82 months; 69 patients were treated with BCS and 46 were treated with modified radical mastectomy or skin-sparing mastectomy.

Results

At histological examination, 59 patients (59/115, 51.0%) had an underlying invasive carcinoma; in 11 patients (11/115, 9.0%), only PD was found. In 45 patients (45/115, 40.0%), only noninvasive cancer was found. Nine patients (9/115, 7.8%) developed a local recurrence, 7 patients (7/115, 6.0%) are alive with distant metastasis, and 10 patients (10/115, 8.6%) died.

Discussion

In our series, no statistically significant differences were shown between PD alone, PD associated with in situ cancer, and PD with invasive cancer, regardless of the surgical procedure. BCS followed by radiotherapy appears to be an effective and safe option for patients with PD.

Conclusion

PD is a rare form of breast cancer and, in half of the cases, is associated with an invasive carcinoma. Separating our sample into three subgroups based on tumor histology, there were no significant differences in terms of LC, DFS, and OS rate in patients treated with different types of surgery. This study presents some limitations due to its retrospective nature and being confined to a single institution.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience

Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. Results: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. Conclusions: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

Post-acute cardiac complications following SARS-CoV-2 infection in partial lipodystrophy due to LMNA gene p.R349W mutation

PURPOSE

SARS-CoV-2 infection may cause varying degrees of cardiac injury and the presence of underlying cardiovascular morbidities contributes to the frequency and severity of occurrence of this complication. Lipodystrophy syndromes are frequently characterized by severe metabolic derangements that represent relevant cardiovascular risk factors. Besides causing lipodystrophy, mutations in the lamin A/C (LMNA) gene can lead to a wide spectrum of tissue-specific disorders including cardiac involvement.

METHODS AND RESULTS

We herein examine the case of two patients affected by atypical progeroid syndrome and partial lipodystrophy due to a heterozygous missense LMNA mutation c.1045 C > T (p.R349W) who presented initially with mild COVID-19 and developed severe cardiovascular complications within few weeks of SARS-CoV-2 infection. Before being infected with SARS-CoV-2, our patients had cardiovascular morbidities (mild mitral regurgitation in one patient, ischemic heart disease with bifascicular block in the other patient) in adjunct to cardiovascular risk factors, but the SARS-CoV-2 infection contributed to quickly and significantly decompensate their balance.

CONCLUSION

These findings warn that patients affected by LMNA p.R349W mutation and likely other LMNA mutations associated with cardiovascular morbidity should be considered at extremely elevated risk of post-acute cardiological manifestations and should therefore undergo a vigilant follow-up after SARS-CoV-2 infection. Both patients developed COVID-19 before the specific vaccination was available to them and this unfortunate situation should remark the importance of vaccination coverage against SARS-CoV-2 infection for all patients affected by lipodystrophy, especially those with underlying comorbidities.

Mastectomy and immediate prepectoral versus submuscular breast reconstruction after neoadjuvant chemotherapy: Our early experience

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Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that allows to improve aesthetic results and patient quality of life. Traditionally, implants have been placed in a submuscolar (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of prosthesis is increasingly used in order to avoid morbidities related to manipulation of PMM. The aim of this study was to compare outcomes of SM vs PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our Istitution from January 2018 to December 2021. Conservative mastectomy was performed in 155 of the 400 patients that underwent NAC during the study period. Patients were divided in 2 groups based on the positioning of implants: 60 SM versus 95 PP. Results: The two cohorts were similar for age (mean age 45 and 42 years in the SM and PP group respectively) and follow‐up (32 and 21 months, respectively). Mean operative time was 55 minutes shorter in the PP group (298 and 243 minutes in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss occurred was observed in 1.6% of patients (1/60) in the SM group and 1,05% of patients (1/95) in PP group. No differences were observed among the two groups in local or regional recurrence. Conclusions: Our preliminary experience, that represents one of the largest series of PP-IPBR after NAC at a single Institution documented in the Literature, seems to confirm that PP - IPBR after NAC is a safe, reliable and effective alternative to traditional SM - IPBR with excellent aesthetic and oncological outcomes; it is easy to perfom, reduces operative time and minimizes complications related to manipolation of PPM. However this promising results need to be confirmed in prospective trials with longer follow-up.

The Impact of Mediterranean Dietary Intervention on Metabolic and Hormonal Parameters According to BRCA1/2 Variant Type

The female carriers of BRCA1/2 pathogenic variants (mutations) face a high lifetime risk of developing breast and/or ovarian cancer. However, the risk may differ depending on various genetic and non-genetic elements, including metabolic and hormonal factors. We previously showed that a 6-month Mediterranean dietary intervention trial reduced body weight and the levels of insulin-like growth factor I and other metabolic factors in BRCA mutation carriers. We also found that higher baseline levels of glucose and insulin were significantly associated with BRCA loss-of-function (LOF) variants. In this study, we evaluated whether the BRCA mutation type influences in a different way the metabolic and hormonal response to the dietary intervention in 366 female carriers. The LOF variant carriers randomized in the intervention group (IG) showed significantly higher changes in most considered parameters compared to the control group (CG). The nonsynonymous variant carriers in the IG showed similar changes, but none of them were statistically significant. Performing the “delta” analysis of differences (intention-to-treat analysis), we observed that in LOF variant carriers, the reduction of insulin levels was significantly more pronounced that in nonsynonymous variant carriers. These findings suggest that the changes in insulin levels might be modulated by a different response to the dietary intervention mediated by BRCA LOF variants.

Sexuality in breast cancer survivors: sexual experiences, emotions, and cognitions in a group of women under hormonal therapy

BACKGROUND

Earlier diagnosis and improved treatments have led to better outcomes in breast cancer, making quality of life a key issue. Sexuality represents a pillar of quality of life, although it is often neglected by both healthcare providers and patients when it comes to cancer. This study aims to explore the differences in sexual functioning, distress, psychopathology, emotions, and cognitions between breast cancer patients under hormonal treatment and controls.

