Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network.

PURPOSE: Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity. MATERIAL AND METHODS: In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice. RESULTS: (1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy. CONCLUSION: This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.

Portable Negative Pressure Wound Dressing in Oncoplastic Conservative Surgery for Breast Cancer: A Valid Ally.

Background and Objectives: The use of oncoplastic techniques has spread widely in the last decade, with an expansion of the indications and demonstration of excellent oncological safety profiles. A potential downside may be the increased complication rates, which could influence the timing of adjuvant therapy. To date, there is increasing evidence that negative pressure therapy on closed wounds can reduce complication rates after surgery. From this perspective, we tested the use of portable negative pressure wound dressings (NPWDs) in oncoplastic surgery to minimize early post-operative admissions to the outpatient clinic and prevent surgical complications. Materials and Methods: An observational prospective cohort study was conducted on a population of patients who underwent quadrantectomy and wise-pattern reduction mammoplasty for breast cancer. The primary objective of the study is represented by the evaluation of the impact of NPWD on post-operative outcomes in an oncoplastic surgery setting. Patients enrolled between January 2021 and January 2023 were divided into two groups, the conventional dressing (CD) group and the NPWD group, by a simple randomization list. Results: A total of 100 patients were enrolled, with 52 in the CD group and 48 in the NPWD group. The use of NPWD significantly reduced the wound dehiscence rate (2.0% vs. 7.7% p = 0.002) and the number of one-month postoperative admissions to our clinic (3.8 ± 1.1 vs. 5.7 ± 1.3 p = 0.0009). Although not significant, it is possible to note a trend of reduction of clinically relevant postoperative total complications in patients treated with NPWDs. Conclusions: NPWDs may represent a useful tool in the post-surgical management of complex oncoplastic procedures, ensuring less wound dehiscence. Furthermore, the use of these dressings led to a significant reduction in admissions to the clinic, promoting a lower use of resources by hospitals and effective prevention of possible complications.

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.

"Hook Shape" Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series.

INTRODUCTION: Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results. MATERIALS AND METHODS: From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases. RESULTS: Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results. CONCLUSION: The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II). LEVEL OF EVIDENCE IV: 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.

Controlateral Symmetrisation in SRM for Breast Cancer: Now or Then? Immediate versus Delayed Symmetrisation in a Two-Stage Breast Reconstruction.

Introduction: The timing of contralateral symmetrisation in patients with large and ptotic breasts undergoing a unilateral skin-reducing mastectomy (SRM) is one of the most debated topics in the reconstructive field. There is no evidence to support the advantage of immediate or delayed symmetrisation to help surgeons with this decision. The aim of this study was to investigate the clinical and aesthetic outcomes of immediate symmetrisation. Methods: A randomised observational study was conducted on patients who underwent an SRM for unilateral breast cancer. Based on a simple randomisation list, patients were divided into two groups: a delayed symmetrisation group versus an immediate symmetrisation group. The postoperative complications, BREAST-Q outcomes and reoperations were compared. Results: Out of a total of 84 patients undergoing an SRM between January 2018 and January 2021, 42 patients underwent immediate symmetrisation and 42 patients had delayed symmetrisation. Three implant losses (7.2%) were observed and we reported three wound dehiscences; one of these was in a contralateral breast reconstruction in the immediate symmetrisation group. The BREAST-Q patient-reported outcome measures recorded better aesthetic outcomes and a high patient satisfaction for the immediate symmetrisation group. Conclusions: Simultaneous controlateral symmetrisation is a good alternative to achieve better satisfaction and quality of life for patients; from a surgical point of view, it does not excessively impact on the second time of reconstruction.

New safer management for breast cancer patients who need neoadjuvant therapy during SARS-COVID pandemic.

