The Extended Chest Wall Perforator Flap: Expanding the Indication for Partial Breast Reconstruction.

Background: The intercostal artery perforator flap has traditionally been used to reconstruct small or moderate-sized single defects in the lateral or lower medial breast during breast-conserving surgery. We report a modification of the intercostal artery perforator flap that allows for reconstruction of larger breast tumors than previously described flap designs. Methods: A retrospective study of breast cancer patients undergoing breast-conserving surgery and immediate partial breast reconstruction with an extended chest wall perforator flap. Primary outcomes were successful tumor excision, adequate radial margins, postoperative complications, and delays to adjuvant radiotherapy. Results: Thirty patients were included. Mean radiological tumor size was 27 mm (11-56 mm) and excision volume, 123 cm3 (18-255 cm3). All tumors had satisfactory excision margins, and no patient required further surgery for re-excision. In the early postoperative period, one patient required radiological drainage of seroma, and one returned to theater for debridement of fat necrosis affecting the flap. Ten other patients were managed on an outpatient basis for minor wound complications. All patients were followed up annually for 5 years. No patients had a delay to adjuvant treatment or required revisional procedures for cosmesis. Conclusions: The modified chest wall perforator flap allows for breast conservation for larger tumors from all quadrants of the breast, including centrally located tumors and reconstruction of the axillary defect following lymph node clearance. The length of the flap allows for the use of multiple perforators in the pedicle area and freedom of the flap to reach the defects. This can be performed with low morbidity and no delay to adjuvant radiotherapy.

Radio-frequency identification (RFID) tag localisation of non-palpable breast lesions a single centre experience.

AIM: The purpose of this study is to report the surgical experience and outcomes with pre-operative localisation of non-palpable breast lesions using the RFID tag system. METHODS: The cohort for this prospective study included patients over the age of 18 with biopsy proven, non-palpable indeterminate lesions, DCIS or breast cancer requiring pre-operative localisation before surgical excision between September 2020 and July 2022. RESULTS: A total of 312 RFID tags were placed in 299 consecutive patients. Indications for localisation included non-palpable invasive cancer in 255 (85.3%) patients, in situ disease in 38 (12.7%) and indeterminate lesions requiring surgical excision in 6 (2.0%). Both in situ and invasive lesions had a median size of 13 mm (range 4-100 mm) on pre-operative imaging. The RFID tags were in situ for a median time of 21 days before surgery (range 0-233 days). Of the 213 tags, 292 (93.6%) were introduced using ultrasound (USS) guidance and stereotactically in 20 (6.4%). In 3 (1.0%) cases the RFID tag was either not satisfactorily deployed at the intended target or retrieved intra-operatively. Following discussion of post-operative histology by the multi-disciplinary team, further surgery for close or involved margins was for 26 (8.7%) patients. CONCLUSION: The Hologic RFID tag system can be used for accurate pre-operative localisation of non-palpable masses as well as diffuse abnormalities such as mammographic distortions and calcifications. It has advantages of flexibility for scheduling image-guided insertion independently of scheduled operating lists and can be placed to localise lesions prior to initiating neoadjuvant systemic treatment.

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial.

INTRODUCTION: Breast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure. METHODS: A randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the "reshaping" group (closure of excision defect with mobilised breast tissue; n = 124) and to the "control" group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ). RESULTS: There were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of "good" or "excellent" by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001). CONCLUSIONS: Simple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.

Usefulness of supplementary ultrasound surveillance in the detection of a second breast cancer in patients with ductal carcinoma in situ.

INTRODUCTION: Supplementary ultrasound surveillance in breast cancer patients can detect additional cancers but is associated with unnecessary biopsies and follow-ups. We aim to determine, in patients with ductal carcinoma in situ (DCIS), the prevalence and factors associated with second breast cancers and the usefulness of supplementary ultrasound surveillance. This is the first study which focused on the usefulness of ultrasound surveillance in DCIS patients. METHODS: DCIS patients were retrospectively analyzed to determine the prevalence and factors associated with second breast cancers. The prevalence of patients with benign biopsies, additional ultrasound follow-ups and second breast cancers, resulting from ultrasound surveillance, were calculated. RESULTS: Three hundred and thirty- two patients were included. 25 (7.5%) patients developed second breast cancers after a mean follow-up of 77.7 months. Breast conservation (P= .0218), involved margins after lumpectomy (P = .0003) and shortened hormonal therapy (P= 0.0369) were associated with second cancers. Of the 314 patients who had ultrasound surveillance, ipsilateral, and contralateral ultrasounds yielded 1.7%/1.3% cancer detection, 5.8%/6.7% benign biopsies and 10.4%/15.3% additional follow-ups. Patients with involved margins after lumpectomy have ipsilateral cancer detection, benign biopsies and additional follow-ups of 4.5%, 4.5%, and 9.1% respectively. A total of 85.4% patients had mammographically dense breasts. CONCLUSION: In DCIS patients, the rate of second breast cancers was 7.5%. Breast conservation, involved margins after lumpectomy and shortened hormonal therapy were associated with second cancers. Patients with involved margins after lumpectomy have the highest cancer detection rate and minimal unnecessary biopsies and follow-ups. Hence, ipsilateral breast ultrasound surveillance could be personalized for this high-risk group with mammographically dense breasts.

The Use of Antifibrotic Recombinant nAG Protein in a Rat Liver Fibrosis Model.

OBJECTIVES: The "nAG" protein is the key protein mediating the regeneration of amputated limbs in salamanders. The senior author (MMA) developed the original hypothesis that since "nAG" is a "regenerative" protein, it must be also an "antifibrotic' protein. The antifibrotic properties were later confirmed in a rabbit skin hypertrophic scar model as well as in a rat spinal cord injury model. The aim of this study is to evaluate the potential therapeutic properties of the nAG protein in a rat liver fibrosis model. METHODOLOGY: Liver fibrosis was induced using intraperitoneal injections of carbon tetrachloride (CCL4). A total of 45 rats were divided equally into 3 groups: Group I (the control group) received normal saline injections for 8 weeks, Group II received CCL4 for 8 weeks, and Group III received CCL4 and nAG for 8 weeks. At the end of the experiment, the serum levels of 6 proteins (hyaluronic acid, PDGF-AB, TIMP-1, laminin, procollagen III N-terminal peptide, and collagen IV-alpha 1 chain) were measured. Liver biopsies were also taken and the stages of live fibrosis were assessed histologically. RESULTS: The CCL4 treatment resulted in a significant increase in the serum levels of all 6 measured proteins. The nAG treatment significantly reduced these high levels. The degree of liver fibrosis was also significantly reduced in the CCL4/nAG group compared to the CCL4 group. CONCLUSIONS: nAG treatment was able to significantly reduce the serum levels of several protein markers of liver fibrosis and also significantly reduced the histological degree of liver fibrosis.