METHODS

Seventy-nine women (age range between 24 and 69 years) in hormonal therapy for breast cancer completed a self-reported protocol. A matched control group of 103 women was randomly extracted from an Italian general population database. Eight self-report questionnaires exploring biopsychosocial factors were administered.

RESULTS

The current study showed an impaired sexuality in breast cancer patients compared to controls. Breast cancer women under hormonal treatment were characterized by diminished or absent sexual activity (chi² = 36.16; p < 0.001), lower level of sexual functioning in all areas except for pain (F_(1,180) = 8.1; p < 0.01), higher sexual (F_(1,180) = 10.08; p < 0.001) and psychological distress (F_(1,180) = 6.23; p < 0.05), higher scores in Difficulties in Identifying Feelings (F_(1,180) = 7.31; p < 0.01) and Externally Oriented Thinking (F_(1,180) = 6.64; p < 0.05), higher level of negative emotions related to sexuality (F_(1,180) = 11.13; p < 0.001), and more rigid cognition towards peculiar aspects of sexuality, such as Failure Disengagement Thoughts (F_(1,180) = 22.01; p < 0.001) and Age related Beliefs (F_(1,180) = 5.7; p < 0.05).

CONCLUSIONS

Health care providers do not usually assess those issues in their routine practice, so that sexuality remains an unmet need with remarkable effects on general health and quality of life.

Nipple sparing mastectomy with prepectoral immediate prosthetic reconstruction without acellular dermal matrices: a single center experience

BACKGROUND

Nipple-sparing mastectomy (NSM) with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that allows to improve aesthetic results and patient quality of life. Traditionally, implant for reconstruction have been placed in a submuscolar (SM) plane, beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of prosthesis is increasingly used in order to avoid morbidities related to manipulation of PMM. The aim of the present study was to report our experience with 209 NSMs and IPBR using a prepectoral approach and polyurethane-coated implant without acellular dermal matrices (ADMs).

METHODS

A retrospective review of breast cancer patients who underwent NSM followed by PP - IPBR from January 2018 to April 2021 was performed. Data were recorded in order to evaluate operative details, major complications and oncological outcomes. Aesthetic results and patient quality of life were measured by a specific "QOL assessment PRO" survey.

RESULTS

Two hundred and nine patients (269 breasts) with PP - IPBR after NSM were included. Mean age was 47 (25-73) years and median follow-up was 14 (1-40) months. A simultaneous contralateral implant-based mammoplasty of symmetrization after unilateral NSM was carried out in six of 149 (4%) patients. Implant loss was observed in three of 209 patient (1.44%); two of 209 (0.96%) patients developed a full-thickness NAC necrosis that required excision. During follow-up one local relapse (0.48%) and two regional nodes recurrences (0,96%) was observed. Patient satisfaction, assessed using a personalized QOL Assessment PRO survey, in term of aesthetic results, chronic pain, shoulder dysfunction, sports activity, sexual and relationship life and skin sensibility, was excellent.

CONCLUSIONS

Our experience shows that PP-IPBR using polyurethane-coated implant after NSM is a safe, reliable and effective alternative to traditional IPBR with excellent aesthetic outcomes and high patient quality of life; it is easy to perform, minimizes complications related to manipulation of PPM and reduces operative time while resulting also in a cost-effective technique.

Surgical management of BRCA pathogenic variant carriers with breast cancer: a recent literature review and current state of the art

INTRODUCTION

Surgical management of breast cancer patients carrying pathogenic variants (PV) on breast cancer genes (BRCA) 1 and 2 has changed throughout the last decade due to growing availability of genetic testing, and has shifted towards the diffusion of bilateral mastectomy. Today's scenario however is in further evolution because of emerging data that suggest a personalized modulation of treatment. In this work we aimed to gather recent evidence supporting a prophylactic or conservative surgical approach in order to define the state of the art in today's treatment of BRCA carriers with breast cancer.

EVIDENCE ACQUISITION

We reviewed the literature to identify studies providing evidence on surgical treatment in breast cancer patients with BRCA 1 and 2 PVs. We included articles comparing outcomes between patients undergoing breast conserving surgery (BCS) and mastectomy, and articles investigating contralateral risk-reducing mastectomy (CRRM), with a particular focus on recent literature. International guidelines were also reviewed.

EVIDENCE SYNTHESIS

Optimal surgical management of BRCA PV carriers with breast cancer remains controversial. While the introduction of routine genetic testing has initially led surgeons to favor more radical treatments, recent literature provides evidence that a conservative approach is safe and feasible in selected cases. Guidelines are heterogeneous and provide guidance without constraining the surgeon.

CONCLUSIONS

Patients should undergo adequate genetic and surgical counseling in order to receive the best tailored surgical treatment. Because guidelines vary in different countries and provide no definite protocol, they highlight the importance of accurate surgical planning. Clinical, familial and psychosocial factors should be taken into account when approaching a BRCA PV carrier with breast cancer, in order to guarantee the best evidence-based patient care in an era of personalized treatment.

Integrated Treatment of Breast Cancer-related Lymphedema: A Descriptive Review of the State of the Art

BACKGROUND/AIM

Upper limb breast cancer-related lymphedema (BCRL) is a chronic and severe condition affecting a significant percentage of breast cancer survivors. Even though its physiopathology is well-known, there is no worldwide consensus on BCRL evaluation and a gold-standard treatment. This narrative review aims at providing a brief descriptive overview with regard to BCRL treatment modalities.

MATERIALS AND METHODS

We conducted a literature search within the PubMed database, and 33 articles out of 56 were selected, including reviews, systematic reviews, and meta-analyses aiming find the most updated evidence regarding BCRL treatment modalities.

