Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study

OBJECTIVE

The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio.

METHODS

We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed.

RESULTS

Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8 mm, p = 0.019).

CONCLUSIONS

Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy.

CLINICAL RELEVANCE STATEMENT

Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions.

KEY POINTS

• Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

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.

Selective Axillary Dissection after Neoadjuvant Chemotherapy in Patients with Lymph-Node-Positive Breast Cancer (CLYP Study): The Radio-Guided Occult Lesion Localization Technique for Biopsy-Proven Metastatic Lymph Nodes

(1) Background: To help to refine the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer (BC) patients with biopsy-proven nodal disease prior to neoadjuvant chemotherapy (NACT), a method of marking the biopsy-proven positive LN at diagnosis to enable its removal during surgery was proposed. The aim of this study was to evaluate the accuracy of the Radio-Guided Occult Lesion Localization (ROLL) technique of biopsy-proven metastatic LN in nodal staging after NACT among node-positive BC patients. (2) Methods: Patients with invasive BC and biopsy-proven axillary metastases receiving NACT were enrolled. A clip marker was placed on the sampled LN (clipped lymph node, CLN) before NACT. Before surgery, the ROLL procedure (radioactive tracer injection into CLN under ultrasound guidance) was performed, and the CLN was surgically resected. The correspondence between the CLNs and SLNs was evaluated. The pathologic findings of the CLNs and SLN(s) were compared with remaining axillary nodes at ALND to determine false negative rates (FNRs). (3) Results: Seventy-two patients were analyzed. Surgery successfully identified the CLN in 70/72 procedures (97.2%). For 60/72 patients who underwent ALND, the FNRs dropped from 19.35% for SLNB to 3.13% for CLN biopsy. (4) Conclusions: The ROLL procedure got CLNs is accurate in axillary nodal staging after NACT in node-positive BC patients at diagnosis.

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.

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.

Impact on survival of primary tumor resection in patients with metastatic breast cancer: preliminary results of a retrospective analisys

BACKGROUND

Treatment of de novo metastatic breast cancer is usually centered around systemic therapy, with local therapy (surgery and radiation therapy) largely reserved for palliation in patients with significant symptoms from primary tumour. The efficacy of locoregional treatment like surgery and/or radiotherapy is still controversial and the debate about surgical resection of primary tumor (PT) in de novo metastatic breast cancer (MBC) patients persists.

METHODS

All patients with de novo MBC undergone surgical treatment between January 2015 and January 2020 at the Multidisciplinary Breast Center of the Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome were included in this study. The primary endpoint was overall survival (OS) after PT resection, the secondary endpoint was progression free survival (PFS). The survival analyses were done using Kaplan-Meier method. Patients and tumour characteristics were analyzed in an exploratory modality in order to identify prognostic factor.

RESULTS

45 patients received resection of the primary breast cancer (26 mastectomy and 19 breast conserving surgery). Median age of diagnosis was 53 years old (range 25-75 years old). Median follow-up was 25.67 months. The median OS was not reached with 75% of patients alive over 2 years from PT resection. The median PFS was not reached with 64% of patients alive over 2 years from PT resection. For both PFS and OS only the triple negative (TN) immunophenotype appears to be a prognostically unfavorable factor in multivariate analysis.

CONCLUSIONS

In view of the low number of disease progression events and deaths, although our results are preliminary, surgical treatment of primary breast cancer in metastatic setting seems to be an option after systemic therapies in luminal and HER2 positive breast cancer. Randomized prospective trials in for each immunophenotype are necessary order to confirm this evidence.

Is subareolar intraoperative biopsy still necessary to predict nipple involvement?

OBJECTIVE

To predict the occult tumor involvement of nipple-areola complex (NAC) using preoperative MR imaging and to investigate whether the intraoperative histopathological examination of the subareolar tissue is still necessary.

PATIENTS AND METHODS

Out of 712 patients submitted to nipple-sparing mastectomy (NSM) between 2014 and 2019, we selected 188 patients who underwent preoperative breast MRI. Breast MRI and intraoperative histopathological examination of the subareolar tissue were performed to predict NAC involvement at permanent pathology. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis.

RESULTS

Forty-three patients (22.9%) had tumor involvement of the NAC. At univariate analysis, non-mass enhancement type (p = 0.009), multifocality/multicentricity (p = 0.002), median tumor size (p < 0.001), median tumor-NAC distance measured by MRI (p < 0.001), tumor-NAC distance ≤ 10 mm (p < 0.001) and tumor-NAC distance ≤ 20 mm (p < 0.001), and lymphovascular invasion (p = 0.001) were significantly correlated with NAC involvement. At multivariate analysis, only tumor-NAC distance ≤ 10 mm retained statistical significance. The sensitivity and specificity of MRI tumor-NAC distance ≤ 10 mm were 79.1% and 97.2% and those of intraoperative pathologic assessment were 74,4% and 100%, respectively.

