New techniques versus standard mapping for sentinel lymph node biopsy in breast cancer: a systematic review and meta-analysis

New tracers for sentinel lymph node biopsy (SLNB), as indocyanine green (ICG), superparamagnetic iron oxide (SPIO) and micro bubbles, have been recently introduced in clinical practice showing promising but variable results. We reviewed the available evidence comparing these new techniques with the standard tracers to evaluate their safety. To identify all available studies, a systematic search was performed in all electronic databases. Data regarding sample size, mean number of SLN harvested for patient, number of metastatic SLN and SLN identification rate of all studies were extracted. No significant differences were found in terms of SLNs identification rates between SPIO, RI and BD but with a higher identification rate with the use of ICG. No significant differences were also found for the number of metastatic lymph nodes identified between SPIO, RI and BD and the mean number of SLNs identified between SPIO and ICG versus conventional tracers. A statistically significant differences in favor of ICG was reported for the comparison between ICG and conventional tracers for the number of metastatic lymph nodes identified. Our meta-analysis demonstrates that the use of both ICG and SPIO for the pre-operative mapping of sentinel lymph nodes in breast cancer treatment is adequately effective.

Generation and Characterization of a Tumor Stromal Microenvironment and Analysis of Its Interplay with Breast Cancer Cells: An In Vitro Model to Study Breast Cancer-Associated Fibroblast Inactivation

Breast cancer-associated fibroblasts (BCAFs), the most abundant non-cancer stromal cells of the breast tumor microenvironment (TME), dramatically sustain breast cancer (BC) progression by interacting with BC cells. BCAFs, as well as myofibroblasts, display an up regulation of activation and inflammation markers represented by α-smooth muscle actin (α-SMA) and cyclooxygenase 2 (COX-2). BCAF aggregates have been identified in the peripheral blood of metastatic BC patients. We generated an in vitro stromal model consisting of human primary BCAFs grown as monolayers or 3D cell aggregates, namely spheroids and reverted BCAFs, obtained from BCAF spheroids reverted to 2D cell adhesion growth after 216 h of 3D culture. We firstly evaluated the state of activation and inflammation and the mesenchymal status of the BCAF monolayers, BCAF spheroids and reverted BCAFs. Then, we analyzed the MCF-7 cell viability and migration following treatment with conditioned media from the different BCAF cultures. After 216 h of 3D culture, the BCAFs acquired an inactivated phenotype, associated with a significant reduction in α-SMA and COX-2 protein expression. The deactivation of the BCAF spheroids at 216 h was further confirmed by the cytostatic effect exerted by their conditioned medium on MCF-7 cells. Interestingly, the reverted BCAFs also retained a less activated phenotype as indicated by α-SMA protein expression reduction. Furthermore, the reverted BCAFs exhibited a reduced pro-tumor phenotype as indicated by the anti-migratory effect exerted by their conditioned medium on MCF-7 cells. The deactivation of BCAFs without drug treatment is possible and leads to a reduced capability of BCAFs to sustain BC progression in vitro. Consequently, this study could be a starting point to develop new therapeutic strategies targeting BCAFs and their interactions with cancer cells.

Clinical value of radiomics and machine learning in breast ultrasound: a multicenter study for differential diagnosis of benign and malignant lesions

Objectives

We aimed to assess the performance of radiomics and machine learning (ML) for classification of non-cystic benign and malignant breast lesions on ultrasound images, compare ML’s accuracy with that of a breast radiologist, and verify if the radiologist’s performance is improved by using ML.

Methods

Our retrospective study included patients from two institutions. A total of 135 lesions from Institution 1 were used to train and test the ML model with cross-validation. Radiomic features were extracted from manually annotated images and underwent a multistep feature selection process. Not reproducible, low variance, and highly intercorrelated features were removed from the dataset. Then, 66 lesions from Institution 2 were used as an external test set for ML and to assess the performance of a radiologist without and with the aid of ML, using McNemar’s test.