RESULTS

Physical exercise (aerobic exercise, resistance exercise, aquatic therapy), bandages, and intermittent pneumatic compression were shown to be most effective in BCRL patients, in terms of swelling reduction in the acute-intensive phase. Furthermore, physical exercise was beneficial also as a maintenance tool. Manual lymphatic drainage demonstrated efficacy in preventing secondary lymphedema if applied immediately after breast cancer surgery or in early phases of BCRL or as a maintenance tool. Complementary procedures such as acupuncture, reflexology, yoga and photo-biomodulation therapy did not show conclusive results in BCRL treatment. Surgery was shown effective in managing symptoms (liposuction), preventing (lymphaticovenular anastomosis) and treating BCRL (vascularized lymph node transfer).

CONCLUSION

BCRL is still a challenging condition either for breast cancer survivors and clinicians, deeply impacting patient functioning and quality of life. Due to the lack of globally accepted criteria in evaluating BCRL, to date a gold standard treatment for this widespread issue is still needed.

Neoadjuvant Chemotherapy in Breast Cancer: An Advanced Personalized Multidisciplinary Prehabilitation Model (APMP-M) to Optimize Outcomes

Neoadjuvant chemotherapy is increasingly being employed in the management of breast cancer patients. Efforts and resources have been devoted over the years to the search for an optimal strategy that can improve outcomes in the neoadjuvant setting. Today, a multidisciplinary approach with the application of evidence-based medicine is considered the gold standard for the improvement of oncological results and patient satisfaction. However, several clinical complications and psychological issues due to various factors can arise during neoadjuvant therapy and undermine outcomes. To ensure that health care needs are adequately addressed, clinicians must consider that women with breast cancer have a high risk of developing "unmet needs" during treatment, and often require a clinical intervention or additional care resources to limit possible complications and psychological issues that can occur during neoadjuvant treatment. This work describes a multidisciplinary model developed at "Fondazione Policlinico Universitario Agostino Gemelli" (FPG) in Rome in an effort to optimize treatment, ease the application of evidence-based medicine, and improve patient quality of life in the neoadjuvant setting. In developing our model, our main goal was to adequately meet patient needs while preventing high levels of distress.

A Model of an Integrative Approach to Breast Cancer Patients

BACKGROUND

Breast cancer (BC) survivors have physical and psychological needs that require convincing responses by health care providers. The quality of life issue and clinical unmet needs are among the main reasons pushing a number of patients toward "natural" therapies that are often misleading and alternative to mainstream cancer care. Integrative Oncology (IO) tries to respond to many of those needs, by combining lifestyle counseling, body-mind activities, and complementary evidence-informed therapies with anticancer standard treatments.

METHODS

In our model at Fondazione Policlinico Gemelli (FPG), every woman diagnosed with a BC waiting for surgery or candidate to neoadjuvant chemotherapy undergoes a preliminary psycho-oncological distress evaluation and a brief lifestyle interview. Anthropometric measurements, body composition analysis, and individual levels of physical activity are recorded. Patients are given evidence based recommendations about the advisable diet and physical activity in a prehabilitation setting. A physician provides patients with information about integrative care plans to treat symptoms related to the disease or its treatments. Therapeutic approaches include acupuncture, mindfulness-based protocols, qigong, massage therapy, and classes of music/art therapy.

RESULTS

Between September 2018 and February 2020, the Center for Integrative Oncology at FPG has carried out 1249 lifestyle counseling sessions, 1780 acupuncture treatments, 1340 physiotherapy sessions, 3261 psycho-oncological consultations, 218 herbal medicine counseling sessions. Moreover, 90 BC patients completed the mindfulness based stress reduction (MBSR) protocol and 970 patients participated in qigong, art therapy, and music therapy classes.

CONCLUSIONS

Our integrative approach aims to achieve a person-centered medicine by improving symptoms management, adherence to oncological protocols, and eventually overall quality of life.

A Mediterranean Dietary Intervention in Female Carriers of BRCA Mutations: Results from an Italian Prospective Randomized Controlled Trial

Background: Women carriers of BRCA1/2 mutations face a high lifetime risk (penetrance) of developing breast and/or ovarian cancer. Insulin-like growth factor I (IGF-I), body weight and markers of insulin resistance affect BRCA penetrance. We conducted a multicenter prospective two-armed (1:1) randomized controlled trial (NCT03066856) to investigate whether a Mediterranean dietary intervention with moderate protein restriction reduces IGF-I and other metabolic modulators of BRCA penetrance. Methods: BRCA carriers, with or without a previous cancer, aged 18-70 years and without metastases were randomly assigned to an active dietary intervention group (IG) or to a control group (CG). The primary endpoint of the intervention was the IGF-I reduction. Results: 416 women (216 in the IG and 200 in the CG) concluded the six-month dietary intervention. The IG showed significantly lowered serum levels of IGF-I (-11.3 ng/mL versus -1.3 ng/mL, p = 0.02), weight (-1.5 Kg versus -0.5 Kg, p < 0.001), waist circumference (-2 cm versus -0.7 cm, p = 0.01), hip circumference (-1.6 cm versus -0.5 cm, p = 0.01), total cholesterol (-10.2 mg/dL versus -3.6 mg/dL, p = 0.04) and triglycerides (-8.7 mg/dL versus + 5.5 mg/dL, p = 0.01) with respect to the CG. Conclusions: A Mediterranean dietary intervention with moderate protein restriction is effective in reducing IGF-I and other potential modulators of BRCA penetrance.

