Evaluation of the efficacy and concordance of indocianine color green angiography in oncoplastic and reconstructive breast surgery. Preliminary results of the gBREAST-22 prospective study.

INTRODUCTION: During oncoplastic procedures, the vascularization and perfusion of the skin flaps is modified, thus increasing the possibility of skin necrosis. The objective of this study is to evaluate the effectiveness of indocyanine color green angiography (ICG-A) to determine intraoperative skin necrosis after oncoplastic surgery or skin-sparing or nipple-skin sparing mastectomy (NSSM). PATIENTS AND METHOD: Prospective observational study to evaluate the sensitivity, specificity and positive and negative predictive values ​​of the ICG-A in women with high-risk breast cancer. RESULTS: 98 women and 156 breasts were included in the study. A total of 20 women (20.4%) presented an image of ischemia in the ICG-A. 21 women (21.4%) presented ischemic events in the postoperative period, 71.4% of these events had been detected in the third ICG-A. Three of these patients (3.1%) presented a serious complication that required reintervention. The sensitivity and specificity of the ICG-A was 71.4% and 93.5%, respectively. CONCLUSIONS: ICG-A has high specificity and negative predictive value for detecting areas of low perfusion. In breast units with highly complex surgery, it can be useful to plan extreme surgeries and identify skin areas of low perfusion.

The impact of advanced oncoplastic surgery on breast-conserving surgery rates: A retrospective cohort study of 3,875 breast cancer procedures at a tertiary referral centre.

INTRODUCTION: As the treatment of breast cancer advances, the focus has shifted from solely improving oncological endpoints to a greater weight being placed on cosmetic and psychological outcomes. The advent of advanced oncoplastic techniques allows for successful breast-conserving surgery (BCS) to patients who otherwise would have required a mastectomy. The aim of this study is to ascertain if the adoption of these procedures has assisted in the reduction of mastectomies performed. METHODS: A dataset of all breast cancer procedures based upon coding between April 2016 and July 2023 was evaluated, categorising procedures into: BCS, mastectomy, oncoplastic BCS and total reconstructions. R-Studio Software 4.3.1 (®) was used to explore statistical analysis and data visualisation. Registered as a clinical services evaluation study (Project ID: 14649). RESULTS: During the period stated, 3875 index breast cancer procedures were recorded (sample size = 3638 patients). The BCS rate increased from 66.2 % in 2016 to 80.7 % in 2023. Using a linear regression model, the BCS rate demonstrates an increase of 2.1 % each year (coefficient = 2.12, p-value = 0.0069). Concurrently, the rate of oncoplastic BCS increased from 10.5 % to 22.9 % (coefficient = 2.14, p-value = 0.00017). Using Pearson's product-moment, a positive correlation between these two variables is seen (coefficient = 0.86, p-value = 0.0056). CONCLUSION: Having reviewed 3875 index breast cancer procedures over the past eight years, the BCS rate has shown a statistically significant increase and a positive correlation with the oncoplastic BCS rate. This suggests oncoplastic surgery has helped to reduce the rates of mastectomy at the centre.

Oncoplastic breast surgery - a pictorial classification system for surgeons and radiation oncologists (OPSURGE).

INTRODUCTION: Changes to the tumour bed following oncoplastic breast surgery complicate the administration of adjuvant radiotherapy. Consensus guidelines have called for improved interdisciplinary communication to aid adjuvant boost radiotherapy. We propose a framework of tumour bed classification following oncoplastic surgery to enhance understanding and communication between the multidisciplinary breast cancer team and facilitate effective and more precise delivery of adjuvant boost radiotherapy. METHODS: A classification system was devised by grouping oncoplastic procedures based on skin incision, tissue mobilization, tumour bed distortion, seroma formation and flap reconstruction. The system is supplemented by a colour-coded pictorial guide to tumour bed rearrangement with common oncoplastic procedures. RESULTS: A 5-tier framework was developed. Representative images were produced to describe tumour bed alterations. CONCLUSION: The proposed framework (OPSURGE) improves the identification of the primary tumour bed after initial breast-conserving surgery, which is imperative to both the surgeon in planning re-excision and the radiation oncologist in planning boost radiotherapy.

