Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach.

Background: Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases. Objectives: The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation. Methods: A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared. Results: Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases. Conclusions: Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.

Autologous mastectomy reconstruction: Communication among the breast surgery team to maximize aesthetic and oncologic outcome.

Mastectomy breast reconstruction with autologous tissue is challenging. Oncologic and aesthetic goals face previous surgical scars, radiation, chemotherapy, or other comorbidities. We describe a simple approach for autologous mastectomy reconstruction so that breast and plastic and reconstructive surgeons can maximize aesthetic outcomes and minimize wound complications. A retrospective chart review was done on patients who underwent mastectomy and autologous reconstruction. The surgical flight plans were reviewed to delineate an approach, and pre- and postoperative photographs were examined to create a step-by-step process. The most encountered mastectomy and autologous flap reconstruction scenarios were categorized to create a step-by-step process. Successful autologous mastectomy reconstruction to optimize aesthetic outcome and minimize complications requires team communication. Creation of a surgical flight plan using information from the physical examination, MRI and adjunctive imaging, and preoperative photographs is imperative. Thoughtful incision choice and exposure approach are paramount.

Improving Breast Cancer Detection Accuracy of Mammography with the Concurrent Use of an Artificial Intelligence Tool.

PURPOSE: To evaluate the benefits of an artificial intelligence (AI)-based tool for two-dimensional mammography in the breast cancer detection process. MATERIALS AND METHODS: In this multireader, multicase retrospective study, 14 radiologists assessed a dataset of 240 digital mammography images, acquired between 2013 and 2016, using a counterbalance design in which half of the dataset was read without AI and the other half with the help of AI during a first session and vice versa during a second session, which was separated from the first by a washout period. Area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and reading time were assessed as endpoints. RESULTS: The average AUC across readers was 0.769 (95% CI: 0.724, 0.814) without AI and 0.797 (95% CI: 0.754, 0.840) with AI. The average difference in AUC was 0.028 (95% CI: 0.002, 0.055, P = .035). Average sensitivity was increased by 0.033 when using AI support (P = .021). Reading time changed dependently to the AI-tool score. For low likelihood of malignancy (< 2.5%), the time was about the same in the first reading session and slightly decreased in the second reading session. For higher likelihood of malignancy, the reading time was on average increased with the use of AI. CONCLUSION: This clinical investigation demonstrated that the concurrent use of this AI tool improved the diagnostic performance of radiologists in the detection of breast cancer without prolonging their workflow.Supplemental material is available for this article.© RSNA, 2020.

Intraoperative Radiation Using Low-Kilovoltage X-Rays for Early Breast Cancer: A Single Site Trial.

INTRODUCTION: Two prospective, randomized trials, TARGIT-A and ELIOT, have shown intraoperative radiation therapy (IORT) to be a safe alternative to whole breast radiation therapy following breast-conserving surgery for selected low-risk patients. However, minimal data are available about the clinical effectiveness of this modality of treatment using the Xoft® Axxent® Electronic Brachytherapy (eBx®) System®. METHODS: A total of 201 patients with 204 early-stage breast cancers were enrolled in a prospective X-ray IORT trial from June 2010 to September 2013. All tumors were treated with breast-conserving surgery and IORT. Data were collected at 1 week, 1 month, 6 months, 1 year, and yearly thereafter. RESULTS: With a median follow-up of 50 months, there have been seven ipsilateral breast tumor events (IBTE), no regional or distant recurrences, and no breast cancer-related deaths. One IBTE was within the IORT field, four outside of the IORT field but within the same quadrant as the index cancer, and two were new biologically different cancers in different quadrants. Three events were in patients who deviated from the protocol criteria. Kaplan-Meier analysis projects that 2.9% of patients will recur locally at 4 years. CONCLUSIONS: Recurrence rates observed in this trial were comparable to those of the TARGIT-A and ELIOT trials as well as the retrospective TARGIT-R trial. The low complication rates previously reported by our group as well as the low recurrence rates reported in this study support the cautious use and continued study of IORT in selected women with low-risk breast cancer.

Acute and Chronic Complications in Patients with Ductal Carcinoma in Situ Treated with Intraoperative Radiation Therapy.