CONCLUSIONS

Tumor-NAC distance is the only reliable MRI characteristic that can predict NAC involvement in breast cancer patients. Although several cut-offs showed promising performances, intraoperative pathologic assessment is still mandatory.

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.

Magnetic Resonance Imaging prediction of large volume displacement oncoplastic surgery versus mastectomy in the treatment of breast cancer

PURPOSE

To analyse the influence of tumor volume/breast volume ratio (TV/BV ratio) measured on magnetic resonance imaging (MRI) and other factors on surgeons' choice between large volume displacement oncoplastic surgery (LVOS) versus mastectomy (M) in patients with large sized tumors. Secondly, we investigate the predictive value of TV/BV ratio and other possible predictors for cosmetic results.

MATERIALS AND METHODS

We retrospectively reviewed 80 MRI examinations performed on 77 breast cancer patients who underwent M (58 breasts, 72.5%) or LVOS (22 breasts, 27.5%) at our institution between January 2016 and December 2017. The TV and BV measurements were performed by a semiautomated analysis and the TV/BV ratio was calculated by dividing TV by BV in cm3 and multiplying it by 1,000. Cosmetic result was determined by an expert panel assessment of postoperative photographs.

RESULTS

Median TV/BV was significantly higher in the M group (44,8 IQR 17,3-93,6) than in the LVOS group (17,5 IQR 11,7-57,5) (P=0.002). Multifocal/multicentric disease (P=0.005), lower degree of breast ptosis (P<0.0001) and unfavourable tumor location (P=0.024) are significantly more frequent in the M group. After multivariable linear regression, the independent predictors for cosmetic result were: unfavourable tumor location (OR 6.637 95% CI 1.564- 28.172 P=0.010) and a higher TV/BV ratio (OR 4.907 95% CI 1.461-16.478 P=0.010) CONCLUSION: Preoperative evaluation of TV/BV ratio, tumor location and tumor multifocality/multicentricity could improve treatment decision making (LVOS versus M) in breast cancer patient eligible for both options. Increasing TV/BV ratio and unfavourable tumor location are adversely affecting cosmetic result.

KEY WORDS

Breast cancer, Magnetic Resonance Imaging, Mastectomy, Large volume displacement oncoplastic surgery, Tumor volume/breast volume.

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.

Nipple-sparing mastectomy combined with endoscopic immediate reconstruction via axillary incision for breast cancer: A preliminary experience of an innovative technique

INTRODUCTION

Nipple-sparing mastectomy (NSM) has known an exponential diffusion worldwide for prophilaxis and therapeutic mastectomies in selected candidates, being oncologically safe and improving reconstructive outcomes and patients' satisfaction. The two most common used skin incisions are the radial and inframammary fold ones, which represent an imperfect aesthetic solution. The aim of this work was to give insights on our surgical technique, which allows to perform the NSM, node surgery, and endoscopic direct-to-implant reconstruction using a cosmetic axillary incision.

MATERIALS AND METHODS

Between June 2016 and January 2019, 7 consecutive patients underwent NSM, lymph node surgery and endoscopic direct-to-implant reconstruction using a small cosmetic axillary incision for breast cancer treatment in a single Institution. An operative rigid endoscope with working channel (Richard Wolf) was used to dissect the entire submuscular-subfascial pocket. The mean age of the patients was 42.8 years old (range: 36-49 years). The evaluation methods were clinical and photography-based assessments, as well as the BREAST-Q which was used to quantify patient satisfaction.

RESULTS

The average follow-up time was 9 months (range 3-22 months). Tumor-free margins were obtained in all cases. No tumor recurrence or metastasis occurred during follow-up. No major complications were experienced. There were no cases of malposition, wrinkling, or rippling. All patients were satisfied with their esthetic results, especially the absence of visible scars.

CONCLUSIONS

From our preliminary experience, NSM combined with endoscopic immediate reconstruction via axillary incision for breast cancer treatment seems to be a promising new procedure in cup A and B breasts alternative to the conventional techniques, as it allowed to have safe and pleasant aesthetic and oncologic outcomes.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

BACKGROUND

Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge.

METHODS

The ANISC collected SBA data by means of a survey sent to all Italian breast centres in the ANISC. The clinicopathological characteristics and the management of this disease were analysed.

RESULTS

Twenty-four centres participated in this survey in which 112 cases of SBA were analysed. The median age of the women with SBA was 68.9 years and it appeared approximately 90 months after the first irradiation for breast cancer. In 92% of cases, a mastectomy was performed without axillary dissection for those patients having a high grade of SBA (74.2%). The prognosis was worse in the high-grade cases (overall survival-OS: 36 months) as compared with the low-grade cases (OS: 48 months). After a follow-up of 5 years, 50.5% of the patients were still alive. Disease-free survival (DFS) was 35 months, and there were no differences between the groups of patients with either high- or low-grade histology.

