BACKGROUND:The environmental impact of climate change is unequivocal, and surgical practice, given its substantial carbon footprint, must also move toward sustainability. The primary aim of the study is to assess the environmental impact of surgical practice in breast cancer treatment and to identify interventions that can effectively reduce it. The secondary aim was to explore the feasibility and preliminary clinical performance of indocyanine green (ICG) compared with technetium-99m (99mTc) for sentinel lymph node mapping, within the context of a pilot project on sustainable surgical practices. METHODS:At the Breast Surgery Clinic of Polyclinic San Martino IRCCS Hospital in Genoa, a prospective study was conducted from September 2024 to May 2025 to assess the effectiveness of a series of environmentally sustainable measures within the operating room. Thirty-four women diagnosed with HR-positive/HER2-negative, T1-T2, cN0 invasive breast cancer underwent quadrantectomy and sentinel lymph node biopsy (SLNB). Seventeen patients were treated using a conventional high-impact surgical protocol, while the remaining 17 were treated with a green protocol based on the "5R rule" (Reduce, Reuse, Recycle, Rethink, Research). Key strategies included the use of ICG for SLNB, local anesthesia with intravenous sedation, waste minimization, and the adoption of reusable surgical gowns, drapes, and instruments, along with the segregation of non-infectious plastic waste. RESULTS:Sentinel lymph node identification was achieved in 100% of patients in the 99mTc group and in 94.1% of patients in the ICG group. The green approach was operationally feasible and associated with preliminary indicators of reduced environmental burden, although a full quantitative analysis was beyond the scope of this pilot study. Patients avoided preoperative hospitalization, radiotracer administration, and, importantly, 58.8% were discharged the same day. CONCLUSIONS:Considering the pressing climate crisis, these findings highlight the feasibility and necessity of adopting sustainable practices in surgical oncology to mitigate greenhouse gas emissions while maintaining high-quality patient care.

Mucoepidermoid carcinoma of the lung is a rare salivary gland-type tumor with heterogeneous clinical behavior and the potential to mimic neoplasms arising in other organs. The purpose of this report is to describe an exceptionally uncommon presentation of pulmonary mucoepidermoid carcinoma manifesting as a breast metastasis in a male patient, a scenario that poses significant diagnostic challenges due to its rarity and its morphological resemblance to primary breast carcinoma. We evaluated the patient through clinical examination, cross-sectional imaging, endobronchial procedures, ultrasound-guided biopsy, immunohistochemistry, and molecular analysis, integrating these data to establish the diagnosis. Imaging revealed a primary lung mass and a second lesion in the left breast infiltrating the pectoralis muscle. Biopsy of the breast mass showed high-grade salivary gland-type mucoepidermoid carcinoma, clinically and radiologically suggestive of pulmonary origin. Because the lesion showed signs of impending ulceration, palliative surgical debulking was performed with good postoperative recovery. The patient subsequently began systemic therapy with gemcitabine. This case underscores the need for careful clinicopathologic correlation when evaluating atypical breast lesions and highlights the diagnostic value of molecular testing in distinguishing primary from metastatic salivary gland-type tumors. Recognizing such rare metastatic patterns is essential for appropriate therapeutic planning.

Background: Women carrying BRCA1 and BRCA2 pathogenic variants face a substantially increased lifetime risk of breast and ovarian cancer. Risk-reducing bilateral mastectomy and salpingo-oophorectomy are well-established strategies to lower this risk. Traditionally, these procedures are performed in separate surgical sessions; however, a simultaneous approach may reduce the overall treatment burden. Evidence regarding the safety and feasibility of combined procedures remains limited. Methods: We conducted a retrospective observational study of BRCA1 and BRCA2 pathogenic variant carriers who underwent risk-reducing or therapeutic breast surgery at the Breast Unit of Policlinico San Martino Hospital (Genova, Italy) between January 2013 and March 2025. Patients were divided into two groups according to surgical strategy: a simultaneous procedure group undergoing risk-reducing mastectomy with immediate breast reconstruction and concurrent salpingo-oophorectomy in a single operative session, and a staged procedure group undergoing the same interventions in separate surgeries. Demographic, surgical, and postoperative variables were collected and analyzed descriptively. Results: A total of 124 BRCA1 and BRCA2 pathogenic variant carriers were included, with 73 patients undergoing the simultaneous approach and 51 undergoing staged procedures. The mean age was similar between the Simultaneous and Staged Procedure Groups Descriptively, similar patterns were observed across the two groups in terms of age distribution, postoperative outcomes, and length of hospital stay (mean 4.56 days). Minor complications such as seroma or delayed wound healing showed similar patterns across both groups, with no apparent increase in major complications in the simultaneous surgery group. Patients undergoing the simultaneous approach required fewer surgical sessions and were exposed to general anesthesia only once. Conclusions: Simultaneous risk-reducing mastectomy with immediate reconstruction and salpingo-oophorectomy appears to be a safe and feasible strategy for selected BRCA1 and BRCA2 pathogenic variant carriers. This integrated surgical approach may reduce the overall surgical burden, with descriptively similar perioperative outcome patterns.

