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.

Treatment With Oxygen-Enriched Olive Oil Improves Healing Parameters Following Augmentation-Mastopexy.

BACKGROUND: Breast augmentation-mastopexy can yield an aesthetically attractive breast, but the 1-stage procedure is prone to unsatisfactory outcomes, including poor wound healing. OBJECTIVES: The authors evaluated whether postsurgical application of a polyurethane bra cup coated with oxygen-enriched olive oil (NovoX Cup; Moss SpA, Lesa, Novara, Italy) would decrease pain associated with augmentation-mastopexy and improve the quality of the surgical scar. METHODS: This retrospective study was conducted at a single center from January 2016 to June 2019. All patients underwent 1-stage augmentation-mastopexy with the inverted T incision. For 2 weeks postsurgically, wounds were dressed either with the oxygen-enriched olive oil bra or with Fitostimoline (Farmaceutici Damor SpA, Naples, Italy). Patients indicated their pain intensity on postoperative days 2, 3, and 10, and patients and independent observers scored scar quality on the Patient and Observer Scar Assessment Scale (POSAS) 6 and 12 months after the procedure. RESULTS: A total of 240 women (120 per study arm) completed the study. All the patients had satisfactory aesthetic results, and there were no tolerability concerns with either postoperative dressing. Compared with patients in the Fitostimoline group, patients who received the oxygen-enriched olive oil bra cup had significantly lower pain levels, and their surgical scars were given better scores on the POSAS. CONCLUSIONS: The results suggest that maintenance of the surgical wound in a film of oxygen-enriched olive oil for 2 weeks is a safe, effective modality for suppressing pain and promoting healing following augmentation-mastopexy.

"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving the Decision-Making Dilemma. Retrospective Results of a Multicenter Experience.

BACKGROUND: Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction. METHODS: Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed. RESULTS: Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement. CONCLUSIONS: To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Diagnostic challenges and potential early indicators of breast periprosthetic anaplastic large cell lymphoma: A case report.

RATIONALE: Anaplastic large T-cell lymphoma (BI-ALCL) is a rare primitive lymphoma described in women with breast implant prostheses, which has been arousing interest in recent years due to its potentially high social impact. The difficult diagnosis associated with the high and increasing number of prosthetic implants worldwide has led to hypothesize an underestimation of the real impact of the disease among prosthesis-bearing women. The aim of this work is to search for specific radiological signs of disease linked to the chronic inflammatory pathogenetic mechanism. PATIENT CONCERNS: This work describes a case of BI-ALCL in an American woman with no personal or family history of cancer, who underwent breast augmentation for esthetic purposes at our Institute. After about 10 years of relative well-being, the patient returned to our Institute with clear evidence of breast asymmetry due to the increase in volume of the right breast which had progressively become larger over a period of 6 months. There was no evidence of palpable axillary lymph nodes or other noteworthy signs. DIAGNOSIS: The ultrasound and magnetic resonance (MR) tests indicated the presence of seroma with amorphous material in the exudate which was confirmed by indirect signs, visible in right breast mammography. Due to suspected cold seroma, an ultrasound-guided needle aspiration was performed for the cytological analysis of the effusion which highlighted the presence of a number of large-sized atypical cells with an irregular nucleus with CD30 immunoreactivity, leucocyte common antigen (CD45) compatible with the BI-ALCL diagnosis. INTERVENTIONS: In our case, a capsulectomy was performed because the disease was limited inside the capsule and periprosthetic seroma. The final histological examination confirmed the stage. LESSONS: The patient is being monitored and shows no signs of recurrence of disease >24 months after surgery. CONCLUSION: A diagnosis of BI-ALCL can be reached using new radiological indicators, such as fibrin, which is clearly visible by MR in the form of nonvascularized debris of amorphous material hypointense in all sequences, free flowing or adhered to the external surface of the prosthesis.

Feasibility, Image Quality and Clinical Evaluation of Contrast-Enhanced Breast MRI Performed in a Supine Position Compared to the Standard Prone Position.