Results

After feature selection, 10 of the 520 features extracted were employed to train a random forest algorithm. Its accuracy in the training set was 82% (standard deviation, SD, ± 6%), with an AUC of 0.90 (SD ± 0.06), while the performance on the test set was 82% (95% confidence intervals (CI) = 70–90%) with an AUC of 0.82 (95% CI = 0.70–0.93). It resulted in being significantly better than the baseline reference (p = 0.0098), but not different from the radiologist (79.4%, p = 0.815). The radiologist’s performance improved when using ML (80.2%), but not significantly (p = 0.508).

Conclusions

A radiomic analysis combined with ML showed promising results to differentiate benign from malignant breast lesions on ultrasound images.

Key Points

• Machine learning showed good accuracy in discriminating benign from malignant breast lesions

• The machine learning classifier’s performance was comparable to that of a breast radiologist

• The radiologist’s accuracy improved with machine learning, but not significantly

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08009-2.

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL): a challenging cytological diagnosis with hybrid PET/MRI staging and follow-up

We report a case of a 55-year-old woman with left breast cosmetic augmentation performed 5 years earlier, showing at ultrasound a left small amount of peri-implant effusion suspicious for an anaplastic large cell lymphoma localization. The final diagnosis was obtained by cytology using a small amount of fluid (6 ml). Subsequently, hybrid 18F-FDG PET/MRI was used for pre-operative staging and follow-up. An appropriate management of BIA-ALCL could be obtained even in cases of a small amount of peri-implant effusion, using a comprehensive approach of clinical and imaging evaluation, including PET/MRI as useful and innovative staging imaging technique.

Influence of Fibroblasts on Mammary Gland Development, Breast Cancer Microenvironment Remodeling, and Cancer Cell Dissemination

The stromal microenvironment regulates mammary gland development and tumorigenesis. In normal mammary glands, the stromal microenvironment encompasses the ducts and contains fibroblasts, the main regulators of branching morphogenesis. Understanding the way fibroblast signaling pathways regulate mammary gland development may offer insights into the mechanisms of breast cancer (BC) biology. In fact, the unregulated mammary fibroblast signaling pathways, associated with alterations in extracellular matrix (ECM) remodeling and branching morphogenesis, drive breast cancer microenvironment (BCM) remodeling and cancer growth. The BCM comprises a very heterogeneous tissue containing non-cancer stromal cells, namely, breast cancer-associated fibroblasts (BCAFs), which represent most of the tumor mass. Moreover, the different components of the BCM highly interact with cancer cells, thereby generating a tightly intertwined network. In particular, BC cells activate recruited normal fibroblasts in BCAFs, which, in turn, promote BCM remodeling and metastasis. Thus, comparing the roles of normal fibroblasts and BCAFs in the physiological and metastatic processes, could provide a deeper understanding of the signaling pathways regulating BC dissemination. Here, we review the latest literature describing the structure of the mammary gland and the BCM and summarize the influence of epithelial-mesenchymal transition (EpMT) and autophagy in BC dissemination. Finally, we discuss the roles of fibroblasts and BCAFs in mammary gland development and BCM remodeling, respectively.

Palbociclib added to ongoing endocrine therapy for hormone receptor-positive HER2-negative metastatic breast cancer: A case report series

Palbociclib is a potent cyclin-dependent kinase (CDK)4/6 inhibitor that disrupts cell cycle progression and has been recently approved in combination with an aromatase inhibitor or fulvestrant as first- and second-line treatment in hormone receptor (HR)⁺, human epidermal growth factor receptor (HER)2^- metastatic breast cancer. There is evidence that palbociclib may reverse endocrine therapy resistance and that it may also be added to ongoing endocrine therapy beyond progression to obtain clinical benefit. The aim of the present study was to explore this possibility in 5 patients who received palbociclib + fulvestrant following disease progression while under treatment with fulvestrant alone. The median progression-free survival was not reached during a median follow-up of 25 months, and the most frequent best response was stable disease. Three patients remained under treatment on the last re-evaluation. All patients had highly endocrine-sensitive disease and had previously received fulvestrant for ≥12 months. The hypothesis that a selected subpopulation of patients with HR⁺/HER2^- metastatic breast cancer may benefit from the addition of palbociclib to ongoing endocrine therapy beyond disease progression merits further investigation.

