Male breast cancer: a multicenter study to provide a guide for proper management.

INTRODUCTION: To offer an extensive retrospective experience on the management of male breast cancer. METHODS: A multicenter retrospective observational cohort study was conducted, including male patients diagnosed with breast cancer (invasive or in situ) in 12 Italian breast units from January 1975 to December 2019. Patients aged 18 years or older were assessed for eligibility. Exclusion criteria were metastatic cancer at diagnosis, previous cancer(s), received neoadjuvant treatment, incomplete data on (neo) adjuvant treatment(s), and/or follow-up data. Data on radiological examinations, demographic characteristics, risk factors, histological features, receptor status, treatments, and follow-up were collected. RESULTS: In a series of 671 male patients with breast cancer assessed for eligibility, 403 (28 in situ and 375 invasive neoplasms) were included in the study. All included patients underwent surgery. The median age at surgery was 63.8 years (IQR 56.1-72.1). In 68% of cases, patients underwent echography, and in 55.1%, a mammography. Most patients were ER and PR positive (63.8%), HER2 negative (80.4%), with high (≥ 20%) Ki67 values (61.3%), and luminal B subtype (51.1%). The 10-year overall survival was 73.6% (95% CI 67.0-79.1) for invasive breast cancer and 90% (95% CI 65.6-97.4) for in situ breast cancer. In patients with invasive breast cancer, at univariable analysis, having a G3 tumor (vs. G1), pT2/3/4 (vs. pT1), pN2/3 (vs. pN0), luminal B subtype with Ki67 ≥ 20% (vs. Luminal A), were significantly associated with a higher risk of death. In multivariable analyses, pT2/3/4 (vs. pT1) remained significantly associated with a higher risk of death (HR 3.14, 95% CI 1.83-5.39), and having a HER2 positive or a triple-negative subtype (vs. Luminal A) was also significantly associated with a higher risk of mortality (HR 4.76, 95% CI 1.26-18.1). CONCLUSION: Male breast cancer is a rare disease, the better understanding of which is necessary for a more effective diagnostic and therapeutic approach.

The Emergency Surgery Frailty Index (EmSFI) in Elderly Patients with Acute Appendicitis: An External Validation of Prognostic Score.

BACKGROUND: Identification of reliable risk-stratification tools is critical for surgical decision making, particularly in frail and elderly. The aim of the study is to validate the Emergency Surgery Frailty Index (EmSFI), in over 65 years old patients operated on for acute appendicitis. METHODS: An observational study was conducted enrolling elderly patients with diagnosis of acute appendicitis who underwent emergency appendicectomy or right colectomy, between 2016 and 2021. All patients were treated according to the last SIFIPAC/WSES/SICG/SIMEU guidelines. RESULTS: Overall, 61 patients were analyzed. Complication rate was higher for patients in the second EmSFI risk Class. Moreover, ROC analyses identified 3 as the best cutoff value in predicting risk of adverse postoperative events. Complication rate was higher in oldest elderly patients-over 80 years-(42.9 vs 22.5%; p 0.05) and was mainly related to medical complications (42.9 vs 12.5%, p 0.007). However, intestinal obstruction, peri-appendicular abscess on preoperative CT, peritonitis and a longer duration of surgery are related with increased risk of complications in the group of patients under 80 years. CONCLUSION: The EmSFI score results a valid prognostic marker for frailty status, and it may support the surgeon in emergency setting for acute appendicitis. Patients aged 80 years or older have a higher risk of complications, independent from those factors which relate to increased morbidity in younger elderly patients. Age alone is not a reliable indicator of the real surgical risk, but it must encourage the adoption of multidisciplinary collaborative models of care for this group of patients.

"Hook Shape" Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series.

INTRODUCTION: Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results. MATERIALS AND METHODS: From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases. RESULTS: Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results. CONCLUSION: The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II). LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Moderate-density parity-check codes from projective bundles.

New constructions for moderate-density parity-check (MDPC) codes using finite geometry are proposed. We design a parity-check matrix for the main family of binary codes as the concatenation of two matrices: the incidence matrix between points and lines of the Desarguesian projective plane and the incidence matrix between points and ovals of a projective bundle. A projective bundle is a special collection of ovals which pairwise meet in a unique point. We determine the minimum distance and the dimension of these codes, and we show that they have a natural quasi-cyclic structure. We consider alternative constructions based on an incidence matrix of a Desarguesian projective plane and compare their error-correction performance with regards to a modification of Gallager's bit-flipping decoding algorithm. In this setting, our codes have the best possible error-correction performance after one round of bit-flipping decoding given the parameters of the code's parity-check matrix.