BACKGROUND: To assess the feasibility, image quality and diagnostic value of contrast-enhanced breast magnetic resonance imaging (MRI) performed in a supine compared to a prone position. METHODS: One hundred and fifty-one patients who had undergone a breast MRI in both the standard prone and supine position were evaluated retrospectively. Two 1.5 T MR scanners were used with the same image resolution, sequences and contrast medium in all examinations. The image quality and the number and dimensions of lesions were assessed by two expert radiologists in an independent and randomized fashion. Two different classification systems were used. Histopathology was the standard of reference. RESULTS: Two hundred and forty MRIs from 120 patients were compared. The analysis revealed 134 MRIs with monofocal (U), 68 with multifocal (M) and 38 with multicentric (C) lesions. There was no difference between the image quality and number of lesions in the prone and supine examinations. A significant difference in the lesion extension was observed between the prone and supine position. No significant differences emerged in the classification of the lesions detected in the prone compared to the supine position. CONCLUSIONS: It is possible to perform breast MRI in a supine position with the same image quality, resolution and diagnostic value as in a prone position. In the prone position, the lesion dimensions are overestimated with a higher wash-in peak than in the supine position.

Elite VABB 13G: A New Ultrasound-Guided Wireless Biopsy System for Breast Lesions. Technical Characteristics and Comparison with Respect to Traditional Core-Biopsy 14-16G Systems.

The typification of breast lumps with fine-needle biopsies is often affected by inconclusive results that extend diagnostic time. Many breast centers have progressively substituted cytology with micro-histology. The aim of this study is to assess the performance of a 13G-needle biopsy using cable-free vacuum-assisted breast biopsy (VABB) technology. Two of our operators carried out 200 micro-histological biopsies using the Elite 13G-needle VABB and 1314 14-16G-needle core biopsies (CBs) on BI-RADS 3, 4, and 5 lesions. Thirty-one of the procedures were repeated following CB, eighteen following cytological biopsy, and three after undergoing both procedures. The VABB Elite procedure showed high diagnostic performance with an accuracy of 94.00%, a sensitivity of 92.30%, and a specificity of 100%, while the diagnostic underestimation was 11.00%, all significantly comparable to of the CB procedure. The VABB Elite 13G system has been shown to be a simple, rapid, reliable, and well-tolerated biopsy procedure, without any significant complications and with a diagnostic performance comparable to traditional CB procedures. The histological class change in an extremely high number of samples would suggest the use of this procedure as a second-line biopsy for suspect cases or those with indeterminate cyto-histological results.

A machine learning approach on multiscale texture analysis for breast microcalcification diagnosis.

BACKGROUND: Screening programs use mammography as primary diagnostic tool for detecting breast cancer at an early stage. The diagnosis of some lesions, such as microcalcifications, is still difficult today for radiologists. In this paper, we proposed an automatic binary model for discriminating tissue in digital mammograms, as support tool for the radiologists. In particular, we compared the contribution of different methods on the feature selection process in terms of the learning performances and selected features. RESULTS: For each ROI, we extracted textural features on Haar wavelet decompositions and also interest points and corners detected by using Speeded Up Robust Feature (SURF) and Minimum Eigenvalue Algorithm (MinEigenAlg). Then a Random Forest binary classifier is trained on a subset of a sub-set features selected by two different kinds of feature selection techniques, such as filter and embedded methods. We tested the proposed model on 260 ROIs extracted from digital mammograms of the BCDR public database. The best prediction performance for the normal/abnormal and benign/malignant problems reaches a median AUC value of 98.16% and 92.08%, and an accuracy of 97.31% and 88.46%, respectively. The experimental result was comparable with related work performance. CONCLUSIONS: The best performing result obtained with embedded method is more parsimonious than the filter one. The SURF and MinEigen algorithms provide a strong informative content useful for the characterization of microcalcification clusters.

Intraoperative Ultrasound and Oncoplastic Combined Approach: An Additional Tool for the Oncoplastic Surgeon to Obtain Tumor-Free Margins in Breast Conservative Surgery-A 2-Year Single-Center Prospective Study.

