Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study.

BACKGROUND: The ideal technique for lymph node staging for patients with pathologically confirmed node-positive breast cancer at diagnosis and neoadjuvant chemotherapy (NAC) is unclear. OBJECTIVE: The aim of this study was to analyze the feasibility of wire/clip localization and sentinel lymph node biopsy (SLNB) for the axillary staging of these patients. METHODS: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and an SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an axillary lymph node dissection (ALND). The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS: Forty-two patients met the inclusion criteria. We identified and extirpated the clip/wire-marked node in all patients (100%), with SLNB performed successfully in 95.3% of patients. The SLN and wire-marked node matched in 80% of patients; 73.8% of patients did not undergo ALND. DISCUSSION AND CONCLUSIONS: Several studies have evaluated the efficacy of various procedures for lymph node marking for women with prechemotherapy lymph node involvement. Most of the studies reported high identification rates (> 94.8%), with false negative rates of < 7%. Similarly, our study allows us to conclude that combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and NAC offers a high identification rate (100%) and a high correlation between the wire-marked lymph node and the SLN (80%). This procedure has enabled the suppression of ALND for a significant number of patients (73%).

Single-Incision Approach for Breast-Conserving Surgery: Effectiveness, Complications and Quality of Life.

OBJECTIVE: The aim of this study was to assess the success of tumor resection and its postoperative complications, satisfaction, and quality of life using a single-incision approach for breast-conserving surgery. MATERIALS AND METHODS: This was an observational, prospective study conducted between 2015 and 2018. The study group consisted of patients in whom tumor extirpation and lymph node (LN) staging was performed using a single incision, while the control group consisted of patients who underwent a breast-conserving procedure with independent incisions. All patients were given the preoperative and postoperative module of the Breast-Q™ questionnaire. RESULTS: Overall, 226 patients met the study's inclusion criteria, 152 of whom successfully underwent breast and LN removal using a single-incision approach (98.7% overall success). There were no significant differences in postoperative complications, although there was a greater tendency towards breast seroma in the study group and axillary neuralgia in the control group. Both groups presented a similar rate of breast and axillary salvage surgery. The postoperative Breast-Q™ questionnaire showed that the study group had greater satisfaction with both the breast and the information provided by the surgeon. CONCLUSION: The single-incision approach is as effective as standard surgery, with custom incisions in terms of breast resection, LN staging, and complications. There was greater satisfaction with both the breast and the information provided.

Adult-onset Morgagni's hernia.

We report the case of a 65-year-old male patient with Down's syndrome and a deep venous thrombosis on anticoagulation with acenocoumarol. The case presented due to nonspecific, predominantly postprandial epigastric discomfort, meteorism and aerophagia. A thoracoabdominal computed tomography (CT) scan revealed a Morgagni hernia with a cephalad migration of part of the stomach, ascending colon and transverse colon. After laparotomy, the defect was repaired using a titanium mesh and the patient had a favorable outcome.

The role of oncoplastic breast reduction in the conservative management of breast cancer: Complications, survival, and quality of life.

BACKGROUND AND OBJECTIVES: Reduction Mammaplasty (RM) in breast cancer allows mammary remodeling after wide excisions. We aimed to analyze the complications, survival, and quality of life after RM. METHODS: Retrospective study of women who underwent a surgical intervention for breast cancer between 2000 and 2016. Patients were divided into two groups: RM and tumorectomy. Postoperative complications, survival and quality of life were assessed using the Breast-Q questionnaire. RESULTS: A total of 801 patients were evaluated, with a mean follow up of 84 months. RM patients experienced a longer operating time and hospital stay, and a higher proportion of tissue necrosis compared to tumorectomy patients (P < 0.001). No significant differences were observed regarding rate of re-excision or rate of mastectomy, but the recurrence rate at 10 years was higher for RM patients (P < 0.03). Patients who underwent RM reported optimal satisfaction with the breast and a good quality of life. CONCLUSIONS: RM is a useful approach in breast cancer surgery, with a low rate of re-excision and mastectomy. Overall survival at 10 years is similar to that associated with tumorectomy, though with a higher rate of local recurrence. Patient satisfaction and quality of life appears to be good one year after radiotherapy.