Low-rank parity-check codes over Galois rings.

Low-rank parity-check (LRPC) codes are rank-metric codes over finite fields, which have been proposed by Gaborit et al. (Proceedings of the workshop on coding and cryptography WCC, vol 2013, 2013) for cryptographic applications. Inspired by a recent adaption of Gabidulin codes to certain finite rings by Kamche et al. (IEEE Trans Inf Theory 65(12):7718-7735, 2019), we define and study LRPC codes over Galois rings-a wide class of finite commutative rings. We give a decoding algorithm similar to Gaborit et al.'s decoder, based on simple linear-algebraic operations. We derive an upper bound on the failure probability of the decoder, which is significantly more involved than in the case of finite fields. The bound depends only on the rank of an error, i.e., is independent of its free rank. Further, we analyze the complexity of the decoder. We obtain that there is a class of LRPC codes over a Galois ring that can decode roughly the same number of errors as a Gabidulin code with the same code parameters, but faster than the currently best decoder for Gabidulin codes. However, the price that one needs to pay is a small failure probability, which we can bound from above.

The patient's pathway for breast cancer in the COVID-19 era: An Italian single-center experience.

COVID-19 has been declared a pandemic by the World Health Organization. As of April 1, 2020, Italy was the country with the second highest number of cases in the world. The spread of COVID-19 has required a rapid reorganization of health service delivery in face of the pandemic. Breast cancer units have reprioritized their workload to guarantee the health of oncologic patients at the highest risk and regular screening activities. However, at the end of the pandemic emergency, many benign and reconstructive cases will return to our attention and their surgical treatment will be necessary as soon as possible.

Preliminary design and characterization of a low-cost and low-power visible light positioning system.

Designs and results for a low-power and economical fingerprint visible light positioning (VLP) system are discussed in this paper. A system using four white LEDs and one photodiode was deployed. The LEDs are independently controlled and modulated by individual transmitter circuits, removing the requirement for a large, expensive signal generator. The receiver circuit filters and converts the received signal to DC, allowing a simple microcontroller to save the received signal. We propose the creation of a fingerprint database by recording signal data, fitting a two-dimensional Gaussian distribution to the data, and then generating the fingerprint database for all positions in the evaluation system. System positioning accuracy of 13.44+/-0.36 mm was observed, corresponding to a relative error of 2.8% with respect to the system dimensions. This result presents an improvement on positioning accuracy for fingerprint positioning VLP systems, which build their own transmitters.

"Clinical significance of multifocal and multicentric breast cancers and choice of surgical treatment: a retrospective study on a series of 1158 cases".

BACKGROUND: The biological and clinical significance of multifocal and multicentric (MF/MC) breast cancers and the choice of appropriate surgical treatment for these tumors are still debated. METHODS: 1158 women operated on for a stage I-III breast cancer were included in this retrospective study; clinical and pathological data were obtained from the institutional database of the Department of Oncology of the University of Siena, Italy. The impact of MF/MC breast cancers on patterns of recurrence and breast cancer specific survival (BCSS) was investigated in relation to the type of surgical treatment. RESULTS: MF and MC cancers were present in 131 cases (11.3%) and 60 cases (5.2%) respectively and were more frequently treated with mastectomy (55 MF and 60 MC cancers, 81.2%) than with breast conserving surgery (36 MF cancers, 18.9%; p < 0.001). MF and MC breast cancers were associated with a worse prognosis with a BCSS of 154 months compared to 204 months of unicentric cancers (p < 0.001). In multivariate analysis, MF/MC cancers were independent prognostic factors for BCSS together with higher number of metastatic axillary nodes, absence of estrogen receptors and high proliferative activity. MF and MC cancers were related to a significantly shorter BCSS in patients submitted to mastectomy as well as those submitted to breast conserving surgery. Relapse at any site was higher in the subgroup of MF and MC cancers but the incidence of loco-regional and distant recurrences did not differ between patients treated with mastectomy or breast conserving surgery. CONCLUSIONS: Our results indicate that MF/MC cancers have a negative impact on prognosis and are related to higher loregional and distant relapse independently from the type of surgery performed. Adjuvant therapies did not modify the poorer outcome, but in patients receiving adjuvant anthacyclines, the differences with unicentric tumors were reduced. Our data support the hypothesis that MF/MC tumors may have a worse biological behavior and that the presence of multiple foci should be considered in planning adjuvant treatments.

Gastro-pleuro-pericardial fistula following combined radiation and chemotherapy for lung metastases from renal cell carcinoma: report of a case.