BACKGROUND: The main goal of oncoplastic breast-conserving surgery (OBCS) is to obtain tumor-free resection margins after cancer excision with satisfactory cosmetic results. Positive tumor margins are associated with high rates of tumor recurrence requiring reoperation. The aim of this prospective clinical trial was to demonstrate the reliability of intraoperative ultrasound (IOUS) to obtain tumor-free resection margins in OBCS. PATIENTS AND METHODS: Between December 2016 and March 2018, data from 130 patients with by T1-2 breast cancer, either invasive or in situ, who underwent OBCS were prospectively collected. The oncoplastic surgeon performed IOUS in the operating theater to localize the lesion and mark its skin projection. Then specimens were examined to assess the presence of the lesion and margin adequacy. Definitive histologic reports were reviewed, with a focus on margin status. RESULTS: All patients experienced oncoplastic approaches, and lesions were always found on the specimen at the histologic report. In 126 cases (97%), margins were considered adequate. In 17 cases (13%), IOUS showed positive margins, and resection was contextually enlarged. In 12 of these (9%), the pathologic report confirmed the need for enlarged resection. This study shows that IOUS-guided surgery can obtain a high percentage of tumor-free resection margins in OBCS without scheduling conflicts between radiology, nuclear, and surgery departments. Full cooperation between radiologists and oncoplastic surgeons is required to achieve high-standard oncologic and reconstructive outcomes. CONCLUSION: IOUS represent an additional tool for the breast surgeon to improve margin-free management of neoplastic lesions, preventing reoperations in patients undergoing oncoplastic surgery.

Dual-Energy CT for Locoregional Staging of Breast Cancer: Preliminary Results.

OBJECTIVE. The objective of this study was to demonstrate the feasibility of dual-energy CT (DECT) for locoregional staging of breast cancer and differentiation of tumor histotypes. MATERIALS AND METHODS. From January 2016 to July 2017, a total of 31 patients (mean [± SD] age, 55.8 ± 14.8 years) with breast cancer diagnosed by needle biopsy who underwent preoperative contrast-enhanced DECT for staging purposes were selected from a retrospective review of institutional databases. Monochromatic images obtained at 40 and 70 keV were evaluated by two readers who determining the number of hypervascularized tumors present and the largest tumor diameter for each breast. The attenuation values and iodine concentration of tumors and normal breast tissue and the ratios of these findings in each tissue type were recorded. Cancers were classified as ductal carcinoma in situ, invasive ductal carcinoma, and invasive lobular carcinoma. The reference standard was the final pathologic finding after surgery. RESULTS. A total of 64 tumor lesions were found at histopathologic analysis versus 67 on DECT for 34 breasts (three bilateral cancers were included). Nonparametric statistics were used. The largest lesion diameter observed DECT was 33.2 ± 20.5 mm versus 31.8 ± 20.5 mm on pathologic analysis, and cancer distribution was correctly classified for 31 of 34 (91%) cases. ROC curves derived from lesion iodine concentration showed that the optimal thresholds for distinguishing infiltrating carcinomas (invasive lobular and ductal carcinomas) and from other lesions were 1.70 mg/mL (sensitivity, 94.9%; specificity, 93.0%; AUC value, 0.968). ROC curves derived from the ratio of the iodine concentration in lesions to that in normal breast parenchyma showed that 6.13 was the optimal threshold to distinguish invasive ductal carcinoma from other lesions (sensitivity, 87.0%; specificity, 81.1%; AUC value, 0.914). CONCLUSION. DECT is feasible and seems to be a reliable tool for locoregional staging of breast cancer.

Anaplastic large-cell periprosthetic lymphoma of the breast: could fibrin be an early radiological indicator of the presence of disease?

PURPOSE: The onset characteristics of the anaplastic large cell lymphoma (BI-ALCL) are non-specific and the diagnosis is often difficult and based on clinical suspicion and cytological sampling. The presence of non-pathognomonic radiological signs may delay the diagnosis of BI-ALCL, influencing patient prognosis. This could have an important social impact, considering that the incidence of BI-ALCL correlates with the number of prosthetic implants, which is in constant increase worldwide. The aim of this study was to verify if fibrin can represent a potential early radiological sign of the disease. METHODS: In this study, we present two cases of our series and review the previous studies already described in literature, searching for any early radiological sign of the disease and reporting a diagnostic work-up process for an early diagnosis. RESULTS: Signs clearly recognizable only of magnetic resonance were the following: thickening and hyperemia of the fibrous capsule with seroma and amorphous material (fibrin) present in 8 out of 10 cases (80%) detected on magnetic resonance images (certain or doubtful). CONCLUSION: The presence of fibrin in the periprosthetic effusion, well detectable by magnetic resonance imaging, could represent an early pathognomonic sign of the disease.

Update in diagnostic imaging of the thymus and anterior mediastinal masses.