Is Oncoplastic Surgery Safe in High-Risk Breast Cancer Phenotypes?

BACKGROUND: Oncoplastic surgery (OPS) has increased in popularity over the recent years. It is a form of breast conservation surgery allowing for larger partial mastectomy (PM) resections followed by either volume displacement or volume replacement reconstruction techniques. However, there is a lack of evidence on the effectiveness and safety of OPS with radiotherapy (OPS + RT) in high-risk breast cancer phenotypes, such as triple negative breast cancer (TNBC) and HER2 positive (HER2+) patients. Our aim was to compare the breast cancer-specific survival (BCSS) and postoperative surgical complications in OPS + RT compared to PM alone with radiation (PM + RT) and total mastectomy (MTX) without radiotherapy (MTX-RT). METHODS: Patient data were analyzed from the Surveillance, Epidemiology, and End Results (SEER) cancer registries from January 1, 2012 to December 31, 2020. Patients were stratified according to the type of surgery. Cox regression analysis was performed to assess prognostic factors of BCSS. RESULTS: A total of 24 621 patients with high-risk breast cancer phenotypes were identified, 180 underwent OPS + RT; 13 402, PM + RT; and 11 039 MTX-RT. OPS + RT was more frequently performed in younger (mean age of 65.53 years, SD: 9.29, p < 0.001), non-Hispanic White (90.5% vs. 77.7% vs. 76.3%) and single women (17.9% vs. 12.1% vs. 13.3%). MTX-RT was usually performed in patients with high histological grade, TNBC, and higher stages. Overall complication rates were higher in the MTX-RT, compared to OPS + RT and PM + RT, 2%, 1.1%, and 0.7%, respectively, p < 0.001. Rates of hematoma and surgical site infections were higher in the MTX-RT group. With a median follow-up of 46 months, OPS + RT had better BCSS rates at 5 years compared to PM + RT and MTX-RT (97.1% vs. 94.7% vs. 89.8%, p < 0.001). MTX-RT was found to be an independent prognostic factor of worse BCSS compared to OPS + RT (hazard ratio [HR] = 2.584; 95% confidence interval [CI]: 1.005-7.171), while PM + RT had no difference compared to OPS + RT (HR = 1.670, 95% CI: 0.624-4.469). CONCLUSIONS: OPS is a safe breast surgical option in patients with HER2+ and TNBC. Patients with high-risk phenotypes who underwent OPS + RT and have similar BCSS and complication rates compared to standard breast surgical options. As such, OPS should be considered as an option whenever breast conservation surgery is being discussed.

The Local Rhombus-Shaped Flap-An Easy and Reliable Technique for Oncoplastic Breast Cancer Surgery and Defect Closure in Breast and Axilla.

Primarily, breast-conserving therapy is an oncological intervention, but eventually it is judged by its cosmetic result. Remaining cavities from tumor resection can promote seromas, delay healing and cause lasting discomfort. Additionally, volume loss, dislocation of nipple/areola and fat necrosis lead to (cosmetically) unfavorable results, aggravated by radiotherapy. Oncoplastic surgery can reduce these sequelae. A local flap that has rarely been used in breast cancer surgery is the Limberg rhombic flap. The tumor defect is planned as a rhombus. The sides of the rhombus are of equal length and ideally have an angle of 60° and 120°. The flap that closes the defect is planned as an extension of equal length of the short diagonal. The second incision of the flap is placed according to the defect angle of 60°, running parallel to the defect at the same length. This creates a second rhombus. The flap is transposed into the defect, and the donor area is primarily closed. It is axially perfused and safe with a 1:1 length-to-width ratio. Compared to local perforator flaps, defect closure is easily managed without microsurgical skills. In the breast, the flap can be used in volume replacement and volume displacement techniques as an all-layer flap to cover defects, or it can be deepithelialized and buried. In the axilla, it can cover full-thickness defects when skin is involved. The advantages of the rhombic flap are its safety and simplicity to add volume and close defects, thus reducing the complexity of oncoplastic surgery.

