Background: Breast cancer represents the most common type of neoplasm in women around the world. Breast reconstruction following mastectomy has become a demanding procedure in the treatment of patients suffering from breast cancer. Their major role is to improve the quality of life of women, leading to better aesthetic outcomes. Based on each type of reconstruction, the complications following surgery and the duration of hospital stay, the financial implications slightly vary. Methods: Our study included 168 female patients who underwent immediate or delayed breast reconstruction after mastectomy. We assessed the clinical management of each of these cases and we evaluated the average final cost of the treatment after the reconstruction, focusing on the reconstructive method used, the complications that occurred and the number of days of hospitalization. Results: The total cost of care in breast reconstruction surgery depends on the type of reconstructive procedure used, which consequently affects the duration of hospitalization of the patients. The expenses also depend on the materials that are used: the type of implant/expander or the use of ADM. Costs were higher in patients who underwent breast reconstruction using a latissimus dorsi flap associated with an implant, in comparison to reconstruction using a free flap. Conclusions: Breast reconstruction represents a crucial process in the management of women who underwent mastectomies following cancer and presumes variable financial resources, depending on the chosen reconstructive method.
AIM OF THE STUDY:Use of a radiotherapy (RT) tumor bed boost in addition to whole breast irradiation (WBI) after oncoplastic breast conserving surgery (OBCS) can be very challenging due to the massive tissue displacements. The aim of our study is to present relevant RT data regarding the use of a boost RT in patients who underwent OBCS and received adjuvant RT at Neolife Medical Center Bucharest. Materials and Methods: 12 patients treated with intensity modulated radiotherapy (IMRT), after OBCS, using conventional or hypofractionated schedules, between 10/2018 and 12/2020 were included in the study. Pre- and postoperative CT images and surgical clips when available were used for tumor bed (TB) localization and definition of the boost volume. Results: One or more risk factors associated with local recurrence (age under 51 years, high grade tumors, associated ductal carcinoma in situ) were present in 10 patients. Boost RT was delivered in 3 patients. Conclusions: TB localization for the boost RT is difficult without an appropriate marking. Surgical clips and communication between the surgeon and the radiation oncologist are essential for treatment success.
Introduction: Oncofertility represents a new field, dedicated to patients at childbearing age who are diagnosed with a neoplasic disease and who want to have a biologic child after they complete the oncological and surgical treatment. Because of new screening and treatment methods, most patients survive the disease, but the main long-term complication remains infertility. Young women with breast cancer are candidates for preserving their fertility mostly because of the risk of chemotherapy-related infertility due to the alkylating agent, causing dose-dependent destruction of oocytes and follicular depletion and thus bringing cortical fibrosis and ovarian blood-vessel damage (1). Prof. Dr. Panait S #226;rbu hospital is the first medical facility in Romania which performs oncofertility procedures among breast cancer patients within the program Newborn Oncofertility. Material and Methods: Within the program run by our hospital 21 patients (13 men and 8 women) came for fertility preservation, including 5 patients diagnosed with breast cancer. Our specialists in reproductive medicine performed ovarian stimulation and oocyte pick-up, after which the genetic material was cryopreserved. The procedure could be performed only if the patients were under 35 years old, and provided the case had been previously discussed within the tumor board and the patient had received the oncological agreement. Disscution: There was a slight predominance of breast cancer patients who addressed the clinic with a view for preserving their fertility and those who met the conditions could start the procedure immediately, without any delay when it comes to oncological or surgical treatments. There were no side effects during ovarian stimulation treatment. Oocytes or embryos were cryopreserved using the method of vitrification.
The progresses in surgical field are amazing regarding the possibilities of soft tissue reconstruction. Techniques of breast reconstruction have been evolved since the last 40 years. There was a trend from pedicled flaps toward microsurgical free flaps. In the English literature have been reported several types of free flaps for BR. Although DIEP is the workhorse for the reconstruction, there are patients that do not have enough abdominal tissue to use. In those cases, other donor area such as buttock, thigh, lumbar area has been reported. The present article describes the choices for BR with non-abdominal autologous tissue.
