Giuseppe Falco

Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.

The adoption of neoadjuvant chemotherapy (NACT) for breast cancer (BC) is increasing. The need to repeat the biomarkers on a residual tumor after NACT is still a matter of debate. We verified estrogen receptors (ER), progesterone receptors (PR), Ki67 and human epidermal growth factor receptor 2 (HER2) status changes impact in a retrospective monocentric series of 265 BCs undergoing NACT. All biomarkers changed with an overall tendency toward a reduced expression. Changes in PR and Ki67 were statistically significant (p = 0.001). Ki67 changed in 114/265 (43.0%) cases, PR in 44/265 (16.6%), ER in 31/265 (11.7%) and HER2 in 26/265 (9.8%). Overall, intrinsic subtype changed in 72/265 (27.2%) cases after NACT, and 10/265 (3.8%) cases switched to a different adjuvant therapy accordingly. Luminal subtypes changed most frequently (66/175; 31.7%) but with less impact on therapy (5/175; 2.8%). Only 3 of 58 triple-negative BCs (5.2%) changed their intrinsic subtype, but all of them switched treatment. No correlation was found between intrinsic subtype changes and clinicopathological features. To conclude, biomarkers changes with prognostic implications occurred in all BC intrinsic subtypes, albeit they impacted therapy mostly in HER2 negative and/or hormone receptors negative BCs. Biomarkers retesting after NACT is important to improve both tailored adjuvant therapies and prognostication of patients.

This study aimed to evaluate contrast-enhanced mammography (CEM) accuracy and reproducibility in the detection and measurement of residual tumor after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients with calcifications, using surgical specimen pathology as the reference. Pre- and post-NAC CEM images of 36 consecutive BC patients receiving NAC in 2012–2020, with calcifications in the tumor bed at diagnosis, were retrospectively reviewed by two radiologists; described were absence/presence and size of residual disease based on contrast enhancement (CE) only and CE plus calcifications. Twenty-eight patients (77.8%) had invasive and 5 (13.9%) in situ-only residual disease at surgical specimen pathology. Considering CE plus calcifications instead of CE only, CEM sensitivity for invasive residual tumor increased from 85.7% (95% CI = 67.3–96%) to 96.4% (95% CI = 81.7–99.9%) and specificity decreased from 5/8 (62.5%; 95% CI = 24.5–91.5%) to 1/8 (14.3%; 95% CI = 0.4–57.9%). For in situ-only residual disease, false negatives decreased from 3 to 0 and false positives increased from 1 to 2. CEM pathology concordance in residual disease measurement increased (R squared from 0.38 to 0.45); inter-reader concordance decreased (R squared from 0.79 to 0.66). Considering CE plus calcifications to evaluate NAC response in BC patients increases sensitivity in detection and accuracy in measurement of residual disease but increases false positives.

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Breast oncoplastic techniques followed by radiotherapy represent nowadays the standard of care for breast cancer treatment. For tumours located at the upper outer quadrant in patients with large and ptotic breasts, the use of level II breast reduction mammoplasty, allows large quadrantectomies without compromising the breast natural shape and reducing the breast volume to be irradiated. When the skin overlying the tumour in the upper outer quadrant is involved, the removal of the skin during mammoplasty could lead to an extreme reduction of the breast, resulting in a bad outcome. Different strategies have been adopted to avoid a poor cosmetic result including a Z plastic or latissimus dorsi (LD) mini flap. At our institution we developed a new technique utilizing an inferior bifurcated pedicle mammoplasty with the preservation of a skin island for a patient with a residual tumour following chemotherapy involving the skin in the upper outer quadrant of the right breast. The patient did show no complications, with no delay for adjuvant radiotherapy treatment. Our method is a novel technique to treat malignancies in this location for patients with large and ptotic breasts when skin removal is indicated and it may represent an effective strategy to prevent excessive gland reduction, thus avoiding poor cosmetic result.

Background Acellular dermal matrices have been introduced to optimize direct-to-implant breast reconstruction. We selected a bovine pericardium noncross-linked matrix. Methods The study consists in the retrospective analysis of 123 patients (141 breasts) who underwent conservative mastectomy and immediate implant-based breast reconstruction with bovine pericardium matrix Veritas^® from March 2012 to October 2017. Results The overall rates of early and late complications, after a median follow-up of 51.84 months, were, respectively, 37.6% and 24.1%. The most noticeable early complications were flap ischemia [n = 39 (27.7%)], hematoma [n = 5 (3.6%)], marginal skin flap necrosis [n = 5 (3.6%)] and dehiscence of the surgical wound [n = 2 (1.4%)]. The most common late complications were rippling [n = 18 (12.7%)] and seroma [n = 4 (2.8%)]. The rate of clinically relevant capsular contracture was low: 12.1% (n = 17) presented grade II and only 2.1%% (n = 3) grade III. Implant substitution became necessary for five patients (3.6%). Early complications occurred more frequently in patients undergoing therapeutic mastectomy (p = 0.031). Patients undergoing preoperative radiotherapy more frequently developed late complications (p = 0.012). A clinically relevant capsular contracture (grade II–III) was found in higher average patients age (p = 0.0019). The left side developed less frequently late complications except for rippling (p = 0.002). Rippling occurred more frequently in patients who sustained a nipple skin-sparing mastectomy (p = 0.035). Conclusion Our results further support the safety of Veritas^® in immediate implant-based breast reconstruction. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Background: Nipple-areola complex–sparing mastectomy (NSM) represents, when a mastectomy is unavoidable, the best treatment possible that can be offered to attenuate the negative impact of surgery on patients' quality of life. Unfortunately, NSM can be used only in selected patients with small and nonptotic breasts. In order to save the nipple-areola complex (NAC) also in patients with large and ptotic breast, otherwise subjected to a skin-sparing mastectomy with the sacrifice of the NAC, we described the bipedicled nipple-sparing mastectomy (BNSM). The aim of this study is to obtain a formal outcome assessment of BNSM and analyze the complications rate of this technique compared with traditional NSM. We furthermore attempt to describe the surgical procedures present in the literature that allow to preserve NAC also in large and ptotic breasts presenting the complication rates observed and comparing with our technique. Aesthetic outcome has also been evaluated. Methods: We retrospectively reviewed 42 procedures of consecutive patients undergoing immediate reconstruction with tissue expanders after NSM (20 patients) or BNSM (19 patients). We divided them in 2 groups focused on surgical complications and aesthetic outcome. Results: On a total of 42 procedures, the principal major complication was dehiscence of surgical wound procedures needing 1-day surgery revision occurring in 3 (14.3%) of the BNSM group and 1 (4.8%) of the NSM group, whereas as principal minor complication 4 partial NAC necrosis not requiring surgery in BNSM (19%) and 2 (9.5%) in NSM. No tissue expanders required explantation. Concerning cosmetic results, the overall appearance of the breast and NAC was acceptable in 85.7 % and 77.2%, respectively, in the NSM group and 80.7% and 66.7%, respectively, in the BNSM group. Conclusions: Bipedicled nipple-sparing mastectomy is a valid technique to improve patients' quality of life in large and ptotic breasts otherwise candidate to a skin-sparing mastectomy, but only a progressive learning curve can minimize complications. No significant statistical differences have been observed in terms of complication rates and aesthetical outcomes between the 2 groups. An accurate selection of patients is mandatory in order to obtain low complication rates and good aesthetical outcome.

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. 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. 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. 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.