Latissimus Dorsi Flap and Thoracodorsal Artery Perforator Flap with Immediate Fat Transfer (LIFT and TIFT): A Retrospective Study about Total Breast Reconstruction in High-Risk Patients.

INTRODUCTION: Microsurgical breast reconstruction has become popular over the past twenty years and allows a tailor-tuck approach to each patient. However, smoking or coagulation disorders may switch surgeon's choice towards alternative options. When facing these risk factors, we performed pedicled latissimus dorsi (LD) flap and thoracodorsal artery perforator (TDAP) flap reconstruction with immediate fat transfer (LIFT and TIFT), achieving satisfactory surgical outcomes. Hence, we aim to present our seven-years case-series and discuss our decisional algorithm. MATERIALS AND METHODS: Thirty smoker women and seven women affected by coagulation disorder (n = 37) respectively had LIFT and TIFT surgery and were retrospectively evaluated. Patients' demographics and outcomes were recorded and compared. RESULTS: LIFT patients received higher volumes of immediate fat grafting compared to TIFT patients (p < 0.05), which required additional lipofilling to provide adequate volume amount, since the TDAP flap was not immediately grafted. However, the additional lipofilling procedures and fat volume were similar (p > 0.05). Flap survival reached 100%, and flap necrosis or loss did not occur. Few minor complications were evidenced in the LIFT group only (p > 0.05). CONCLUSION: Based on our experience, we support the reliability of pedicled LD and TDAP flaps with immediate fat transfer in breast reconstruction as valuable alternative to microsurgery in smokers (LIFT) and patients with coagulation disorders (TIFT). However, the results of our study are not conclusive since still must be clarified the role of the smoking and coagulation disorders in microsurgery and the real benefit of a non-microsurgical procedure. LEVEL OF EVIDENCE IV: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Thyroid carcinoma: from diagnosis to therapy]. / Il carcinoma della tiroide dalla diagnosi alla terapia.

From 1999 to 2007 we performed 104 surgical operations for thyroid malignancies. Over the same period, 312 patients underwent surgery for benign lesions of the thyroid gland. The patients were subdivided on the basis of age bracket and gender and the distribution of cancer and benign nodules was evaluated. Feasibility and diagnostic accuracy of ultrasonography, scintigraphy and fine needle aspiration cytology were also evaluated. The incidence of thyroid cancer was 25% in all patients. Patients aged < 30 years and > 71 had the highest rate of malignancies: 52% of patients under 30 years of age and 46% over 70 years. Males showed a higher incidence than females. The scintigraphic findings were an area of low uptake in 19 cases (47.5%), an irregular pattern in 12 patients (30%) and a high uptake in 9 cases (22.5%); in 3 of them (7.5%), cancer was in the contralateral lobe and in 2 cases (5%) the dimensions were 8 and 4 mm. Forty-three patients had a single hypoechoic nodule at ultrasonography (41.3%), 3 (3%) were found with hypoechoic nodules containing calcifications and 1 (0.9%) a single anechoic nodule. Fifty-six patients (53.9%) had multiple nodules and 1 (0.9%) was admitted for a latero-cervical lymph node. FNAC revealed 11 cases of fibronectin expression (14.4%): in particular, 3 patients (4%) had cancer in the contralateral lobe and 3 patients (4%) had tumours measuring less than 5 mm. Thyroid surgery is safe and the morbidity rate is about 2%. We observed only one lesion of recurrent nerve (0.5% of patients), temporary recurrent palsy in 2.8% of patients and transient hypocalcaemia in 6.7% of cases.

Surgical treatment of early breast cancer in day surgery.

