The use of indocyanine green as the only tracer for the identification of the sentinel lymph node in breast cancer: safety and feasibility.

Background: Sentinel lymph node biopsy (SLNB) is now considered the "gold standard" for axillary staging in the treatment of breast cancer. Most of the lymph node mapping experiences have been performed with a radioisotope (albumin-Tc99m) associated or not with the intraoperative injection of a dye, such as Patent-Blue V. Recent studies have shown how the use of indocyanine green (ICG; a drug used for diagnostic use for many years in other sectors) as a fluorescent tracer, allows to obtain alone detection rate of the sentinel lymph node similar or even better, without the risks related to radioactivity and with better use of resources. Methods: From March 2020 to February 2021, 184 patients with breast cancer cN0, candidate for SLNB were enrolled at the Complex Operative Unit (UOC) of Breast Surgery, Breast Unit of the Hospital of Verona. The ICG was injected into the periareolar site and was used the NOVADAQ SPY Elite system (Stryker®) for transcutaneous intraoperative observation of fluorescence. The primary objective of the study is the evaluation of the feasibility of the technique and its sensitivity in the identification of sentinel lymph node; among the secondary endpoints the recognition of predictive factors on the identification (t1-t0) and extraction (t2-t1) times of the sentinel lymph node, and on the number of lymph node uptake pathways. Finally, was analyse the safety of the technique. Results: The sentinel lymph node was detected and removed in 98.3%. The average number of sentinel lymph nodes extracted is 1.527, while the average number of total lymph nodes (TLNs) extracted is 3.375. The sensitivity of the sentinel lymph node detection technique with ICG, turns out to be 100%. Finally, in the literature, lymphatic function decreases with increasing age, reducing the identification rate of the SLN; this is not confirmed in our study. Conclusions: Our study confirms the use of the only ICG tracer for SLNB in cN0 breast cancer, demonstrating that it is a safe, effective and sensitive technique, which also allows to reduce costs, risks and organizational efforts.

Breast conservative surgery and whole breast radiotherapy versus breast conservative surgery and IORT: surgical opinion.

BACKGROUND: To define the possibility of intraoperative radiation therapy (IORT)'s application on clinical practice and point out the problems observed by Verona Breast Unit. METHODS: Among the patients of the Breast Unit at Azienda Ospedaliera Universitaria Integrata of Verona, treated between July 2015 and June 2017, were identified 459 patients undergoing breast conserving surgery for a carcinoma, followed by IORT in 77 cases or by Whole Breast Radiotherapy (WBRT) in 382 cases. The data of WBRT group were analyzed considering IORT eligibility criteria to identify a sub-group of eligible patients, for whom we evaluated the diagnostic process that had led to exclusion from IORT. RESULTS: In WBRT group 184 patients (48%) had a ductal NOS infiltrating carcinoma, of which 64 cases (16.8%) were eligible for IORT. Other 79 patients of WBRT group (21%) presented DCIS, of which only 27 were in the American Society for Radiation Oncology "suitable" group for IORT. Considering the results of the preoperative exams, or rather needle biopsy and MRI scan, 55 patients of 64 (85.9%) resulted unsuitable for IORT, while nine patients (14.1%) could be eligible. CONCLUSIONS: IORT's major limits are: the restricted eligibility criteria, especially on histology; the need of a complete execution of preoperative exams and the technical limits of these exams. ASTRO suitable group, including small diameter, low-grade DCIS, might be used to extend the eligibility criteria. A multidisciplinary approach might improve the preoperative study, so the use of IORT in clinical practice.

Effects of Lean Thinking and Emerging Technologies on Breast Cancer Patients' Therapeutic Process During COVID-19 Pandemic: A Case-Control Matched Study.