Influence of different post-contrast time points on dynamic contrast-enhanced (DCE) MRI T staging in breast cancer

PURPOSE

to assess whether MRI T stage of breast cancer lesions (BCLs) is affected by maximum diameter (MD) measured at different post-contrast time points (TPs) on different acquisition planes on dynamic contrast-enhanced (DCE) MRI sequence.

METHODS

53 DCE-MRI examinations of patients with BCLs were retrospectively selected. MD of BCLs was measured on axial, coronal and sagittal planes on DCE images at five different post-contrast TPs. Friedman test followed by Bonferroni-adjusted Wilcoxon-signed rank test for post-hoc analysis was performed to evaluate differences among the five measurements. Reliability of the measurements was evaluated with the intraclass correlation coefficient analysis. Differences between pathological and MRI T stage assessed at each TP on each acquisition plane were assessed using the Wilcoxon-sign rank test; p values <0.05 were considered statistically significant.

RESULTS

on axial, coronal and sagittal planes, MD measured at TP1 was significantly different (p < 0.0001) compared to those obtained at the subsequent TPs. No significant differences were found between MD measured at TPs 3, 4 and 5. Intra and inter-observer reliability resulted as very good, with ICC ranging between 0.915-0.992 and 0.845-0.911, respectively. MRI T stage assessed at TP1 on axial and sagittal plane as well as at all TPs on coronal plane was significantly different from pathological T stage.

CONCLUSION

MRI T stage definition of BCLs is significantly affected by the TP used for lesions' MD measurement. TPs 3, 4 and 5 are the preferred TPs for the assessment of MRI T stage of BCLs on both axial and sagittal planes.

Usefulness of Ultrasound-Guided Fine-Needle Aspiration Cytology in the Diagnosis of Non-Palpable Small Thyroid Nodules

Aims and background

Diverse and contradictory approaches have been suggested for the management of non-palpable thyroid nodules. The aim of our study was to evaluate the indications and limits of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in non-palpable infracentimetric thyroid nodules.

Methods and study design

From September 2003 to December 2004 we observed 325 patients with non-palpable thyroid nodules. We divided our series into three groups according to the diameter of the lesion in order to verify the effectiveness of US-FNAC for lesions of less than 1 cm.

Results

We assessed the cases with satisfactory and unsatisfactory results in the three groups into which the sample was divided (4 mm to 1 cm; 10.1 mm to 15 mm, and 15.1 mm to 25.5 mm). Our statistical analysis by means of the z-test showed there was no significant (5%) difference in the percentage distribution of the unsatisfactory results in the three groups.

Conclusions

Fine-needle cytology appears to be a useful diagnostic tool also for nodules of less than one cm because the percentage of unsatisfactory results is not related to the size of the nodule.

The axillary flap in oncoplastic resection of breast cancers located in the upper-outer quadrants: a new surgical technique

Background

The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.

Methods

During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.

Results

At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.

Conclusions

The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.

Adenomyoepithelioma of the Breast. A Case Report

Adenomyoepithelioma is a proliferative disorder of both epithelial and myoepithelial cells. This lesion may be found in salivary glands, skin appendages and, very rarely, in the mammary gland. Adenomyoepithelioma was first described in 1970 and very few cases have so far been reviewed in the literature. This paper reports the clinical, histological and immunohistochemical characteristics of an adenomyoepithelioma in a 24 year old woman; to our knowledge this is the first published case in such a young patient. The clinical feature suggested a fibroadenoma. A more complete study of the excised tumor tissue by immunohistochemical and ultrastructural analysis proved that the correct diagnosis was adenomyoepithelioma. Whether adenomyoepithelioma is a benign or a low-grade malignant lesion is still controversial and, therefore, the therapeutic approach is not well defined.

Combined effect of obesity and diabetes on early breast cancer outcome: a prospective observational study

Background

Previous studies suggested that obesity and diabetes were correlated with breast cancer outcome. The aim of the present study was to investigate the prognostic effect of obesity and diabetes on the outcome of early breast cancer patients.