Gastropleural and gastropericardial fistulas are abnormal communications between the stomach and the pleural cavity or pericardium. They are rare and life-threatening complications, which require prompt surgical intervention. We report the case of a gastro-pleuro-pericardial fistula that developed in a patient treated with radiotherapy and then Sunitinib (Sutent(®)), a novel tyrosine-kinase inhibitor, for lung metastases from renal cell carcinoma. To our knowledge, this is the first case of a gastro-pleuro-pericardial fistula developing as a consequence of combined radiation and chemotherapy.

Double Asymmetric Circular Incision, a New Skin-Sparing Mastectomy Technique: Results and Outcomes of the First 46 Procedures.

SUMMARY: Skin-sparing mastectomy (SSM) is a surgical technique that preserves as much of the breast skin as possible. Double asymmetric circular incision (DACI) is a novel immediate breast reconstruction technique for immediate prepectoral implant placement using a titanium-coated polypropylene mesh. The aim of this technique is to optimize the cosmetic benefits of smaller incisions, preserve breast anatomy, avoid breast deformities, and reduce the negative psychological impact on the patient without increasing local recurrence risk. DACI SSM uses a double circular incision: the external drawing contains the nipple-areola complex, while the inner circular skin island is used to provide the skin for the new areola. The authors performed DACI SSM in patients with tumors located within 2 cm of the nipple-areola complex, or in patients with multicentric lesions involving areolar tissue. Forty-six patients underwent DACI SSM at the authors' institutions between February of 2014 and July of 2019. Two patients developed hematoma, and one patient developed seroma. No implant loss was observed. Skin flap necrosis rate was 0%. The BREAST-Q patient-reported outcomes measure was routinely used at the authors' institutions and recorded good aesthetic outcomes and high patient satisfaction. This new technique appears to be safe and easily reproducible in patients with small to medium-sized breasts and with little to moderate ptosis (up to Regnault classification grade II). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

New safer management for breast cancer patients who need neoadjuvant therapy during SARS-COVID pandemic.

During the first hit of SARS-COVID pandemic, an important reorganization of Healthcare Services has been done, and new protocols and pathways to protect frail patients like oncological patients were designed. The second hit of pandemic had stressed these new pathways and suggests to health-workers some improvements for safer management of patents.We reported our experience in organizing the clinical pathway of neoadjuvant therapy candidate patients based on the execution of sentinel lympho-node biopsy and the placement of implantable venous access port in the same access to operating room before neoadjuvant chemotherapy suggesting a possible organizational model. In the period October-December 2020 we have included in this new type of path twelve patients and we have not registered any cases of COVID among the patients included. We think this new path, adopted amid the second hit, will be useful for all Breast Units that are facing the challenge of guaranteeing the highest standards of care in a historical moment where the health emergency occupies the efforts of health workers and the economic resources of health systems.

Derivation of harmonised high-level safety requirements for self-driving cars using railway experience.

The development and manufacture of self-driving cars (SDCs) have triggered unprecedented challenges among car manufacturers and smart road operators to accelerate awareness and implementation of innovative technologies for cooperative, connected and automated mobility (CCAM), especially those with a high level of automation and safety. Safety improvement is a pre-requisite to justify and unleashing a mass deployment of connected and driverless cars to reach the goal of zero-accident in 2050 set by the European Commission. Behind these motivations a well-justified and widely acceptable high-level safety target for SDCs is mandatory. The aim of this article is to contribute to the derivation of an harmonised high-level safety target for SDCs, starting from the safety requirements and the state of the art achieved by train and airplane operations. The novelty of our approach is to leverage the Common Safety Method-Design Targets (CSM-DT) already adopted and widely accepted by the railway community. According to this approach, the derived, justified and harmonised high-level design safety target for SDCs, defined as the average probability of a dangerous failure PFSDC per 1 h, should be 1 × 10-7/h. An example of PFSDC allocation to individual SDC safety functions, including position determination based on Global Navigation Satellite System (GNSS), is described using a fault tree. The proposed methodology can speed up the validation and certification process needed to authorise the SDCs, by capitalising the know-how and best practices in use since many years for the train management.

Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review.