CONCLUSIONS

Secondary breast angiosarcoma is a very aggressive disease associated with a short survival outcome. The surgical approach still remains an important step in the course of treatment; furthermore, an accurate histological examination is helpful in establishing the prognosis of the patient. A mastectomy is mandatory. A longer OS was observed in patients with low-grade angiosarcoma as compared to high-grade angiosarcoma (C.I. 40-57 vs. 31-41 months).

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.

Bilateral prophylactic mastectomy in BRCA mutation carriers: what surgeons need to know

Aim of this paper is to allows to analyze a topic of great relevance and media interest such as the role of prophylactic mastectomy in healthy women with BRCA mutation proposing to the surgeons some useful informations for decision-making. Less than 15% of all breast cancers are associated with germline genetic mutations. The majority of hereditary breast tumors are due to mutations in BRCA1 and BRCA2 genes that are responsible for only one third of hereditary cases. The risk estimates are extremely heterogeneous with a mean cumulative lifetime breast cancer risk of approximately 72% in BRCA1 and 69% in BRCA2 by age 80. The breast cancer is often bilateral and multicentric in BRCA mutation carriers. BRCA1 carriers have earlier-onset disease, particularly before age 50 and are more likely to develop aggressive triple-negative breast cancer than BRCA2 carriers or those who are BRCA mutation negative 1. Multiple strategies are effective in managing the risk of breast cancer in these women, including surveillance, chemoprevention, bilateral salpingo-oophorectomy and risk-reducing mastectomy. More intensive surveillance, including annual mammography and breast magnetic resonance imaging screening (commonly alternated every six months) beginning at age 25 or individualized based upon the earliest age of onset in the family, have significantly improved early detection of breast cancer among patients with deleterious BRCA mutations 1. The risk-reducing benefit of chemoprevention is not as well defined; chemopreventive strategies to reduce the risk of breast cancer have focused exclusively on prevention in high-risk women and involve the use of selective estrogen receptor modulators (SERMs) and aromatase inhibitors for breast cancer prevention. Only limited data are available regarding the preventive benefit of tamoxifene in BRCA mutations carriers 1. Risk-reducing bilateral salpingo-oophorectomy is recommended for BRCA mutation carriers by 35 to 40 or when childbearing is completed, or individualized based on age of onset of ovarian cancer in the family; bilateral salpingo-oophorectomy decreases the risk of both breast cancer and ovarian cancer in BRCA1 and BRCA2 mutation carriers and has also been associated with reduced all cause, breast cancer-specific, and ovarian cancer- specific mortality; risk-reducing bilateral salpingooophorectomy seems to offer an approximate 50% relative reduction in breast cancer risk 1. Prophylactic mastectomy provides the greatest reduction in risk of breast cancer development. In both retrospective and prospective observational studies, bilateral prophylactic mastectomy decreases the incidence of breast cancer by 90 percent or more in patients with BRCA mutation; it also is able to determine a variable gain in life expectancy compared to radiological surveillance; besides risk-reducing mastectomy allows to contain the strong anxiety and the fear of getting sick that often compromise the quality of life of BRCA mutation carriers 2. Prophylactic mastectomy could be technically performed in different ways. However, regarding the surgical technique, on the basis of current evidence, the gold standard seems to be represented by nipple-sparing mastectomy which, thanks to the preservation of the skin envelope and the nipple-areola complex, is able to optimize the oncological and aesthetic results. Nipple-sparing mastectomy provides superior cosmetic results. This procedure is usually performed through an inframmamary or radial or axillary incision where the skin is carefully dissected off the breast until all anatomic boundaries of the breast are reached and the gland in its entirety is excised. This technique does not seem to compromise the oncological/preventive efficacy compared to other types of mastectomy. In a multi-institution review of prophylactic 346 BRCA carriers undergoing either bilateral mastectomy or contralateral mastectomy with nipple- areola sparing there were no cases of breast cancer, whereas, based on models, 22 would have been expected 3. However nipple-sparing mastectomy must be carried out with technical skill and maximum attention not to leave macroscopic residues of mammary gland in particular in the axillary extension, peripheral extremities of the gland and the nipple-areola complex; it is necessary to perform an accurate dissection and a meticulous preparation of the skin flaps and of the areola-nipple complex which must be reasonably thin without however compromising its vitality. Whenever the patients opt to proceed with bilateral prophylactic mastectomy, an accurate preoperative radiological study should always be performed with mammography, ultrasound and magnetic resonance imaging to rule out the presence of suspicious breast lesions and minimize the risk of occult carcinomas by definitive histological examination. In the absence of contraindications, all patients should be candidates for breast reconstruction in order to minimize the negative physical and psychological impact of the mastectomy; the breast reconstruction should preferably be immediate, performed at the same time of the prophylactic mastectomy, by a team of dedicated plastic surgeons, or with permanent prosthesis or autologous tissues; the choice of the most appropriate reconstructive technique depends on various factors such as the physical/anatomical structure of the woman, the morphology/ degree of breast ptosis, the comorbidities but also the patient's wishes and preferences 1. However, in the discussion on the possibility of carrying out a prophylactic mastectomy, it is always necessary to consider a series of issues related to this procedure: - the possible oncological failure because risk-reducing mastectomy does not completely eliminate the risk of developing breast cancer; there is always a residual risk of about 5% to be related to the possible presence of residual glandular tissue or ectopic breast tissue 2; - the surgical morbidity with overall complication rates of 15-20% such as ischemia of the skin and/or of the areola-nipple complex, haematomas, infections, implant failure, partial/total autologous flap loss; in a considerable percentage of cases there is also the need to resort after the prophylactic mastectomy to further aesthetic/ plastic procedures to correct some imperfections or repair surgical complications 3-5; - the presence of sequelae such as the loss of sensitivity of the areola-nipple complex, possible paresthesias, painful sensations and the need for re-adaptation to a different body image 2; - the possible body image issues due to many factors, such as self-consciousness, feeling less sexually attractive and dissatisfaction with the scars 2,3. In addition to these issues we must add that most of the studies that show a gain in life expectancy thanks to prophylactic mastectomy, are based only on mathematical models and that the few prospective cohort studies often do not show a statistically significant improvement in terms of survival among women undergoing MP and intensive radiological surveillance 1,2. Therefore in consideration of the benefits but also of the problems that the prophylactic mastectomy involves, all the international guidelines highlight that this procedure must be considered, must be discussed with healthy BRCA women, however without giving an absolute recommendation to perform it 1. This discussion must take place, case by case, in specialized breast centers with a dedicated risk team. A personalized multidisciplinary path should guarantee an accurate genetic and clinical counselling, adequate psychological support and detailed information about all alternative risk management strategies. Clinical decision-making about strategies to pursue for breast cancer risk reduction should involve a tradeoff between life expectancy and quality of life. However if the patient and the medical team opt to proceed with prophylactic surgery, the cumulative evidence to date supports nipple sparing mastectomy with immediate reconstruction as an appropriate risk-reducing procedure to optimize the oncological and aesthetic results and improve quality of life.

