Is routine axillary lymph node dissection needed to tailor systemic treatments for breast cancer patients in the era of molecular oncology? A position paper of the Italian National Association of Breast Surgeons (ANISC).

BACKGROUND: De-escalation of axillary surgery in breast cancer (BC) management began when sentinel lymph node biopsy (SLNB) replaced axillary lymph node dissection (ALND) as standard of care in patients with node-negative BC. The second step consolidated ALND omission in selected subgroups of BC patients with up to two macrometastases and recognized BC molecular and genomic implication in predicting prognosis and planning adjuvant treatment. Outcomes from the recent RxPONDER and monarchE trials have come to challenge the previous cut-off of two SLN in order to inform decisions on systemic therapies for hormone receptor-positive (HR+), human epidermal growth factor receptor type-2 (HER2) negative BC, as the criteria included a cut-off of respectively three and four SLNs. In view of the controversy that this may lift in surgical practice, the Italian National Association of Breast Surgeons (Associazione Nazionale Italiana Senologi Chirurghi, ANISC) reviewed data regarding the latest trials on this topic and proposes an implementation in clinical practice. MATERIAL AND METHODS: We reviewed the available literature offering data on the pathological nodal status of cN0 breast cancer patients. RESULTS: The rates of pN2 status in cN0 patients ranges from 3.5 % to 16 %; pre-surgical diagnostic definition of axillary lymph node status in cN0 patients by ultrasound could be useful to inform about a possible involvement of ≥4 lymph nodes in this specific sub-groups of women. CONCLUSIONS: The Italian National Association of Breast Surgeons (ANISC) considers that for HR + HER2-/cN0-pN1(sn) BC patients undergoing breast conserving treatment the preoperative workup should be optimized for a more detailed assessment of the axilla and the technique of SLNB should be optimized, if considered appropriate by the surgeon, not considering routine ALND always indicated to determine treatment recommendations according to criteria of eligibility to RxPONDER and monarch-E trials.

Non-Hodgkin Lymphoma Developed Shortly after mRNA COVID-19 Vaccination: Report of a Case and Review of the Literature.

We report on a 66-year-old man who presented with a right axillary lymphadenopathy approximately 10 days after receiving the third dose of the BNT162b2 vaccine. The lymphadenopathy gradually enlarged, and physical examination and ultrasound (US) revealed one right axillary 6.99 cm and one right supraclavicular 2.36 cm lymphadenopathy. Histologic examination of the right axillary nodule revealed anaplastic large-cell lymphoma that was ALK negative and CD30 positive. A total body computerized tomography (CT) scan, positron emission tomography (PET) and bone-marrow biopsy showed a stage-II non-Hodgkin lymphoma (NHL). The patient was treated with chemotherapy and a scheme of Brentuximab Vedotin, Cyclophosphamide, Doxorubicin and Prednisone (BV-CHP) for six cycles and is now well and in complete remission. The revision of the literature revealed eight additional cases of NHL developed shortly after COVID-vaccination. There were four cases of diffuse large-B-cell lymphoma (DLBCL) (one in a patient who was a heart transplant recipient and developed an Epstein-Bar-virus-positive DLBCL), one case of extranodal NK/T-cell lymphoma, one patient with subcutaneous panniculitis-like T-cell lymphoma, one case of marginal zone B-cell lymphoma and one primary cutaneous anaplastic large-cell lymphoma (PC-ALCL). In five cases, the lymphoma developed after BNT162b2 mRNA vaccination, including one case after ChAdOx1 nCOV-19, one case after the adenovirus type 26 (Ad26) vaccine and one after mRNA-1273/Spikevax (ModernaTX). We are aware that the link between COVID-19 vaccination and lymphoma most likely is a chance phenomenon, and that COVID-19 vaccines represent very efficient products for many people around the world. However, we believe that clinical events, even if only temporally associated with novel treatments or novel vaccines, should be reported for the benefit of the patients and the scientific community.

Skin-reducing mastectomy and pre-pectoral breast reconstruction using the Braxon® ADM: a single-center experience.