Introduction: The advent of the COVID-19 pandemic has led to the sudden disruption of routine medical care, and the subsequent reorganization of hospital structures and therapeutic algorithms, aiming at protecting patients and health professionals. This was inevitably bound to affect our Breast Unit, dilating both pre- and post-operative times. The aim of this study was to evaluate the effect on patients' flow of organizational and logistic changes (key interventions) based on lean thinking implemented after the COVID-19 outbreak. Materials and Methods: Clinical and demographic data were retrospectively collected from patients undergoing sentinel lymph node biopsy for breast cancer at the Verona University Hospital from January 2018 to June 2020. Patients enrolled (n = 341) were divided into two groups according to date of admission: before (Group A; n = 294) and after (Group B; n = 47) the implementation of key interventions. Each case in Group B was subsequently matched 1:1 by means of case-control matching with cases from Group A for age, comorbidities, and type of surgery (Subgroup A1; N = 47). Pre-admission time (T0) and length of stay (T1) were compared between the three groups. Results: Median T0 was 312 h, whereas median T1 was 24 h. Patients in Group B had a higher frequency of comorbidities (57.4 vs. 25.2%, p = 0.001) and underwent mastectomy more often than patients in Group A (61.7 vs. 36.7%, p = 0.001). Both median T0 and T1 were higher in group B than in group A (384 vs. 300 h, p = 0.001, 48 vs. 24 h, p = 0.001, respectively). Median T0 and T1 did not significantly differ between Group B and Subgroup A1 (all p > 0.05). Conclusions: Lean thinking and new technologies could prove useful to the optimization of preoperative and postoperative times during the current pandemic, minimizing healthcare personnel and patients' exposure to SARS-CoV-2, and promoting a rational use of limited resources, while complying with oncological principles.

Male Breast Cancer: Surgical and Genetic Features and a Multidisciplinary Management Strategy.

BACKGROUND: Male breast cancer (MBC) is a rare disease with a rising incidence trend. The major risk factors related to MBC are a positive family history of breast cancer (BC) and BRCA1/2 mutations, which indicate a relevant genetic role. METHODS: In this retrospective series, we enrolled 69 male patients presenting with male breast cancer (MBC) between 01/01/1992 and 31/12/2018, and 26 high-risk not-affected men presenting between 01/01/2016 and 31/12/2018. Participants' electronic clinical records were reviewed. Patients' data reported age at diagnosis, tumor characteristics, therapeutic management, and BRCA1/2 status as well as a family history of breast, ovarian, or prostate cancer (PCa) in first-degree relatives. RESULTS: We analyzed 69 MBC patients. Median age was 64 years. The majority of tumors diagnosed were of an early TNM stage. The most frequent histological subtype was invasive ductal carcinoma (76.7%). Hormone receptors were positive in >90% of MBC cases. Nearly all patients underwent modified radical mastectomy or total mastectomy. Adjuvant endocrine therapy was delivered in 59.4%. Among MBC-affected patients, we recorded a high percentage of a positive family history of BC. Mutational analysis for the BRCA1/2 genes was performed in 17 MBC patients; 11.8% were carriers of BRCA2 pathogenic mutations. Among 26 healthy high-risk subjects included in this case series, 4 were BRCA1 mutation carriers and 9 were BRCA2 mutation carriers. DISCUSSION: We evaluated the distribution of clinicopathological characteristics in MBC subjects and assessed the frequency of mutations in the BRCA genes in affected patients and healthy high-risk subjects, with the aim of proposing a surveillance program for BC and PCa.

Axillary Hibernoma in woman with Lobular breast cancer and MEN1 syndrome: A case report.

INTRODUCTION: The present study reports the case of an axillary hibernoma in a patient with lobular homolateral breast cancer and multiple endocrine neoplasia type1 (MEN-1). Hibernoma is a rare benign adipose tissue tumor, and usually manifests as a slowly growing and painless rubbery mass. These tumors can arise in various sites, but mammary hibernomas remain extraordinarily uncommon. Although hibernomas are metabolically active and therefore "glucose-avid" on fluorodeoxyglucose CT-positron emission tomography (FDG CT-PET), imaging alone is inadequate in providing a reliable diagnosis and definitive differential diagnosis from other malignancy. Only complete surgical excision is diagnostic and, in most cases, curative. PRESENTATION OF CASE: A 42-years-old woman was followed for MEN-1 syndrome associating with hyperparathyroidism, insulinoma, non-secretory adrenal adenoma and thyroid lump. A FDG CT-PET found high glucid hypermetabolism in thickened elongated area on the front axillary line. Hibernoma was diagnosed after realization of prophylactic left mastectomy, homolateral sentinel lymph node biopsy and exeresis of the known axillary lesion. DISCUSSION: Clinical importance lies in distinguishing hibernoma from other benign and malignant breast neoplasms, as well as inflammatory conditions that come into the histologic or radiologic differential. Hibernoma is not currently classified as a non-endocrine tumor related to MEN1, but this association could be not fortuitous for the linkage between modification of Menin protein function and pathogenesis of hibernomas. CONCLUSION: Our case deserves extraordinary attention because, not only it's a case of MEN1 syndrome associated with hibernoma, but in the context of this lesion there are multiple micro-foci of infiltrating lobular carcinoma.

