Clipping a Positive Lymph Node Improves Accuracy of Nodal Staging After Neoadjuvant Chemotherapy for Breast Cancer Patients, but Does It Drive Management Changes?

BACKGROUND: Sentinel lymph node (SLN) biopsy for cN+ breast cancer patients after neoadjuvant chemotherapy (NAC) is controversial because the false-negative rate (FNR) is high. Identification of three or more SLNs with a dual tracer improves these results, and inclusion of a clipped lymph node (CLN) (targeted axillary dissection [TAD]) may be even more effective. METHODS: A retrospective, single-institution analysis of consecutive cN+ patients undergoing NAC from 2019 to 2021 was performed. Patients routinely underwent placement of a clip in the positive lymph node before NAC, and TAD was performed after completion of therapy. RESULTS: The study analyzed 73 patients, and the identification rate for CLN was 98.6% (72/73). A complete response in the lymph nodes was achieved for 43 (59%) of the 73 patients. Overall, the CLN was not a SLN in 18 (25%) of 73 cases, and for women who had one or two and those who had three or more SLNs identified, this occurred in 11 (32%) and 7 (21%) of 34 cases, respectively. Failure of SLN or TAD to identify a positive residual lymph node status after NAC occurred in 10 (15%) of 69 and 2 (3%) of 73 cases, respectively (p = 0.01). In four cases, a SLN was not retrieved (5.5%), and two of these cases had a positive CLN. In three cases, the CLN was the only positive node and did not match with a SLN, directing lymphadenectomy and oncologic management change in two cases. Therefore, 7 (10%) of 73 cases had a change in surgical or oncologic management with TAD. CONCLUSIONS: For a conservative axillary treatment in this setting, TAD is an effective method. It is more accurate than SLN alone and allows management changes. Further studies are warranted.

Intraoperative Examination of Retro-Areolar Margin is not Routinely Necessary During Nipple-Sparing Mastectomy for Cancer.

BACKGROUND: Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage. METHODS: Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting. RESULTS: Among 162 women operated in the study period, the presence of neoplastic cells within 2 mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1 mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2 mm was associated with radiological tumor-to-nipple distance less than or equal to 1 cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2 mm were not different. CONCLUSIONS: IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.

Nipple-Sparing Mastectomy After Neoadjuvant Chemotherapy: Definitive Results with a Long-Term Follow-Up Evaluation.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly used for women with breast cancer who are not candidates for conservative surgery. The authors previously reported satisfying results with NSM after neoadjuvant chemotherapy (NACT). METHODS: From 2010 to 2020, 1072 women underwent mastectomy at the authors' institution. In this group, 433 NSMs were performed (40%). The only contraindications to NSM were close proximity to the nipple-areola complex (NAC), bloody discharge, and Paget disease. RESULTS: In 112 cases involving 111 women, NSM followed NACT (group 1), whereas it was performed as primary surgery in 321 instances involving 306 women (group 2). At 5 years, local relapse was 7% in group 1 and 2% in group 2, although in the multivariate analysis, locoregional relapses (LRRs) did not differ between the two groups. An increased incidence of local relapse was associated with higher tumor stage (stage III; p = 0.046) and age younger than 51 years (p = 0.038). For 34 (30.3%) of the 111 women in group 1 with a pathologic complete response (pCR), no LRRs were recorded. Only one NAC recurrence was observed. Overall survival with each tumor stage did not differ between the two groups. No differences in complications were observed. Cosmetic results were satisfying in 83.8% of the cases and did not get worse after NACT. CONCLUSIONS: The study data definitively confirm that NSM is safe even after NACT, with good cosmetic results and complications comparable with those in the primary surgery setting. Tumor stage and age were the only independent factors for local relapse. Patients with pCR enjoyed optimal locoregional control.

Regret and Quality of Life After Mastectomy With or Without Reconstruction.

