Breast implant associated anaplastic large cell lymphoma: Evidence for an efficient diagnostic workup.

INTRODUCTION: During the last few years it has been shown that an anaplastic T cell lymphoma can develop as a rare and late sequelae of implant-based breast reconstruction. This malignancy was recognized in the 2017 by WHO and named breast implant associated anaplastic large T cell lymphoma (BIA-ALCL). BIA-ALCL usually presents as abundant effusion around the implant, thus, in addition to cytology smears, its diagnosis also requires immunohistochemistry, T cells clonality and cytometry. Due to the increasing attention of clinicians, it is likely that the number of the BIA-ALCL suspected cases will grow in the future, implying the necessity of a reliable and cost-effective diagnostic procedure. METHODS: To achieve this goal, we retrospectively analyzed the results of laboratory investigations performed at our Institute (Fondazione IRCCS Istituto Nazionale dei Tumori Milan, Italy) on 44 effusions obtained from 31 women suspected for BIA-ALCL. RESULTS: Through cytology, eight out of 44 effusions showed the presence of BIA-ALCL cells. Lymphoma cells were than confirmed in seven samples by immunohistochemistry and/or T cell clonality and/or cytometry. Overall, cytology showed 100% sensitivity, 97% specificity and positive and negative predictive values of 87.5% and 100% respectively. Further analyses were particularly useful in effusions showing small percentages of BIA-ALCL cells. Moreover, an extended cytometric profile that can be applied when fast confirmation of the cytologic result is required was also identified. CONCLUSIONS: Our results evidenced a central role of cytopathology in the management of BIA-ALCL suspected effusions and suggested that further laboratory investigations might be applied only in cases showing atypical/activated lymphoid cells through cytology.

Health Care Workers' Attitudes Toward Patients With COVID-19.

BACKGROUND: Early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, before the routine availability and/or use of personal protective equipment, health care workers were understandably concerned. Our aim was to explore health care workers' attitudes toward patients infected with SARS-CoV-2 at the time of the nation's first surge in 2 highly affected hospitals in New York. METHODS: We performed a cross-sectional, self-administered survey study of health care workers. The survey consisted of 17 multiple-choice questions including demographic information, ethics, and willingness to care for patients with SARS-CoV-2 infection. Subgroup analyses were performed using the Fisher exact test. RESULTS: Of 340 health care workers approached, 338 (99.4%) consented to the survey; 163 (48.7%) were registered nurses and 160 (48.3%) lived with children. While 326 (97.3%) workers were concerned about putting their family/coworkers at risk of infection after caring for a patient with SARS-CoV-2, only 30 (8.9%) were unwilling to treat a patient with SARS-CoV-2 infection. Registered nurses were more likely than other health care workers to think it was ethical to refuse care for SARS-CoV-2-infected patients, worried more often about contracting infection, and felt that SARS-CoV-2 added to their stress level (P = .009, P = .018, P < .001, respectively). A similar contrast was seen when comparing workers who live with children with those who did not. CONCLUSIONS: Levels of stress and concern were extremely high. In spite of that, the overwhelming majority of workers were willing to treat patients with SARS-CoV-2 infection. Registered nurses and health care workers who live with children were more likely to think it is ethical to refuse care for SARS-CoV-2-infected patients.

Contraceptive Pharmacology and Risk Communication: A Case-Based Flipped Classroom Exercise.

Introduction: Oral contraceptives are widely used for both contraceptive and noncontraceptive purposes. Of women ages 15-44 who have ever had sexual intercourse, 88% have used at least one hormonal contraceptive method. Health care providers caring for reproductive-age women need a strong base of knowledge in hormonal contraception. Those who provide contraceptive counseling must apply this knowledge to shared decision making, including effective quantitative communication. Methods: Students and faculty at Florida International University Herbert Wertheim College of Medicine created a prerecorded lecture and in-class interactive case on contraceptive pharmacology and risk communication. The 20-minute lecture focused on mechanisms of action, bioavailability, drug-drug interaction, effectiveness, and major vascular risks of combined hormonal and progestin-only contraceptives. The 55-minute in-class session integrated knowledge of risks and effectiveness of contraception with risk communication surrounding contraceptive decision making and counseling. For the 2018 academic year, 122 first-year medical students participated in the session. Students anonymously answered three questions related to the session on their end-of-course evaluation. Student learning was assessed with five multiple-choice questions on the pharmacology final exam. Results: Students rated the session very positively. They highly rated the lecture's utility and the sesssion's contribution to solidifying their basic science knowledge and understanding of its clinical applications. Class average performance on the relevant final exam questions was 88.4%. Discussion: The lecture and case discussion successfully addressed gaps in the curriculum and provided students the opportunity to integrate multiple domains of learning. Students' perception of the materials was positive, and they demonstrated adequate learning.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial.