Quadrantectomy and associated sentinel lymph node biopsy (SLNB) is currently employed in most breast surgery centres as the gold standard in the treatment of early breast cancer. This approach has a modest morbidity and can usually be performed in a day-surgery regimen, leading to best acceptance by the patients. This reports outlines the experience of our Breast Unit with quadrantectomy and SLNB in day surgery for early breast cancer. One hundred patients presenting to our institution with primary invasive breast cancer measuring less than 3 cm and clinically negative axillary nodes underwent quadrantectomy and SLNB in day surgery. For 60 women with breast cancer the sentinel node was negative, so the only definitive surgical treatment was performed in the day-surgery regimen; 40 patients with positive sentinel nodes were hospitalised a second time for axillary dissection. In these patients that needed clearance of the axilla, SLNB was performed on the only positive node in 22 cases (55%). None of the patients admitted for quadrantectomy and SLNB in day surgery required re-hospitalisation after discharge. All patients proved to be fully satisfied with early discharge from hospital when questioned on the occasion of subsequent monitoring. Short-stay surgical programs in early invasive breast cancer treatment are feasible today owing to the availability of less invasive approaches such as quadrantectomy and SLNB. There are two main pointers to a distinct advantage for this kind of approach, i.e. recovery and psychological adjustment. Recovery from surgery is faster and the patient tends to play down the seriousness of the operation and to have a better mental attitude to neoplastic disease. Moreover, when performing quadrantectomy with SLNB in day surgery fewer than 50% of breast cancer patients (40% in our experience) require another surgical treatment, concluding the surgery in a single session.

Is sentinel lymph node biopsy more accurate than axillary dissection for staging nodal involvement in breast cancer patients?

Today evaluation of axillary involvement can be routinely performed with the technique of sentinel lymph node biopsy (SLNB). One of the greatest advantages of SLNB is the nearly total absence of local postoperative complications. It is important to understand whether SLNB is better than axillary lymph-node dissection (ALND) for staging axillary nodal involvement. The aim of the study was to evaluate the axillary staging accuracy comparing three different methods: axillary dissection, sentinel node biopsy with the traditional 4-6 sections and sentinel node biopsy with complete analysis of the lymph node. 527 consecutive patients (525 females and 2 males) with invasive breast cancer < or = 3 cm and clinically negative axillary nodes were divided into 3 different groups: group A treated with axillary dissection, group B treated with sentinel nodal biopsy analysed with 4-6 sections, and group C treated with sentinel node biopsy with analysis of the entire node. All patients underwent a quadrantectomy to treat the tumor. Group differences and statistical significance were assessed by ANOVA. The percentages of N+ in group A and group B were 25.80% and 28% respectively, while in the third group it rose to 45%, or almost half the patients. The differences among the three groups were statistically significant (p = 0.02). From our analysis of the data it emerges that axillary dissection and sentinel node biopsy with analysis of 4-6 sections have the same accuracy in staging the nodal status of the axilla; analysis of the entire sentinel lymph node revealed an increased number of patients with axillary nodal involvement, proving more powerful in predicting nodal stage. SLNB with complete examination of the SLN removed can be considered the best method for axillary staging in breast cancer patients with clinical negative nodes. In our study, the percentage of metastases encountered after complete examination of SLN was 45% compared to the accuracy of axillary dissection that was only 25.8%. Moreover, this approach avoids the useless axillary cleaning in about 55-60% of cases, decreasing postoperative morbidity and mortality.

Survival of breast cancer patients. Our experience.

Life expectancy for patients with breast carcinoma has changed in Europe over the last two decades. In Italy, the overall survival rate is about 77% at 5 years. When considering the situation in Sicily, the EUROCARE 2 study examined survival data from the Ragusa Cancer Registry, showing that the curves are worse than in other regions of Italy. Starting from these considerations we decide to evaluate whether these data from the Ragusa Cancer Registry corresponded to Palermo data. So we analysed data from 575 consecutive patients with breast cancer, treated in our Breast Unit from 1990 to 2003 according to the St. Gallen Recommendations and followed for a median period of 5 years. The prognostic role of age, tumour size, nodal status, TNM, stage, grading and hormonal receptors (OR, PR) were analysed and survival curves at 5 and 10 years were produced using the actuarial survival methods. All causes of death were considered. The median follow-up was 33 months. The Log rank test and univariate cox proportional model were used to demonstrate the association between prognostic factors and outcome. When considering T and N status, the curves showed an inverse correlation between survival and increases in these parameters. Overall survival was 92.9% at 5 years and 81.4% at 10 years for T1, 78.4% at 5 years and 61.4% at 10 years for T2 and 40.8% for T3-T4 at 5 and 10 years. Overall survival for NO was 92.1% and 78.2%, respectively, at 5 and 10 years, but decreased to 72.0% and 59.9% at 5 and 10 years for N1. In N2 patients we found that only about 50% of patients were still alive at 5 and 10 years, while for N3 patients the figures were 57.2% and 40%, respectively.