BACKGROUND: Breast cancer is the second leading cause of death in women. The most recent and successful advancement in implant-assisted breast reconstruction after mastectomy is the prepectoral approach using an acellular dermal matrix (ADM). Patients with ptotic breasts and macromastia were initially excluded from this type of immediate reconstruction remaining a difficult group to treat. The aim of this paper is to present our experience in performing skin-reducing mastectomy with pre-pectoral implant and complete ADM coverage as a single-stage procedure in patients with large ptotic breasts, evaluating the benefits and complications resulting from the use of this technique. METHODS: A retrospective analysis of skin-reducing mastectomies and pre-pectoral breast reconstructions using Braxon porcine-derived ADM performed between January 2019 and February 2021 at our Breast Unit. RESULTS: We treated 20 patients and performed a total of 24 skin-reducing mastectomies with pre-pectoral reconstruction. We observed two cases of partial NAC necrosis (8.3%) and one case of total NAC necrosis (4.2%). The incidence of skin flap necrosis was 8.3% (N.=2) healed by secondary intention. No case of prosthesis removal, infection or seroma was reported. Patients scored very good level of satisfaction with breast based on the results of the BREAST- Q questionnaire. CONCLUSIONS: Skin-reducing mastectomy and pre-pectoral breast reconstruction can be offered to patients with large and ptotic breasts with good aesthetic and functional results. New prospective observational studies would be desirable to provide an opportunity to evaluate the long-term capabilities and complications of this technique.

Delay in Breast Cancer Treatments During the First COVID-19 Lockdown. A Multicentric Analysis of 432 Patients.

BACKGROUND/AIM: Extraordinary restrictions aimed to limit Sars-CoV-2 spreading; they imposed a total reorganization of the health-system. Oncological treatments experienced a significant slowdown. The aim of our multicentric retrospective study was to evaluate screening suspension and surgical treatment delay during COVID-19 and the impact on breast cancer presentation. PATIENTS AND METHODS: All patients who underwent breast surgery from March 11, 2020 to May 30, 2020 were evaluated and considered as the Lockdown group. These patients were compared with similar patients of the previous year, the Pre-Lockdown group. RESULTS: A total of 432 patients were evaluated; n=223 and n=209 in the Lockdown and Pre-lockdown-groups, respectively. At univariate analysis, waiting times, lymph-nodes involvement and cancer grading, showed a statistically significant difference (p<0.05). Multivariate analysis identified waiting-time on list (OR=1.07) as a statistically significant predictive factor of lymph node involvement. CONCLUSION: Although we did not observe a clinically evident difference in breast cancer presentation, we reported an increase in lymph node involvement.

Breast implant-associated anaplastic large cell lymphoma: A rare case report of lymphoma in the form of a pericapsular solid formation.

Breast cancer is the most frequently diagnosed cancer in women in the western world and a major cause of premature death. Consequently, breast implants are widely used for breast reconstruction. Despite this, the prevalence of implant complications is low. Given widespread use of breast implants, there is an increased awareness of the risk for developing a breast implant associated- anaplastic large cell Lymphoma (BI-ALCL) although rare. Clinical presentation is variable and may include a palpable mass in the breast or axilla, generalized breast pain, or breast firmness. The estimated incidence of BI-ALCL is <3 per 1 million person years, approximately 0.1-0.3 per 100 000 women with prostheses per year. Since the publication by Keech and Creech in 1997, which reported the first case of BI-ALCL, an increasing number of BI-ALCL have appeared, in patients with both aesthetic and reconstructive indications. In this paper, we describe a patient who was diagnosed with invasive BIA-ALCL seventeen years after placement of silicone breast implants and was treated with only surgery.

Umbilical reconstruction: different techniques, a single aim.

The umbilicus is a unique physiologic scar of human life resulting from the healing process of the cut umbilical cord at birth. Its absence leads to an unnatural abdominal appearance, and an abnormally shaped or misplaced umbilicus may draw undue attention to the central abdomen. Loss of the umbilicus can be an embarrassing deformity; this occurs when older techniques of umbilical hernia or incisional hernia repair are employed and after abdominoplasty, urachal cyst repair, omphalocele repair, gastroschisis repair, some tumor excisions, and mobilization of bipedicled or bilateral TRAM/DIEP flaps for breast reconstruction. Umbilicoplasty, in which the umbilicus remains anchored to the deep abdominal fascia but is transposed through a newly-formed aperture in the upper abdominal skin flap, is performed in abdominoplasty either for abdominal flap harvest or purely for aesthetics. On the other hand, umbiliconeoplasty describes the de novo creation of an umbilicus that is absent for either congenital or acquired reasons. The optimal umbilical reconstruction should be reliable, reproducible, aesthetically appropriate, and associated with low morbidity. Ideally, it is also single-staged, except in the case of an infected wound, in which case a delayed primary approach may be prudent. (www.actabiomedica.it).