BACKGROUND: Mastectomy represents a deep burden for women with breast cancer. Very little is known about the psychological consequences over time and the quality of life (QoL) of women so treated, with or without breast reconstruction (BR). PATIENTS AND METHODS: A total of 709 patients underwent mastectomy with or without BR between 2002 and 2012 at one institution. Among 468 surviving patients, a 60-query QoL questionnaire on personal issues including some European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire items was presented either by email, letter, or telephone interview. RESULTS: Of those questioned, 328 patients participated, whereas 140 (30%) declined the invitation or were unavailable. The median age was 63 years (range, 30-93 years). Stage I or II of disease was recorded in 73% of patients. Immediate BR was performed in 168 (51%) of 328 patients. Of the remaining patients, only 7 (4%) of 160 proceeded to delayed BR. Younger women had significantly worse Emotional Functioning and Social Functioning (SF) scores (P < .001), independently of tumor stage, and immediate BR improved that (P = .02). SF score was also worsened by chemotherapy (P = .03). Cognitive Functioning score was independent of age, BR, stage, or adjuvant therapies. Body Image and Sexual Functioning scores improved with BR (P < .03), and age was a strong co-variable (P < .001). On multivariate analysis, immediate BR was correlated with age and preoperative plastic surgery consultation. Some 68 (21%) of 328 patients regretted their decision or were disappointed with their choice regarding BR. CONCLUSIONS: Younger patients with breast cancer report a worse impact on their Emotional Functioning and SF scores after mastectomy, both of which are improved by BR. Reconstructing the breast at the time of mastectomy has a significant impact on Body Image and Sexual Functioning scores. A preoperative plastic surgeon consultation improves the rate of immediate BR, whereas delayed reconstruction is rarely adopted. Some 20% of patients are disappointed in or regret their decision regarding BR. We need to improve our management in consideration of these findings.

Immediate Breast Reconstruction after mastectomy with polyurethane implants versus textured implants: A retrospective study with focus on capsular contracture.

BACKGROUND: Capsular contracture (CC) is the most common complication following Immediate Breast Reconstruction (IBR) with breast implants. Different implant surfaces were developed aiming to reduce the incidence of CC. We evaluated the incidence and degree of CC after Direct-to-Implant (DTI) IBR with insertion of textured (TE) or polyurethane (PU) covered implants. METHODS: A retrospective review of consecutive patients treated at our Institution with mastectomy and one-stage IBR and implant reconstruction between 2013 and 2018, with or without post mastectomy radiation therapy (PMRT), was conducted. Immediate breast reconstruction was performed by implanting 186 PU covered implants and 172 TE implants. RESULTS: Three-hundred-twelve women underwent 358 DTI IBR with PU or TE implants, were analyzed with a median follow-up time of 2.3 years (range 1.0-3.0). The overall rate of CC Baker grade III and IV was 11.8% (95%CI: 8.4-16.3), while, after PU and TE implant placement it was 8.1% (95% CI: 4.1-15.7) and 15.8% (95% CI: 4.1-15.7) [p = 0.009]), respectively. Irradiated breasts developed CC more frequently rather than non-irradiated breasts (HR = 12.5, p < 0.001), and the relative risk was higher in the TE group compared with the PU group (HR = 0.3, p = 0.003). CONCLUSIONS: After mastectomy and one-stage IBR, the use of PU covered implants is associated with a lower incidence of CC compared to TE implants. This advantage is amplified several folds for patients who necessitate PMRT. Footnote: Capsular contracture (CC); Immediate Breast Reconstruction (IBR); Directto- Implant (DTI); Textured (TE); Polyurethane (PU); Post mastectomy radiation therapy (PMRT); Nipple Sparing mastectomy (NSM).

Direct-To-Implant and 2-Stage Breast Reconstruction After Nipple Sparing Mastectomy: Results of a Retrospective Comparison.

Breast reconstruction after nipple sparing mastectomy (NSM) plays, nowadays, a fundamental role in breast cancer management. There is no consensus on the best implant-based reconstruction technique, considering 2 stages (expander-prosthesis) or direct-to-implant (DTI). A retrospective review of consecutive adult female patients who underwent NSM with breast reconstruction over a 3-year period (January 2013 to December 2015) was performed. Patients were divided into 2 groups according to the type of reconstruction: expander/prosthesis (group A) and DTI (group B). Anamnestic data were collected. Number and type of procedures, complications and esthetic satisfaction were registered and compared. Fifty-six patients were included in group A (34.6%) and 106 in group B (65.4%). Complications associated with the 2 types of breast reconstruction were not different (P = 0.2). Patients in group A received a higher number of total surgical procedures (considering revisions, lipostructures and contralateral symmetrizations) than those in group B (2.5 ± 0.69 and 1.88 ± 1.02, P = 0.0001). Satisfaction with breast reconstruction resulted higher in group A (7.5 ± 2.6 and 6 ± 1.9, P = 0.0004). At the multivariate analysis, chemotherapy and radiotherapy were not correlated with complications, regardless of the group (odds ratio, 0.91 and 2.74, respectively). Radiotherapy and chemotherapy did not even influence the esthetic result, regardless of the group (P = 0.816 and P = 0.521, respectively). Prosthetic breast reconstructions, both in a single and in 2 stages, are welcomed by patients and have relatively low and almost equivalent complication rates, independent of other factors such as chemotherapy, radiotherapy, lymphadenectomy, smoking and age. In our experience, 2-stage breast reconstruction, although requiring more operations, is associated with a higher esthetic satisfaction. Patients who perform a DTI breast reconstruction after NSM should be informed of the high probability of surgical revision.