During the first hit of SARS-COVID pandemic, an important reorganization of Healthcare Services has been done, and new protocols and pathways to protect frail patients like oncological patients were designed. The second hit of pandemic had stressed these new pathways and suggests to health-workers some improvements for safer management of patents.We reported our experience in organizing the clinical pathway of neoadjuvant therapy candidate patients based on the execution of sentinel lympho-node biopsy and the placement of implantable venous access port in the same access to operating room before neoadjuvant chemotherapy suggesting a possible organizational model. In the period October-December 2020 we have included in this new type of path twelve patients and we have not registered any cases of COVID among the patients included. We think this new path, adopted amid the second hit, will be useful for all Breast Units that are facing the challenge of guaranteeing the highest standards of care in a historical moment where the health emergency occupies the efforts of health workers and the economic resources of health systems.

The keystone flap: A multi-centric experience in elderly patients treatment.

Soft tissue reconstruction in elderly patients must be rapid and reliable. The keystone island flap (KF) offers an effective solution, with low complication rates and quick recovery. This multi-centric study aims to show authors' experience with KFs in treating soft tissue defects of trunk and limbs. Patients with soft tissue defects suitable for KF reconstruction were recruited from March 2019 to December 2019. Active inflammation and previous surgeries in the same region were considered exclusion criteria. Complications that occurred during follow-up were recorded, and their incidence pattern was assessed with the Fisher test. Seventy-two patients with mean age of 76.2 years old were selected. They presented lesions in torso (46; 63.9%) or in upper (4; 5.6%) or lower (22; 30.6%) limb regions. Fifteen (20.8%) wounds were non-oncologic lesions, and the others were oncologic lesions, mostly non-melanoma skin cancers. KF type I was carried out in 42 (58.3%) cases, KF type II-A in 13 (18%) cases, double opposed type III KF in 16 (22.2%) patients, and 1 (1.4%) case required partial flap's undermining (IV KF). Mean post-operative recovery period was 4.3 days (range, 1-9 days). Post-surgical complications occurred in 15 (20.8%) cases, 7 (9.7%) of them were considered major complications. No statistically significant difference in complications' incidence, nor among different surgical sites nor among KF types, was registered. Reconstructive surgeons have to adapt their work to elderly patients. The KF allows rapid operative times, low morbidity rates, and short post-operative recovery time, thus appearing as a feasible solution.

"Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review.

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Genital Lymphedema and How to Deal with It: Pearls and Pitfalls from over 38 Years of Experience with Unusual Lymphatic System Impairment.

Background and Objectives: Conservative treatment represents an essential pillar of lymphedema management, along with debulking and physiologic surgeries. Despite the consistent number of treatment options, there is currently no agreement on their indications and possible combinations. When dealing with unusual lymphedema presentation as in the genitalia (Genital Lymphedema-GL), treatment choice becomes even more difficult. The authors aimed to present their targeted algorithm of single and combined treatment modalities for rare GL in order to face this paucity of information. Materials and Methods: Data were collected from a prospectively maintained database since January 1983, and cases of GL that were managed in the authors' department were selected. Only patients that were treated in the authors' institution and presented a minimum follow-up of 3 months were admitted to the current study. Results: From January 1983 to July 2021, 19 patients with GL were recruited. All the patients were male, and their ages ranged from 21 to 73 years old (average: 52). Ten cases (52.6%) presented with ISL (International Society of Lymphology) stage I, five (26.3%) were stage II and four (21.1%) were stage III. GL was managed with conservative treatment (12 cases), LVA (LymphaticoVenous Anastomosis) (3) or surgical excision (4). In a mean follow-up of 7.5 years (range: 3 months-11 years), no major complications occurred, and all cases reached improvements in functional and quality of life terms. Conclusions: Contrary to the predominant thought of the necessity to avoid surgery in unusual lymphedema presentations such as GL, they can be managed using targeted multimodal approaches or by adapting well-known procedures in unusual ways to achieve control of disease progression and improve patients' quality of life.

"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.

The use of human acellular dermal matrices in advanced wound healing and surgical procedures: State of the art.