Materials and Methods

Overall, 841 early breast cancer patients were prospectively enrolled between January 2009 and December 2013. Study population was divided into four groups: (1) patients without obesity or diabetes; (2) patients with only diabetes; (3) patients with only obesity; and (4) patients with both diabetes and obesity. Categorical variables were analyzed by the chi-square test and survival data by the log-rank test.

Results

At diagnosis, obese and diabetic patients were more likely to be older (p < 0.0001) and post-menopausal (p < 0.0001) and to have a tumor larger than 2 cm (p < 0.0001) than patients in groups 1–3. At univariate analyses, obese and diabetic patients had a worse disease-free survival (p = 0.01) and overall survival (p = 0.001) than did patients without obesity and diabetes. At multivariate analyses, the co-presence of obesity and diabetes was an independent prognostic factor for disease-free survival (hazard ratio=2.62, 95% CI 1.23–5.60) but not for overall survival.

Conclusions

At diagnosis, patients with obesity and diabetes were older, had larger tumors and a worse outcome compared to patients without obesity or diabetes. These data suggest that metabolic health influences the prognosis of patients affected by early breast cancer.

Preliminary Results of a Simplified Breast MRI Protocol to Characterize Breast Lesions: Comparison with a Full Diagnostic Protocol and a Review of the Current Literature

RATIONALE AND OBJECTIVES

This study aimed to investigate whether a simplified breast magnetic resonance imaging (MRI) protocol consisting of a localizer, one precontrast sequence, and three time-point postcontrast sequences (at 28 seconds, 84 seconds and 252 seconds after the contrast agent administration) is suitable for the characterization of breast lesions as compared to a full diagnostic protocol (FDP). This study also aimed to review the current literature concerning abbreviated breast MRI protocols and offer an alternative protocol.

MATERIALS AND METHODS

Breast magnetic resonance (MR) examinations with detected breast lesions of 98 patients were retrospectively evaluated. Two expert radiologists in consensus reviewed the simplified breast protocol (SBP) first and only thereafter the regular FDP, recording a diagnosis for each detected lesion for both protocols. Receiver operating characteristic curve analysis was performed to determine the diagnostic performance of the SBP compared to the standard FDP. A revision of the previously reported abbreviated breast magnetic resonance protocols was also carried out.

RESULTS

A total of 180 lesions were identified; of these, 110 (61%) were malignant and 70 (39%) were benign. Of the 110 malignant lesions, 86 (78%) were invasive ductal carcinoma, 18 (16%) were invasive lobular carcinoma, and 6 (6%) were ductal carcinoma in situ. Areas under the curve for the receiver operating characteristic curves for the SBP vs the FDP were equivalent (0.98 vs 0.99, respectively; P = 0.76). The SBP could be performed in approximately 6 minutes and 58 seconds, compared to 14 minutes and 48 seconds for the FDP.

CONCLUSIONS

An SBP protocol including a late postcontrast time point is accurate for the characterization of breast lesions and was comparable to the standard FDP protocol, allowing a potential reduction of the total acquisition and interpretation times.

Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients

The use of contralateral risk reducing mastectomy (CRRM) is indicated in women affected by breast cancer, who are at high risk of developing a contralateral breast cancer, particularly women with genetic mutation of BRCA1, BRCA2 and P53. However we should consider that the genes described above account for only 20-30% of the excess familiar risk. What is contralaterally indicated when genetic assessment results negative for mutation in a young patient with unilateral breast cancer? Is it ethically correct to remove a contralateral "healthy" breast? CRRM rates continue to rise all over the world although CRRM seems not to improve overall survival in women with unilateral sporadic breast cancer. The decision to pursue CRRM as part of treatment in women who have a low-to-moderate risk of developing a secondary cancer in the contralateral breast should consider both breast cancer individual-features and patients preferences, but should be not supported by the surgeon and avoided as first approach with the exception of women highly worried about cancer. Prospective studies are needed to identify cohorts of patients most likely to benefit from CRRM.

Different types of implants for reconstructive breast surgery

BACKGROUND

Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast.

OBJECTIVES

To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

MAIN RESULTS

Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies.

AUTHORS' CONCLUSIONS

Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.