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.

Local Flaps to Cover Skin Necrosis after Skin-sparing Mastectomy and Prepectoral Reconstruction from PreQ-20 Trial.

Background: In recent years, mastectomy has increasingly been indicated for women at high risk and those with breast cancer. Prepectoral reconstruction with polyurethane implant is an option for these patients. Nevertheless, this procedure can become complicated with exposure of the implant. The aim of this article is to describe the feasibility of local flaps to treat skin necrosis and dehiscence after prepectoral reconstruction and its impact on implant loss. Methods: This study includes the women who met the inclusion/exclusion criteria of the PreQ-20 protocol (12), which assessed patients with exposed implant who required a local flap for its coverage. Three types of flaps were used: thoracoepigastric, lateral thoracic, and batwing. Results: The study included 226 skin-sparing mastectomies and immediate reconstruction using prepectoral implants (52.7% bilateral mastectomies). Some 20.9% of the patients showed complications, with wound dehiscence the most frequent. Thirteen local flaps to cover the implant were performed. All flaps presented appropriate perfusion; however, the implant cover failed in six patients (46.2%). Conclusions: The use of local flaps can be a low-morbidity option for preventing implant loss when skin dehiscence or necrosis occurs and delays in oncology treatments.

Our house believes that: The clipped lymph node is the true sentinel node after neoadjuvant chemotherapy in N+ patients.

Axillary staging is an important prognostic factor in breast cancer, being sentinel lymph node biopsy (SLNB) the gold standard staging method in early stages. However, in clinically node positive (cN+) patients who converted to clinically node-negative (cN0) after primary systemic therapy (PST) the axillary staging method during surgery remains controversial. There are at least three validated methods: SLNB, targeted axillary dissection (TAD) and marking axillary nodes with radioactive iodine seeds (MARI) procedure. Our house believe that the biopsied and clipped lymph node could predict response to systemic treatment.

Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis.

OBJECTIVE: The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. METHODS: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS: Eighty one patients met the inclusion criteria. We identified and extirpated the clip/ wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. CONCLUSIONS: The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%) and a high correlation between the wire-marked lymph node and the SLN (78.9%). This procedure has enabled the suppression of ALND in 76.2% of patients.

Immediate breast reconstruction by prepectoral polyurethane implant: Preliminary results of the prospective study PreQ-20.

INTRODUCTION: In recent years, mastectomy and reconstruction techniques have evolved towards less aggressive procedures, improving the satisfaction and quality of life of women. For this reason, mastectomy has become a valid option for both women with breast cancer and high-risk women. The objective of this study is to analyze the safety of mastectomy and immediate prepectoral reconstruction with polyurethane implant in women with breast cancer and risk reduction. METHOD: Observational prospective study to evaluate the feasibility and safety of immediate reconstruction using prepectoral polyurethane implant. All women (with breast cancer or high risk for breast cancer) who underwent skin-sparing or skin-and-nipple-sparing mastectomy with immediate reconstruction with a prepectoral polyurethane implant were included. Women with breast sarcomas, disease progression during primary systemic therapy (PST), delayed, autologous or retropectoral reconstruction, and those who did not wish to participate in the study were excluded. Surgical procedures were performed by both senior and junior surgeons. All patients received the corresponding complementary treatments. All adverse events that occurred during follow-up and the risk factors for developing them were analyzed. RESULTS: 159 reconstructions were performed in 102 women, 80.4% due to breast carcinoma. Fourteen patients developed complications, the most frequent being seroma and wound dehiscence. Eight women required a reoperation (5.0%), seven of them due to implant exposure. Four reconstructions (2.5%) resulted in loss of the implant. Three patients progressed from their oncological process: a local relapse in the mastectomy flap, an axillary progression and a systemic progression. CONCLUSIONS: Prepectoral reconstruction with a polyurethane implant is a procedure with a low incidence of postoperative complications (8.8%) and implant loss (2.5%). Its use is safe with perioperative cancer treatments (neoadjuvant chemotherapy and radiotherapy).