A Feasibility Study of Neo-Adjuvant Low-Dose Fractionated Radiotherapy with Two Different Concurrent Anthracycline-Docetaxel Schedules in Stage IIA/B-IIIA Breast Cancer

Aims and Background

The aim of the study was to evaluate the feasibility of neoadjuvant low-dose fractionated radiotherapy, in combination with two anthracycline-docetaxel regimens, in breast cancer treatment.

Materials and Methods

Women with stage IIA/B-IIIA breast cancer were assigned to receive the treatment of low-dose fractionated radiotherapy (0.4 Gy/per fraction, 2 fractions per day, for 2 days, every 21 days for 8–6 cycles) with concomitant neoadjuvant chemotherapy with non-pegylated liposomal doxorubicin and docetaxel. Two chemotherapy schedules were planned to be combined with low-dose fractionated radiotherapy. The first schedule consisted of four cycles of non-pegylated liposomal doxorubicin sequentially followed by four cycles of docetaxel, and the second schedule consisted of six cycles of non-pegylated liposomal doxorubicin plus concomitant docetaxel. Acute toxicity was evaluated according to the Radiation Therapy Oncology Group score system. Pathological response was evaluated by the Mandard score and expressed as tumor regression grade.

Results

Between March 2008 and February 2009, 10 patients underwent low-dose fractionated radiotherapy and concomitant chemotherapy. No grade 3–4 breast toxicity was observed. Five patients had a clinical complete response. Seven patients underwent conservative surgery. Overall, tumor regression grade 1 (absence of residual cancer) was achieved in one patient (10%) and grade 2 (residual isolated cells scattered through the fibrosis) in 4 patients (40%). The pathologic major response rate (tumor regression grade 1 + 2) was 20% in patients receiving low-dose fractionated radiotherapy and sequential non-pegylated liposomal doxorubicin and docetaxel and 80% in the group receiving low-dose fractionated radiotherapy and concurrent non-pegylated liposomal doxorubicin and docetaxel treatment.

Conclusions

Concomitant low-dose fractionated radiotherapy combined with anthracycline and docetaxel is feasible. The toxicity profile of radio-chemotherapy was similar to that of chemotherapy alone: there was no acute skin or cardiac toxicity. The concurrent application of liposomal doxorubicin and docetaxel with low-dose fractionated radiation led to higher histological response rates compared to the sequential application of the same two drugs.

The professional quality criteria of Italian breast screening radiologists: results from a national survey comparing the programmes started in 2000-2012 versus the ones started in 1990-1999

INTRODUCTION

In Italy, due to increasing healthcare budget and staff shortages, the recently created regional mammography screening programmes were established under worse radiology practice quality criteria than the previously created programmes.