Improving quality of breast conservative surgery for lower quadrants cancer in small and medium sized breasts: Crescent technique versus J mammoplasty.

Background: For medium/small size breast, breast conserving surgery (BCS) is usually associated to poor cosmetic results. The objective of the study is to evaluate oncological safety and cosmetic results comparing the "Crescent" and the "J" mammoplasty technique and to develop an algorithm for the treatment of breast cancer located in lower quadrants in medium/small breast. Methods: We retrospectively analysed all consecutive patients who underwent a "J" mammoplasty or a "Crescent" technique at AUSL IRCCS Reggio Emilia between 2016 and 2021. Fifty-eight patients were enrolled, the first group including 29 "Crescent" technique procedures and the second one including 29 patients who underwent the "J" mammoplasty technique. Oncological safety and surgical minor and major complications were evaluated. Aesthetic results were evaluated by two senior breast surgeons, independently, at least 6 months after radiotherapy (RT). Results: At follow-up of 36 months, no recurrences and no major complications were observed in both groups. Minor complications were observed in two (6.9%) "J" group cases and in six (20.7%) "Crescent" ones (P<0.05). The 96.6% of "Crescent" and the 73.5% of "J" cases were judged excellent/good. One (3.4%) "Crescent" was judged fair versus six (20.7%) "J" mammoplasty. Two (6.9%) "J" cases were judged poor, requiring ipsilateral re-operation. Conclusions: When a favourable ratio between tumor size and breast volume is present, BCS can be performed for tumors located in the lower quadrants. Evaluating patients' anthropometric characteristics, skin involvement and tumor features is the key to select the right technique and to obtain both great cosmetic result and low rate of complications.

Efficacy and safety of oncoplastic breast-conserving surgery versus conventional breast-conserving surgery: An updated meta-analysis.

INTRODUCTION: Breast cancer is the most common cancer among women. The surgical treatment of breast cancer has transitioned progressively from radical mastectomy to breast-conserving surgery. In this meta-analysis, we are aiming to compare oncoplastic breast-conserving surgery (OS) with conventional breast-conserving surgery (BCS) in terms of efficacy and safety. METHODS: We searched Medline, Web of Science, Embase, Cochrane databases, Clinicaltrial.gov, and CNKI until April 30, 2024. Data from cohort studies and randomized controlled trials (RCTs) were included. Outcomes included primary outcomes (re-excision, local recurrence, positive surgical margin, mastectomy), secondary outcomes and safety outcomes. The Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa Scale were used to evaluate the quality of outcomes. RESULTS: Our study included 52 studies containing 46,835 patients. Primary outcomes comprise re-excision, local recurrence, positive surgical margin, and mastectomy, there were significant differences favoring OS over BCS (RR 0.68 [0.56, 0.82], RR 0.62 [0.47, 0.82], RR 0.76 [0.59, 0.98], RR 0.66 [0.44, 0.98] respectively), indicating superior efficacy of OS. Additionally, OS demonstrated significant aesthetic benefits (RR 1.17 [1.03, 1.33] and RR 1.34 [1.18, 1.52]). While total complications were significantly fewer in the OS group (RR 0.70 [0.53, 0.94]), the differences in specific complications were not significant. Furthermore, subgroup analyses were conducted based on nationality, sample size, quality, and type. CONCLUSION: OS demonstrates either superior or at least comparable outcomes across various aspects when compared to BCS.

Patient Satisfaction, Esthetic Outcome, and Quality of Life in Oncoplastic and Reconstructive Breast Surgery: A Single Center Experience.