Additional covering of the lower pole with allomaterial or its synthetic analogues during immediate breast reconstruction is being perfomed at the N.N. Petrov National Medical Research Oncology Center, Ministry of Healthcare of Russian Federation for last 7 years. Initially, epidermal flap was the only option for lower pole coverage, later ADM was used as part of clinical approbation. Average complication rate ranges from 20-35% due to blood circulatory (supply) disorders. Since 2018, a titanized mesh (TiLoop Bra) been used as a additional coverage of the lower pole. Methods: From July 2018 to April 2019, 103 breast reconstructions were performed using TiLoop-BRA mesh. All operations were performed due to malignant tumors of breast, of which in 94 operations were performed for unilateral breast carcinoma, 9 for bilateral breast carcinoma.74 patients received neoadjuvant therapy, 31 received adjuvant therapy, 17 patients required radiation therapy. Results: Overall complications rates significally decreased. Complete loss of breast implant and mesh endoprosthesis 5.88%, Capsular contracture 17.65 %, Only mesh removal due to painful syndrome 5.88%,* Red breast * syndrome (by analogy with ADM) 5.88%.
Background: Oncoplastic breast conserving surgery (BCS) becomes the standard of care in multidisciplinary breast cancer treatment. From our perspective, the aim of oncoplastic BCS is the best oncological, aesthetic and functional surgical treatment results. The study's objective is to present our approaches to the selection of surgical techniques and determine operative and oncological outcomes of oncoplastic surgery. Methods: This retrospective study presents a single institution experience with patients who underwent oncoplastic BCS for breast cancer between 2007 and December 2020. Demographic and clinicopathologic characteristics as well as postoperative complications were analyzed. The analysis was performed by taking into account the types of procedures. Surgeries were categorized into two types: 1. volume displacement (level 1; advanced parenchyma displacements; therapeutic mammaplasties) and 2. volume replacement techniques (regional flaps with wide base, regional island perforant flaps). We consider as oncoplastic all the operations that are planned and performed taking into account an optimal aesthetic result regardless of the specific technique. Results: There were 833 surgeries performed for 823 cancer patients. In 153 cases, patients had symmetrized procedures. The average weight of specimens was 112,9 g (2-1034 g); the average size of tumors was 2,8 cm (0,2-15,8 cm). 106 patients (12,7%) had multifocal/multicentric tumors. In (3,8%) 32 cases involved margins were found and re-excision was required. 793 (96,4%) patients were on follow up. The median follow-up period was 48 months (6 164 months). Local recurrence was found in 10 (1,2%) patients, regional axillary recurrence in 2 (0,3%), systemic progression in 87 (11,0%) patients and 50 (6,2%) of them have died. Complications were observed in 190 (23,1%) patients, mostly seromas and ischemic disorders. Conclusions: We present our approaches to oncoplastic breast conserving surgery with focusing on the aesthetic results of the procedures. Oncological outcomes demonstrate the safety of advanced oncoplastic BCS in the framework of multidisciplinary teamwork.
Medical visual documentation is an especially important source of information for medicine. Medical photography has become the main method of medical visual documentation. In breast surgery, as in all other medical branches, medical photography has a major role in education and patient follow-up. The published literature was reviewed for medical photography techniques. In co-operation with the University fine arts faculty photography unit, standards for clinical, intra-operative and specimen photography in breast surgery were analyzed and identified. As a result, we have made recommendations for obtaining high quality and academically more effective medical photographs in breast surgery.
Introduction: The rate of contralateral prophylactic mastectomy (CPM) increased within the recent years. The main reasons are: genetic testing, availability of breast reconstruction, more often use of preoperative breast MRI, improvement of postoperative aesthetic results and reimbursement of breast reconstruction. The purpose of this study was to analyze the indication of CPM, it's evolution and the surgical techniques used for this type of surgery. Materials and methods: This prospective study enrolled patients with unilateral breast cancer for which conservative treatment was not an option and underwent CPM concomitant with therapeutic mastectomy, using different techniques, followed by immediate breast reconstruction using alloplastic materials. Results: A total of 45 patients with unilateral breast cancer underwent therapeutic mastectomy and CPM followed by immediate breast reconstruction, between January 2015-December 2020. The mean age was 43.5 years, 64,44% patients had stage I and II breast cancer and 22,22% were triplenegative. The indications for CPM were: pathogenic mutation of BRCA or of other genes associated with high risk of breast cancer, strong family history, suspicious findings on breast MRI, extended micro-calcifications, dense breasts, and extreme anxiety. Conclusions: A growing rate of bilateral mastectomy for unilateral breast cancer was observed. Availability of immediate breast reconstruction and reimbursement plays an important role for patients in choosing CPM. Factors associated with CPM include: young age, pathogenic BRCA mutation, significant family history and triple-negative disease. The rate of immediate postoperative complications was low. CPM is a valid option to reduce the risk of contralateral breast cancer and to achieve a good aesthetic outcome for patients with unilateral breast cancer with high risk of contralateral breast cancer.
