Assessment of Mastectomy Skin Flaps for Immediate Implant-Based Breast Reconstruction

Objectives: The aim of this study is to identify the appropriate preoperative evaluation methods for the quality of the skin flaps and subcutaneous breast layer using different imaging techniques in correlation with the intraoperative findings and also their importance for the outcome in immediate implant-based breast reconstruction. Materials and Methods: Clinical evaluation, mammography, breast ultrasound and breast MRI were used for the assessment of the mastectomy skin flaps which enhanced the selection of the adequate surgical technique for breast reconstruction. The evaluation started with the skin flap measurement of 50 patients with breast cancer, who were candidates for modified radical mastectomy (MRM) in 2014, using the above-mentioned methods, without immediate breast reconstruction. Consequently, 46 nipple-sparing mastectomies (NSM) and 21 skin-sparing mastectomies (SSM) with immediate breast reconstruction with implants were performed between 2014 and 2017 after having such a preoperative subcutaneous tissue thickness evaluation. Results: The intraoperative findings of the MRM group showed a 90% accuracy for the MRI preoperative evaluation, 87% for the ultrasound, 81% for the mammography and 71% for the pinch test. The preoperative measurements for the patients undergoing SSM or NSM were a criterion for choosing the surgical technique for breast reconstruction. The rate of postoperative complications was low. Conclusion: Preoperative clinical measurements, breast ultrasound, breast MRI and mammography can enhance the prediction of the skin flap thickness and thus lead to a low rate of complications and good aesthetic results in implant-based immediate breast reconstruction.

Evolution of radical mastectomy for breast cancer

Surgical treatment of breast cancer has been marked by a constant evolution since the Halsted radical mastectomy described in the late 19th century has become the current standard Madden radical mastectomy, a breast surgery that involves the ablation of tissue with the axillary lymphatic preserving both pectoral muscles. The purpose of this paper was to present the stages that have marked the evolution of this intervention and to provide an overview of the way breast cancer has been understood and treated in the last century.

Modulating the extension of axillary lymphadenectomy for early stage breast cancer

Axillary lymph node evaluation remains essential in breast cancer surgery, first as a prognostic factor, because it indicates the degree of dissemination of the disease to the main lymphatic drainage basin of the breast, and, on the other hand, as an element of preventing the local relapse. In the era of the sentinel lymph node, complete axillary lymphadenectomy, considered valuable until recently, but as therapeutic and diagnostic, has become an intervention performed increasingly rare in selected cases. Axillary lymphatic tissue resections are accompanied by morbidity (lymphedema, paresthesia, limitations of arm movement) and symptom magnitude is proportional to the extension of the intervention. For this reason, a solution to avoid these kinds of complications was looked for. Since Gould, in 1960, who mentioned cancer parotid and continuing with Cabanas, Morton, or Veronesi, many surgeons have contributed to the development of safe techniques with which the multidisciplinary team involved in the surgical treatment for breast cancer could perform a safe oncological intervention and at the same time could conserve the healthy tissue, thus limiting morbidity. To achieve this standard, axillary lymphadenectomy has passed through several stages, from over radical interventions that followed the Halsted era, in which, besides axillary lymph nodes, the internal mammary and jugulo-carotidian lymph nodes were excised, to the absence of axillary surgery and replacing it with radiation therapy.

Clinical significance of the lymphoscintigraphy in the evaluation of non-axillary sentinel lymph node localization in breast cancer

BACKGROUND

Identification and biopsy of the sentinel lymph node (SLN) in early-stage breast cancer (T1-T2N0) has become the standard method in the surgical treatment of the axilla, due to its accuracy in the evaluation of axillary lymph node status,thus avoiding extensive axillary lymph node dissection inpatients with negative SLN. The aim of our study is to highlight the role of 99mTc-nanocolloid lymphoscintigraphy in the preoperative lymphatic mapping, especially for SLN localizations outside the axilla, as well as the benefits of this technique in the accurate staging of breast cancer.