METHODS

Using available data from a national questionnaire survey conducted at the end of 2013 and involving 222 responder radiologists, we compared the main professional quality standards of radiologists working in the screening programmes established during the period 2000-2012 with those working in the screening programmes created from 1990 to 1999.

RESULTS

The former reported more years of clinical experience in breast imaging and a greater clinical mammogram reading volume than the latter. Conversely, they dedicated less working time to breast imaging, were less likely to participate in the diagnostic assessment of screen-detected lesions, to work in large-staffed screening centres, and to have a screening and a total mammogram reading volume (SMRV and TMRV) ≥ 5000 per year.

CONCLUSIONS

The level of most professional quality criteria of Italian mammography screening radiologists has decreased over time. As SMRV and TMRV are important predictors of diagnostic accuracy, we can expect a lower interpretation performance of radiologists working in the recently created screening programmes.

Anti-Müllerian hormone as an ovarian reserve marker in young cancer women who undergo ovarian tissue cryopreservation

AIM

To evaluate if anti-Müllerian hormone (AMH) is a reliable marker of ovarian reserve in young women undergoing ovarian tissue cryopreservation.

PATIENTS & METHODS

Relationships of serum AMH levels with primordial follicle density, age and reproductive hormones were investigated using the Pearson or Spearman correlation coefficient in 86 women with cancer (12-38 years) undergoing ovarian tissue cryopreservation. AMH variations through the menstrual cycle were assessed by the Kruskal-Wallis test. p < 0.05 was accepted as significant.

RESULTS

AMH positively correlated with primordial follicle density (p = 0.03), showed great interindividual variability at all ages and negatively correlated with estradiol (p = 0.007) in the early follicular phase. AMH did not vary across the menstrual cycle (p = 0.415).

CONCLUSION

AMH appears a valid ovarian reserve marker in young cancer women.

Role of the Apparent Diffusion Coefficient in the Prediction of Response to Neoadjuvant Chemotherapy in Patients With Locally Advanced Breast Cancer

BACKGROUND

We evaluated the diagnostic performance of the baseline diffusion weighted imaging (DWI) and the apparent diffusion coefficient (ADC) in the prediction of a complete pathologic response (pCR) to neoadjuvant chemotherapy (NAC) in patients with breast cancer stratified according to the tumor phenotype.

PATIENTS AND METHODS

We retrospectively studied 225 patients with stage II, III, and IV breast cancer who had undergone contrast-enhanced magnetic resonance imaging (MRI) and DWI before and after NAC, followed by breast surgery.

RESULTS

The tumor phenotypes were luminal (n = 143; 63.6%), triple-negative (TN) (n = 37; 16.4%), human epidermal growth factor receptor 2 (HER2)-enriched (n = 17; 7.6%), and hybrid (hormone receptor-positive/HER2(+); n = 28; 12.4%). After NAC, a pCR was observed in 39 patients (17.3%). No statistically significant difference was observed in the mean ADC value between a pCR and no pCR in the general population (1.132 ± 0.191 × 10(-3) mm(2)/s vs. 1.092 ± 0.189 × 10(-3) mm(2)/s, respectively; P = .23). The optimal ADC cutoff value in the general population was 0.975 × 10(-3) mm(2)/s (receiver operating characteristic [ROC] area under the curve [AUC], 0.587 for the prediction of a pCR). After splitting the population into subgroups according to tumor phenotype, we observed a significant or nearly significant difference in the mean ADC value among the responders versus the nonresponders in the TN (P = .06) and HER2(+) subgroups (P = .05). No meaningful difference was seen in the luminal and hybrid subgroups (P = .59 and P = .53, respectively). In contrast, in the TN and HER2(+) subgroups (cutoff value, 0.995 × 10(-3) mm(2)/s and 0.971 × 10(-3) mm(2)/s, respectively), we observed adequate ROC AUCs (0.766 and 0.813, respectively).

CONCLUSION

The pretreatment ADC value is not capable of predicting the pCR in the overall population of patients with locally advanced breast cancer. Nonetheless, an ameliorated diagnostic performance was observed in specific phenotype subgroups (ie, TN and HER2(+) tumors).

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.

MRI evaluation of neoadjuvant low-dose fractionated radiotherapy with concurrent chemotherapy in patients with locally advanced breast cancer

OBJECTIVES

We address the diagnostic performance of breast MRI and the efficacy of neoadjuvant radiochemotherapy (NRC) treatment (NRC protocol) vs conventional neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer.

METHODS

The NRC protocol consists of six anthracycline/taxane cycles and concomitant low-dose radiotherapy on breast tumour volume. Breast MRI was performed at baseline and after the last therapy cycle in 18 and 36 patients undergoing the NRC protocol or conventional NAC (propensity matching).