Background: Pathological complete response (pCR) after neoadjuvant systemic treatment represents a good surrogate marker for the prognosis of Her-2 positive Breast Cancer (BCs). The results improved after adding anti-Her-2 therapy to chemotherapy in neoadjuvant setting. Methods: Our retrospective study enrolled a cohort of 56 invasive Her-2 positive non-metastatic BCs treated with neoadjuvant systemic therapy between 2001 and 2018. The patients received neoadjuvant chemotherapy with or without anti-Her-2 therapies before surgery and adjuvant endocrine and anti-Her-2 treatment together with adjuvant radiotherapy, based on clinical, pathological and hormonal receptor expression characteristics. The primary end point was pCR rate and disease-free-survival (DFS), defined as the interval between surgery and documented disease recurrence, progression, or death from any cause. Results: the rate of pCR for our patients was 41% independent of type of chemotherapy regimen and the anti-Her2 therapy used. The results were improved by adding Trastuzumab in the neoadjuvant setting with statistical significance (p = 0.038). Median DFS was 68 months for the entire cohort. The risk of recurrence was higher in the group without pCR after neoadjuvant treatment (52% vs 17%; p = 0.003). 10 patients died (18%), all of them from group without pCR. The prognosis at 36-months was good, with 84% survival chance at 3 years follow-up. Conclusion: Our retrospective study underlines the positive impact of neoadjuvant systemic treatment on pCR rate and on disease-free survival in real-life Her-2 positive breast cancer patients.
Melatonin is a relatively recently isolated hormone, produced by the pineal gland. Its implication in several cell functions has augmented interest from scientists worldwide. There is ongoing research investigating the deterrent relationship between melatonin and malignancies and in particular breast cancer. 'The aim of this article is to review some of the most important findings concerning the effect of melatonin on cancer biology, from both preclinical and clinical studies providing an insight to the complex biological actions of this molecule, as well as their potential significance. The last part concentrates on the oncostatic activities of melatonin on breast cancer and special attention is given on the interplay between melatonin and estrogen. Epidemiological, experimental and clinical evidence indicates that this area is worth further investigation.
In the field of implant-based breast reconstruction (IBBR), the most recent and successful progress has been the evolution of the prepectoral approach through the use of acellular dermal matrix (ADM). ADM-assisted breast reconstruction is now gaining a foothold as standard practice, but its advantages are often clouded due to discouraging studies reporting increased seroma formation. The origin of the serum accumulation still remains unclear, but it has always been the most frequent early complication in breast reconstruction, thus proving to be crucial to address since it can lead to further complications. Using a standardized approach to obtain high-quality scientific evidence, the aim of this review is therefore to investigate the occurrence of seroma in breast implant-based reconstructive surgery and its possible relation with matrices. We conducted the review investigating only pre-pectoral implant positioning and one specific ADM (BraxonÃÂî) which is the one who has the highest number of cases in literature. nterestingly, ADM does not appear to be causative of seroma formation, but a surgery-related origin is discussed. In this setting, a series of rigorous guidelines have therefore been identified and analyzed to allow not only the treatment, but also the prevention of seroma, thus leading to a reduction in the incidence of this frequent problem.
Background: Breast cancer is the most common cancer affecting women worldwide. In Germany, in almost 70% of cases, women require a complete mastectomy and wish for breast reconstruction which is especially difficult when the breast was previously irradiated. The DIEP flap is then the gold standard for autologous breast reconstruction and shows an overall low complication rate. This study aims to underline the safety of the procedure yet point out potential risk factors for flap edge and fat necrosis in a retrospective series of 1274 DIEP flaps in our center. Patients and Methods: 1274 autologous breast reconstructions with the DIEP flap were performed in 1124 patients between July 2004 and December 2014 in our department. Retrospective risk factor analysis included age, BMI, smoking, chemotherapy and/or radiotherapy and comorbidities. Mean follow-up constituted out of 24 months. Results: Out of 1274 free DIEP flap breast reconstructions, 150 were bilateral reconstructions. In 785 cases the primary indication was previous mastectomy, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Patients with a higher BMI and smokers had significantly higher complication rates than the rest of the cohort. Elderly patients ( 65 years), patients with diabetes and ones who had undergone chemo-/ radiotherapy did not present with higher complication rates. Conclusions: The DIEP flap surgery is a well-established method for autologous breast reconstruction with a low complication rate. Yet patient characteristics in terms of risk factors need to be taken into account for result prognosis and satisfactory long-term reconstructive results.