Safety and Quality of Life in Women with Immediate Reconstruction with Polyurethane Implants after Neoadjuvant Chemotherapy: Outcomes from The Preq-20 Trial.

INTRODUCTION: Various studies have evaluated the impact of neoadjuvant chemotherapy (NAC) on the complications of breast cancer surgery, most of which were retrospective and did not assess the variables related to postoperative risk factors. The aim of this study is to analyse the safety and satisfaction of women included in the PreQ-20 trial who underwent NAC and who underwent mastectomy and immediate reconstruction with prepectoral polyurethane implants. MATERIAL AND METHODS: The patients included in the study belong to the prospective study PreQ-20. The study group consisted of patients who underwent immediate reconstruction after primary systemic therapy. The control groups consisted of patients with immediate reconstruction and adjuvant chemotherapy (control group 1) and patients with an infiltrating carcinoma or in situ ductal carcinoma who did not require chemotherapy (control group 2). RESULTS: The study included 157 women, 58 (36.9%) of whom underwent primary systemic therapy. The indication for genetic study was significantly greater for the study group (87.9%) than for control groups 1 (49.1%) or 2 (30.4%). Seventy-two (45.9%) of the patients underwent bilateral mastectomy (BM), a procedure that was performed significantly more frequently in the study group (69%) than in control groups 1 (30.2%) or 2 (34.8%). The incidence rate for BM after complete pathologic response was 78%. There were no statistically significant differences in the number of complications between the groups. Implant loss was significantly more frequent in control group 1 (13.2%) than in the study group (3.4%) and control group 2 (2.2%). CONCLUSIONS: Mastectomy with prepectoral polyurethane implant reconstruction in patients with neoadjuvant chemotherapy presented a similar incidence of complications compared with patients who underwent primary surgery. There is a high rate of BM in women with NAC.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters.

BACKGROUND: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MATERIALS AND METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. / Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa.

INTRODUCTION: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.

The decline of axillary lymph node dissection in breast cancer. Evolution of its indication over the last 20 years. / El declive de la linfadenectomía axilar en el cáncer de mama. Evolución de su indicación durante los últimos 20 años.

INTRODUCTION: In last 20 years, lymph node staging procedures in breast cancer have been modified. The objective of this study is to describe the evolution of these procedures at our hospital. METHODS: A prospective observational study that included women with breast cancer who were treated surgically between 2001 and 2017. Four groups were identified according to the therapeutic regimen and 3 study periods defined by the lymph node dissection. RESULTS: 1319 patients met the inclusion criteria. Primary conservative surgery was the most frequent therapy (54.13%), and 615 (46.62%) axillary lymph node dissections (ALND) were performed in the 20-year study period. The percentage of ALND decreased progressively over time, going from 91% in the first period to 34% in the last period. The futile ALND fell to 6.6% in the last year. In the primary conservative surgery, no futile ALND was performed in the last two years. CONCLUSION: The introduction of sentinel lymph node biopsy and the ACOSOG Z0011 criteria have modified the indication for ALND. Thus, ALND without involvement have been reduced, thereby avoiding the associated morbidity. The study demonstrates the progressive decrease in the indication of lymphadenectomy in the different study groups, similar to reports by other authors. Several clinical trials have described that these changes have not negatively impacted survival.