Surgical site infection occurs with high frequency in gastrointestinal surgery, contributing to the high incidence of morbidity and mortality. The accepted practice worldwide for the prevention of surgical site infection is providing single- or multiple-dose antimicrobial prophylaxis. However, most suitable antibiotic and optimal duration of prophylaxis are still debated. The aim of the systematic review is to assess the efficacy of antimicrobial prophylaxis in controlling surgical site infection rate following esophagogastric surgery. PubMed and Cochrane databases were systematically searched until 31 October 2021, for randomized controlled trials comparing different antimicrobial regimens in prevention surgical site infections. Risk of bias of studies was assessed with standard methods. Overall, eight studies concerning gastric surgery and one study about esophageal surgery met inclusion criteria. No significant differences were detected between single- and multiple-dose antibiotic prophylaxis. Most trials assessed the performance of cephalosporins or inhibitor of bacterial beta-lactamase. Antimicrobial prophylaxis (AMP) is effective in reducing the incidence of surgical site infection. Multiple-dose antimicrobial prophylaxis is not recommended for patients undergoing gastric surgery. Further randomized controlled trials are needed to determine the efficacy and safety of antimicrobial prophylaxis in esophageal cancer patients.

Controlateral Symmetrisation in SRM for Breast Cancer: Now or Then? Immediate versus Delayed Symmetrisation in a Two-Stage Breast Reconstruction.

Introduction: The timing of contralateral symmetrisation in patients with large and ptotic breasts undergoing a unilateral skin-reducing mastectomy (SRM) is one of the most debated topics in the reconstructive field. There is no evidence to support the advantage of immediate or delayed symmetrisation to help surgeons with this decision. The aim of this study was to investigate the clinical and aesthetic outcomes of immediate symmetrisation. Methods: A randomised observational study was conducted on patients who underwent an SRM for unilateral breast cancer. Based on a simple randomisation list, patients were divided into two groups: a delayed symmetrisation group versus an immediate symmetrisation group. The postoperative complications, BREAST-Q outcomes and reoperations were compared. Results: Out of a total of 84 patients undergoing an SRM between January 2018 and January 2021, 42 patients underwent immediate symmetrisation and 42 patients had delayed symmetrisation. Three implant losses (7.2%) were observed and we reported three wound dehiscences; one of these was in a contralateral breast reconstruction in the immediate symmetrisation group. The BREAST-Q patient-reported outcome measures recorded better aesthetic outcomes and a high patient satisfaction for the immediate symmetrisation group. Conclusions: Simultaneous controlateral symmetrisation is a good alternative to achieve better satisfaction and quality of life for patients; from a surgical point of view, it does not excessively impact on the second time of reconstruction.

Optimization of Prepectoral Breast Reconstruction.

INTRODUCTION: Acellular dermal matrix (ADM) were introduced in the early 2000s and more recently permitted new protocols for breast reconstruction allowing a short operative time with improved outcomes until the new muscle-sparing breast reconstruction proposed in 2014 using the Braxon® ADM. The aim of this research is to propose a technique to improve the aesthetic outcome using Braxon ADM with prepectoral implants. MATERIALS AND METHODS: The enrolled patients were submitted to a nipple skin-sparing mastectomy leaving 1 additional centimeter of subcutis on the proximal part of the upper pole of the breast (see Surgical Technique). Aesthetic outcomes were compared to those obtained with traditional breast reconstruction with prosthesis and the Braxon ADM placed in the prepectoral space. Mean values of aesthetic outcomes were analyzed using the Student t test, and the κ test was used to analyze interobserver variability. RESULTS: The overall aesthetic score was improved of 29.6% of the patients; in particular the most improved score was that for contour (+98.01%). Statistical significance was found for contour, upper pole definition, and total score average (p < 0.05). The κ test showed interobserver variability with a good level of agreement on contour (κ = 0.832). CONCLUSIONS: The proposed technique has allowed attainment of good results in terms of aesthetic outcomes. In a small sample we did not register any particular complications but we verified a better satisfaction on the evaluation of the aesthetic result (level of evidence: 3).

A rare case of primary small bowel adenocarcinoma with intussusception.

Other than in childhood, intussusception is unusual and nearly always caused by a structural and well demonstrable lesion. In contrast with the colon tract, the incidence of primary malignancies in the small bowel is very low. We report the case of a 51-year-old man presenting with jejunal intussusception due to a primary adenocarcinoma. To our knowledge, only a few similar cases have been reported in the literature to date. The patient was referred to our division for bowel obstruction. A CT scan showed a jejunal intussusception and surgical exploration was hence considered. At laparotomy, jejunal intussusception located just after the ligament of Treitz due to a polypoid lesion was confirmed and resection of the first jejunal loop was carried out. Histological examination of the specimen resulted in a diagnosis of a primary adenocarcinoma of the small bowel. In adult intestinal intussusception, resection without reduction is considered the optimal management if an underlying primary malignancy cannot be excluded.

Robotic versus laparoscopic gastrectomy for gastric cancer: protocol for umbrella review of systematic reviews and meta-analyses.