Background: Oncoplastic surgery has become an important part of the surgical repertoire to offer both oncologically safe and aesthetically pleasing results in patients with breast cancer. Data comparing oncoplastic and reconstructive breast surgeries are limited. This study aimed to assess patient-reported outcomes (PRO) in our cohort of oncoplastic and reconstructively operated patients. Methods: Patients who underwent oncoplastic surgery, including immediate reconstruction by a single surgeon, between 2010 and 2018 were contacted to participate in this study. In total, 157 patients fulfilled the inclusion criteria. 54 patient data sets were used for statistical evaluation. Body Image Scale (BIS) and BreastQ questionnaires were used to measure subjective PRO scores, and pictures were taken to objectively measure symmetry using the Breast Analyzing Tool (BAT). Patients were divided into three groups according to the Tübingen classification (group 1: Tübingen 3-4 (n = 16), group 2: Tübingen 5 (n = 26), group 3: Breast Reconstruction/Tübingen 6 (n = 12]). Results: The mean age was 53.5 for group 1, 51.4 for group 2 and 46.8 for group 3. The mean follow-up was 62.9 ± 35.82 months. BIS was significantly better in group 3 (3.92 ± 1.73) than in group 1 and 2 (7.69 ± 4.48 and 4.81 ± 3.41, p = 0.016). Symmetry measured using BAT showed only a trend favoring reconstruction (p = 0.12). The BreastQ item "Sexual well-being" was significantly better in oncoplastic breast reduction surgery (p = 0.036). Conclusion: BIS was better after reconstructive breast surgery than after oncoplastic surgery. Reconstructive breast surgery in experienced breast care units offers high patient satisfaction and a high quality of life.

Current trends in breast cancer surgery.

The incidence of breast cancer has been increasing significantly over the past decades, while the mortality rate has, actually, been decreasing. Behind this favorable trend in the decrease in mortality are not only high-quality screening programs, but also undoubtedly advances in therapy, especially new methods in surgical treatment. The importance of oncoplastic approach integrating resection and reconstruction procedures is obvious. Our efforts continue to maximize breast-conserving therapy, which is being improved in parallel with the development of new localization methods of non-palpable lesions. Breast-conserving therapy indication spectrum is also increasing with the use of oncoplastic approach allowing the resection of a significant part of the mammary gland while achieving an acceptable cosmetic result. We improve guidelines for skin-sparing procedures and also possibilities and availability of breast reconstruction. Most popular is breast reconstruction with free abdominal flap transfer. However, due to such demanding complex procedure with limited availability, there is also a significant development of silicone-implant-based reconstruction or methods of fat transfer. Constant attention is focused on axillary surgery, now especially in cases of initial nodal involvement that responds favorably to neoadjuvant systemic treatment. Current findings indicate tendency to modify and differentiate surgical indications according to the tumor phenotype. Complex lymphedema prevention surgery, such as lymphatic mapping or restoring lymphatic flow via microsurgical lymphaticovenous anastomosis, can provide effective and long-term improvement and is challenging. Recently in the Czech Republic, we reopened the discussion about the optimal concentration of medical care in a smaller number of specialized breast centers, which we think is one of a number of steps on the constant path to improve medical results.

Comparative analysis of the degree of patient satisfaction after breast-conserving surgery with or without oncoplastic surgery: systematic review and meta-analysis.

Introduction: Conservative surgery is the gold standard for the treatment of single and small tumors and, combined with the concept of oncoplastic tumors, brings good aesthetic results while maintaining cancer safety. The objective was to comparatively analyze the degree of satisfaction of patients undergoing breast conserving surgery (BCS), with and without oncoplastic surgery (OPS) using level II OPS techniques. Methods: Review with a search in the databases MEDLINE (by PubMed), EMBASE, Clinical Trials, Scopus, Web of Science, BVS and Oppen gray. The meta-analysis of random effects was performed using the Der Simonian-Laird method considering the odds ratio (OR) with a 95% confidence interval (95% CI). Results: There was no statistically significant difference in the aesthetic outcome between women who underwent OPS and BCS (OR 0.90; 95% CI 0.62-1.30). The staging (OR 1.93; 95% CI 0.97-3.84; I 2 = 15.83%); tumor location [central (OR 1.28; 95% CI 0.06-27.49; I 2 = 17.63%); lower (OR 0.75; 95% CI 0.21-2.65; I 2 = 2.21%); superior (OR 0.67; 95% CI 0.26-1.74; I 2 = 0.00%] and tumor size (OR 8.73; 95% CI -11.82-29.28; I 2 = 93.18%) showed no association with the type of BCS performed, with or without OPS. The degree of satisfaction remains even in cases of extreme oncoplasty. Conclusion: The level of patient satisfaction in relation to BCS was similar to that of the group undergoing OPS, highlighting that OPS allows the patient's satisfaction rate to be maintained even in the case of large or multicentric tumors.

Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION: Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described. OBJECTIVE: We aimed to compare the costs of eOBCS and mastectomy. METHODS: We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included. RESULTS: Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416. CONCLUSION: eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

Breast Conservation Project: Clinical Outcomes of Extreme Oncoplastic Breast-Conserving Therapy Versus Mastectomy for Large and Multiple Lesions.

INTRODUCTION: Patients with multiple or large malignant breast lesions are classically considered mastectomy candidates, but extreme oncoplastic breast-conservation surgery (eOBCS) has become an alternative approach. There is a paucity of outcomes data comparing eOBCS with mastectomy. METHODS: We reviewed our prospectively maintained, single-institution database. We included patients with non-metastatic breast cancer with multiple ipsilateral or single large (≥ 5 cm) malignant breast lesions identified preoperatively who underwent either eOBCS or mastectomy. Patient demographics, clinicopathologic features, and surgical, oncologic, and cosmetic outcomes were evaluated. RESULTS: Seventy-six (88%) patients underwent eOBCS and 10 (12%) underwent mastectomy. Median follow-up was 24.8 months. Mastectomy patients had larger lesions than eOBCS patients (median 70 mm vs. 32.5 mm; p = 0.06). Six (60%) index mastectomy patients underwent at least one additional surgery. For eOBCS patients, 34 (44%) required re-excision, 7 of whom underwent more than one subsequent surgery to obtain negative margins, and 6 (7.9%) ultimately underwent mastectomy. For patients undergoing additional surgery (n = 40), median time between index and final operation was 315 days for mastectomy versus 21 days for eOBCS patients (p < 0.001). Mastectomy patients more frequently experienced complications (p = 0.001) and underwent cosmetic revision (p < 0.001). There was no difference in cosmetic scores, and eOBCS patients reported less pain (p = 0.009). There were two local and three distant recurrences in the eOBCS cohort and one distant recurrence in the mastectomy group. CONCLUSION: Breast conservation was attainable in over 90% of eOBCS patients. Increased postoperative complications and discomfort and longer duration of surgical treatment in mastectomy patients without oncologic superiority should drive informed patient discussions.

Extreme Oncoplasty: Oncologically Safe When Compared with Mastectomy.

BACKGROUND: Extreme oncoplasty is a breast-conserving operation using oncoplastic techniques in a patient who does not meet the traditional criteria for breast conservation and in whom most physicians would suggest a mastectomy. These tumors are generally multicentric and/or multifocal, they span more than 50 mm, or they can be large recurrences in a previously irradiated breast. METHODS: A prospective single institution database was queried from 2008 through mid 2023 for patients who met the criteria for extreme oncoplasty and were treated with excision plus whole-breast radiation therapy (WBRT) or mastectomy without WBRT. Patients with recurrent breast cancer were excluded. Endpoints were local, regional, and distant recurrence as well as overall and breast-cancer-specific survival. RESULTS: 272 patients were treated with oncoplastic mammaplasty, using a standard or split reduction excision followed by postoperative WBRT. An additional 101 patients elected to be treated with mastectomy without postoperative radiation therapy. With a median follow-up of 7 years, there were no significant differences in local, regional, or distant recurrence, nor in breast-cancer-specific survival or overall survival. CONCLUSIONS: We strongly support extreme oncoplasty plus WBRT as the default procedure of choice for patients with large multifocal/multicentric lesions amenable to reconstruction with volume displacement mammaplasty.

The value of patient-reported experience in oncoplastic breast conservation following standardized assessment and shared-decision making. A qualitative study.