Multidisciplinary management of CDH1 germinal mutation and prophylactic management hereditary lobular breast cancer: A case report.

INTRODUCTION: Germline CDH1 mutations, classically associated with hereditary diffuse gastric cancer (HDGC), also imply an increased lifetime risk of developing lobular breast cancer (LBC) in a highly penetrant autosomal dominant manner. PRESENTATION OF CASE: We report a 44-year-old woman CDH1 mutation carrier with a strong family history of cancer, who previously had prophylactic total gastrectomy. We registered normal findings at the breast and axilla assessment. Mammography, ultrasonography and breast MRI scans were negative for cancer. In our Institute a bilateral prophylactic mastectomy followed by breast reconstruction was performed. Foci of atypical lobular hyperplasia(ALH) and lobular carcinoma in situ (LCIS) were histologically shown. DISCUSSION: The current consensus guidelines for women with pathogenic CDH1 mutations recommend annual mammography, ultrasound, breast MRI scans and clinical breast examination starting at the age of 35. Due to the well-documented aggressive behavior of this particular type of cancer, bilateral mastectomy and reconstruction would be more beneficial for this kind of high-risk patients. CONCLUSION: Conflicting evidences and lacking data about the benefits in terms of overall survival, disease-free survival and the long-term outcomes related to prophylactic bilateral mastectomy for CDH1 mutation carriers restrict the instruction for this type of procedure to selected cases, which should always be managed by a multidisciplinary team.

Breast cancer and neoadjuvant chemotherapy: indications for and limits of breast-conserving surgery.

AIM: The aim of our study was to determine how many and what subtypes of breast cancer could be treated with breast-conserving surgery after NACT. Another outcome was to determine the applicability of MD Anderson Cancer Center nomogram to predict it. MATERIAL OF STUDY: We reviewed the histological examinations of 86 performed mastectomies according to the indications to BCS after NACT. For 73 cases, collected all the necessary data, we could use the nomogram available on the MDACC website to calculate the probability of BCS and pCR. RESULTS: In our experience the BCS rate would increase by 34,1%, from 3,7% to 3.,8%. Patients with Triple Negative and HER2+, ER- more than ER+, show higher rates of pCR and BCS. The MDACC nomogram predicts accurately the probability of pCR and BCS after NACT in HER2 negative cancers but not in HER2 positive ones treated with Trastuzumab. This suggests that a specific nomogram for HER2 positive carcinomas has to be developed. CONCLUSION: BCS after NACT is feasible and safe in terms of LRR, DFS and OS, if patients are properly studied and selected. Indication to BCS after NACT needs of a multidisciplinary assessment considering clinical staging, biological characteristics, the radiological response pattern and the expected concordance between imaging and histology. KEY WORDS: Breast Cancer, Breast-conserving surgery, Neoadjuvant chemotherapy.

Breast cancer and gastrointestinal metastasis. A case report and review of the literature.

INTRODUCTION: Invasive lobular cancer (ILC) is the second most common type of a heterogeneous group of different histological types of invasive breast carcinoma. Breast cancer can metastatize anywhere, the most common sites are bones, liver, lungs and brain. Gastrointestinal tract (GI) metastases observed in autopsy studies account for about 6% to 18% of the overall metastases from breast cancer. OBJECTIVE: We describe a 54-year old woman with recurrent ILC in the contralateral breast. She underwent right mastectomy 16 years before. After symptomatic presentation a duodenal invasion was found and subjected to diagnostic scrutiny (FDG PET/CT, diagnostic CT, MR, EGDS). In particular, we analyse if FDG PET/CT is enough accurate in the restaging of the patient. A review of our database and of the literature of similar cases were made. RESULTS: In this patient CT and RM were suspicious for a slow developing process of the duodenum but FDG PET/CT did not show pathological uptake in the affected duodenal tract. A highly intense focus was described in a cervical lymph node, that there isn't metastatic lesion, whereas the recurrent breast lesion had only slight increased glycolytic activity. CONCLUSION: Metastatic lobular carcinoma of the breast is a rare entity with a heterogeneous range of clinical presentations. Detection of eventual gastrointestinal metastases are complicated to assess. ILC has various scale of glycolytic activity both in the primary lesion as well in the metastatic foci. When the level of suspicion is high and there is no uptake of FDG, further investigations are necessary. KEY WORD: Abdominal metastasis, FGD PET-TC, Lobular Breast Cancer.