Primary angiosarcoma of the breast

Primary angiosarcoma (AS) of the breast is a rare neoplasia that is not related to radiation exposure. It represents less than 0.05% of all malignant breast tumors. This lesion is characterized by aggressive patterns and poor prognosis and by the absence of typical features at radiologic examination. Currently there are not evidence-based guidelines regarding surgical and adjuvant treatment for this tumor even though wide surgical resection followed by chemo- radiotherapy appears to improve both disease free survival and overall survival. The aim of this study was to analyze the available series of AS patients suggesting the most reliable treatment options for this rare neoplasia.

Confocal laser endomicroscopy in breast surgery: a pilot study

Background

Breast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions.

Methods

Thirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination.

Results

Histopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated “slit-like” structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix.

Conclusions

This is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

Poly Implant Prothèse (PIP) incidence of rupture: a retrospective MR analysis in 64 patients

AIM OF THE STUDY

The purpose of this retrospective study was to describe the magnetic resonance imaging (MRI) features of Poly Implant Prothèse (PIP) hydrogel implants in a group of 64 patients and to assess the incidence of rupture, compared to other clinical trials.

MATERIAL AND METHODS

In this double-center study, we retrospectively reviewed the data sets of 64 consecutive patients (mean age, 43±9 years, age range, 27-65 years), who underwent breast MRI examinations, between January 2008 and October 2013, with suspected implant rupture on the basis of clinical assessment or after conventional imaging examination (either mammography or ultrasound). All patients had undergone breast operation with bilateral textured cohesive gel PIP implant insertion for aesthetic reasons. The mean time after operation was 8 years (range, 6-14 years). No patients reported history of direct trauma to their implants.

RESULTS

At the time of clinical examination, 41 patients were asymptomatic, 16 complained of breast tenderness and 7 had clinical evidence of rupture. Normal findings were observed in 15 patients. In 26 patients there were signs of mild collapse, with associated not significant peri-capsular fluid collections and no evidence of implant rupture; in 23 patients there was suggestion of implant rupture, according to breast MRI leading to an indication for surgery. In particular, 14 patients showed intra-capsular rupture, with associated evidence of the linguine sign in all cases; the keyhole sign and the droplet signs were observed in 6 cases. In 9 patients there was evidence of extra-capsular rupture, with presence of axillary collections (siliconomas) in 7 cases and peri-prosthetic and mediastinal cavity siliconomas, in 5 cases.

CONCLUSIONS

The results of this double center retrospective study, confirm the higher incidence (36%) of prosthesis rupture observed with the PIP implants, compared to other breast implants.

Assessment of bacterial infection in chronic wounds in the elderly: biopsy versus VERSAJET

AIM

The aim of this study was to evaluate the hydro-surgery VERSAJET system as a suitable alternative to the traditional invasive tissue sampling technique in detecting bacteria and their load in chronic wounds in the elderly.

MATERIALS AND METHODS

To investigate and evaluate bacterial incidence and load in chronic wounds, we simultaneously performed on 19 affected patients a deep tissue biopsy and tissue collections by the VERSAJET hydro-surgical system. After local cleaning and anesthesia, a deep biopsy was performed with a punch of 3-4 mm in diameter. Subsequently, three tissue samples were collected by the VERSAJET system: one from the first washing in order to investigate the superficial contamination; one from the second washing to investigate deep tissue infection investigation and one from the third washing as a control procedure. After treatment, all tissue samples were cultured in vitro for diagnostic and micro-biological assessment.

RESULTS

Nineteen patients with chronic wounds of the lower limbs were enrolled from February 2010 to May 2013. Concordance between deep tissue biopsy cultures and tissue cultures collected by the VERSAJET system was examined. The deep tissue biopsy cultures showed complete concordance with the VERSAJET as follows: 2 patients (11%) for the first washing sample; 10 patients (53%) for the second washing sample; 4 patients (21%) for the third washing sample. However, with reference to only aerobic isolated strains, the concordance of the VERSAJET second washing samples cultures with a biopsy of the deep tissue cultures was very high (84%) and fairly high (63%) in the anaerobic isolated strains. The second VERSAJET washing sample cultures seem to have the highest concordance with the biopsy of the deep tissue cultures.