RESULTS

In both groups, we observed reduced tumour dimensions after the last cycle (p<0.001), and the response evaluation criteria in solid tumours (RECIST) class directly correlated with the tumour regression grade class after the last cycle (p<0.001). Patients in the NRC group displayed a higher frequency of complete/partial response than those in the NAC group (p=0.034). 17 out of 18 patients in the NRC group met the criteria for avoiding mastectomy based on final MRI evaluation. The RECIST classification displayed a superior diagnostic performance in the prediction of the response to treatment [area under the receiver operating characteristic curve (AUC)=0.72] than time-to-intensity curves and apparent diffusion coefficient (AUC 0.63 and 0.61). The association of the three above criteria yielded a better diagnostic performance, both in the general population (AUC=0.79) and in the NRC and the NAC group separately (AUC=0.82 and AUC=0.76).

CONCLUSIONS

The pathological response is predicted by MRI performed after the last cycle, if both conventional MRI and diffusion imaging are integrated. The NRC treatment yields oncological results superior to NAC. Advances in knowledge MRI could be used to establish the neoadjuvant protocol in breast cancer patients.

A feasibility study of neo-adjuvant low-dose fractionated radiotherapy with two different concurrent anthracycline-docetaxel schedules in stage IIA/B-IIIA breast cancer

AIMS AND BACKGROUND

The aim of the study was to evaluate the feasibility of neoadjuvant low-dose fractionated radiotherapy, in combination with two anthracycline-docetaxel regimens, in breast cancer treatment.

MATERIALS AND METHODS

Women with stage IIA/B-IIIA breast cancer were assigned to receive the treatment of low-dose fractionated radiotherapy (0.4 Gy/per fraction, 2 fractions per day, for 2 days, every 21 days for 8-6 cycles) with concomitant neoadjuvant chemotherapy with non-pegylated liposomal doxorubicin and docetaxel. Two chemotherapy schedules were planned to be combined with low-dose fractionated radiotherapy. The first schedule consisted of four cycles of non-pegylated liposomal doxorubicin sequentially followed by four cycles of docetaxel, and the second schedule consisted of six cycles of non-pegylated liposomal doxorubicin plus concomitant docetaxel. Acute toxicity was evaluated according to the Radiation Therapy Oncology Group score system. Pathological response was evaluated by the Mandard score and expressed as tumor regression grade.

RESULTS

Between March 2008 and February 2009, 10 patients underwent low-dose fractionated radiotherapy and concomitant chemotherapy. No grade 3-4 breast toxicity was observed. Five patients had a clinical complete response. Seven patients underwent conservative surgery. Overall, tumor regression grade 1 (absence of residual cancer) was achieved in one patient (10%) and grade 2 (residual isolated cells scattered through the fibrosis) in 4 patients (40%). The pathologic major response rate (tumor regression grade 1 + 2) was 20% in patients receiving low-dose fractionated radiotherapy and sequential non-pegylated liposomal doxorubicin and docetaxel and 80% in the group receiving low-dose fractionated radiotherapy and concurrent non-pegylated liposomal doxorubicin and docetaxel treatment.

CONCLUSIONS

Concomitant low-dose fractionated radiotherapy combined with anthracycline and docetaxel is feasible. The toxicity profile of radio-chemotherapy was similar to that of chemotherapy alone: there was no acute skin or cardiac toxicity. The concurrent application of liposomal doxorubicin and docetaxel with low-dose fractionated radiation led to higher histological response rates compared to the sequential application of the same two drugs.

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.

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.

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.

Conservative and radical oncoplastic approches in the surgical treatment of breast cancer

In the attempt to optimise the balance between the risk of local recurrence and the cosmetic outcomes in breast surgery, new surgical procedures, so-called oncoplastic techniques, have been introduced in recent years. The term oncoplastic surgery refers to surgery on the basis of oncological principles during which the techniques of plastic surgery are used, mostly for reconstructive and cosmetic reasons. The advantage of the oncoplastic surgery for breast cancer is the possibility of performing a wider excision of the tumour with a good cosmetic result. Oncoplastic surgery is a broad concept that can be used for several different combinations of oncological surgery and plastic surgery: excision of the tumour by reduction mammoplasty, tumour excision followed by remodelling mammoplasty, mastectomy with immediate reconstruction of the breast and partial mastectomy with reconstruction. Careful patient selection and preoperative planning are key components for the success of any oncoplastic operation for breast cancer. Accurate preoperative evaluation of the clinical and biological features of the tumour as well as of the morphological aspects of the breast allow the surgeon to make a decision if a conservative or radical approach is preferable and select the most effective oncoplastic surgical technique. In this review we summarise the indications, advantages and limitations of several oncoplastic procedures.