INTRODUCTION: Patient-reported outcomes (PROs) are emerging as a quality marker for breast cancer care provision. Patient-reported experience (PRE) is equally important, but challenges in qualitative research and documentation have resulted in limited data on oncoplastic breast-conserving surgery (OPBCS). This qualitative study aimed to explore the experiences of patients who underwent OPBCS. PATIENTS AND METHODS: Women who underwent OPBCS between 2015 and 2021 at the Breast Unit of Uppsala University Hospital were followed up longitudinally using PROs. All participants were invited to share their experiences beyond PROs through a "diary." Patients' experiences with care, pre- and postoperatively, and other insights and thoughts that they considered important were documented and analyzed. A narrative research methodology, along with thematic analysis, was employed. RESULTS: Of the 122 women, 60 (49.2 %) desired to further elaborate on their experiences beyond PROs-related aspects. The most common themes included postoperative side effects, challenges responding to questionnaires, adverse effects of adjuvant treatment, external factors contributing to the preoperative and postoperative overall health status, and satisfaction with the surgery and medical staff. Specifically, 26.7 % of the respondents stated that they felt that PROs were not adequately specific and had further reflections. CONCLUSIONS: Patients did not report different experiences depending on the operative technique. Their experience focused on the perception of wholeness and potential ambiguities in the PRO questionnaires. Documenting PRE is crucial, as it enables individualized assessment following breast cancer treatment, thereby strengthening patient-centered care.

Long-Term Safety of Level II Oncoplastic Surgery after Neoadjuvant Treatment for Locally Advanced Breast Cancer: A 20-Year Experience.

Background: Oncoplastic surgery (OPS) reliability in the post-neoadjuvant chemotherapy (NACT) setting is still debated due to weak scientific evidences in such scenarios. Methods: Our analysis aims to report results obtained in a retrospective series of 111 patients consecutively treated with level II OPS after NACT at the Multidisciplinary Breast Center of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS between 1998 and 2018. The surgical endpoints were the mean specimen volume, rates of positive margins (PMR), re-excision (RR), conversion to mastectomy (CMR), and complications (CR). The oncological endpoints were overall survival (OS), disease-free survival (DFS), and local recurrence (LR). To evaluate the impact of NACT on surgical and oncological outcomes at 302 months, we conducted a propensity score matching, pairing patients in post-NACT and upfront surgery groups. Results: The mean sample volume was 390,796 mm3. We registered a 3.6% of PMR, 1.8% RR, 0.9% CMR, 5% CR. The 10-year OS and 10-year DFS with a median follow-up of 88 months (6-302) were 79% and 76%, respectively, with an LR recurrence rate of 5%. The post-NACT group received significantly larger excised volumes and lower PMR. NACT did not affect surgical and oncological outcomes. Conclusions: Level II OPS can be considered a reliable alternative to mastectomy even in the post-NACT setting.

Primary Invasive Paget's Disease in a Clinical Practice: A Case Report.

Invasive Paget's disease (IPDN) is a rare phenomenon characterised by invasive carcinoma localised to the nipple. It is associated with Paget's disease of the nipple (PDN) whereby Paget cells locally invade the underlying epidermis. Often in PDN, histopathological confirmation is needed, due to a lack of clear symptoms on clinical presentation. An 82-year-old female with single duct ectasia presented to the breast clinic in September 2023 with a tender, inflamed right nipple with a necrotic appearance. The lesion was excised, and an ultrasound scan showed right U2, implying no underlying malignancy. Microscopy showed Paget's disease with underlying ductal carcinoma in situ and two small (0.4 and 0.3mm) foci of dermal invasion by Paget cells in keeping with IPDN. Research suggests that dermal invasion by Paget cells has little effect on clinical outcome and prognosis depends largely on the associated underlying malignancy. However, all cases of IPDN with deep invasion or penetration of Paget cells into the dermis have the potential for regional and distant lymphatic spread. In extramammary Paget's disease, depth of invasion has been associated with poorer survival. Therefore, wide variability in clinical patterns and presentations of PDN mandates that a careful clinical approach correlated with in-depth histopathological evaluation is adopted in all cases.

Nipple reconstruction using spiral-peeling technique during oncoplastic breast-conserving surgery for a patient with small breasts.