Precisión diagnóstica de la mamografía con contraste vs RM en la valoración de la respuesta del cáncer de mama tratado con quimioterapia neoadyuvante / Diagnostic accuracy of contrast-enhanced mammography vs MRI in evaluating the response of breast cancer treated with neoadjuvant chemotherapy

Introducción: la resonancia magnética es el método diagnóstico más preciso en la evaluación de la enfermedad residual en el cáncer de mama tratado con quimioterapia neoadyuvante. La mamografía con contraste puede ser una alternativa eficaz a la resonancia en la evaluación de tumor residual. Esta técnica disminuiría los costes significativamente, mejoraría el flujo de pacientes y apenas tiene contraindicaciones. Métodos: hemos realizado un estudio observacional y prospectivo en 43 pacientes con cáncer de mama tratadas con quimioterapia neoadyuvante. El estudio prequirúrgico incluyó tanto la mamografía con inyección de contraste como la resonancia magnética. Se correlacionó el tamaño tumoral residual por imagen con el estudio anatomopatológico posquirúrgico. Resultados: la MC presenta un coeficiente de correlación interclase superior al de la RM (0,9 vs. 0,7). Los valores de sensibilidad y especificidad de la MC (83,9 y 83,3%) son altos y equiparables a los de la RM (74,2 y 91,6%). Además, el valor predictivo negativo de la MC es mayor que el de la RM (66,7 vs. 57,9%) y VPP es muy similar (92,9 vs. 95,8%). Conclusión: la mamografía con contraste es una prueba equiparable a la resonancia magnética para la evaluación de la respuesta tumoral posneoadyuvancia en las pacientes con cáncer de mama. También es una prueba válida para la visualización de lesiones adicionales en la misma mama o en la contralateral. (AU)

Introduction: Magnetic resonance imaging is the most accurate diagnostic method for evaluating residual disease in breast cancer treated with neoadjuvant chemotherapy. Contrast-enhanced mammography can be an effective alternative to MRI in the evaluation of residual tumor. This technique would significantly reduce costs, improve patient flow and hardly has any contraindications. Methods: We have carried out an observational and prospective study in 43 patients with breast cancer treated with neoadjuvant chemotherapy. The pre-surgical study included both mammography with contrast injection and magnetic resonance imaging. Residual tumor size by imaging was correlated with the postoperative pathology study. Results: The CM presents a higher interclass correlation coefficient than the RM (0.9 vs. 0.7). The sensitivity and specificity values of CM (83.9% and 83.3%) are high and comparable to those of MRI (74.2% and 91.6%). Furthermore, the negative predictive value of CM is greater than that of MRI (66.7% vs 57.9%) and PPV is very similar (92.9% vs 95.8%). Conclusion: Contrast-enhanced mammography is a test comparable to magnetic resonance imaging for the evaluation of post-neoadjuvant tumor response in patients with breast cancer. It is also a valid test in visualizing additional lesions in the same or contralateral breast. (AU)

Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa / Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

Introducción: El objetivo de nuestro estudio consistió en identificar aquellas pacientes con diagnóstico preoperatorio de carcinoma ductal in situ (CDIS) y alto riesgo de presentar un carcinoma infiltrante en la lesión, en las que se debería considerar realizar una biopsia selectiva de ganglio centinela (BSGC). Métodos: Se estudiaron 105 pacientes con CDIS tratadas mediante cirugía conservadora o mastectomía. Se analizaron las características preoperatorias de los tumores para investigar su asociación con la infraestimación de carcinoma infiltrante. Resultados: El porcentaje global de infraestimación de carcinoma infiltrante fue del 16,2%. El porcentaje de infraestimación fue mayor en las lesiones con un tamaño inicial superior a 2 cm en comparación con las lesiones con un tamaño igual o menor a 2 cm (26,8% vs. 4,1%, respectivamente; p < 0,003). Se realizó la BSGC en 88 pacientes (83,8%), encontrándose afectación ganglionar en un solo caso (1,1%). Conclusiones: En pacientes con diagnóstico inicial de CDIS tratadas mediante cirugía conservadora, se debería considerar realizar una BSGC cuando el tamaño de la lesión es superior a 2 cm, ya que uno de cada cuatro casos albergará la presencia de un carcinoma infiltrante. (AU)

Introduction: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. Methods: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. Results: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). Conclusions: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC. (AU)