MATERIALS AND METHOD

430 patients (age 31-81 years) with breast cancer (T1-T2N0 stage) were included in the study group, who underwent lymphoscintigraphy in order to identify the sentinel lymph node in the Nuclear Medicine Department of "€œProf. Dr. Al. Trestioreanu"€ Institute of Oncology, Bucharest,between October 2008 - July 2014. Radiocolloid (99mTc-nanocolloid)was injected using peritumoral or periareolar intradermal technique, doses between 20-37 MBq (0.3-0.5 ml volume), followed by static and dynamic post-injection acquisitions.Intraoperative identification of the SLN was performed using a gamma-probe, guided by the skin marker performed preoperatively after completion of lymphoscintigraphy.

RESULTS

697 sentinel lymph nodes were identified through imaging techniques in 427 patients (99%). Of them, 364 patients had axillary localization of the SLN, while 48 patients(11%) had non-axillary (pectoral, internal mammary, supraclavicular,intra-mammary) localization and 15 patients (3%)had multiple localization (axillary and non-axillary).Intraoperative histopathological exam revealed lymphatic invasion in 74 SLN (12% macrometastases and 88% micrometastases).

CONCLUSIONS

The identification and biopsy of the sentinel lymph node in stages I and IIA is a useful routine for accurate breast cancer staging, suited for axillary lymphatic drainage, as well as for unusual non-axillary SLN localization, guiding the clinician for further postoperative management of these patients.

Sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND) in the current surgical treatment of early stage breast cancer

The identification and biopsy of the sentinel lymph node has become a standard method of treatment for stage I and II breast cancer in the last decades, taking into account the fact that the management of the axilla in patients with breast cancer has evolved from the routine lymphadenectomy to a selective attitude, based on the histopathological evaluation of the sentinel lymph node, as well as on the tumor and on the patients' characteristics. Since the introduction of the method into clinical practice, in 1994, different methods of identification have been used (radioisotope injection, vital blue dye, or, more recently, lipophilic contrast agent for ultrasound visualization or paramagnetic nanoparticles (NPs) or the method of indocyanine green fluorescence), each presenting certain limits, but the radioisotopic method proving the most accurate. Moreover, during the development of the method, beside the standard indications specific for T1 or T2 breast tumor, without clinical or imagistic axillary adenopathies, their extension to a series of other particular situations such as the following, has been tried: ductal carcinoma in situ, multicentre tumors, after excisional biopsy or tumors preoperatively treated by neoadjuvant chemotherapy. The aim of the paper is to present the progress made regarding the current stage in the use of sentinel lymph node technique in breast cancer, while mentioning the established indications, as well as the ones that are still debating and need further studies. Likewise, the cases in which the axillary lymph node dissection remains the major indication for treatment of the axilla, in patients with early stage breast cancer, will be discussed.

Perioperatory pain in oncological patient - physiopathological and therapeutical implications

Perioperatory pain in oncological patients represents a witness of anesthetic-surgical aggression, frequently exacerbated by the complementary radio-chemotherapy and also a predictive factor for postoperatory evolution. The objectivation of perioperative pain by scales of clinical evaluation does not offer a certain and objective quantification; so, the dosing of some hormonal and acute phase inflammation mediators could realize a more realistic projection. Clinical and biological correlation can offer a support for an adequate and well-balanced treatment.

Immunological aspects predicting metastatic sentinel lymph node in early breast cancer patients

Tumour antigens are poorly expressed, heterogeneous and they modulate rapidly. As a result, their recognition and elimination by the immune system is very difficult. There are several mechanisms, by means of which, the host can neutralize oncogenesis and prevent it from occurring. The sentinel lymph node concept has brought about a revolution in the surgical treatment of the regional lymphatic basin while preserving the prognostic value of the regional lymph node status in breast cancer. This prospective study included 93 women with early breast cancer with initial indication for surgery in whom the sentinel lymph node technique was employed. Cell immune response was assessed prior to surgery by means of in vitro mononuclear cells blastic transformation assay (BLT), of immunoglobulin (Ig) and interleukin 2 (IL-2) measurements. The results were correlated with tumour size, presence of positive sentinel lymph node, tumour proliferation and growth markers (Ki-67, c-erbB2, bcl-2). Even in its less advanced stages, breast cancer is more aggressive and associates with an increased rate of sentinel lymph node metastases in patients below 50 years old, the tumour size exceeds 20 mm, with the presence of peritumoral lymphocytic infiltrate, positive Ki-67 and bcl-2, an alteration of T helper (Th) lymphocytes function, increased immune suppression through IL-2 decrease, signalled by blastic transformation indexes modifications and a drop in IL-2 production (p<0.01).