BACKGROUND/AIM:Preoperative planning in oncoplastic and reconstructive breast surgery requires synthesizing patient- and tumor-specific variables with aesthetic considerations. Variability in documentation and expertise may hinder reproducibility across centers. Large language models (LLMs) can process structured data into consistent outputs. We assessed whether a prompt-engineered artificial intelligence (AI) assistant (BREAST AI-PLAN) could replicate multidisciplinary team (MDT) decisions and aesthetic scores from routinely collected clinical data. PATIENTS AND METHODS:This single-center retrospective study included 30 women undergoing breast cancer surgery. Each case was recorded in a standardized form covering demographics, comorbidities, breast anatomy, tumor biology, and staging. This form was used to generate structured prompts for the AI assistant. The AI returned eight outputs: 1) neoadjuvant therapy suitability; 2) planned surgery; 3) surgical approach; 4) reconstruction type; 5) direct-to-implant feasibility; 6) implant type; 7) adjuvant therapy; and 8) an aesthetic score (BCCT.core-aligned). Clinical MDT decisions were the reference standard. Agreement was measured using Cohen's κ, with linear and quadratic weights for aesthetics. RESULTS:Mean age was 59.2±9.8 years; median body mass index (BMI) 24.2 (20.9-26.8). One patient carried a BRCA2 mutation; 13.3% had prior radiotherapy; 33.3% were smokers. Tumors were mainly Luminal A (43.3%) and Luminal B (26.7%). Agreement was very good for neoadjuvant therapy (κ=0.91; observed 96.7%) and good/moderate for planned surgery (κ=0.58; observed 70.0%), surgical approach (κ=0.43; observed 60.0%), reconstruction (κ=0.36; observed 57.1%), and adjuvant therapy (κ=0.29; observed 64.3%). Aesthetic scoring showed high observed concordance (0.778-0.896) but only slight weighted κ (0.14-0.16). CONCLUSION:BREAST AI-PLAN reproduced MDT planning elements and aesthetic assessments with moderate-to-very-good agreement. Transparent, auditable AI assistance may standardize surgical planning and support training. Prospective validation with imaging integration is warranted.

Post-surgical pyoderma gangrenosum is a rare neutrophilic dermatosis that may occur after surgical procedures, mimicking a wound infection. Early recognition is crucial to prevent unnecessary debridement and worsening of lesions due to pathergy. We report the case of a 67-year-old woman who underwent nipple-sparing mastectomy for invasive breast carcinoma with immediate reconstruction using a tissue expander. In the early postoperative period, she developed an extensive sterile necrotic-ulcerative inflammation of the left breast, unresponsive to broad-spectrum antibiotics and repeated surgical revisions. Histopathology revealed an aseptic neutrophilic infiltrate, confirming the diagnosis of post-surgical pyoderma gangrenosum. The patient responded favorably to high-dose corticosteroid therapy, achieving complete wound healing and definitive reconstruction with a TRAM flap. This case highlights the importance of considering post-surgical pyoderma gangrenosum in the differential diagnosis of inflammatory postoperative complications in breast oncology surgery. Prompt diagnosis and early initiation of immunosuppressive therapy within a multidisciplinary approach are key to preserving tissues and ensuring optimal functional and aesthetic outcomes.