CONCLUSIONS

Tissue biopsy remains the leading technique for detecting bacteria and their load in chronic wounds. However, this study shows that the hydro-surgery VERSAJET system is sufficiently effective in detecting bacteria and their load in chronic wounds and can be a potential alternative to a biopsy. In particular, the second washing sample culture showed the best correlation with the deep tissue biopsy culture. However, further studies are needed in order to modify techniques of tissue collection in the VERSAJET system before drawing any conclusions.

Increase of mastectomy rates after preoperative MRI in women with breast cancer is not influenced by patients age

Preoperative magnetic resonance imaging (MRI) is increasingly used for staging women with breast cancer, including screening for occult ipsilateral or contralateral cancer. If breast-conserving surgery is planned, a MRI examination should be performed in all ages women with suspected breast cancer, especially those exhibiting dense or heterogeneously dense breast parenchyma, for which the sensitivity of both ultrasonography and mammography is low. MRI staging causes more extensive breast surgery in a significative proportion of women by identifying additional cancer. If the ability to find additional occult cancer is the true value of MRI, this is not influenced by patients' ages. For this reason, preoperative MRI should be counseled to all women with breast cancer by clinicians, independently from the age, as the age alone does not preclude additional findings.

Unusual breast lesion mimicking cancer: diabetic mastopathy

Diabetic mastopathy represents an uncommon tumor-like proliferation of fibrous tissue of the breast that usually occurs in patients who suffered from type 1 diabetes mellitus for a long time. We report an uncommon case of diabetic mastopathy presenting in a type 2 non-insulin dependent diabetes mellitus 61-year-old postmenopausal woman. Physical examination revealed a hard, low movable mass in the upper outer quadrant of the right breast. Mammography and ultrasonography showed typical features of breast cancer. Ultrasound-guided fine-needle aspiration cytology (US-FNAC) was performed showing inflammatory infiltrate, suggesting excisional biopsy. Histological findings demonstrated typical diabetic mastopathy with fibrosis, histiocytic and limphocytic infiltration without evidence of malignancy.

Upper extremity vein thrombosis: an alert symptom of breast cancer in elderly patients. Experience on personal casuistry and review of the literature

Background

Breast Cancer in elderly patients is a significant health problem representing an important source of morbidity and mortality. Although the most common presentation is the presence of a palpable lump there may be, especially in the elderly population, rare clinical manifestations such as thromboembolic events that often involve the upper limbs.

Methods

We retrospectively reviewed a ten year clinical casuistry of patients with Breast Cancer who presented for an initial diagnosis of upper extremity vein thrombosis.

Results

13 patients with initial diagnosis of upper limbs vein thrombosis (1M-12 F; age range 48-76; median age 70 years) resulted affected from Breast Cancer. The diagnosis of vein thrombosis represented the first clinical manifestation related to thier malingancy. All patients of our casuistry had positive ER/PR receptor status.

Conclusions

A case of upper vein extrmity thrombosis in an elderly patient should prompt a high index of suspicion for breast malignancy in order to avoid diagnostic delay that may retard appropriate treatment.

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

Background

Inguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.

Methods

The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia.

Results

Evaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics.

Conclusions

Clinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling.

Breast cancer surgery in elderly patients: postoperative complications and survival

Aims and background

Old age is associated with comorbidity and decreased functioning which influences treatment decisions in elderly breast cancer patients. The purpose of this study was to identify risk factors for complications after breast cancer surgery in elderly patients, and to assess mortality in patients with postoperative complications.

Methods

We retrospectively considered all female patients aged 65 years and older with invasive and in situ breast cancer who were diagnosed and treated between 1997 and 2012 in the Department of General and Geriatric Surgery of the University of Naples "Federico II".

Results and conclusion

449 patients received surgery, of whom 18,2% (n = 82) developed one or more postoperative complications. The odds ratio of having postoperative complications show an increase with age, reaching statistical significance only for patients older than 85 [OR 5,75 (95% confidence interval 2,38-14,04); p < 0,001]. Number of concomitant diseases [OR 2,51 (95% CI 1,17 - 5,45); p = 0,01 for 3 or more concomitant diseases] and polypharmacy [OR 16,7 (95% CI 9,12 - 30,58); p < 0,0001) are associated to an increased risk of postoperative complications. Overall survival was worse in patients with postoperative complications [HR 2,06 (95% CI 1,52-2,70), p < 0,001]. This increased risk of mortality is probably due to geriatric parameters such as comorbidity or poor physical function, more than to higher complication rates.