Occult breast lesion localization and concomitant sentinel lymph node biopsy in early breast cancer (SNOLL)

AIMS

Mammographic screening and the increasing resolution output of mammography have raised the identification number of small-size mammary lesions without clinical expression. The aim of this study was to evaluate in a prospective study the localization techique and concomitent sentinel lymph node biopsy for breast cancer (SNOLL - Sentinel lymph Node biopsy and Occult Lesion Localization).

METHODS

We identified by means of imaging techniques a number of 107 patients with clinically occult suspicious breast tumors. All patients preoperatively underwent a protocol in which the injection of 99mTc-nannocolloid under imaging procedures was performed. Surgical excision was performed, guided by the hand held gammaprobe. The sentinel lymph node was identified as an axillary hot spot on the probe.

RESULTS

All primary lesions were identified and were clear of invasive margins needing excision. 98 tumors proved to be malignant on frozen sections. 7 lesions could not be clearly examined through frozen section and 2 proved to be benign. 6 out of 7 suspicious lesions confirmed to be malignant on parrafin embedded sections. Sentinel lymph node was identified in a number of 95 out of 98 patients. In 14 cases complete axillary lymphadenectomy was performed. The average specimen weight was 40 grams.

CONCLUSIONS

Using this technique, we removed the lesions identified prior to surgery in all cases, achieving a complete pathologic diagnostic, the necessary surgical treatment and also prognostic data by axillary lymph node assessment.

Delayed presentation of tattoo lymphadenopathy mimicking malignant melanoma lymphadenopathy

Tattooing is a popular cosmetic practice and the technique has been adopted in breast reconstruction. Pigment injected intradermally is transported to lymph nodes leading to permanent pigmentation. Differential diagnosis between melanoma and tattoo pigmentation of lymph nodes is done microscopically. We present the case study of a patient who presented with palpable and pigmented axillary lymph nodes, 2 years after excision of melanoma and 20 years after tattooing. Intraoperative finding of enlarged, pigmented lymph nodes is not a certain sign of metastasis, as causes other then melanoma can lead to pigmented lymphadenopathy. The diagnostic and investigation process should start with history (including history of previous tattooing) and fine needle aspiration (FNA) of enlarged lymph node. If FNA is negative an open biopsy should be performed for confirmation of diagnosis before proceeding to completion lymphadenectomy.

[Validation protocol of sentinel node biopsy for breast cancer using radioactive tracer at the Institute of Oncology Bucharest "Prof. Dr. Alexandru Trestioreanu"]

The sentinel ganglion concept originates in the assumption according to which the primary tumor drains into a specific lymph node area and then runs through the lymphatic nodes in an orderly, sequential mode. When neoplastic dissemination along the lymphatic pathway occurs, there is an initial invasion of a specific lymph node (rarely more than one) located on the drainage route. That first lymph node has been identified as the sentinel node, which mirrors the regional lymph node status. In order to establish the indication for lymphadenectomy and avoid the situations in which such a surgical procedure would be of no use (N-), the only correct method consists in the identification and biopsy of the sentinel node which can be performed using vital staining (blue dye), radioactive tracers or both. The technique of sentinel lymph node identification and biopsy by means of radioactive tracing includes: -pre-surgical lymphoscintigraphy, -identification of the sentinel lymph node and its excisional biopsy, -intra-operative histopathological examination, paraffin embedded sections and immunohistochemical stains of the sentinel lymph node. The paper presents the refinement of the technique and the validation of the method for identification and biopsy of the sentinel lymph node in breast cancer with the intra-operative use of NEOPROBE 2000 gamma probe at the "Prof. Dr. Alexandru Trestioreanu" Oncological Institute in Bucharest. It is a prospective study which enrolled 93 patients with breast cancer between September 2003-December 2005, who underwent sentinel node biopsy. Complete axillary dissection (back-up lymphadenectomy) was performed in all cases. By comparing the pathological results of the frozen section of the sentinel node, with the paraffin embedded and immunohistochemical ones of the remaining axillary nodes, we present the following results: sensibility 97,15% (34/35), specificity 100% (93/93), positive predictive value 100% (34/34), negative predictive value 98,3% (58/59).