Anterior mediastinal masses include a wide spectrum of malignant and benign pathologies with a large percentage represented by thymic lesions. Distinguishing these masses on diagnostic imaging is fundamental to guide the proper management for each patient. This review illustrates possibilities and limits of different imaging modalities to diagnose a lesion of the anterior mediastinum with particular attention to thymic disease.

Fully Automated Support System for Diagnosis of Breast Cancer in Contrast-Enhanced Spectral Mammography Images.

Contrast-Enhanced Spectral Mammography (CESM) is a novelty instrumentation for diagnosing of breast cancer, but it can still be considered operator dependent. In this paper, we proposed a fully automatic system as a diagnostic support tool for the clinicians. For each Region Of Interest (ROI), a features set was extracted from low-energy and recombined images by using different techniques. A Random Forest classifier was trained on a selected subset of significant features by a sequential feature selection algorithm. The proposed Computer-Automated Diagnosis system is tested on 48 ROIs extracted from 53 patients referred to Istituto Tumori "Giovanni Paolo II" of Bari (Italy) from the breast cancer screening phase between March 2017 and June 2018. The present method resulted highly performing in the prediction of benign/malignant ROIs with median values of sensitivity and specificity of 87 . 5 % and 91 . 7 % , respectively. The performance was high compared to the state-of-the-art, even with a moderate/marked level of parenchymal background. Our classification model outperformed the human reader, by increasing the specificity over 8 % . Therefore, our system could represent a valid support tool for radiologists for interpreting CESM images, both reducing the false positive rate and limiting biopsies and surgeries.

Occupational Lung Diseases: Underreported Diagnosis in Radiological Practice.

Underreporting of occupational lung diseases is a widespread problem in clinical practice. In Europe there is not a common regulation even for the recognition of occupational cancers. Furthermore epidemiologic data on occupational interstitial lung diseases, in general, is limited by no standardized diagnostic criteria, varied physician awareness and training, limitations inherent to the various data sources, and the long latency period. Therefore, to optimize the management of the patient with occupational pathology, the collaboration and skills of the multidisciplinary at the service of the patient, play a fundamental role. In particular, radiologists should give substance to a clinical suspicion on an anamnestic basis and at the same time should recognize patterns of illness that can lead to the emergence of stories of misunderstood exposures. This article aims to provide an overview of the main occupational lung diseases with attention to diagnostic possibilities of the different imaging techniques. The issue of the radiological error is investigated, providing tools to minimize it in the daily practice.

Six-year prospective evaluation of second-look US with volume navigation for MRI-detected additional breast lesions.

OBJECTIVE: The aim of this study is to present a 6-year prospective evaluation of second-look ultrasound (US) using volume navigation (V Nav) for MRI-detected additional breast lesions. METHODS: After IRB approvals in both institutions, 1930 consecutive prone MRI breast examinations in 1437 patients were prospectively evaluated. All patients with an MRI-detected additional lesion underwent second-look US, and if occult, contrast-enhanced MRI in supine position was performed for US and MRI co-registration. For patients with breast hypertrophy, MRI-guided biopsy was performed directly. Pathologic examination was the standard of reference. One-way ANOVA and chi-square tests were used. RESULTS: In 490 MRI examinations (25.4%, 490/1930), at least one additional breast lesion was detected for a total of 722 only MRI-detected lesions. Second-look US identified 549 additional lesions (23 ± 8 mm); 362 (65.9%, 362/549) proved benign at pathology and 187 (34.1%, 187/549) malignant. Second-look US with V Nav identified 151 additional lesions (17 ± 9 mm, p = n.s.); 67 (44.4%, 67/151) proved benign at pathology and 84 (55.6%, 84/151) malignant. MRI-guided biopsy was performed on 22 additional breast lesions (22 ± 8 mm, p = n.s.); pathology revealed 20 (90.9%, 20/22) benign lesions and 2 (9.1%, 2/22) malignant ones. Mass lesions were significantly higher in the second-look US group (p < 0.001). No significant difference in lesion dimension was found between the three groups (p = 0.729). CONCLUSIONS: Second-look US with V Nav can be effective in detecting a large number of additional breast lesions occult at second-look US and to biopsy a significant number of malignant lesions safely and irrespective of distance from skin or lesion position. KEY POINTS: • Second-look US with volume navigation is effective in detecting occult additional lesions. • Permits safe biopsies irrespective of position and depth • Reduces the need for MRI-guided biopsy.