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Pagliara D, Rubino C, Grieco F, Pili N, Serra PL, Schiavone L, Lattanzi M, Montella RA, Rinaldi PM, Ribuffo D, De Santis G, Salgarello M. Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy. Aesthet Surg J 2024; 44:624-632. [PMID: 38299427 DOI: 10.1093/asj/sjae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results. OBJECTIVES The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients. METHODS We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest. RESULTS We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved. CONCLUSIONS The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy. LEVEL OF EVIDENCE: 3
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Pagliara D, Schiavone L, Garganese G, Bove S, Montella RA, Costantini M, Rinaldi PM, Bottosso S, Grieco F, Rubino C, Salgarello M, Ribuffo D. Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques. Clin Breast Cancer 2023; 23:249-254. [PMID: 36725477 DOI: 10.1016/j.clbc.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/31/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023]
Abstract
Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.
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Affiliation(s)
- Domenico Pagliara
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy.
| | - Laurenza Schiavone
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Roma, Italy
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Rino Aldo Montella
- Radiology Unit, Mater Olbia Hospital, Mater Olbia Hospital, Olbia, Italy
| | - Melania Costantini
- Radiology Unit, Mater Olbia Hospital, Mater Olbia Hospital, Olbia, Italy
| | | | - Stefano Bottosso
- Department of Medical, Surgical and Health Sciences, Plastic Surgery Unit, University of Trieste, Ospedale di Cattinara, ASUGI, Trieste, Italy
| | - Federica Grieco
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Marzia Salgarello
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Diego Ribuffo
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Roma, Italy
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Pagliara D, Montella RA, Garganese G, Bove S, Costantini M, Rinaldi PM, Pino V, Grieco F, Rubino C, Salgarello M. Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio. Clin Breast Cancer 2023; 23:e37-e44. [PMID: 36610826 DOI: 10.1016/j.clbc.2022.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/28/2022]
Abstract
We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast). BACKGROUND The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction. METHODS We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data. RESULTS The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).
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Affiliation(s)
- Domenico Pagliara
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy.
| | - Rino Aldo Montella
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Olbia, Italy
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Melania Costantini
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Olbia, Italy
| | - Pierluigi Maria Rinaldi
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Olbia, Italy
| | - Valentina Pino
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Federica Grieco
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Marzia Salgarello
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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Costantini M, Montella RA, Fadda MP, Tondolo V, Franceschini G, Bove S, Garganese G, Rinaldi PM. Diagnostic Challenge of Invasive Lobular Carcinoma of the Breast: What Is the News? Breast Magnetic Resonance Imaging and Emerging Role of Contrast-Enhanced Spectral Mammography. J Pers Med 2022; 12:jpm12060867. [PMID: 35743654 PMCID: PMC9224821 DOI: 10.3390/jpm12060867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 02/01/2023] Open
Abstract
Invasive lobular carcinoma is the second most common histologic form of breast cancer, representing 5% to 15% of all invasive breast cancers. Due to an insidious proliferative pattern, invasive lobular carcinoma remains clinically and radiologically elusive in many cases. Breast magnetic resonance imaging (MR) is considered the most accurate imaging modality in detecting and staging invasive lobular carcinoma and it is strongly recommended in pre-operative planning for all ILC. Contrast-enhanced spectral mammography (CESM) is a new diagnostic method that enables the accurate detection of malignant breast lesions similar to that of breast MR. CESM is also a promising breast imaging method for planning surgeries. In this study, we compare the ability of contrast-enhanced spectral mammography (CESM) with breast MR in the preoperative assessment of the extent of invasive lobular carcinoma. All patients with proven invasive lobular carcinoma treated in our breast cancer center underwent preoperative breast MRI and CESM. Images were reviewed by two dedicated breast radiologists and results were compared to the reference standard histopathology. CESM was similar and in some cases more accurate than breast MR in assessing the extent of disease in invasive lobular cancers. Further evaluation in larger prospective randomized trials is needed to validate our preliminary results.
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Affiliation(s)
- Melania Costantini
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Area Diagnostica per Immagini, 00168 Rome, Italy
| | - Rino Aldo Montella
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
- Correspondence: ; Tel.: +39-078-9189-9901
| | - Maria Paola Fadda
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
| | - Vincenzo Tondolo
- General Surgery Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy;
| | - Gianluca Franceschini
- Multidisciplinary Breast Center, Dipartimento Scienze Della Salute Della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (S.B.); (G.G.)
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (S.B.); (G.G.)
- Dipartimento Scienze Della Vita e Sanità Pubblica, Sezione Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Pierluigi Maria Rinaldi
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), Strada Statale 125 Orientale Sarda, 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
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Costantini M, Montella RA, Fadda MP, Garganese G, Di Leone A, Sanchez AM, Franceschini G, Rinaldi PM. Axillary Nodal Metastases from Carcinoma of Unknown Primary (CUPAx): Role of Contrast-Enhanced Spectral Mammography (CESM) in Detecting Occult Breast Cancer. J Pers Med 2021; 11:jpm11060465. [PMID: 34070278 PMCID: PMC8225076 DOI: 10.3390/jpm11060465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/14/2022] Open
Abstract
Axillary lymph node metastases of occult breast cancer (CUPAx) is an unusual condition that represents both a diagnostic and therapeutic challenge. The first steps in the diagnostic work-up of patients with CUPAx are the histological analysis of the lymph node metastasis and the execution of basic breast diagnostic imaging (mammography and ultrasound). In the case of occult breast cancer, breast Magnetic Resonance (MR) must be performed. Breast MR identifies a suspicious lesion in many patients and second-look ultrasound detects a corresponding ultrasound alteration in about half of cases, allowing the performance of a US-guided biopsy. In the case of an MR-only lesion, MR-guided biopsy is mandatory. We present a case of CUPAx in which contrast-enhanced spectral mammography (CESM) is used to help the detection of occult breast cancer and to guide stereotactic vacuum breast biopsy (VABB). CESM is a new breast imaging technique that is proving to have good performance in breast cancer detection and that is showing potential in the identification of occult breast cancer in a CUPAx setting. The use of an innovative and personalized breast imaging approach in breast cancer patients improves diagnostic possibilities and promises to become the focus in decision strategies.
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Affiliation(s)
- Melania Costantini
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
- Area Diagnostica per Immagini, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
| | - Rino Aldo Montella
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
- Correspondence: ; Tel.: +39-0789-1899901
| | - Maria Paola Fadda
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), 07026 Olbia, Italy;
- Dipartimento Scienze della Vita e Sanità Pubblica, Sezione Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Alba Di Leone
- Multidisciplinary Breast Center, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (A.D.L.); (A.M.S.); (G.F.)
| | - Alejandro Martin Sanchez
- Multidisciplinary Breast Center, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (A.D.L.); (A.M.S.); (G.F.)
| | - Gianluca Franceschini
- Multidisciplinary Breast Center, Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (A.D.L.); (A.M.S.); (G.F.)
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Pierluigi Maria Rinaldi
- Radiology Unit, Mater Olbia Hospital (Qatar Foundation Endowment and Policlinico Universitario Agostino Gemelli IRCCS Foundation), 07026 Olbia, Italy; (M.C.); (M.P.F.); (P.M.R.)
- Area Diagnostica per Immagini, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
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