Melanomas in renal transplant recipients

BACKGROUND

It is well documented that renal transplant recipients are at increased risk of developing skin cancers, in particular squamous cell carcinomas. Less extensively reviewed in the literature is the increased incidence of malignant melanoma. We have reviewed 10 patients in the Oxford renal transplant population who developed 12 melanomas following transplantation.

OBJECTIVES

To determine the incidence and characteristics of melanoma in renal transplant recipients.

METHODS

We reviewed the case notes and pathology of all patients who developed melanoma within the Oxford Renal Transplant Unit. The clinical details were recorded including date of transplant, immunosuppressive therapy, interval between transplant and melanoma, site of occurrence, history of sun exposure, type of clinician diagnosing the melanoma, history of other skin malignancies and outcome. From the histopathology we documented various prognostic factors.

RESULTS

Ten patients developed 12 melanomas (one patient had three melanomas) from a population of 1874 transplanted patients. The total number of transplant years was 11 942.2. The incidence of melanoma in our population was 12 per 11 942.2 transplant years, which is approximately 8 times greater than the standardized rate for this region. We found that the mean interval between transplant and melanoma was approximately 11 years (median 8.5). A dermatologist was the diagnosing clinician in at least 67% of cases. Melanomas occurred on the trunk in the majority of cases (58%), followed by the upper limb (25%). All patients apart from one are alive with no recurrence of their melanoma. One patient died as a result of metastatic melanoma. The mean follow-up period following melanoma was 3.7 years. In all patients apart from the patient who died, the melanomas were < 1 mm Breslow thickness. That patient's melanoma was 4.5 mm thick. There was no precursor naevus in eight of the 12 melanomas. In two there was a precursor dysplastic naevus. In the cases in vertical growth phase the tumour-infiltrating lymphocyte response was absent in four cases and nonbrisk in one patient.

CONCLUSIONS

In the Oxford transplant population studied melanomas occurred at approximately 8 times the rate in the general population. This is the highest rate reported in the literature. The patients had a better outcome than reported previously. This may be due to detection at a relatively early stage. Renal transplant recipients attend dedicated dermatology clinics in Oxford, which may have contributed to the early diagnosis and good outcome.

Increased risk of skin cancer associated with the presence of epidermodysplasia verruciformis human papillomavirus types in normal skin

BACKGROUND

Human papillomaviruses (HPVs) are found in normal skin and in benign and malignant skin conditions. Epidermodysplasia verruciformis (EV) HPV types are those most plausibly linked to the development of squamous cell carcinomas of the skin.

OBJECTIVES

To assess the risk of nonmelanoma skin cancer (NMSC) associated with the presence of EV HPV in normal skin in immunocompetent (IC) individuals and renal transplant recipients (RTRs).

METHODS

Using a degenerate and nested polymerase chain reaction technique, HPV DNA was sought in 124 normal skin samples from sun-exposed and nonsun-exposed sites, from 39 IC individuals and 38 RTRs, both with and without NMSC. Data were analysed using the Mantel-Haenszel test and by logistic regression analysis.

RESULTS

HPV DNA was detected in 58/67 (87%) and 20/57 (35%) samples from renal transplant and IC patients, respectively. There was no difference in either the prevalence or spectrum of HPV types found in sun-exposed and nonsun-exposed normal skin. However, there was significant association between NMSC and the presence of EV HPV DNA. Multivariate analysis provided an odds ratio of 6.41 (95% confidence interval 1.79-22.9) for the association of EV HPV DNA in normal skin (irrespective of site) and NMSC status, even after stratifying for patient group and adjusting for the clustering effect of multiple sampling. Conversely, there was no association between skin cancer status and the presence of cutaneous or mucosal HPV types in either sun-exposed or nonsun-exposed skin.