INTRODUCTION: Laparoscopic surgery has been adopted in some parts of the world as an innovative approach to the resection of gastric cancers. However, in the modern era of surgical oncology, to overcome intrinsic limitations of the traditional laparoscopy, the robotic approach is advocated as able to facilitate the lymph node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer patients. Previous meta-analyses highlighted a lower complication rate as well as bleeding in the robotic approach group when compared with the laparoscopic one. This potential benefit must be balanced against an increased time of intervention. The aim of this umbrella review is to provide a comprehensive overview of the literature for surgeons and policymakers in order to evaluate the potential benefits and harms of robotic gastrectomy (RG) compared with the laparoscopic approach for gastric cancer. METHODS AND ANALYSIS: We will perform a comprehensive search of the PubMed, Cochrane and Embase databases for all articles published up to May 2019 and reference list of relevant publications for systematic review and meta-analyses comparing the outcomes of RG and laparoscopic gastrectomy in patients with gastric cancer. Studies will be selected by two independent reviewers based on prespecified eligibility criteria and the quality will be assessed according to AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist. All information will be collected using piloted and standardised data-extraction forms in DistillerSR developed following the Joanna Briggs Institute's recommended extraction items. ETHICS AND DISSEMINATION: This umbrella review will inform clinical and policy decisions regarding the benefits and harms of RG for treating gastric cancer. The results will be disseminated through a peer-reviewed publication, conference presentations and the popular press. Formal ethical approval is not required as primary data will not be collected. PROSPERO REGISTRATION NUMBER: CRD42019139906.

Clinical evaluation of the Mannheim Prognostic Index in post-operative peritonitis: a prospective cohort study.

Postoperative peritonitis (PoP), despite their relatively low incidence, are associated with high mortality. Such poor outcomes are also related to the high proportion of aged patients, whose intra-abdominal infections are difficult to manage. The study included 84 consecutive patients with PoP. The aim was the validation of the Mannheim Prognostic Index (MPI) in the context of PoP and the assessment of the prognostic impact of age and other clinical factors in a large series from a tertiary center. PoP had an incidence of 3.9% in all the abdominal surgeries in the study period. Surgical control of POP focus was achieved in 90.5% of cases and a complete abdominal clearance in 58.3%. Complication rate was 75% with a mortality of 26.2%. For MPI score, the ROC curve indicated a cut-off value of 29 with a sensitivity of 72.7% and specificity of 67.7% in predicting death. At univariate analysis, factors significantly related to poorer prognosis included advanced age (p 0.001), site of primary surgery (p 0.05), lack of abdominal clearance (p 0.003), generalized peritonitis (p 0.04) and high MPI score (p < 0.001). Age, MPI score and absence of abdominal clearance resulted in independent prognostic factors at multivariate analysis. MPI showed good efficacy in identifying POP patients at high risk of death. The increased risk of mortality related to advanced age should be considered with MPI score in planning the treatment. An aggressive and early diagnostic-therapeutic approach is required to reduce the MPI score and improve the prognosis.

Different pathological features and prognosis in gastric cancer patients coming from high-risk and low-risk areas of Italy.

OBJECTIVE: To compare clinicopathological features and long-term outcome in gastric cancer patients coming from high-risk and low-risk areas of Italy. SUMMARY BACKGROUND DATA: Better survival rates have been reported from countries with higher incidence of gastric cancer. METHODS: Data regarding 829 patients coming from Tuscany (group A) and 143 patients coming from Southern Italy (group B) were analyzed. Mean follow-up time was 56 +/- 57 months; it was 85 +/- 63 months in surviving patients or not tumor-related deaths. Prognostic factors were investigated by multivariate analysis with Cox proportional hazard model after verifying the assumption of proportionality of the risk associated with covariates. RESULTS: Lauren diffuse-mixed histotype, younger age, extended lymphadenectomy, and advanced stages were more common in group B. Gastric cancer-related 10-year survival probability was 48% in group A versus 29% in group B (log-rank test: P < 0.001). By multivariate analysis, geographic area was confirmed as a significant prognostic factor (hazard ratio for group B vs. group A: 1.52, 95% confidence interval: 1.12-2.06, P = 0.006). The influence of this factor on long-term survival was independent from other clinical, surgical, and pathologic factors, and was notable in neoplasms involving the serosa (10-year survival probability: 15% in group A vs. 3% in group B, log-rank test: P = 0.005). CONCLUSIONS: Patients coming from low-risk area of Italy showed distinct pathologic features, more advanced stage, and worse prognosis when compared with patients coming from high-risk area. These findings may be indicative of different tumor biology, and may contribute to partly explain worldwide geographic variability in prognosis reported in different series.