Weight loss effect of liraglutide in real-life: the experience of a single Italian obesity center

PURPOSE

Several randomized controlled clinical trials (RCCTs) have shown that the use of Liraglutide (L) in addition to diet and exercise in patients with obesity or overweight (OO), compared to dietary behavioral changes alone, leads to a significantly greater weight loss. This retrospective study aimed at evaluating the effectiveness of L therapy in a real-life setting.

METHODS

93 consecutive non-diabetic OO, referring to a single Obesity Center, started L therapy from October 2016 to December 2018: 21/93 OO discontinued the treatment within 90 days for various reasons. 72/93 OO (55 females, 17 males), mean ± SD age 49 ± 12.5 years (18-78) and mean body mass index 39.1 ± 5.8 (28.3-55.3) were included for further analysis. 60/72 OO reached the final dose of 3.0 mg/day.

RESULTS

Mean weight loss was 7.1% in the OO who reached the dose of 3.0 mg; 68.3%, 20.0% and 10.0% of OO lost ≥ 5%, 10% and 15% of body weight, respectively. A linear correlation between early and final weight loss was found. Moreover, we observed a significant reduction of mean systolic and diastolic blood pressure and a significant increase of mean heart rate. The overall incidence of side effects was 18.3% (17/93).

CONCLUSION

L treatment of OO in a real life setting yielded results comparable to those reported by the major RCCTs. Combining the results of RCCTs with the observations from real life may increase their power and overcome their respective limitations.

BRCA1/2 Variants and Metabolic Factors: Results From a Cohort of Italian Female Carriers

Women carriers of pathogenic variants (mutations) in the BRCA1/2 genes face a high lifetime risk of developing breast cancer (BC) and/or ovarian cancer (OC). However, metabolic factors may influence BRCA penetrance. We studied the association of metabolic factors with BRCA1/2 variants and the risk effect of metabolic exposures in relation to the position of the mutations within the BRCA1/2. Overall, 438 women carriers of BRCA1/2 mutations, aged 18-70, with or without a previous diagnosis of BC/OC and without metastases, who joined our randomized dietary trial, were included in the study. The pathogenic variants were divided, according to their predicted effect, into loss of function (LOF) and nonsynonymous variants. The association between metabolic exposures and variants were analyzed by a logistic regression model. LOF variant carriers showed higher levels of metabolic parameters compared to carriers of nonsynonymous variants. LOF variant carriers had significantly higher levels of plasma glucose and serum insulin than nonsynonymous variant carriers (p = 0.03 and p < 0.001, respectively). This study suggests that higher insulin levels are significantly associated with LOF variants. Further investigations are required to explore the association of metabolic factors with LOF variants and the mechanisms by which these factors may affect BRCA-related cancer risk.

Pregnancy-Associated Breast Cancer: A Multidisciplinary Approach

The diagnosis of breast cancer (BC) during pregnancy is uncommon. It has varied among different studies from 1:10,000 to 1:3000 of all pregnancies, with a median age of 33 years. Pregnancy-associated BC represents a challenge in terms of clinical management to guarantee both maternal and fetal security in choosing the right treatment. This situation is complex and requires a multidisciplinary approach, including the surgeon, anesthesiologist, oncologist, radiotherapist, psychologist, and maternal-fetal medicine specialist. In the present review, we examined the management of pregnancy-associated BC, focusing on pathophysiologic background, risk factors, diagnosis, staging procedures, anesthesia, surgical management, and systemic treatment.

[Self-care for health professionals.]

In this pandemic global emergency, self-care and psycho-physical wellbeing's programs for healthcare workers are an absolute priority. Now more than ever, physicians and nurses are facing abnormal burdens of work, stressful clinical and organizational conditions and emotional charges that are challenging their ability to cope and jeopardizing their own lives. By improving nutritional education in medical faculties, implementing healthy lifestyles promotion and burnout prevention projects in the hospitals, we will be able to maintain a good quality of care throughout these trying times and hopefully we will improve the selfcare strategies for health professionals for the next future.

Update on sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patient

Today, sentinel lymph node biopsy (SLNB) is considered the gold standard for axillary staging in early breast cancer patients with clinically negative lymph nodes (cN0). SLNB allows to determine the axillary lymph node status sparing the axillary dissection (AD) and its potential complications (seroma formation, loss of sensation, shoulder dysfunction and lymphedema) On the other hand, SLNB for nodal staging in breast cancer patients with clinically negative lymph nodes after neoadjuvant chemotherapy (ycN0) is a highly debated topic due to different reported success rates. In order to optimize oncological results, high identification rate (> 90%) and false negative rate as low as possible (< 10%) should always be obtained when performing SLNB after neoadjuvant chemotherapy. The success rates of SLNB after neoadjuvant chemotherapy (NAC) mainly depend on the clinical lymph node status pre-NAC. In patients with pre-NAC clinically negative nodes (cN0) and at restaging with post-NAC clinically negative nodes (ycN0), SLNB after chemotherapy should be performed because it is an accurate and safe procedure. In patients with pre-NAC clinically positive nodes (cN+) and at restaging with post-NAC clinically negative nodes (ycN0), SLNB after chemotherapy might be considered thanks to the high lymph nodal pathologic complete response rate; however, in this last setting, individual ability, technical skills and repetitive performance of specific tasks must always be followed to improve the identification rate and false negative rate. AD may be avoided only if sentinel lymph node is negative [ypN0(sn)]; instead, to date, patients with metastatic sentinel lymph node after neoadjuvant chemotherapy, even with only isolated tumor cells, [ypN+(sn) including ypN0i+(sn) and ypN1mic(sn)] should always be treated with AD. However, NAC significantly increases the difficulties and complexity of axillary surgical management. A personalized multidisciplinary path in specialized breast centers should ensure an accurate clinical counselling and refined patient selection for SLNB post-NAC. KEY WORDS: Axillary treatment, Breast cancer, Neoadjuvant chemotherapy, Sentinel lymph node biopsy.