The association between breast cancer and non-Hodgkin lymphoma of the spleen is extremely rare, with very few cases documented in the medical literature. We present the case of a 39-year-old woman in good health but with a family history of breast cancer, who, in 2017, developed invasive lobular carcinoma in her right breast, which was treated with mastectomy followed by hormonal therapy. In 2024, she presented with a suspicious right axillary mass, suspected of recurrence, which was confirmed by fine-needle aspiration biopsy. The patient received neoadjuvant chemotherapy, followed by axillary lymph node dissection and bilateral adnexectomy. CT and PET scans showed suspicious splenic lesions suggestive of metastases. Infectious and hematological tests were negative, leading to the decision to perform laparoscopic splenectomy. Histological examination revealed follicular B-cell non-Hodgkin lymphoma. The patient is now in good general condition and is on a biannual follow-up. The case highlights the diagnostic complexity of tumor recurrences and the need to consider alternative diagnoses other than metastasis in oncological patients.

Background/Objectives: In the setting of breast surgery, indocyanine green angiography (ICGA) allows estimating the perfusion of cutaneous tissues during surgical interventions, in order to reduce vascularization-related complications. This study has a dual objective: to evaluate the correlation between preoperative factors and the level of skin vascularization, measured by ICGA, in patients undergoing subcutaneous mastectomy for breast cancer; and to establish any relationship between low intraoperative vascularization and the onset of postoperative complications. Methods: This is a preliminary, non-randomized, prospective clinical study that includes 46 female patients undergoing subcutaneous mastectomy with reconstruction for breast cancer between February 2022 and July 2024. The relationship between vascularization and the following preoperative variables was assessed: smoking, previous breast surgeries, prior radiotherapy, neoadjuvant or prior chemotherapy/anti-Her2 therapy, and the thickness of breast subcutaneous tissue evaluated through mammography. For the analysis, three ICGA procedures were performed, using 0.125 mg/kg of indocyanine green (ICG) for each procedure before the surgical incision (V1), at the end of the demolition phase (V2), and at the end of the reconstruction phase (V3). The results of this analysis were finally correlated with the occurrence of any postoperative complications. Results: Vascularization was conventionally classified as “low” and “good” using a cutoff of 33%. Previous surgeries on the ipsilateral breast and neoadjuvant or prior chemotherapy/anti-Her2 therapy were found to be predictive factors of “low” vascularization (p = 0.031). Patients with “low” vascularization at time V3 showed a significantly higher risk of developing complications (p = 0.038). Incision length emerged as an independent predictor of complications, with a 23% increase in risk per additional centimeter (p = 0.006), independent of perfusion level. Conclusions: This study supports the use of ICGA as a useful tool to improve outcomes in patients undergoing subcutaneous mastectomy with prosthetic reconstruction for breast cancer. The results of this preliminary work are encouraging, and recruiting a larger number of patients could provide more significant data.

Background: Negative Pressure Wound Therapy (NPWT) has proven to be an effective intervention in preventing postoperative complications across a range of surgical specialties, including orthopedics, vascular, and abdominal surgery. This study aimed to assess the prophylactic use of NPWT dressing compared to the Standard of Care (SOC) in high-risk patients undergoing oncoplastic and reconstructive breast surgery. Materials and Methods: This preliminary case-control study included 23 high-risk patients, enrolled between September 2023 and February 2024, at San Martino Polyclinic Hospital, Genoa. High-risk patients were defined as those with one or more of the following risk factors: obesity, prior radiotherapy, neoadjuvant chemotherapy, smoking history, diabetes, or corticosteroid use. The surgical procedures evaluated in this study included mastectomy with immediate implant-based breast reconstruction, reduction mammoplasty, and oncoplastic breast surgery following local excision or quadrantectomy. NPWT dressing was applied immediately after skin closure in the operating room, replaced after 2-3 days, and removed 7 days post-procedure. Surgical outcomes assessed included skin flap necrosis, wound dehiscence, infection, implant loss, and delays in adjuvant therapy. Results: A total of 23 patients, aged 45 to 57 years, were enrolled. Eleven patients received NPWT dressing, while twelve were treated with SOC. No complications occurred in the NPWT dressing group, whereas four complications were observed in the SOC group. Of the control group, three patients developed infections, which were treated with oral antibiotics for two, while one required implant replacement surgery. The remaining patient in the control group experienced wound dehiscence, which was successfully managed conservatively on an outpatient basis. Discussion and Conclusions: Our findings suggest that prophylactic NPWT dressing in oncoplastic and reconstructive breast surgery results in a significantly lower rate of wound-related complications. Although this is a preliminary study, it provides a foundation for further research in a larger cohort. These results also prompt a discussion of the cost-effectiveness of NPWT dressing relative to the SOC, given its higher cost.