Intraoperative radiation therapy (IORT) delivers radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available regarding IORT complications in patients diagnosed with ductal carcinoma in situ (DCIS) using the Xoft® Axxent eBx® System. 146 patients with pure DCIS received X-ray based IORT therapy using the Xoft® Axxent eBx® System at Hoag Memorial Hospital Presbyterian between June 2010 to April 2016 and were accrued to an IORT data registry study. The protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1 week, 1 month, 6 months, 1 year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months. Acute complications were observed in 18% of patients and included hematomas that required drainage, an infection treated with antibiotics, and erythema. Chronic complications were observed in 12% of patients and included a seroma, fibrosis and hyperpigmentation. The majority of acute and chronic problems were mild (Grade I). If Grade I erythema, fibrosis, and hyperpigmentation are not included, only 11/146 patients (7.5%) had significant complications. The rate of acute and chronic complications from X-ray IORT in DCIS patients was low compared to historical toxicity rates observed in DCIS patients treated with whole breast irradiation. Our data indicate that X-ray IORT can be utilized safely in patients diagnosed with DCIS.

Acute and Chronic Complications in Breast Cancer Patients Treated with Intraoperative Radiation Therapy.

INTRODUCTION: Intraoperative radiation therapy (IORT) permits the delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the complications associated with this modality of treatment using the Xoft(®) Axxent Electronic Brachytherapy (Axxent) System. METHODS: A total of 702 patients who received IORT using the Xoft(®) Axxent System at Hoag Memorial Hospital Presbyterian between June 2010-February 2016 were accrued in an IORT data registry study. The prospective and retrospective protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months. RESULTS: Acute complications were observed in 21 % of patients and included hematomas that required drainage, seromas requiring drainage more than 3 times, infections treated with antibiotics or surgery, necrosis requiring surgery, and erythema. Chronic complications were observed in 13 % of patients and included seromas, fibrosis, and hyperpigmentation. The majority of acute and chronic problems from IORT were mild. If grade I erythema, fibrosis, and hyperpigmentation were removed, only 32 of 702 (4.6 %) had significant complications. Our complication rates were comparable to those of the TARGIT trial. CONCLUSIONS: IORT is a modality that safely delivers radiation therapy to patients diagnosed with breast cancer. This technique allows women who cannot (or decline to) undergo whole breast radiation to consider breast-conserving therapy rather than mastectomy.

Invasive lobular carcinoma of the breast: spectrum of mammographic, US, and MR imaging findings.

The reported prevalence of invasive lobular carcinoma (ILC) is variable, with more recent studies indicating that ILC accounts for 10%-15% of all invasive breast carcinomas. However, the radiologic diagnosis and management of ILC can be uniquely challenging. Current imaging modalities are not very specific for differentiating ILC from other invasive breast cancers, and ILC has a tendency to have appearances at mammography that are atypical for invasive ductal carcinomas, resulting in higher false-negative rates. The clinical detection of ILC can also be difficult, since ILC frequently fails to form a palpable lesion. This tendency of ILC to have atypical imaging and clinical appearances is related to its histopathologic features and its failure to elicit a desmoplastic response. Despite these diagnostic challenges, however, imaging remains crucial in the detection and management of ILC. Mammography, ultrasonography (US), and magnetic resonance (MR) imaging all play important roles, with each modality having its own advantages and limitations. The use of US and MR imaging as adjuncts to mammography increases sensitivity in the detection of ILC and provides useful information for further management and presurgical planning. Familiarity with the spectrum of imaging appearances of ILC is essential.

Bronchial artery embolization for treatment of life-threatening hemoptysis.

Massive hemoptysis is an emergent and life-threatening condition with a broad range of underlying causes. Fortunately, massive hemoptysis accounts for a minority of cases of hemoptysis, ~5%. Unlike hemorrhage in other areas of the body, the primary cause of death from pulmonary hemorrhage is most commonly asphyxiation rather than exsanguination. Given the limited capacity for the lung to preserve oxygen transfer in the setting of massive hemoptysis, a rapid and effective method for controlling hemorrhage is essential to minimize death in patients demonstrating respiratory compromise. Since its introduction in 1973, bronchial artery embolization has proven to be a safe and effective tool for the treatment of massive hemoptysis and is now considered the treatment of choice, with initial success rates ranging from 77 to 94%. The long-term control rate of hemoptysis ranges from 70 to 85% and is largely a function of the degree of inflammation and the natural progression of the underlying disease. This article reviews the current literature on bronchial artery embolization for the treatment of massive hemoptysis.