Nab-paclitaxel after docetaxel hypersensitivity reaction: case report and literature review.

Taxanes, including paclitaxel and docetaxel, are one of the most active cytotoxic agents in breast cancer  treatment  including  Her-2  positive  subtype characterized  by  aggressive  clinical  and pathological features since the early stage. However, their use is sometimes limited by the occurrence of hypersensivity reactions (HSRs) characterized by erythematous rashes, bronchospasm, respiratory distress, hypotension, and pulmonary edema. Cross-reactions between paclitaxel and docetaxel are described in literature with a rate ranging from 49% to 90%. Abraxane (nab-paclitaxel), an albumin-bound form of paclitaxel, has a different toxicity profile from solvent-based paclitaxel and a lower rate of HSRs. Interestingly, several authors have recently reported cases of patients who developed HSRs to taxanes, principally paclitaxel, and were then safety treated with Abraxane, suggesting the absence of cross-reactivity between these drugs. Based on these considerations, we report our clinical experience and perform a literature review on this topic with the aim to investigate the cross-reactivity between nab-paclitaxel and other taxanes, in particular with docetaxel.

Post-bariatric abdominoplasty: our experience.

The fast increase in obesity has been followed by the growth in the demand for plastic surgery in formerly obese patients. The weight loss is accompanied by new dysfunctions and disorders of the outline of the body that affects the quality of life of the patient. Abdominoplasty is a cosmetic surgery procedure that aims to remove the excess of skin and the redundant fat. The aim of this paper was to analyze our experience in this field and to test how functional abdominoplasty improved quality of life in the operated patients. In our Unit from January 2012 to December 2014, 25 patients (18 women and 7 men, age: 24 - 79 years, mean: 51 years) underwent abdominoplastic surgery. Only at least six months after bariatric surgery the patients were eligible for functional abdominoplasty. Average weight of the patients before surgery was 83.5 kg (range 58 - 163 Kg); averege BMI was 31 (range 24.77 - 57). The average quantity of tissue removed was 1.765 Kg (range 250 g - 11,5 Kg). Minor complications rate was in agreement with the percentages reported in literature. No mortality and major complications have occurred in our series. The majority of patients undergoing post-bariatric abdominoplasty reported an improvement in the quality of life and psychological well-being. In our opinion, however, only a multidisciplinary (surgical, psychological, dietological) approach of the post-bariatric patient allows to maintain long-term aesthetic and functional results.

Evaluation of a pilot surgical adverse event detection system for Italian hospitals.

OBJECTIVE: To devise an adverse event (AE) detection system and assess its validity and utility. DESIGN: Observational, retrospective study. SETTING: Six public hospitals in Northern Italy including a Teaching Hospital. PARTICIPANTS: Eligible cases were all patients with at least one admission to a surgical ward, over a 3-month period. INTERVENTIONS: Computerized screening of administrative data and review of flagged charts by an independent panel. MAIN OUTCOME MEASURES: Number of records needed to identify an AE using this detection system. RESULTS: Out of the 3310 eligible cases, 436 (13%) were extracted by computerized screening. In addition, out of the 2874 unflagged cases, 77 randomly extracted records (3%) were added to the sample, to measure unidentified cases. Nursing staff judged 108 of 504 (21%) charts positive for one or more criteria; surgeons confirmed the occurrence of AEs in 80 of 108 (74%) of these. Compared with random chart review, the number of cases needed to detect an AE, with the computerized screening suggested by this study, was reduced by two-thirds, although sensitivity was low (41%). CONCLUSIONS: This approach has the potential to allow the timely identification of AEs, enabling to quickly devise interventions. This detection system could be of true benefit for hospitals that intend assessing their AEs.