[Thyroidectomy with LigaSure versus traditional thyroidectomy: our experience]. / Tiroidectomia con LigaSure vs. tiroidectomia tradizionale. Nostra esperienza.

Over the past few decades the surgical strategy for both benign and malignant thyroid diseases has undergone several changes. In particular, total thyroidectomy today has become the routine operation for most thyroid diseases. The complications of this surgical procedure, though of multifactorial aetiopathogenesis, are often related to the efficacy of the haemostasis. Our aim in this study was to verify whether the use of the new LigaSure haemostatic system is capable of reducing the incidence of these complications as well as operative times and length of hospital stay as compared to the conventional haemostatic procedures. Twenty-five patients were randomly assigned to thyroidectomy with LigaSureTM (group A), and 25 to total thyroidectomy using the conventional haemostasis procedures (group B). Of these, 39 were women and 11 men, with a mean age +/- standard deviation of 52.26 +/- 13.57 years. In both groups the thyroidectomy was performed according to the standard total thyroidectomy surgical technique entailing the placement of two aspiration drainages at the end of the operation. As regards the assessment of operative times, these were significantly lower in thyroidectomy with LigaSureTM compared to traditional thyroidectomy (duration: 60 +/- 14.8 min [range: 60-105) in group A versus 92.4 +/- 27.5 min [range: 70-150] in group B, p = 0.02). The total amount of fluid drained postoperatively was substantially similar in the two groups (145 +/- 80 cc in group A versus 140 +/- 64.1 cc in group B). The incidence of postoperative complications was also similar in the two groups. We had only one case of haemorrhage in a patient submitted to thyroidectomy with LigaSureTM, 8 cases of transitory hypocalcaemia, 3 of which in patients with LigaSure thyroidectomy and 5 in patients treated with traditional thyroidectomy (p = 0.42), 2 cases of stupor of the recurrent nerve (1 in group A and 1 in group B) and a single definitive recurrent lesion in a group B patient with carcinoma, in which the tumour infiltrated the recurrent nerve. We observed no cases of definitive hypocalcaemia. The mean postoperative hospital stay of the patients in group A was 1.88 +/- 0.44 days as against 2.2 +/- 0.41 days in group B. The statistical analysis revealed a significant difference between the two groups (p = 0.01).

The role of sentinel lymph-node biopsy (SLNB) in the treatment of breast cancer.

Sentinel lymph-node biopsy is an innovative method for axillary staging in breast cancer patients, based on the concept that information about the status of the entire lymphatic drainage from a tumour site could be obtained by identification and sampling of a "sentinel node". The aim of the study was to evaluate the impact of sentinel lymph-node biopsy in the management of patients with early invasive breast carcinoma. Three hundred and forty-one patients with primary invasive breast carcinoma measuring less than 2 cm (less than 3 cm from January 2001) and clinically negative axillary nodes were recruited into the study. Sentinel lymph-nodes were positive for metastases in 108/341 cases (31.7%). Micrometastases were found in 22 patients and isolated tumour cells in 1 case. The mean number of sentinel lymph-nodes removed was 1.8 per patient. The sentinel lymph-node was the only positive node in 57 of 108 patients (52.8%). The percentage of axillary recurrence in sentinel lymph-node-negative patients was 0%. The accuracy of sentinel lymph-node biopsy for axillary staging has been confirmed in many studies. Axillary recurrences after sentinel lymph-node biopsy range from 0 to 1.6% in many series, while axillary recurrence after axillary lymph-node dissection is about 0-3%. In our experience we observed no axillary recurrences in 233 patients with sentinel lymph-node biopsy alone, with a median follow-up of 33 months, confirming the accuracy of the procedure, and sentinel lymph-node-negative patients with sentinel lymph-node biopsy alone are no more at risk for axillary recurrences than those undergoing axillary lymph-node dissection.