Abstract P1-11-03: Impact of scalp cooling device (SCD) in preventing alopecia in women undergoing chemotherapy for breast cancer

Background.

Alopecia (A) is a common and emotionally traumatic adverse effect for breast cancer (BC) patients (pts) undergoing chemotherapy (CT). Food and Drug Administration (FDA) cleared the DigniCap® SCD, for patients with breast cancer in 2015. This device was designed to reduce hair loss during chemotherapy. However, the impact of SCD in pts undergoing anthracycline and taxane-based sequential regimen is not entirely established. Thus, the aim of this analysis was to prospectively explore the role of SCD in a cohort of pts including also this regimen.

Methods.

From February 2016 to June 2018 patients with early/locally advanced breast cancer treated with neoadjuvant/adjuvant CT including anthracycline, taxane or both in sequential regimen were enrolled. The estimate of hair-loss was evaluated by photographs of the head using the Dean scale during and one month after the end of chemotherapy. Alopecia was graduated according to Dean scale: G0 = no A; G1 &lt; 25% A; G2 = 25–50% A; G3 = 50–75% A; G4 &gt; 75%. A score of 0-2 (≤ 50% hair loss) was defined as treatment success. Tolerability was defined as the percentage of patients who completed all chemotherapy cycles using the SCD. All patients received the Patient Symptoms Survey (self-reported). A database for individual data and information was appropriately fulfilled. Descriptive statistics was adopted.

Results.

Overall 121 pts were enrolled; 118 pts were evaluable for efficacy of Dignicap® SCD. Median age was 44 years (range: 24-74 years). CT regimens included docetaxel/cyclophosphamide (37 pts), epirubicin (90 mg/m2) and cyclophosphamide (600 mg/m2 iv) three weekly followed by 12 courses of paclitaxel (80 mg/m2 iv weekly) (84 pts). Alopecia all grade was showed in 52.5% (n=62): G1 in 35 pts (29.6%)and G2 in 23 pts (19.5%). No hair loss in 42 pts (35.6 %). Treatment success was seen in 103 pts (87.3%). Toxicity included grade 1/2 headache in 56 pts (47.4%), cervical discomfort in 36 pts (30.5%), pain of skin in one pts (8.5%). Discontinuation of SCD was seen in 28 pts (23.7%) primarily for headache G3 (4 pts – 3.4%), hair loss G3 in 15 pts (12.7%), discomfort in 8 pts (6.8%), use of head cover in one pt (0.8%).

Conclusions.

This prospective observational study suggests that SCD is effective in preventing A in a relevant number of patients (87.3%), undergoing also anthracyclines followed by taxanes regimen in sequential schedule.

Citation Format: Paris I, Accetta C, Carbognin L, Di Giorgio D, Magno S, Terribile D, Franceschini G, Sanchez M, Ferrandina G, Pasciuto T, Fulvi A, Scambia G, Masetti R. Impact of scalp cooling device (SCD) in preventing alopecia in women undergoing chemotherapy for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-03.

LDL-cholesterol lowering effect of a new dietary supplement: an open label, controlled, randomized, cross-over clinical trial in patients with mild-to-moderate hypercholesterolemia

Background

Hypercholesterolemia is a major risk factor for cardiovascular disorders and requires specific intervention through an adequate lifestyle (diet and physical exercise) and, if necessary, an appropriate drug treatment. Lipid-lowering drugs, although generally efficacious, may sometimes cause adverse events. A growing attention has been devoted to the correction of dyslipidemias through the use of dietary supplements. The aim of this study was to assess the lipid-lowering activity and safety of a dietary supplement containing monacolin K, L-arginine, coenzyme Q10 and ascorbic acid, named Argicolina (A), compared to a commercially available product containing monacolin K and coenzyme Q10, Normolip 5 (N).

Methods

This was a single center, controlled, randomized, open-label, cross-over clinical study enrolling 20 Caucasian outpatients aged 18–75 years with serum LDL-C between 130 and 180 mg/dL. Patients assumed two different dietary supplements (A and N) both containing monacolin K 10 mg for 8 weeks each, separated by a 4-week wash-out period. Evaluated parameters were: Total cholesterol (Tot-C), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides (TG), fasting blood glucose, aspartate aminotransferase, alanine aminotransferase, creatinekinase, gamma-glutamyl-transpeptidase, brachial arterial pressure and heart rate, measured at the start and at the end of each treatment period. Safety was monitored through the study.

Results

LDL-C decreased by 23.3% during treatment with N (p < 0.0001) and by 25.6% during treatment with A (p < 0.0001); the LDL-C mean reduction was 36.4 (95% CI: 45,6–27,1) mg/dL during N treatment and 40.1 (95% CI: 49.2–30,9) mg/dL during A treatment. Tot-C decreased significantly (p < 0.0001) within each treatment period. HDL-C increase was negligible during A whereas it was significant during N. TG diminished markedly during A and not significantly during N. The difference between treatments was not statistically significant for all variables. No serious or severe adverse events occurred during the study.

Conclusions

Our results confirm the clinically meaningful LDL-C lowering properties of monacolin K. At variance with a supplement already in the market (N), the novel association (A) of monacolin K with L-arginine, coenzime Q10 and ascorbic acid also produces a significant reduction of triglycerides without significant effects on HDL.

Trial registration

ClinicalTrials.gov ID: NCT03425630.

