Nicola Rocco

Background/Objectives: The aim was to assess whether a machine learning (ML) algorithm could empower the ability of ultrasound (US) integrated with shear-wave elastography (SWE) to preoperatively define the ALN status in breast cancer (BC). Methods: Patients with at least one histologically proven BC lesion, who underwent preoperative breast US and SWE were retrospectively enrolled. BC lesions were segmented on US and SWE images by three different operators and radiomics features were extracted. A multi-step US and SWE feature selection was performed. A Simple Logistic ML classifier was applied to the dataset to predict the ALN status, its performance assessed through the AUC and Matthews Correlation Coefficient (MCC). The performance of the ML classifier was compared to that of an expert radiologist, who evaluated the US B-mode lymph-node features included in the test set. Results: A total of 133 BC lesions were included and divided into a training set, composed of 89 BC lesions (ALN−: 52; ALN+: 37), and a test set, including 44 BC lesions (ALN−: 24; ALN+: 20). Eight features out of the 1098 radiomics features extracted from US and SWE images were selected to build the predictive model. Simple Logistic classifier showed AUC of 0.685 and 0.677, MCC of 0.387 and 0.375 in the training and test set, respectively. The performance of the expert radiologist was higher than that of the ML classifier (AUC = 0.817), but not significantly different (p = 0.481). Conclusions: The inclusion of SWE-derived radiomics features could aid in the preoperative assessment of ALN status in BC using an ML approach.

After mastectomy for breast cancer, implant-based breast reconstruction (IBBR) is the main approach to define a new breast shape. While conventionally implants were typically located beneath the pectoralis major muscle, the choice is moving to place directly the implant in the pre-pectoral space covered by subcutaneous tissue, also supported by advancements like acellular dermal matrices and synthetic meshes. We report the first case of a 50 years old patient affected by breast cancer suitable for mastectomy and pre-pectoral IBBR with the use of a new titanium-coated polypropylene mesh (TCPM) TiO2Mesh BRA®. No complications occurred post-operatively. 18-month follow-up, the patient was disease-free with a satisfactory cosmetic outcome. TCPM provides a large pocket for implant support, making it possible to place a high-volume prosthetic implant, and reducing risks of implant dislocation. This new mesh used by our team improves pre-pectoral IBBR outcomes, towards customized breast reconstruction for women.

Significant disparities exist in axillary management between and within countries, particularly regarding patients undergoing neo-adjuvant chemotherapy (NAC) who present with nodal disease and subsequently become ycN0 after systemic treatment. The aim of this study was to evaluate the efficacy and safety of the single-tracer technique for clinically node-positive (cN +) breast cancer patients who achieve node-negativity (ycN0) after NAC and compare this approach with the dual-tracer technique. We included consecutive patients diagnosed with cT1-T2, cN1-N2 breast cancer who underwent NAC and achieved nodal disease regression (ycN0). The patients were divided into two groups: “dual tracer” technique for sentinel lymph node identification and “single tracer” technique. In both groups, axillary lymph node dissection (ALND) was performed in patients with positive sentinel lymph nodes. Out of the 76 patients included, 42 underwent sentinel lymph node removal using the dual-tracer technique, while 34 underwent the single-tracer technique. In the single-tracer group, an average of two lymph nodes were removed per patient versus an average of three lymph nodes per patient in the dual-tracer group ( p = 0.001). No loco-regional recurrences have been reported in either group at a mean follow-up of 34 months. The single-tracer technique can be a reliable method for the axillary management in cN + breast cancer patients undergoing neo-adjuvant chemotherapy and achieving nodal disease regression (ycN0), in terms of loco-regional recurrences. This demonstrates that even if fewer sentinel lymph nodes are identified using the single tracer technique (and potentially the false negative rate of the procedure is higher), this does not impact on the rate of loco-regional recurrences. However, longer follow-up is required to confirm these findings.