Surgical delay may extend the indications for nipple-sparing mastectomy: A multicentric study.

INTRODUCTION: Nipple-sparing mastectomy (NSM) is considered an oncologically sound procedure but necrosis of the nipple-areola complex (NAC) or skin flaps is a concern, particularly in the presence of risk factors. To increase the indications for NSM and decrease such complications, different procedures of "surgical delay" (SD) have been described. MATERIALS AND METHODS: A retrospective analysis of patients who underwent SD for NSM at four Italian Breast Centers from 2014 to 2017 was performed. SD generally consisted of a periareolar or "hemi-batwing" incision, dissecting the skin and the NAC from the underlying breast tissue. NSM was scheduled after 2-3 weeks. RESULTS: Eighty-eight procedures were analyzed. Mild complications of SD were registered in 7.9% of cases. NSM was performed in 85 cases, whereas in three cases (3.4%) a "skin-sparing" mastectomy was necessary due to positivity of the retroareolar biopsy for cancer at SD. A direct-to- implant (DTI) reconstruction was performed in 42 cases (49.4%), while in 43 (50.6%) a tissue-expander (TE) was inserted. After NSM, eight complications (9.4%) were recorded: one total necrosis (1.2%), one partial necrosis (1.2%) and four minimal ischemia (4.7%) of NAC, one skin flap necrosis (1.2%), one haematoma (1.2%). In only two cases (2.3%) prosthesis removal was needed. Aesthetic outcome was evaluated excellent or good in 92.9% of cases. At a median follow-up of 24 months no local recurrences were seen. CONCLUSION: This is the largest series of SD with NSM presented so far in the literature. In our experience, SD extends indications for NSM in high-risk women.

Pleomorphic lobular carcinoma: is it more similar to a classic lobular cancer or to a high-grade ductal cancer?

BACKGROUND: Pleomorphic invasive lobular carcinoma (P-ILC) is an uncommon variety of invasive lobular carcinoma with aggressive clinical features. Little is described in the literature regarding this topic. MATERIALS AND METHODS: We reviewed our experiences from 2010 to 2015 and compared 40 patients with P-ILC, 126 patients with classic-ILC (C-ILC) and 574 cases of high-grade invasive ductal carcinoma (HG-IDC). We studied the histologic and immunohistochemical features, clinical presentation and surgical treatment. RESULTS: P-ILC is diagnosed at the same age and tumor diameter as those of the other two histologic types. It is associated more frequently with multiple lymph node metastases and high proliferative index, and HER2/neu is amplified in 10% of cases. In spite of sharing some histologic characteristics with C-ILC (same growth pattern, loss of E-cadherin expression, same genetic pathway), its clinical and pathologic features define an autonomous entity. Its surgical treatment is similar to those of C-ILC and HG-IDC. CONCLUSION: This is the first review comparing these three pathologic entities. Our findings may be useful in understanding this variety of invasive lobular carcinoma, and further studies are certainly needed in this field.