Neo-adjuvant chemotherapy and distress in breast cancer patients: The moderating role of generalized self-efficacy

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Background: Neo-Adjuvant Chemotherapy (NAC) is commonly recommended as a preoperative treatment for patients with locally advanced breast cancers (BC). However, several studies have shown that NAC can increase patients’ distress. A first aim of this study was to evaluate if BC patients treated with NAC show higher levels of distress as compared to patients undergoing primary surgery (PS). A secondary aim was to evaluate if distress could be significantly correlated with patients’ depression and anxiety, and if generalized self-efficacy (GSE) may moderate these relationships. Methods: one hundred and twenty-four BC patients (61 waiting for PS and 63 undergoing NAC), with a mean age of 51.64 (SD = 9.67), were instructed to complete a series of questionnaires evaluating socio-demographic data, anxiety, depression, distress and GSE. Results: An analysis of covariance was conducted, including treatment condition (NAC vs PS) as an independent variable, patients’ distress as a dependent variable, and age as a covariate. A significant mean difference emerged between groups [F(1, 121) = 5.66, p < .05)]. In particular, NAC patients showed a higher distress (Mean = 6.79) than PS ones (Mean = 5.72). Moreover, patients’ distress appeared moderately correlated with both anxiety (r = .34, p < .05) and depression (r = .36 < .05). Finally, results revealed a significant interaction effect of distress and GSE on depression (β = -.19, p < .05), confirming the moderating role of GSE. In particular, for low levels of GSE (-1 SD), the correlation between distress and depression was large and significant (r = .53, p < .001), while for high level of GSE (+1 SD) this relationship was definitively lower (r = .14, p = .03). No significant moderating effects of GSE were found for stress-anxiety relationship. Conclusions: Results of this study seems to confirm that NAC may induce distress in BC patients. Moreover, distress, significantly related to anxiety and depression, may play a detrimental role for patients’ psychological well-being. Finally, GSE emerged as a moderator of distress-depression relationship, suggesting that negative consequences of stress could be reduced during NAC using GSE-based psychological intervention.

Effects of plantar reflexology on sleep and quality of life in patients with breast cancer undergoing chemotherapy and hormonal therapies

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Background: In the last decade, several studies have shown the role that integrative therapies (e.g. acupuncture, herbal medicine, body-mind practices) can play to relieve symptoms related to cancer and its mainstream treatment. However, conclusive evidence about the value of Plantar Reflexology (PR) on side effects management in breast cancer patients is still lacking. Methods: Forty-four breast cancer patients, treated at Catholic University Hospital’s Breast Unit, were enrolled and invited to complete the Pittsburgh Sleep Quality Index (PSQI) and the Quality of Life index (QL). Afterward, they were randomized into two groups: 23 patients were treated with 6 weekly sessions of PR (1 hour each) conducted by a specialist (experimental arm), while the other 21 underwent standard medical treatment alone (control arm). At the end of treatment sessions, PSQI and QL were re-administered in both groups. Results: A Multivariate Analysis of Covariance (MANCOVA) was conducted, including the participation to experimental vs. control group as an independent variable, PSQI and QL post-test scores as dependent variables, PSQI and QL pre-test scores and patients’ age as covariates. Results showed that PR improved significantly the quality of sleep [F(1, 39) = 4.94, p < .05)], but no significant effects emerged on the quality of life. A further MANCOVA, conducted on the subscales of the PSQI, showed significant mean differences in sleep disturbances [F(1, 34) = 4.38, p < .05), sleep latency [F(1, 34) = 4.88, p < .05) and sleep quality [F(1, 34) = 6.92, p < .05) in favor of the experimental group. Conclusions: Results suggest that PR may relieve sleep difficulties typically linked to mainstream therapies for breast cancer. No effects of PR emerged for patients’ quality of life, although the small sample tested does not allow to draw any definitive conclusion. These promising results encourage further investigations about the beneficial role of PR. In our initial experience, PR appears as easy, well-tolerated and safe procedure, that can play a role in the management of symptoms that are poorly controlled by conventional pharmacological treatments.

New trends in breast cancer surgery: a therapeutic approach increasingly efficacy and respectful of the patient

The surgical management of breast cancer has undergone continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long, but constant, despite the controversies that appeared every time a new procedure came to light. Today, the aesthetic satisfaction of breast cancer patients coupled with the oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and cosmesis by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present work will highlight the new surgical treatment options increasingly efficacy and respectful of breast cancer patients.

Integrated breast cancer surgical treatment: novel aspects of minimally-invasive treatments

The surgical management of breast cancer has been undergoing continuous and profound changes over the last 40 years. The evolution from aggressive and mutilating treatment to conservative approach has been long but constant, despite the controversies arising every time a new procedure came to light. Today, the esthetic satisfaction of breast cancer patients coupled with oncological safety is the goal of the modern breast surgeon. Breast-conserving surgery with adjuvant radiotherapy is considered the gold standard approach for patients with early stage breast cancer and the recent introduction of "oncoplastic techniques" has furtherly increased the use of breast-conserving procedures. Mastectomy still remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. New surgical procedures called "conservative mastectomies" are emerging as techniques that combine oncological safety and esthetic outcome by entirely removing the breast parenchyma sparing the breast skin and nipple-areola complex. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy and new therapeutic strategies are emerging in patients with a pathological positivity in sentinel lymph node biopsy. The present special article will highlight the new surgical treatment options, which are more and more effective and respectful of breast cancer patients.