Treatment of early breast cancer using breast-conserving surgery (BCS) commonly leads to local control and acceptable cosmetic results. We report a useful technique to achieve symmetry of the breast shape and nipple-areola, with excellent results. A Japanese patient with early breast cancer located in the inner central area of the breast was enrolled in this study. Intraductal spread of breast cancer to the nipple was suspected; however, no invasion was observed outside the nipple wall. We preserved the cylindrical surface, but resected the inner tissue with the top surface of the nipple. After coring the nipple, the remnant cylindrical surface was cut into a spiral shape. Nipple reconstruction using the spiral-peeling technique during oncoplastic breast-conserving surgery (OPBCS) may be useful for patients who desire nipple preservation.

Advancing indocyanine green fluorescence flap perfusion assessment via near infrared signal quantification.

Introduction: Intraoperative indocyanine green fluorescence angiography (ICGFA) perfusion assessment has been demonstrated to reduce complications in reconstructive surgery. This study sought to advance ICGFA flap perfusion assessment via quantification methodologies. Method: Patients undergoing pedicled and free flap reconstruction were subjected to intraoperative ICGFA flap perfusion assessment using either an open or endoscopic system. Patient demographics, clinical impact of ICGFA and outcomes were documented. From the ICGFA recordings, fluorescence signal quality, as well as inflow/outflow milestones for the flap and surrounding (control) tissue were computationally quantified post hoc and compared on a region of interest (ROI) level. Further software development intended full flap quantification, metric computation and heatmap generation. Results: Fifteen patients underwent ICGFA assessment at reconstruction (8 head and neck, 6 breast and 1 perineum) including 10 free and 5 pedicled flaps. Visual ICGFA interpretation altered on-table management in 33.3% of cases, with flap edges trimmed in 4 and a re-anastomosis in 1 patient. One patient suffered post-operative flap dehiscence. Laparoscopic camera use proved feasible but recorded a lower quality signal than the open system.Using established and novel metrics, objective ICGFA signal ROI quantification permitted perfusion comparisons between the flap and surrounding tissue. Full flap assessment feasibility was demonstrated by computing all pixels and subsequent outputs summarisation as heatmaps. Conclusion: This trial demonstrated the feasibility and potential for ICGFA with operator based and quantitative flap perfusion assessment across several reconstructive applications. Further development and implementation of these computational methods requires technique and device standardisation.

Association of relative resection volume with patient-reported outcomes applying different levels of oncoplastic breast conserving surgery - A retrospective cohort study.

INTRODUCTION: The American Society of Breast Surgeons (ASBrS) recently classified oncoplastic breast conserving surgery (OBCS) into two levels. The association of resection ratio during OBCS with patient-reported outcomes (PRO) is unclear. MATERIALS AND METHODS: Patients with stage 0-III breast cancer undergoing OBCS between 01/2011-04/2023 at a Swiss university hospital, who completed at least one postoperative BREAST-Q PRO questionnaire were identified from a prospectively maintained institutional database. Outcomes included differences in PROs between patients after ASBrS level I (<20 % of breast tissue removed) versus level II surgery (20-50 %). RESULTS: Of 202 eligible patients, 129 (63.9 %) underwent level I OBCS, and 73 (36.1 %) level II. Six patients (3.0 %) who underwent completion mastectomy were excluded. The median time to final PROs was 25.4 months. Patients undergoing ASBrS level II surgery were more frequently affected by delayed wound healing (p < 0.001). ASBrS level was not found to independently predict any BreastQ domain. However, delayed wound healing was shown to reduce short-term physical well-being (estimated difference -26.27, 95 % confidence interval [CI] -39.33 to -13.22, p < 0.001). Higher age was associated with improved PROs. CONCLUSION: ASBrS level II surgery allows the removal of larger tumors without impairing PROs. Preventive measures for delayed wound healing and close postoperative follow-up to promptly treat wound healing disorders may avoid short-term reductions in physical well-being.

Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery.

BACKGROUND: Little is known about disparities in oncoplastic breast surgery delivery. METHODS: The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. RESULTS: We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). CONCLUSION: Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.