Introduction: Achieving good aesthetic outcomes during immediate reconstruction in women with large ptotic breast presents a unique challenge for the reconstructive surgeon. We present our paradigm regarding immediate reconstruction in patients with large ptotic breasts, using the inferiorly based dermal flap. Materials and Methods: Ten patients with large ptotic breasts underwent mastectomy and immediate implant reconstruction at the "Prof. Dr. I. Chiricuta" Institute of Oncology. The mastectomy was carried out using a Wise pattern skin resection with preservation of a dermal flap at the lower pole of the breast. The flap was sutured to the pectoralis major muscle and completed the subpectoral pocket created for the implant. Results: The reconstruction was done bilaterally in three cases with a total number of 13 reconstructed breasts. Of these 11 required dermal flaps. All reconstructions were completed successfully and there were no implant losses. Four breasts (36%) developed superficial necrosis of the tip of the mastectomy flaps at the T junction. Conclusion: The dermal flap technique is safe, versatile and reliable. It is used in a wide array of reconstructive scenarios as it provides the surgeon with an excellent alternative to more costly and unreliable methods.
Background: In dealing with the inferior pole coverage of an implant or a tissue expander in the partial submuscular technique, various surgical strategies have been introduced over the years. Among them, ADM and synthetic meshes were intensively studied and performed in order to obtain a good aesthetic result with satisfactory lower pole contouring, create a strong support of the implant and offer flexibility in adapting the volume of a tissue expander to the remaining mastectomy flaps (1,2). However, the viability of the skin from the mastectomy flaps is not always optimal. Vascular impairment and subsequent necrosis can occur at various extent in the mastectomy flaps (3). The necrosis of the mastectomy flaps is unpredictable and sometimes occurs with no obvious cause (4). Implant exposure and extrusion, ADM or mesh exposure are serious complications which can lead to the reconstructive failure. Methods: The scarless latissimus dorsi flap technique was introduced and observed in patients eligible for skin sparing and nipple sparing mastectomy with implant-based submuscular breast reconstruction. The keypoints of the surgical steps are described. Results: The main priorities of the outcome of the reconstructive process were stability and good definition of the lower pole of the reconstructed breast. The good vascularized underlying muscular tissue totally covering the implant increases chances in avoiding exposure or extrusion of the implant. In the advent of partial mastectomy flap necrosis, the healing by secondary intention provided good and stable results. Also, this technique decreases the morbidity and risks related with the change of the patient position during the procedure, improves the aesthetic results, by avoiding additional incisions for harvesting the flap. Conclusions: The scarless latissimus dorsi flap in implant based breast reconstruction is a valuable option for stable results and viable alternative to the use of ADM.
Background: In the era of NAT, to accurately predict pathologic response is a great challenge, which might influence surgical approach for breast and axilla. Axillary staging via imaging methods as an adjunct have long been used with various reported accuracy rates. However, the role of preoperative axillary ultrasonography (AUS) in clinical N0 patients after NAT is still controversial. The primary goal of the present study was to evaluate the precision of preoperative AUS for identifying pathologic complete response (ypCR = ypT0, ypN0) after NAT. Methods: A single-institution, retrospective review of a prospectively maintained database was analyzed to identify breast cancer patients treated with NAT. Only those patients who underwent AUS and 18F-FDG-PET/CT before and after NAT with documentation of clinical and radiological response were incorporated for outcome analysis. Results: In 253 consecutive invasive breast cancer patients axillary ypN0 disease was achieved in 67.19%. In 11.23% ynon-pCR patients AUS failed to detect residual disease presence 80% of which were ITCs and micrometastases. Macrometastasis was present in 21.73% (55/253) of the cases 98.18% (54/55) of which was determined by AUS. Overall accuracy for axillary pCR was found to be 89.32% for AUS and 76.28 % for 18-FDG-PET/CT. The false negative rate (FNR) of AUS and 18-FDG-PET/CT was 12.04% and 15.59%, respectively. The PPV of AUS was higher in Luminal-like tumors (%87.69), whereas HER-2 positive (%100) and triple-negative (93.47%) subtypes had higher NPV. Conclusions: AUS is a beneficial tool with the potential of accurate prediction of pCR in more than 80% of patients following NAT. Nevertheless, in cases of residual ITCs and micrometastasis the accuracy of US should be interrogated cautiously.