Update on the surgical management of breast cancer

The surgical management of breast cancer has undergone continuous and profound changes over the last three decades. For patients with early stage breast cancer, breast-conserving surgery followed by radiation therapy has been definitively validated as a safe alternative to radical mastectomy, with similar survival rates, better cosmetic outcomes and acceptable rates of local recurrence. Thanks to the improvements in diagnostic work-up, as well as the wider diffusion of screening programs and efforts in patient and physician education, tumors are more often detected at an early stage, furtherly facilitating the widespread use of breast conserving techniques. Breast-conserving surgery has been introduced also in the treatment of patients with locally advanced tumors after tumor downsizing with preoperative chemotherapy, with acceptable rates of ipsilateral breast tumor recurrence. When performing breast-conserving surgery all efforts should be made to ensure negative surgical margins in order minimize the risk of ipsilateral breast tumor recurrence as they are associated with worse distant-disease-free and breast cancer- specific survival rates. The recent introduction of "oncoplastic techniques", that may allow more extensive excisions of the breast without compromising the cosmetic results, has furtherly increased the use of breast-conserving procedures. Mastectomy remains a valid surgical alternative in selected cases and is usually associated with immediate reconstructive procedures. Staging of the axilla has also gradually evolved toward less aggressive approaches with the adoption of sentinel node biopsy, but several controversies still remain about completion of axillary lymph node dissection in patients with a pathologic positivity in sentinel lymph node biopsy. The present work will highlight the benefits and unresolved issues of the different surgical treatment options in breast cancer and axillary treatment.

Magnetic resonance imaging features in triple-negative breast cancer: comparison with luminal and HER2-overexpressing tumors

BACKGROUND

It has been ascertained that triple-negative (TN) breast cancer is characterized by an aggressive clinical course and a poor prognosis. The purpose of our study was to compare the magnetic resonance imaging (MRI) features of the 3 major different breast cancer subtypes (TN, luminal, and human epidermal growth factor receptor 2 [HER2]-overexpressing) and to suggest the criteria that might predict TN phenotype.

MATERIALS AND METHODS

From October 2007 to April 2011, we studied 77 patients with histologically confirmed TN breast cancer who underwent breast MRI. We randomly included 148 patients with non-TN breast cancer (110 luminal and 38 HER-overexpressing) as a control group. We evaluated the clinicopathologic data, the MRI morphologic and kinetic features, the signal intensity on T2-weighted images, and the apparent diffusion coefficient (ADC).

RESULTS

Our results confirmed that TN tumors are more aggressive, are usually diagnosed at a younger age compared with the other study groups, and show benign morphologic features with MRI. Backward stepwise logistic regression identified some parameters as independent predictors of TN-type lesions: age, size, shape, presence of edema, and infiltrative characteristics. The receiver operating characteristic (ROC) curve, built with 4 of 5 these factors as criteria to predict TN status, showed a 0.664 area under the curve (AUC) value (sensitivity 58.4%, specificity 73.2%). The inclusion of the fifth criterion showed a 0.699 AUC value (sensitivity, 49.4%; specificity, 89.4%).

CONCLUSION

We identified the clinicoradiologic parameters that are independent predictors of TN breast lesions, which might be helpful for earlier prediction of the TN status of a breast lesion.

Update on oncoplastic breast surgery

Oncoplastic surgery of the breast (OPS) has generated great excitement over the past years and has become an integrated component of the surgical treatment of breast cancer. Oncoplastic surgical procedures associate the best surgical oncologic principles to achieve wide tumor-free margins with the best principles of plastic surgery to optimize cosmetic outcomes. Thanks to oncoplastic techniques, the role of breast conserving surgery (BCS) has been extended to include a group of patients who would otherwise require mastectomy to achieve adequate tumor clearance. As OPS continues to gain acceptance and diffusion, an optimal and systematic approach to these techniques is becoming increasingly necessary. This article has the aim to review the essential principles and techniques associated with oncoplastic surgery, based on the data acquired through an extensive search of the PUBMED and MEDLINE database for articles published using the key words "breast cancer oncoplastic surgery". This review analyzes possible the advantages", classifications, indications, and the criteria for a proper selection of oncoplastic techniques to facilitate one's ability to master these procedures and make OPS a safe and an effective procedure.

The role of oxidized regenerate cellulose to prevent cosmetic defects in oncoplastic breast surgery

BACKGROUND

Breast conserving surgery (BCS) combined with postoperative radiotherapy has become the gold standard of locoregional treatment for the majority of patients with early-stage breast cancer, offering equivalent survival and improved body image and lifestyle scores as compared to mastectomy. In an attempt to optimize the oncologic safety and cosmetic results of BCS, oncoplastic procedures (OPP) have been introduced in recent years combining the best principles of surgical oncology with those of plastic surgery. However, even with the use of OPP, cosmetic outcomes may result unsatisfying when a large volume of parenchyma has to be removed, particularly in small-medium size breasts.

AIM

The aim of this article is to report our preliminary results with the use of oxidized regenerate cellulose (ORC) (Tabotamp fibrillar, Johnson & Johnson; Ethicon, USA) as an agent to prevent cosmetic defects in patients undergoing OPP for breast cancer and to analyze the technical refinements that can enhance its efficacy in optimizing cosmetic defects.

METHODS

Different OPP are selected based on the location and size of the tumor as well as volume and shape of the breast. After excision of the tumor, glandular flaps are created by dissection of the residual parenchyma from the pectoralis and serratus muscles and from the skin. After careful haemostasis, five layers of ORC are positioned on the pectoralis major in the residual cavity and covered by advancement of the glandular flaps. Two additional layers of ORC are positioned above the flaps and covered by cutaneous-subcutaenous flaps.

RESULTS

The use of ORC after OPP has shown promising preliminary results, indicating a good tolerability and positive effects on cosmesis.

CONCLUSIONS

This simple and reliable surgical technique may allow not only to reduce the rate of post-operative bleeding and infection at the surgical site but also to improve cosmetic results.

An unusual case of acute pancreatitis and gastric outlet obstruction associated with wandering spleen treated by laparoscopic splenopexy

Wandering spleen (WS) is an uncommon condition, usually asymptomatic, often recognized as an incidental finding. When symptoms occur, they can vary, although acute abdominal pain is the most common presentation in the pediatric population. In some cases, WS can become a dangerous condition because of the risk of splenic ischemia from persistent pedicle torsion. We describe a case of WS in a 3-year-old boy presenting with vomiting, abdominal swelling, and acute pancreatitis; the diagnosis was obtained by ultrasound and computed tomography. Laparoscopic splenopexy was successfully performed through an extraperitoneal pocket and a Vicryl mesh. To the best of our knowledge, the combination of gastric outlet obstruction and acute pancreatitis has never been reported as presenting symptoms of WS.