Sentinel lymph node biopsy in women with pT1a or "microinvasive" breast cancer

The role of sentinel lymph node biopsy (SLNB) in pT1a and "microinvasive" breast cancer has not been extensively studied. We report our experience with SLNB in patients with "minimal" breast cancer to determine the incidence and type of SLN metastases, and to study the potential impact on their surgical or oncological management. Among some 3387 women operated upon for primary breast cancer who underwent sentinel lymph node biopsy at nine institutions participating in the Rome Breast Cancer Study Group, 251 were staged pT1a or pT1mic (7.4%). There were 13 cases of sentinel lymph node metastases identified in this group of patients (5.2%), seven macrometastases and six micrometastases. Additionally, ITC were diagnosed by immunohistochemistry in four cases (1.6%). The incidence of SLN metastases was 7/174 (4%) and 6/77 (7.8%) in patients with pT1a and pT1mic tumors, respectively (p=0.2). Age and histological grade were predictive factors for SLN metastases. Chemotherapy was seldom directed by axillary node status (8/38 patients). As the incidence of SLN metastases in these patients is very small, particularly in the pT1a group, the indications for even a minimally invasive procedure, such as sentinel lymph node biopsy, should be probably individualized.

Current controversies in the treatment of ductal carcinoma in situ of the breast

The incidence of ductal carcinoma in situ (DCIS), a noninvasive form of breast cancer, has increased markedly in recent decades, and DCIS now accounts for approximately 20% of breast cancers diagnosed by mammography. Laboratory and patient data suggest that DCIS is a precursor lesion for invasive cancer. Controversy exists with regard to the optimal management of DCIS patients. In the past, mastectomy was the primary treatment for patients with DCIS, but as with invasive cancer, breast-conserving surgery has become the standard approach. A mini-review of the management of ductal carcinoma in situ is presented, and the roles and dilemmas of surgery, radiotherapy and endocrine therapy are discussed.

Conservative treatment of the central breast cancer with nipple-areolar resection: an alternative oncoplastic technique

Conservative surgery with radiation therapy is the standard treatment for early-stage breast cancer. Nevertheless, the patients with subareolar breast cancer have been often excluded from breast-conserving surgery and treated with mastectomy because of the unacceptable cosmetic effect associated with the resection of the nipple-areola complex (NAC), as well as oncologic concerns about multicentricity or multifocality associated with these tumours. We show a conservative "oncoplastic technique" in which the resection of the central portion of the breast, including the NAC, can allow a wide excision of the tumour with uninvolved margins of resection and good cosmetic results.

[Progresses in the treatment of early breast cancer. A mini-review]

The treatment of breast cancer has undergone continuous and profound changes over the last three decades; breast conservation therapy has been progressively validated as a safe alternative to radical mastectomy for patients with early stage breast cancer. Several large trials have shown that overall survival time of patients treated with conservative surgery and axillary dissection followed by radiation therapy is equivalent to that of patients treated with modified radical mastectomy, with better cosmetic outcomes and acceptable rates of local recurrence. Improvements in diagnostic work-up and the wider diffusion of screening programs have allowed the detection of smaller, often non palpable tumours, furtherly facilitating the widespread use of tumour localization and breast conserving techniques. Since the removal of negative lymph nodes is useless, eventually harmful and plays no therapeutic role in breast cancer patients, techniques for staging of the axilla have also gradually evolved toward less aggressive approaches, such as lymphatic mapping and sentinel node biopsy. The introduction of "onco-plastic techniques", that combine the concepts of oncological and plastic surgery of the breast, achieve the goal of allowing more extensive excisions while improving the aesthetic results, and eventually patient's quality of life. The present work will highlight potential benefits as well as unresolved issues of the above mentioned therapeutic options, with special emphasis on technical aspects of conservative surgery in the treatment of early breast cancers.

Update in the treatment of locally advanced breast cancer: a multidisciplinary approach

Locally advanced breast cancer represents a wide variety of neoplasms and constitutes approximately 10%-20% of the newly diagnosed breast cancers. These cancers may have widely different clinical and biological characteristics. According to the American Joint Committee on Cancer (AJCC) staging system, all of stage III disease is considered locally advanced. The clinical treatment of locally advanced breast cancer is complex and should be tailored to the individual patient. In this paper we discuss the options of management of locally advanced breast cancer, focusing on a multidisciplinary approach through a combined-modality care involving surgery, radiotherapy and systemic therapy.

Management of locally advanced breast cancer. Mini-review

The term locally advanced breast cancer (LABC) encompasses a heterogeneous group of breast neoplasms; in the last revision of the American Joint Committee on Cancer (AJCC) staging system, all of stage III disease is considered locally advanced. LABC constitutes up to 20% of breast cancer in medically underserved populations in the United States and up to 75% of breast cancers in developing countries. The prognosis depends on tumor size, extent of lymph node involvement, and the presence or absence of an inflammatory component. The clinical management of LABC is complex and should be tailored to the individual patient. However, a multidisciplinary approach is always recommended combining surgery, radiotherapy and systemic therapy (chemotherapy and/or hormone therapy). In this paper, we discuss the possible options in the management of operable (stage IIIA) and inoperable (stage IIIB-IIIC) LABC.