Day-surgery inguinal hernia repair in the elderly: single centre experience

BACKGROUND

Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients.

METHODS

A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups.

RESULTS

Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients.

CONCLUSIONS

Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.

Emergency groin hernia repair: implications in elderly

BACKGROUND

Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients.

METHODS

We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications.

RESULTS

A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died.

CONCLUSIONS

Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.

Undertreatment of breast cancer in the elderly

Aims

The effect of undertreatment with adjuvant hormonal therapy, chemotherapy or radiation was studied in elderly women with breast cancer.

Methods

A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1997 and 2011. The presentation, pathologic findings, treatment and outcomes of 449 women over 65 were compared to the findings in 1049 younger patients. Moreover, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared.

Results

Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were signicantly more favorable than cancers in younger patients with more infiltrating lobular, fewer ductal carcinoma in situ and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary surgery, less adjuvant radiation therapy and more hormonal therapy. Fourty-six percent of the 449 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during follow-up without disease recurrence.

Conclusions

Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated.

Medullary breast carcinoma in an 18-year-old female: report on one case diagnosed on fine-needle cytology sample

Medullary breast carcinoma (MBC) is a rare epithelial malignancy of the breast accounting for about 1-7% of all breast carcinomas. It is characterized by well-defined borders, a syncytial/solid pattern of growth of high grade atypical cells showing no glandular differentiation and a massive diffuse lympho-plasmacytic peritumoral infiltrate. Despite the high-grade atypias characterizing this neoplasm, MBC has been reported to have a better prognosis when compared with the common infiltrating duct carcinoma. MBCs typically lack estrogen and progesterone receptor (ER and PgR) expression and have a low incidence of ERBB2 overexpression. Genetically, they are often associated with BRCA-1 oncogene mutations and TP53 alterations. While MBC generally occurs in middle-aged women, ranging from 45 to 52 years of age, we report the case of a 18-year-old female patient which was diagnosed by means of fine-needle cytology sample.

Unexpected autoptic finding in a sudden death: gossypiboma

Gossypiboma, i.e. a retained surgical sponge, is a serious and rare complication in surgical practice, most commonly occurring in abdominal procedures. Migration of retained surgical sponge is an unusual sequelae, particularly if occurring in tracheo-bronchial tree. Herein, we report a 35-year-old man who had had a retained surgical sponge forgotten during a radical thyroidectomy, and subsequently a trans-luminal migration of the gossypiboma which went through the trachea causing a sudden death of the patient. All the operators of the surgical team should keep in mind this terrible complication to avoid unpleasant consequences to patient and themselves.

Squamous metaplasia of the breast simulating a malignant neoplasm: a case

Squamous metaplasia of the breast ductal epithelium is a well-documented lesion; however, it represents a very uncommon histopathologic finding. We present a case of primary florid squamous metaplasia of the mammary ducts closely simulating a breast carcinoma in a 67-year-old woman. Patient after ultrasound examination and mammography, was submitted to a fine-needle aspiration biopsy (FNAB) that was considered inconclusive, and, in order to suspicious clinic and mammographic findings, a frozen evaluation during the surgical excision was performed. Primary squamous cell metaplasia is rarely observed in the breast. This condition closely mimics a malignant lesion at US-scan, X-ray evaluation and even at FNAB. Frozen examination, in this case, is considered decisive, preserving the patient from an unnecessary aggressive surgical approach.

Usefulness of ultrasound-guided fine-needle aspiration cytology in the diagnosis of non-palpable small thyroid nodules: our growing experience

AIMS AND BACKGROUND

Contradictory approaches have been suggested for the management of non-palpable thyroid nodules. The aim of our study is to evaluate indications and limits of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in the management of non-palpable infracentimetric thyroid nodules.