Cystic breast lesions: sonographic findings and clinical management

OBJECTIVE

This article reviews basic sonographic findings for distinguishing cystic lesions of the breast.

METHODS

We describe sonographic features of simple and complicated cysts in comparison with complex masses and intracystic carcinomas.

RESULTS

We correlate cystic lesion appearances with histologic patterns and illustrate the diagnostic and therapeutic management of cystic breast lesions.

CONCLUSIONS

Sonography is a useful tool in distinguishing simple cysts from complicated cysts and complex masses of the breast.

Conservative treatment of a rare case of multifocal adenoid cystic carcinoma of the breast: case report and literature review

BACKGROUND

Adenoid cystic carcinoma of the breast is a rare neoplasm accounting for 0.1% of all malignant breast tumors and presenting most commonly as a painful breast mass. Compared with the more common histological forms of breast cancer, it has a more favorable prognosis and lymph node involvement or distant metastases seldom occur.

CASE REPORT

A unique case of multifocal adenoid cystic carcinoma of the breast presenting as a painful and well-defined lump and treated with conservative surgery with adjuvant radiotherapy is reported.

CONCLUSIONS

There is no consensus on the optimal management of this disease. A breast-conserving approach may be recommended even if mastectomy has been traditionally the treatment of choice. Chemotherapy, radiation, and hormonal therapy have been infrequently used and so far have had no defined role in this kind of neoplasm. The authors found no other reports in the literature focusing on a conservative approach to multifocal adenoid cystic carcinoma.

DWI in breast MRI: role of ADC value to determine diagnosis between recurrent tumor and surgical scar in operated patients

INTRODUCTION

Purpose of our study is to evaluate the role of the apparent diffusion coefficient (ADC) in the diagnosis of recurrent tumor on the scar in patients operated for breast cancer. Assess, therefore, the weight of diagnostic diffusion echo-planar sequence, in association with the morphological and dynamic sequences in the diagnosis of tumor recurrence versus surgical scar.

MATERIALS AND METHODS

From September 2007 to March 2009, 72 patients operated for breast cancer with suspected recurrence on the scar were consecutively subjected to magnetic resonance imaging (MRI), including use of a diffusion sequence. All patients with pathological enhancement in the scar were then subjected to histological typing. MRI was considered negative in the absence of areas of suspicious enhancement. In all cases it was measured the ADC value in the scar area or in the area with pathological enhancement. The ADC values were compared with MRI findings and histological results obtained.

RESULTS

26 cases were positive/doubtful at MRI and then subjected to histological typing: of these recurrences were 20 and benign were 6. 46 cases were judged negative at MRI and therefore not sent to cyto-histology. The average ADC value of recurrences was statistically lower of scarring (p<0.001).

CONCLUSIONS

ADC value can be a specific parameter in differential diagnosis between recurrence and scar. The diffusion sequence, in association with the morphological and dynamic sequences, can be considered a promising tool for the surgical indication in suspected recurrence of breast cancer.

Early onset lactating adenoma and the role of breast MRI: a case report

Introduction

Lactating adenoma is a benign condition, representing the most prevalent breast lesion in pregnant women and during puerperium; in this paper, a case of a woman with lactating adenoma occurring during the first trimester of pregnancy is reported. There have been no reports in the literature, according to our search, focusing on magnetic resonance imaging findings in cases of lactating adenomas. Also the early onset of the lesion during the first trimester of pregnancy is quite unusual and possibly unique.

Case presentation

We report the case of a primiparous 30-year-old Caucasian woman, who noted an asymptomatic lump within her left breast during the 9^th week of gestation, slightly increasing in size over the next few weeks. Ultrasound demonstrated a hypoecoic solid mass, hypervascularized and measuring 4 cm. On magnetic resonance imaging, performed in the first month after delivery, the lesion appeared as an ovoidal homogeneous mass, with regular margins and a significant contrast enhancement indicative of a giant adenoma.

Conclusion

Magnetic resonance imaging could play an important role in the differential diagnosis of pregnancy-related breast lumps, particularly during puerperium, thus avoiding unnecessary surgical biopsies.

Accessory nipple reconstruction following a central quadrantectomy: a case report

Introduction

nipple dichotomy (or intra-areolar polythelia) is a rare congenital malformation in which one or more supernumerary nipples are located within the same areola.

A case of a woman undergoing a central quadrantectomy with a contralateral supernumerary nipple used for reconstruction is reported. No other report in the Literature, according to our search, has focused on reconstructive use of an accessory nipple after breast conserving surgery.

Case presentation

the patient is a 73 year-old Caucasian woman, who two years earlier underwent a lower-outer left Quadrantectomy plus axillary sampling and radiation therapy for a 2,2 cm lobular carcinoma with no lymph node involvement.

A routine follow-up assessment showed an important fibrotic change on the operated breast, just across the infra-mammary fold; at a breast Magnetic Resonance Imaging, a 1,5 cm area in retroareolar position, suspicious for local recurrence, was evident.

An open biopsy was therefore performed, under local anaesthesia, including the nipple-areolar complex to realize a central Quadrantectomy with a Grisotti procedure; a congenital dichotomic nipple in the contralateral breast was then used to repair the defect through a "nipple-sharing" technique. The final histological examination reported a fibrotic mastopathy without atypias.

Conclusion

in this case, the "nipple-sharing" technique has allowed in the same time the correction of a rare congenital defect and provided the surgeon with a supernumerary nipple to be used in the immediate reconstruction after breast conserving surgery.