Wound closure after post-traumatic injuries and/or localized at peculiar body sites (head-and-neck, oral cavity, legs) are particularly challenging and can often be delayed due to local and systemic factors. In case of deep wounds and/or hard-to-heal wounds, grafting of dermal acellular matrices (ADM) is often needed. Though a great variety of synthetic and semisynthetic dermal and skin equivalents are available, viable human dermis, is still considered the most physiological alternative to replace the loss of autologous dermis, by acting as a physiological scaffold that add structural support to soft tissues. To date, human ADMs (hADMs) have been employed in the reconstruction of skin defects affecting almost all body sites, ranging from visceral sites to the skin and subcutaneous tissues. This review aims to investigate the use of hADM at different body sites and their peculiar advantages. A literature search was using the search terms "acellular dermal matrices", "dermal regeneration", "advances wound healing", "human acellular dermal matrices surgery". A total of 50 out of 150 papers was included. Based on the current body if evidence, hADMs appear to bring several advantages, such as: protection of deep structures (eg, tendons, bones, cartilage and nerves); stimulation of a functional new dermis (rather than a scar); reduction of wound closure time; control of pain and exudate. Finally, hADMs may represent the best treatment option for hard-to-heal wound not only in terms of efficacy and patient satisfaction bout also in terms of sanitary costs, especially across Europe, where hADMs cannot be commercialized as medical devices.

Positive ROS (Reactive Oxygen Species) Modulator Engineered Device Support Skin Treatment in Locally Advanced Breast Cancer (LABC) Enhancing Patient Quality of Life.

The development of research in genetic and biochemical fields has made it possible to investigate certain metabolic aspects of the microenvironment of chronic skin lesions, including altered cell signalling, highlighting its importance in determining the blockage of repair processes. The purpose of this prospective observational study is to evaluate the efficacy of a medical device consisting of a polyester scaffold enriched with an oleic matrix with controlled release of ROS in the management of LABC skin lesions. During the period from October 2018 to March 2020, 20 patients with locally advanced breast cancer were enrolled and ten were treated with the devices abovementioned. After 30 days of treatment all patients treated reported a general improvement in local conditions with reduction in ulceration area, exudate and odour. The results suggest that the application of these devices even in particular conditions (healthy and neoplastic tissue) does not lead to the onset of negative effects due to the release of ROS, though their role in tissue repair requires further study to fully understand their potential and increase the fields of application of the device by exploiting its modulation capabilities.

Breast Animation Deformity: A Retrospective Study on Long-Term and Patient-Reported Breast-Q Outcomes.

BACKGROUND: We evaluated the aesthetic outcomes and quality of life of patients who underwent neurotomy of the lateral and medial branch of the pectoralis nerve for animation deformity after breast reconstruction. MATERIAL AND METHODS: Health-related quality of life questionnaire and cosmetic outcome evaluation were conducted using the preoperative and the postoperative BREAST-Q modules for reconstructive surgery. An external author also assessed the general aesthetic outcome before and after surgery. RESULTS: Sixty-two patients with animation deformity after breast reconstruction were enrolled: 43 in group 1 (second-stage breast reconstruction), 10 in group 2 (permanent breast prosthesis), and 9 in group 3 (Baker III-IV capsular contraction). Patients scored high level of satisfaction with outcome concerning all aspects of the survey. Overall satisfaction with breast was significantly increased after surgery in all the 3 groups, whereas physical well-being was improved in group 1 and group 3 and psychosocial well-being was improved in group 1. General outcome evaluation by an external author, compared with the preoperative condition, also showed significant improvement. CONCLUSIONS: Section of the lateral and medial branches of the pectoralis nerve represents an easy and reproducible technique, associated with low morbidity and very good results in terms of patient satisfaction, comfort, and hospitalization.

Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts.

BACKGROUND: The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction. METHODS: Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided. RESULTS: Average body mass index was 29.7 kg/m2 (range 25-40 kg/m2). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: "overall satisfaction with breasts" (p < 0.05), "psychosocial well-being" (p < 0.05), "physical impact of the surgery" (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for "satisfaction with back" and "satisfaction with shoulder and back function" domains. CONCLUSIONS: The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of patients. LEVEL OF EVIDENCE IV: 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 .

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.