Background/Objectives: Zuska disease is a rare inflammatory condition of the mammary gland, characterized by recurrent non-puerperal abscesses in the periareolar region, often complicated by fistula formation. It predominantly affects women who smoke, particularly perimenopausal women. This study aims to investigate the clinical features, treatment outcomes, and recurrence rates of Zuska disease in a cohort of patients. Methods: We conducted a retrospective analysis of 19 patients diagnosed with Zuska disease and treated at the Breast Surgery Clinic of San Martino Policlinic Hospital between January 2021 and June 2024. Data were collected on demographics, clinical presentation, imaging findings, surgical interventions, intraoperative cultures, and postoperative outcomes. The types of surgeries performed, antibiotic therapy regimens, and histological findings were recorded. Results: The mean age of the patients was 43.8 years. The most common presentation was a painful breast mass without fistula formation (12 patients), signs of a past abscess with negative preoperative ultrasound findings (five patients), and abscesses with fistulas (two patients). Intraoperative cultures revealed a range of bacterial species. Recurrence occurred in five patients (26%), and reoperation was required in three cases. All patients were free of symptoms at follow-up, with an average recurrence time of 13.6 months. Conclusions: Zuska disease presents significant treatment challenges due to its recurrent nature. While surgical interventions, such as abscess drainage and ductal excision, are effective, recurrence remains common, particularly in patients with risk factors like smoking. A personalized therapeutic approach, tailored to each patient’s clinical profile, is essential to improving long-term outcomes. Early diagnosis, timely surgical management, and lifestyle modifications play a crucial role in reducing recurrence. Future studies should focus on optimizing treatment protocols and developing individualized strategies for managing comorbidities.

Breast cancer (BC) is a prevalent malignancy with various subtypes, each presenting unique diagnostic and therapeutic challenges. Triple-negative breast cancer (TNBC), which comprises 12-17% of breast cancers, is particularly aggressive due to its lack of estrogen receptor (ER), progesterone receptor (PR), and HER2 expression. This case report details the management of a 64-year-old woman with TNBC. Initially presenting with a left breast nodule, she underwent a biopsy that confirmed triple-negative infiltrating ductal carcinoma. Despite negative BRCA genetic testing, her significant family history of cancer and a newly detected right breast lesion led to a bilateral mastectomy. Post-surgery imaging revealed multiple hypodense nodules and a spiculated pulmonary nodule, prompting further investigation. An endoscopic lung biopsy identified a primary pulmonary carcinoma with histological features similar to the breast cancer, indicating the lung as the primary source. This case underscores the complexity of TNBC, the importance of comprehensive diagnostic evaluations, and the need for considering extramammary origins in metastatic cases. The findings emphasize the role of multidisciplinary teams in managing such rare and challenging cases and highlight the necessity for thorough and repeated evaluations in atypical BC presentations.

Breast metastasis originating from a primary lung tumor is exceedingly rare and can present challenges in distinguishing it from primary breast cancer. This case report discusses the management of a 64-year-old woman who initially presented with a nodule in her left breast. A biopsy revealed an infiltrating ductal carcinoma. Despite negative BRCA genetic testing, her significant family history of cancer and the presence of a newly detected right breast lesion led to a bilateral mastectomy. Post-operative imaging identified multiple hypodense nodules and a spiculated pulmonary nodule, necessitating further investigation. An endoscopic lung biopsy confirmed a primary pulmonary carcinoma with histological features similar to the breast carcinoma, suggesting the lung as the primary source. This case highlights the complexity of differentiating breast metastasis originating from a lung tumor and primary breast cancer. It underscores the importance of comprehensive diagnostic evaluations and the consideration of extramammary origins in metastatic cases. The findings emphasize the role of multidisciplinary teams in managing such rare and challenging cases and highlight the necessity for thorough and repeated assessments in atypical breast cancer presentations.