CONCLUSIONS

HPV DNA is widespread in normal adult skin, particularly in transplant patients. In our study, the presence of EV but not cutaneous HPV DNA in normal skin was significantly associated with NMSC status and may prove to be of predictive value for skin cancer risk. These data provide reason to focus on EV HPV types as causal agents in skin cancer.

Skin cancers in renal-transplant recipients occur more frequently than previously recognized in a temperate climate

BACKGROUND

Renal-transplant recipients are at increased risk of developing skin cancers, especially squamous cell carcinoma. We have carried out a comprehensive epidemiologic review of skin cancers occurring in a population receiving transplants in Oxford over a 21-year period, where nearly all patients have remained under the care of the Oxford Transplant Centre.

METHODS

Between 1975 and 1996, 1,360 renal transplants were performed in 1,115 patients. Skin cancer data were reviewed in 979 patients from this group who remained under the care of the Oxford Transplant Centre. The lesions included in the analysis were histologically confirmed basal cell carcinoma, Bowen's disease, squamous cell carcinoma, keratoacanthoma, malignant melanoma, Merkel cell tumor, and sebaceous carcinoma.

RESULTS

One hundred eighty-seven (19.1%) transplant patients developed at least one skin malignancy. The rate of skin cancer was 141 per 1,000 person years at risk. Sixty-four percent of patients with skin cancer had multiple lesions (maximum 50). Squamous cell carcinoma was the most common skin cancer to develop and the most common first skin cancer to present. The mean time to presentation of the first skin cancer was 8 years. Six patients developed nodal metastases, and two patients died secondary to skin cancer. Risk factors identified were increasing age at transplantation, recipient sex, total time of exposure to immunosuppression, increased creatinine levels at 1 year, and graft relation. The cumulative incidence of skin cancer reached 61% at 20 years after transplantation.

CONCLUSION

The data from this study suggest that more patients develop skin malignancies than previously reported from Europe. It is important to advise patients before transplantation in regard to skin complications, provide regular dermatological follow-up, and tailor immunosuppressive regimen to minimum doses to be compatible with good graft function.

Distribution of upper limb skin cancers in relation to arteriovenous fistula side in renal transplant recipients

BACKGROUND

Renal transplant patients have an increased incidence of skin cancers, predominantly on sun-exposed surfaces. Clinical observation identified some patients with an increased number of viral warts, keratoses, and skin malignancies on the side of the arteriovenous fistula.

METHODS

In a population of 980 patients who underwent transplantation in Oxford, we identified 68 patients with known fistula site who had developed cutaneous malignancies on the upper limbs. We compared the distribution of skin malignancies in relation to the side of the arteriovenous fistula with regard to histologically confirmed Bowen's disease, squamous cell carcinoma, basal cell carcinoma, and keratoacanthoma.

RESULTS

No significant difference was found between the distribution of skin cancers, total malignancies or subgroups, in the fistula limbs compared with the nonfistula limbs.

CONCLUSION

We have been unable to demonstrate that the presence of an arteriovenous fistula predisposes to the development of cutaneous malignancies.

Glutathione S-transferase polymorphisms and skin cancer after renal transplantation

BACKGROUND

Susceptibility to skin cancer after transplantation is multifactorial, and risk factors include skin type, sun exposure, and level of immunosuppression. A major mechanism of carcinogenesis is ultraviolet radiation-induced free radical damage, and genetically determined ability to metabolize free radicals may also predispose to skin cancer. The glutathione S-transferase enzymes play a major role in limiting the toxic effects of reactive oxygen species, and this study was designed to determine whether polymorphisms in these enzymes are associated with skin cancers in renal transplant recipients.

METHODS

Two hundred twenty-two long-term survivors of renal transplantation were examined for polymorphisms in the GSTM1, GSTT1, and GSTP1 genes, using a unified polymerase chain reaction with sequence specific primers (PCR-SSP) genotyping method.

RESULTS

The GSTP1*C allele was associated with the development of squamous cell carcinomas (SCCs; P = 0.01). No associations of the GSTM1 null genotype or the GSTT1 null genotype were identified, and the development of basal cell carcinomas was not associated with any GST polymorphism studied.