Neoadjuvant chemotherapy is not a contraindication for nipple sparing mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) has been recently implemented to improve cosmetic outcome after mastectomy, but it is rarely considered today after neoadjuvant chemotherapy (NCH). PATIENTS AND METHODS: Among 275 NSMs performed from January 2007 to January 2015, 186 cases, with a minimum follow-up of 12 months, were carried out for invasive or intraductal carcinoma. Patients were considered for NSM if there were no clinical and radiological evidence of invasion or close proximity (<1 cm) to the nipple-areola complex (NAC). We compared patients operated with NSM after NCH (Group I N = 51) with those who underwent primary surgery (Group II, N = 135). RESULTS: At a median follow-up of 35 months, 166/186 patients were alive and disease-free (89.7%). Three local relapses (1.6%) were observed, all in the skin flap outside the NAC in Group I: (6%; p < 0.01). No NAC recurrences have been recorded, in either group. Nipple loss due to full thickness necrosis or resection for insufficient margins was recorded in 31 cases (17%); 12 in Group I (24%) and 19 in Group II (14%) (P = 0.1). This event decreased by half in the second part of the study (21/93 vs 10/93) (P = 0.03). CONCLUSIONS: NSM after NCH is not associated with a statistically significant difference in terms of post-operative complications, total nipple loss for necrosis or margins, and results improve with experience. The loco-regional relapse rate was higher after NCH, yet it was consistent with traditional mastectomy in the high-risk setting. There is no need to avoid NSM after NCH for locally advanced cancers, if the retro-areolar margins of resection are clear at the time of surgery.

[The surgical tratment of the subperitoneal rectal cancer]. / Trattamento chirurgico del carcinoma del retto sottoperitoneale.

AIM: To value the results of "open" surgery with sphincter preservation, TME nerve-sparing, fast-track, without a protective stoma in a consecutive series of patients with subperitoneal rectal cancer (s.p.r.c.). MATERIALS AND METHODS: In January 1989, we started a prospective, non-randomized study designed to assess when a primary derivative stoma was warranted in a series of consecutive patients electively treated with open low and ultralow AR. The inclusion criteria were: all patients with middle and low rectal cancer who underwent elective low and ultralow AR, including those treated with neoadjuvant therapy. The exclusion criteria were: urgent surgery, incomplete rings in the stapler, a positive hydropneumatic test, preoperative involvement of the external sphincter and/or surrounding structures by the tumor as demonstrated by CT-scan and endorectal MR and/or transrectal ultrasound. Anastomoses between 7 cm and 4 cm from the pectinate line were defined as low colo-rectal anastomoses, while anastomoses lower than 4 cm from the pectinate line were defined as ultralow anastomoses. A fistula or anastomotic dehiscence was suspected when pelvic and/or peritoneal pain, fever, leucocytosis, fecaloid liquid in the drainage and/or perianal erythematosus swelling were present. An anastomotic leak was confirmed by means of angio-CT and/or endoscopy and/or contrast enema depending on the procedure available most promptly. Signs of peritoneal reaction were considered to be indicative of a major dehiscence, regardless of the diameter of the fistula; when diagnosed, a transverse colostomy was immediately performed. Clinically less serious cases were defined as minor dehiscences, for which a "wait and see" strategy or a transcutaneous CT or ultrasound guided drainage of an abscess were used. Sixty-five patients were treated according to a fast-track postoperative protocol. RESULTS: Between 1998 and 2007, 89 patients with s.p.r.c. were treated according to a prospective protocol. One hundred and nineteen patients (69.6%) underwent low anastomoses and 52 patients (30.4%) underwent ultra low anastomoses. Forty-two (24.6%) were treated with traditional AR, 129 (75.4%) with AR and nerve-sparing TME. Forty-six (26.9%) patients underwent neoadjuvant therapy. One hundred and two patients underwent a mechanical end-to-end anastomosis, 67 a double stapled anastomosis, and 2 a colo-anal anastomosis at the pectinate line performed according to our technique. All 6 patients with major dehiscences underwent a protective colostomy within hours of the onset of clinical symptoms immediately after the radiologically- or endoscopically-confirmed diagnosis. The 7 minor dehiscences were successfully treated with conservative therapy (antibiotic and enteral feeding) using an out-patient regimen. Two (28.6%) required percutaneous drainage: one pelvic CT-guided drainage and the other (an ultralow dehiscence) perineal drainage. The 72.6% of the patients survived at 5-years follow-up. The incidence of local recurrences in 2-years followup was 3.2% (on 124 patients). We had no deaths in patients treated with fast-track protocol. CONCLUSION: Open, TME nerve-sparing A.R. with selective use of neoadjuvant therapy, can be successfully performed without a protective stoma in more than 80% of the patients. Fast-track protocol seems to increase quality of p.o. period and decrease hospital stay