The impact of climate change is undeniable: considering the significant carbon footprint of surgical activity, there is an urgent need to pursue sustainability in the operating room as well. At the Breast Surgery Clinic of the IRCCS Ospedale Policlinico San Martino in Genoa, a prospective study was conducted from September 2023 to May 2024 to evaluate the effectiveness of a series of measures aimed at reducing the environmental impact in the operating room. 34 women affected by invasive breast cancer T1-2, cN0 underwent quadrantectomy and sentinel lymph node biopsy (SNLB): 17 according to a standard, high environmental impact approach; 17 according to a green approach based on the "5 R rule" (reduce, reuse, recycle, rethink, research). The implementation of measures such as the use of indocyanine green (ICG) for SNLB, the use of local anesthesia and intravenous sedation, the minimization of waste production, the use of reusable gowns, drapes and surgical instruments and the separate collection of non-infectious plastic waste resulted not only in a reduced environmental impact, but also in benefits for patients, who were spared a hospital admission the day before surgery, the administration of a radiotracer, and, in 58.8% of cases, an overnight stay. Considering the alarming data regarding the threat to our health, it is both possible and necessary to adopt virtuous behaviors in the operating room that reverse the current trend of emitting greenhouse gases.

Locally advanced breast cancer (LABC) is a complex disease that requires a multidisciplinary approach. Neoadjuvant chemotherapy (NAC) is usually performed in order to achieve loco-regional radical resection; although its importance in the multidisciplinary approach to LABC is well recognized, a small number of patients show Progressive Disease (PD). No standard salvage treatment (ST) has been defined and different strategies can be adopted, such as second-line systemic therapies, radiation therapy, and surgery. Herein, a case of LABC in PD during NAC is reported with a literature review, with the aim of highlighting the importance of a tailored multidisciplinary treatment for each patient.

Locally advanced breast cancer (LABC) may rarely present with acute severe bleeding. A case report dealing with transcatheter arterial embolization to control acute bleeding in a patient with a voluminous ulcerated breast mass is described. Our findings confirm that the endovascular approach is effective in such patients in order to stabilize the patient whenever conventional treatments have failed or bleeding may be life-threatening.

Locally Advanced Breast Cancer (LABC) is a complex disease that requires a multidisciplinary approach. Neoadjuvant Chemotherapy (NAC) is usually performed in order to achieve loco-regional radical resection; although its importance in the multidisciplinary approach to LABC is well recognised, a small number of patients show Progressive Disease (PD). No standard Salvage Treatment (ST) has been defined and different strategies can be adopted, such as second line systemic therapies, radiation therapy, and surgery. Herein a case of LABC in PD during NAC is reported with a literature review, with the aim of highlighting the importance of a tailored multidisciplinary treatment in each patient.

Oncoplastic breast-conserving surgery (OBCS) is increasingly used to treat breast cancer with the dual purpose of performing a radical oncological resection while minimizing the risk of post-operative deformities. The aim of the study was to evaluate the patient outcomes after Level II OBCS as regards oncological safety and patient satisfaction. Between 2015 and 2020, a cohort of 109 women consecutively underwent treatment for breast cancer with bilateral oncoplastic breast-conserving volume displacement surgery; patient satisfaction was measured with BREAST-Q questionnaire. The 5-year overall survival and disease-free survival were 97% (95%CI 92, 100) and 94% (95%CI 90, 99), respectively. In two patients (1.8%), mastectomy was finally performed due to margin involvement. The median patient-reported score for "satisfaction with breast" (BREAST-Q) was 74/100. Factors associated with a lower aesthetic satisfaction index included: location of tumour in central quadrant (p = 0.007); triple negative breast cancer (p = 0.045), and re-intervention (p = 0.044). OBCS represents a valid option in terms of oncological outcomes for patients otherwise candidate to more extensive breast conserving surgery; the high satisfaction index also suggests a superiority in terms of aesthetic outcomes.