Video-thoracoscopic surgical pleurodesis in the management of malignant pleural effusion: the importance of an early intervention.

Thoracentesis plays an important role in cancer patients with symptomatic effusions, although its effect is short-lived and symptoms recur in almost all patients. Early video-thoracoscopic surgical pleurodesis may provide added benefit to a group of patients with advanced cancer presenting with symptomatic malignant pleural effusion. Seventy-six patients with advanced cancer and pleural effusion due to pulmonary-pleural metastases were recruited. In 51 cases (67.1%), at least one thoracentesis was performed before admission for surgery. Preoperative staging consisted of chest radiograph, CT scan, and blood gas analysis. The mean Karnofsky performance status was about 50. Pleurodesis with talc poudrage was completely successful in all patients, with a morbidity rate of 2.6%. There was no post-operative mortality. Three patients (3.9%) underwent further thoracenteses for recurrence of pleural effusion within two months after the procedure. Early use of talc insufflated by video-thoracoscopic surgery is an effective and relatively safe method for treating pleural effusion, and preventing recurrence, in advanced cancer patients.

[The role of fine-needle aspiration in the diagnosis of thyroid nodules]. / II ruolo dell'agoaspirazione nella diagnosi dei noduli tiroidei.

The aim of this study was to prospectively evaluate the sensitivity, specificity and accuracy of fine-needle aspiration of thyroid nodules. From January 1978 to December 2003, 497 patients underwent fine-needle aspiration of thyroid nodules and then thyroidectomy. Fine-needle aspiration was performed with a fine 23-25 gauge and the aspirate was fixed and dyed with May-Grounwald-Giemsa method. The results of cytology were divided into four groups: positive for malignancy (77 patients), negative for malignancy (370 patients), suspect for malignancy (34 patients) and not diagnostic (16 patients). Suspect specimens also included follicular neoplasm and Hürthle cell neoplasm. Fine-needle aspiration results were compared with histopathologic analysis after thyroidectomy. There were 2 false-positive (0.5%) and 5 false-negative patients (1%). Sensitivity, specificity and accuracy were respectively 94.7%, 99% and 98.4%. This study confirms that fine-needle aspiration of thyroid nodules can be performed easily with high sensitivity, specificity and accuracy.

Localization of the sentinel lymph node in breast cancer: prospective comparison of vital staining and radioactive tracing methods.

The aim of the study was to evaluate possible differences in accuracy between the radioactive tracing and vital staining method in the search for sentinel nodes in patients with breast cancer. From January 1999 to December 2000, 102 patients with T1 N0 breast carcinoma were recruited into the study for localization of sentinel nodes with vital blue dye staining and radioactive tracing and were then submitted to lumpectomy and axillary dissection. For the two methods, we estimated the percentage of sentinel nodes localized, the false-negative rate, the predictive negative and positive value and the accuracy. The vital blue dye staining method permitted localization of the sentinel node in 73% of patients with a false-negative rate of 8%, a predictive negative value of 92% and 92% accuracy. The radioactive tracing method permitted localization of the sentinel node in 97% cases with a false-negative rate of 0%, a predictive negative value of 100% and 100% accuracy (P<0.0005). The method that offers the better results is radioactive tracing. Currently, many authors use both techniques, since, in common practice, staining helps to identify the sentinel node with the probe.