METHODS AND STUDY DESIGN

From September 2003 to June 2007 we studied 1043 patients with non-palpable thyroid nodules. We divided our series into three groups according to the diameter of the lesion in order to verify the effectiveness of US-FNAC for lesions <1 cm.

RESULTS

We assessed the cases with satisfactory and unsatisfactory results in the 3 groups into which the sample was divided. Our statistical analysis using the z-test showed there was no significant (p=0.05) difference in the percentage distribution of the unsatisfactory results in the 3 groups.

CONCLUSIONS

FNAC appears to be a useful diagnostic tool also for nodules <1 cm because the percentage of unsatisfactory results is not related to the size of the nodule.

Cholesterol granuloma of the breast with unusual ossification features (osseous metaplasia)

Cholesterol granuloma of the breast is a rare benign condition that can be mistaken for breast cancer. We present a case of a 42-year-old woman who presented with a 1-year history of asymptomatic palpable nodule in the upper external quadrant of the right breast. Mammography and ultrasonography suggested carcinoma, but excisional biopsy revealed cholesterol granuloma with unusual osseous metaplasia. Although reported to occur more frequently in the middle ear and mastoid process, we believe that better awareness of this rare benign condition is most important to avoid misdiagnosis and unnecessary surgery.

Targeting HER2 as a therapeutic strategy for breast cancer: a paradigmatic shift of drug development in oncology

Targeted therapies are causing a dramatic change in cancer drug development. Trastuzumab, a humanized recombinant monoclonal antibody that recognizes the extracellular domain of HER2 trans-membrane protein, is among the first target-specific drugs that have been licensed for clinical use and its development represents a model of integration of new agents with classical treatment strategies. In preclinical models, trastuzumab has demonstrated a marked antiproliferative effect and a synergistic action with several chemotherapeutic agents. Monotherapy trials indicate that trastuzumab is active as a single agent in HER2 positive patients, is well tolerated, and is associated with preservation of quality of life (QoL). Furthermore, as first line therapy for metastatic breast cancer overexpressing HER2 receptor, the addition of trastuzumab to taxane-based chemotherapy significantly increased rate of objective response, time to disease progression and survival when compared with chemotherapy alone. Trastuzumab has shown important activity when used with many chemotherapeutic agents such as platinum salts, gemcitabine, vinorelbine and capecitabine and liposomal anthracyclines. Various trials are now ongoing to optimize the use of trastuzumab and to investigate its role in the adjuvant and in the neo-adjuvant setting.

Metaplastic breast carcinoma on fine-needle cytology samples: A report of three cases

Metaplastic breast carcinoma (MBC) may have a varied presentation on fine-needle cytology samples. We herewith describe three cases of MBC found in our series. One of these cases showed a peculiar mixture of malignant ductal, apocrine type, and squamous epithelial cells with fascicles of spindle cells with variable degree of atypia and was diagnosed as metaplastic carcinoma of the carcino-sarcomatous type. The other two lesions were characterized by an abundant chondroid extracellular matrix to which were variably admixed carcinomatous and chondroid-type cells, with variable degree of atypia. Both these latter cases were defined as matrix-producing metaplastic carcinomas. Because of the various presentation of MBC on fine-needle cytology samples and the possible influence of needle "sampling" on the cytological specimen, the spectrum of differential diagnoses to be considered may encompass a number of benign and malignant entities, like keratinous subareolar cysts, malignant fibroepithelial lesions with myxo-chondroid stroma, and true sarcomas of the breast, with cartilaginous metaplasia. It is the Authors' feeling that, with optimal samples, the cytomorphological findings of this rare variant of breast carcinoma permit its accurate pre-operative diagnosis.

Comparison of descending volleys evoked by monophasic and biphasic magnetic stimulation of the motor cortex in conscious humans

The descending spinal volleys evoked by monophasic and biphasic magnetic stimulation of the motor cortex were recorded from a bipolar electrode inserted into the cervical epidural space of four conscious human subjects. The results suggest that both phases of the biphasic pulse are capable of activating descending motor output. The pattern of recruitment of descending activity depends on the intensity of the stimulus and the relative threshold of each volley to each direction of current flow.