[Sentinel lymph node biopsy in breast cancer. Experience of the Rome Breast Cancer Study Group]

We report our multicentric experience with sentinel lymph node biopsy for breast cancer patients. Patients with breast cancer operated on from January 1999 to March 2005 in 6 different institutions in the Rome area were retrospectively reviewed. All patients gave written informed consent. 1440 consecutive patients were analysed, with a median age of 59 years (range: 33-81) and a median tumour diameter of 1.3 cm (range: 0.1-5). Patients underwent lymphatic mapping with Tc99 nanocolloid (N = 701; 49%), with Evans Blue (N = 70; 5%), or with a combined injection (N = 669, 46%). The majority of patients were mapped with an intradermal or subdermal injection (N = 1193; 84%), while an intraparenchymal or peritumoral injection was used in 41 (3%) and 206 patients (13%), respectively. Sentinel lymph nodes were identified in 1374/1440 cases (95.4%), and 2075 sentinel lymph nodes were analysed (average 1.5/patient). A total of 9305 additional non-sentinel lymph-nodes were removed (median 6/patient). Correlations between sentinel lymph nodes and final lymph node status were found in 1355/1374 cases (98.6%). There were 19 false-negative cases (5%). Lymph node metastases were diagnosed in 325 patients (24%). In this group, micrometastases (< 2 mm in diameter) were diagnosed in 103 cases (7.6%). Additionally, isolated tumour cells were reported in 61 patients (4,5%). In positive cases, additional metastases in non-sentinel lymph-nodes were identified in 117/325 cases after axillary dissection (36%). Axillary dissection was avoided in 745/1440 patients (52%). At a median follow-up of 36 months, only 1 axillary recurrence has been reported. Sentinel lymph node biopsy improves staging in women with breast cancer because it is accurate and reproducible, and allows detection of micrometastases and isolated tumour cells that would otherwise be missed. Our multicentric study confirms that this is the preferred axillary staging procedure in women with breast cancer.

Oncoplastic techniques in the conservative surgical treatment of breast cancer: an overview

Conservative surgery has become a well-established alternative to mastectomy in the treatment of breast cancer. However, in case of larger lesions or small-size breasts, the removal of adequate volumes of breast tissue to achieve tumor-free margins and reduce the risk of local relapse may compromise the cosmetic outcome, causing unpleasant results. In order to address this issue, new surgical techniques, so-called oncoplastic techniques, have been introduced in recent years to optimize the efficacy of conservative surgery both in terms of local control and cosmetic results. This article discusses the indications, advantages, and limitations of these techniques and their results in terms of local recurrence and overall survival.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

Background

Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.

Case presentation

We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.

Conclusion

To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

A giant papillary carcinoma of the breast treated with mastectomy and bipedicled TRAM flap

Although the surgical treatment of breast cancer has become more conservative in the last decades, some patients still arrive at the first physical examination with advanced diseases and with large skin infiltration. We report an unusual case of giant invasive papillary carcinoma of the breast underwent mastectomy and reconstruction with a bipedicled transverse rectus abdominis myocutaneous (TRAM) flap.

Combined diagnostic imaging and management of a breast tumor in a young woman

The typical presentation of breast cancer in a young woman is discussed. Diagnostic imaging of the breast showed the presence of an extensive pathological area, approximately 5 cm in size, at the level of the upper quadrants of left breast. On mammography the pathological sign was represented by numerous regional granular microcalcifications. On sonography an inhomogeneously hypoechoic area with intralesional hyperechoic spots was identified. On MRI a large area of pathological enhancement was visualized. For the tumor extent and the patient's young age neoadjuvant chemotherapy was performed. Post-treatment assessment showed good response to therapy, suggestive of possible better prognosis.

Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy

BACKGROUND

The need to dissect axillary nodes in patients with early breast cancer and clinically negative axilla remains controversial. The aim of the study was to assess the role of axillary radiotherapy (RT) in reducing axillary metastases in patients with early breast cancer who did not receive axillary dissection.

PATIENTS AND METHODS

From 1995 to 1998, 435 patients over 45 years old with breast cancer up to 1.2 cm and no palpable axillary nodes were randomized 214 to breast conservation without axillary treatment and 221 to breast conservation plus axillary RT.

RESULTS

After a median follow-up of 63 months, overt axillary metastases were fewer than expected: three cases in the no axillary treatment group (1.5%) and one in the RT group (0.5%). Expected cases were 43 in the no axillary treatment group and 10 in the RT group. Rates of distant metastases and local failures were low, and 5-year disease free survival was 96.0% (95% confidence interval, 94.1%-97.9%) without significant differences between the two arms.

CONCLUSIONS

This study suggests that occult axillary metastases might never become clinically overt and axillary dissection might be avoided in patients with small carcinomas and a clinically negative axilla. Axillary RT seems to protect the patients from axillary recurrence almost completely.