CONCLUSIONS

These results indicate that genetic variation in enzymes involved in free radical metabolism in the skin are associated with the development of skin cancer. While all renal transplant recipients should be advised to protect themselves from the sun, the identification of transplant patients with a genetic predisposition to skin tumors may permit the targeting of preventative and early intervention strategies to high-risk individuals.

p53 codon 72 polymorphism and susceptibility to skin cancer after renal transplantation

BACKGROUND

Infection with human papillomavirus (HPV) is an important risk factor for the development of skin cancer after renal transplantation. It has recently been suggested that degradation of the tumor suppressor gene p53 is an important mechanism for human papillomavirus-induced carcinogenesis. A common genomic polymorphism occurs at codon 72 of the p53 gene, and in vitro the codon 72Arg variant appears to be particularly susceptible to degradation.

METHODS

To test the hypothesis that this polymorphism predisposes to the development of human papillomavirus-associated tumors, we studied p53 codon 72 genotype in 222 long-term survivors of renal transplantation, of whom 55 had developed at least one skin tumor.

RESULTS

No differences in allele or genotype frequency were detected between individuals who had or had not developed skin tumors after transplantation, or any subgroup thereof.

CONCLUSIONS

The p53 codon 72Arginine allele does not confer susceptibility to the development of skin tumors after renal transplantation.

[The attitude before subclinical breast lesions on mammography]

Mammographic screening and improvement of mammography resolution have resulted in the increasingly frequent identification of small-size mammary lesions that have no clinical expression. If in Western countries, approximately one quarter of breast cancers are discovered when clinically occult, in Romania such cases are rare and, most of the times, discovered merely by chance. Infraclinical mammary lesions identified by mammography pose problems concerning the appropriate response. The paper assesses the various diagnosis and therapy choices as well as the localization techniques to be employed in order to establish the best approach. We describe twelve cases of infraclinical mammary lesions identified by mammography. In two of this cases fine needle aspiration biopsy with cytological examination was used, and in one case we performed core biopsy and histological examination. In those cases, lesion localization has been performed using stereotactic X-ray devices. In nine cases, we performed excisional biopsy with histologic assessment. In four of those cases, the lesions proved to be malignant. Preoperative localization was performed with hookwires placed in the proximity of the lesion under mammographic control. In five of those cases, lesion coordinates have been determined by stereotaxy. Using this technique, we removed, in all cases, the clinical lesions identified by mammography. We believe surgical excision to be the best approach in such lesions. Total removal of the lesion enables a thorough histopathological examination resulting in more accurate diagnosis. Curative surgery is also possible within the same surgical procedure. Unless preoperative localization is performed the surgeon is in the position to excise an image that has no clinical expression. Under this circumstances surgical removal is performed blind, as the lesion is hard to be found even intraoperatory. Preoperative localization provides guidance to the surgeon, ensures removal of the lesion that has been identified by mammography and helps avoids unnecessary mammary resection.

Multiple cutaneous malignancies arising in limbs with signs of lymphatic insufficiency in transplant patients

We report the cases of four renal transplant patients who developed multiple skin cancers located preferentially on lymphoedematous lower limbs. All skin tumours appeared post-transplant and the diagnosis was confirmed on histologic examination. In addition, one of the patients also underwent mastectomy with axillary dissection and radiotherapy for a left breast ductal carcinoma and subsequently developed multiple squamous carcinomas and intraepithelial carcinomas on the left upper limb.The aetiology of lymphoedema in these patients is multifactorial. In addition to immunosuppression, ultraviolet exposure, genetic factors and possibly infection with the human papilloma virus, which are thought to have a role in the aetiology of certain skin tumours, lymphoedema may have contributed to the predominant location of these skin malignancies on the lymphoedematous limbs.

Benign familial Degos disease worsening during immunosuppression

We describe a 61-year-old woman with skin lesions consistent with those found in Degos disease, both in clinical and in histological appearance. She had had several of these lesions for many years, as had her mother, sister and niece. In 1991, she underwent cadaveric renal transplantation and was treated with immunosuppression: prednisolone, azathioprine and cyclosporin. At that time, she developed many more characteristic skin lesions, and these were slightly larger and more noticeable than those she had had previously. She and the other affected family members appear to fit into the more benign subgroup of Degos disease, and it seems that her immunosuppression aggravated her cutaneous disease.