Benign symmetrical lipomatosis (BSL), or Madelung's disease, is a rare disease characterized by the progressive growth of diffuse, painless, non-enveloped symmetric lipomas. The etiology of this disease remains unknown, although it was associated in the medical literature with alcohol and nicotine abuse, metabolic disorders and a number of malignancies. It is assumed that there is a genetic predisposition for this affliction. The management in such cases is surgical removal of the lipomas, most times in several sessions, but this is often followed by relapse. However, surgical removal of the lipomas can provide satisfactory patient functionality and cosmetic results. The differential diagnosis is made with morbid obesity, Cushing syndrome, angiolipomatosis, encapsulated lipomas, neurofibromatosis, myxoid liposarcoma, lymphoma, salivary gland disease, Frolich and lipomatosis syndrome in patients infected with HIV. The current paper reports the case of a 55 year-old man, who presented with several large lipomatous masses, arranged symmetrically on the front and back of the trunk, and several smaller lipomas in the upper and lower limbs. Treatment consisted of resection of these lipomas in several sessions, without recurrence at one year after the last operation.
Carcinoids (neuroendocrine tumours) are considered the most common primary appendiceal neoplasm. Primary appendiceal tumours are uncommon. Routine histopathological examination of appendicectomy specimens is justified given the not infrequent incidental finding of appendiceal tumours. In cases of appendicitis in the elderly, the index of suspicion for epithelial tumours of the appendix should be raised. Moreover, once the diagnosis of an adenomatous lesion is made, colonoscopic examination of the entire large bowel is mandatory given the frequency of synchronous colorectal neoplasia in our population. In our study, we review 3 cases of carcinoid tumor of the appendix and describe their presentation, treatment and outcome. They are often diagnosed incidentally after histopathological examination of the vermiform appendix submitted in the course of the management of another clinical diagnosis. Appendectomy is appropriate for lesions < 1 cm but for lesions over 2 cm in diameter there is a significant increase in metastatic spread and thus right hemicolectomy is required in such cases. Appendiceal carcinoid tumours are found in 0,3 0,9 per cent of patients undergoing appendicectomy. Controversy exists over the management following appendicectomy, especially with regard to the role of right hemicolectomy in patients with tumours smaller than 2 cm in diameter.
The article presents the case of a male patient, hospitalized due to severe pain in the upper abdomen area, nausea, and vomiting. The patient was diagnosed with surgical acute abdomen, for which emergency surgery is performed. Upon penetration into the peritoneal cavity, stomach inspection shows at the medio-gastric level, on the greater curvature, a callous gastric ulcer, with a central perforation. A large excision is decided up to the healthy (normal) gastric tissue, and the resulting pieces are sent to the pathological anatomy laboratory. The histopathological exam reveals signet ring cell recent gastric carcinoma. The biopsy performed 1 month after surgery, prelevated from the antropyloric zone, reveals antropyloric gastritis with moderate activity and Helicobacter pylori positive. Due to the fact that such cases when this gastric cancer type is diagnosed in recent stages are extremely rare, we considered it useful to present it and look into its macroscopic and microscopic aspects, as well as into the differentiating diagnosis.
Laparoscopic ultrasound is an intraoperative exploration of the abdominal viscera using ultrasounds. The aim of this work is to obviate this new method of exploration and to underline its advantages and limits. In this study were enroled 65 pacients with gallbladder stones, admitted in The Surgical Clinic, Elias Emergency Hospital, from October 2005 until December 2006. The measured parameters were CBD size and the presence of stones or sludge within CBD, and various methods were compared: abdominal ultrasound, laparoscopic ultrasound and laparoscopic cholangiography. The results allowed us to consider that laparoscopic ultrasound is a useful tool for the intraoperative diagnosis of choledocolithiasis. When compared to laparoscopic cholangiography, our study revealed the same specificity and positive predictive value, and a sensitivity of 0.93.
The aim of the study was to evaluate the improvement in quality of life for patients that have undergone the laparoscopic gastric banding, using the BAROS and Moorehead-Ardelt II questionnaires.Methods: We selected a 20 patient group (65% women) that underwent this surgical procedure in our clinic. The initial average weight was 123.45kg, and the body-mass index of 42.36. The average age was 29.25 years. The pars flaccida technique was used in 18, and the perigastric approach in 2 cases.Results: No complications or intraoperative accidents occurred. The mean operation time was 115.5 minutes. Elective conversion was needed in one case with a BMI of 55. The average hospital stay was of 3.2 days. The follow-up was conducted at least through phone in 95% of cases, and its average duration was of 10 months. The only postoperative complications were infections of the subcutaneous port (5 cases - 25%) which needed removal of the port, but not of the banding. The average loss of excess weight was 48.23%. Using the BAROS score to determine the overall improvement of quality of life, 30% of the patients scored as "Very Good", 50% as "Good", 20% as "Fair". Using the Moorehead-Ardelt QLQ II score, 65% scored as "Very Good", 30% as "Good" and 5% as "Fair".Conclusion: The laparoscopic adjustable gastric banding significantly improves the quality of life for most patients with this procedure.