BACKGROUND: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. METHODS: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome. RESULTS: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. CONCLUSIONS: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Skin/nipple sparing mastectomies and implant-based breast reconstruction in patients with large and ptotic breast: oncological and reconstructive results.

In this study we performed 77 procedures on 65 patients fulfilling the oncological criteria for skin-sparing mastectomy and presenting with large or medium size breasts. All the operations were performed as a single-stage procedure with an anatomical prosthesis allocated into a compound pouch, made up of the pectoralis major, serratus anterior fascia, and a lower dermal adipose flap. The medium size of the anatomical implants employed was 444.3 cc. The implant removal rate was 14.2%. At a median follow-up of 36 months we reported a 0.5% local recurrence rate per year. The overall specific survival rate was 98.2%. This study confirms the safety and effectiveness of this technical variation of skin and nipple-sparing mastectomies. All breast, irrespective of mammary shape and size, can be reconstructed with medium size implants and, if required, contralateral adjustments. The overall complication rate is in keeping with previous studies.

Maximizing the use of abdominoplasty incision in oncoplastic and aesthetic breast surgery: four transabdominal (transumbilical-like) augmentations.

BACKGROUND: The transabdominal (transumbilical [TUBA]) procedure for breast implant insertion is known for aesthetic aims, but cosmetic and psychosocial improvements reported in aesthetic surgery should be transferred to breast reconstruction patients. METHODS: Surgical and psychological aspects were analyzed in four cases through clinical evaluation and psychosocial assessment. Three patients were candidates for postmastectomy reconstruction by transverse rectus abdominis myocutaneous (TRAM) flap, and one patient was a candidate for cosmetic abdominoplasty. The expectations of the patients were met, and body image improvement was provided through contralateral breast augmentation in all cases. Details of the surgical approach focused on the inframammary fascial system. The psychosocial implications of the TUBA-like breast augmentation combined with the abdominoplasty procedure were emphasized through the analysis of the technical details and the psychological behaviors affecting the surgery. RESULTS: The result, after long-term clinical follow-up (37 months) and administration of a satisfaction questionnaire (CSQ-8), established the importance of scarless surgery to healthy breast tissue and the positive reception by women with different life histories. CONCLUSION: This report concerns only a few potential patients, but supports a trend that surgeons should consider. An elective indication for transabdominal breast augmentation can be represented even by those few patients who are candidates for TRAM flap reconstruction, who are agreeable to a small augmentation in the absence of a scar on their healthy breast, and whose reconstructed breast is larger and more prominent at the central part of the mound than on the contralateral side.

Skin-reducing mastectomy.

BACKGROUND: The authors propose a combined flap technique to reconstruct large and medium-sized ptotic breasts in a single-stage operation by use of anatomical permanent implants. METHODS: The authors enrolled 28 patients fulfilling criteria for skin-sparing mastectomy and presenting with ptotic breasts whose areola-to-inframammary fold distance was more than 8 cm. All reconstructions were performed as a single-stage procedure. After preoperative planning, a large area in the lower half of the breast was deepithelialized according to the conventional Wise pattern. Mastectomy was then carried out. To perform reconstructions, the inferomedial fibers of the pectoralis major muscle were dissected and sutured to the superior border of the inferior dermal flap. An anatomical implant was then inserted into the pouch, which was closed laterally with the previously harvested serratus anterior fascia. Skin flaps were finally closed down to the inframammary fold. RESULTS: The authors performed 30 procedures on 28 patients. The medium size anatomical implants was 433 cc. Twelve women achieved symmetrization in a single stage ending in a symmetric inverted-T scar. The overall complication rate was 20 percent, with four cases (13 percent) complicated by severe, extensive necrosis of the skin flaps requiring implant removal. CONCLUSIONS: Breast cancer treatment must nowadays optimize cosmetic results. This can be accomplished in selected cases by means of a single-stage operation that the authors call "skin-reducing mastectomy." The final scars imitate those of cosmetic surgery. Careful patient selection and improvement in the learning curve may reduce the complication rate.