Background: The pursuit of optimal aesthetic outcomes in breast surgery has led to the evolution of various surgical techniques. The transaxillary approach leads to high patient satisfaction due to its aesthetic advantage of avoiding visible scars on the breast. This approach is particularly useful in procedures such as breast augmentation and reconstructive surgery after breast cancer treatment, in which achieving an optimal cosmetic outcome is key. In this study, the authors compared the transaxillary blind approach with their new semiendoscopic video-assisted transaxillary approach, and analyzed the benefits and limitations of each method. Methods: A total of 118 patients were randomized to either the transaxillary blind approach or the semiendoscopic video-assisted transaxillary approach for breast augmentation from April of 2019 through December of 2022. Results: The results indicate that the semiendoscopic video-assisted approach required longer operative times but was associated with a lower incidence of complications, including asymmetry (eg, bottoming out, double-bubble deformity), breast animation deformity, and capsular contracture. Conclusions: This randomized trial revealed advantages and limitations of the transaxillary blind approach and a new semiendoscopic video-assisted transaxillary approach, highlighting that endoscopic assistance significantly improved surgical outcomes while maintaining an acceptable surgical time.

Background: Breast conservation surgery (BCS) evolved with oncoplastic techniques to improve aesthetic outcomes while maintaining oncological safety. However, a lack of objective criteria for selecting appropriate reconstruction techniques remains. Objectives: This study presents a novel patient-centered decisional algorithm for oncoplastic breast surgery with intercostal artery perforator (ICAP) flaps, aiming to standardize techniques based on patient expectations and objective symmetry evaluation. Methods: A retrospective observational study was conducted including patients who underwent BCS between January 2020 and December 2023. The decisional algorithm guided surgical planning, considering patient preferences, preexisting breast symmetry or asymmetry, and tumor location. Patient satisfaction was evaluated with the BREAST-Q questionnaire, and symmetry outcomes were assessed by external surgeons with a visual analog scale. Results: Of 900 patients who underwent BCS, 256 (28.44%) required volume replacement with ICAP flaps. Contralateral symmetrization was performed in 86 patients (9.55%) and bilateral mastopexy or breast reduction in 180 cases (20%). During an average follow-up of 22 months, the rate of early minor complications was 10.2%. Major complications requiring reoperation occurred in 7.7% of cases. Postoperative BREAST-Q results showed significant improvement in satisfaction (P < .05), and the mean aesthetic outcome score at 6 months was 4.1. Conclusions: The proposed patient-centered decisional algorithm incorporates both objective preoperative assessment and patient preferences, promoting a tailored approach that enhances functional and aesthetic outcomes while maintaining oncological safety. ICAP flaps represent valuable and less invasive tools for volume replacement, contributing to satisfactory symmetry outcomes. Level of Evidence: 4 (Therapeutic):

Background/Objectives: In pre-pectoral breast reconstruction, both synthetic meshes (SM) and acellular dermis or pericardium matrixes (ADM/APM) present drawbacks that can be prevented with targeted device choosing. In daily practice, the authors wrap the implant with a human-derived ADM (hADM) when they found mastectomy flaps thinner than 1 cm. When hADM is not available, an APM is used. Here, the authors present their results with APM utilisation. Methods: From January to September 2024, patients undergoing pre-pectoral breast reconstruction with mastectomy flaps thinner than 1 cm were selected. Specifically, implants were wrapped in bovine pericardium (Exaflex—MAGGI Srl, TO, Italy). During a minimum 6 months follow-up, outcomes were recorded; in particular, rippling incidence was assessed with indication for secondary fat grafting. Results: Nineteen patients met the inclusion criteria. Average age was 54.4 years (range: 39–70), three of them were smokers (15.8%) and three were affected from diabetes or hypertension (15.8%). With one case bilateral, a total of 20 mastectomies were performed. Intra-operative mastectomy flaps’ thickness mean measure was 0.75 cm (range: 0.5–0.8). All of them underwent two-stage pre-pectoral IBR with APM covering the implant. During a mean follow-up of 9.5 months (range: 6–13), no major post-operative complications occurred and five cases (25%) presented rippling. Conclusions: With no consensus on the superiority of either biologic matrixes or SMs, the authors extended their patients’ selection tool to aid in the choice of peri-prosthetic device. The bovine APM use showed capacity of reducing secondary lipofilling interventions in patients with thin mastectomy flaps.