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.

Surgical Management of Inherited Breast Cancer: Role of Breast-Conserving Surgery.

Recent studies have demonstrated that hereditary breast cancer (BC) has a prevalence of 5-10% among all BC diagnoses. Nowadays, significant technological advances in the identification of an increasingly broad spectrum of genetic mutations allow for the discovery of an ever-growing number of inherited pathogenic (P) or likely pathogenic (LP) variants of breast cancer susceptibility genes. As the management of BC patients carrying mutations in the BRCA1/2 genes or other high-penetrance genes is currently a challenge, extensive research is being carried out and a lively scientific debate has been taking place on what the most appropriate local therapy, especially surgical treatment, of patients with inherited BC should be. In many studies, BC outcomes in BRCA carriers and non-carriers have been compared. A number of them showed that, when compared with mastectomy, breast-conserving surgery in BRCA patients is oncologically safe in terms of overall survival, although an increased risk of ipsilateral recurrence was reported. In these patients, devising a specific therapeutic strategy is an inevitably complex process, as it must take into consideration a series of factors, require a multimodal approach, guarantee personalization, strictly adhere to scientific international guidelines, and consider all available evidence. The present narrative review purposes to identify and illustrate evidence from significant selected studies that discussed those issues, as well as to suggest useful tools to clinicians managing this specific clinical condition in daily clinical practice.

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.

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.

Rapid and well tolerated action of idarucizumab for antagonizing dabigatran in a patient needing urgent thrombolysis: a case report.

: Dabigatran is a direct oral anticoagulant drug exhibiting clinical benefits over vitamin K antagonists. A procedure for reversing the anticoagulant effect of direct oral anticoagulants may be needed in emergency clinical settings, and is traditionally accomplished by using plasma products or hemostatic physical interventions. Idarucizumab, a specific antidote for dabigatran, has recently become available. This compound can be rapidly administered by intravenous injection and is effective in reversing anticoagulation in few minutes. We describe here the case of a 78-year-old woman taking dabigatran for atrial fibrillation, who was admitted to the emergency department with a diagnosis of acute cerebral ischemia. Dabigatran plasma levels on admission (74 ng/ml) were measured with diluted thrombin time. Idarucizumab was immediately administered and dabigatran plasma concentration suddenly decreased to less than 2 ng/ml. Successful systemic thrombolysis could hence be performed with full recovery.