Search

Introduction The educational and professional life of everyone have been affected significantly by the COVID -19 pandemic. Many courses and meetings traditionally structured and organized as face-to-face events have been transformed in virtual events. Methods We report on the experience of G.Re.T.A. Fondazione in organizing international conferences, webinars and masterclasses on oncoplastic and aesthetic breast surgery before, during and after the pandemic. Results The organization of the meetings as online or hybrid events allowed to maintain a high number of participants with numbers being in line with those achieved in the traditional face-to-face events or even showing an increased number of participants, in particular from Countries not traditionally involved as Saudi Arabia, United Arab Emirates, India and Russian Federation. Discussion We think that the hybrid modality is likely to become a gold standard, even though purely online meetings will still survive in the post-pandemic era. Webinars are frugal and highly efficient events that can easily reach a worldwide audience with acceptable interaction.

Introduction The potential advantages of oncoplastic breast conserving surgery (BCS) have not been validated in robust studies that constitute high levels of evidence, despite oncoplastic techniques being widely adopted around the globe. There is hence the need to define the precise role of oncoplastic BCS in the treatment of early breast cancer, with consensual recommendations for clinical practice. Methods A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints and establish recommendations for the use of oncoplastic BCS as primary treatment of unifocal early stage breast cancers using the GRADE approach. Results According to the results of the systematic review of literature, the panelists were asked to comment on the recommendation for use of oncoplastic BCS for treatment of operable breast cancer that is suitable for breast conserving surgery, with the GRADE approach. Based on the voting outcome, the following recommendation emerged as a consensus statement: Oncoplastic breast conserving surgery should be recommended versus standard breast conserving surgery for the treatment of operable breast cancer in adult women who are suitable candidates for breast conserving surgery (with very low certainty of evidence). Discussion This review has revealed a low level of evidence for most of the important outcomes in oncoplastic surgery with lack of any randomized data and absence of standard tools for evaluation of clinical outcomes and especially patients’ values. Despite areas of controversy, about one-third (36%) of panel members expressed a strong recommendation in support of oncoplastic BCS. Presumably, this reflects a synthesis of views on the relative complexity of these techniques, associated complications, impact on quality of life and costs.

Multifocal and multicentric breast cancers (MFMCBCs) have traditionally been considered a contraindication to breast-conserving surgery (BCS) because of concerns about locoregional control.The most common definition of MFMCBC is anatomical, based on the presence of cancer foci either in a single breast quadrant (multifocal) or in more than one (multicentric). Other definitions are based on the distance between tumours, with multifocal tumours defined as being within 2 cm of each other (up to 5 cm in some articles), and multicentric tumours further away.The reported incidence of MFMCBC varies between 4 and 60 per cent, and has increased, possibly owing to improved imaging accuracy resulting in better detection rates. Similarly, BCS rates for MFMCBC have increased over time as a result of the introduction of advanced oncoplastic techniques that allow en bloc resection of all cancer foci while preserving (or even improving) breast cosmesis. These advances in oncoplastic breast surgery, together with the support of the St Gallen expert panel and emerging evidence of no significant difference in disease-free or overall survival between MFMCBC and unifocal cancers, have resulted in changing practice, with many surgeons considering BCS in selected patients. This topic is still, however, debated as other authors have questioned the oncological safety of BCS in this setting because of a lack of RCTs or high-quality prospective cohort studies.

Introduction The rapid spread of COVID-19 across the globe is forcing surgical oncologists to change their daily practice. We sought to evaluate how breast surgeons are adapting their surgical activity to limit viral spread and spare hospital resources. Methods A panel of 12 breast surgeons from the most affected regions of the world convened a virtual meeting on April 7, 2020, to discuss the changes in their local surgical practice during the COVID-19 pandemic. Similarly, a Web-based poll based was created to evaluate changes in surgical practice among breast surgeons from several countries. Results The virtual meeting showed that distinct countries and regions were experiencing different phases of the pandemic. Surgical priority was given to patients with aggressive disease not candidate for primary systemic therapy, those with progressive disease under neoadjuvant systemic therapy, and patients who have finished neoadjuvant therapy. One hundred breast surgeons filled out the poll. The trend showed reductions in operating room schedules, indications for surgery, and consultations, with an increasingly restrictive approach to elective surgery with worsening of the pandemic. Conclusion The COVID-19 emergency should not compromise treatment of a potentially lethal disease such as breast cancer. Our results reveal that physicians are instinctively reluctant to abandon conventional standards of care when possible. However, as the situation deteriorates, alternative strategies of de-escalation are being adopted. Implications for Practice This study aimed to characterize how the COVID-19 pandemic is affecting breast cancer surgery and which strategies are being adopted to cope with the situation.

Surgical treatment of breast cancer has changed during the last few decades. Long-term evaluation of several studies performed worldwide have confirmed that conservative surgery (CS) and radical mastectomy have similar survival rates. Due to CS being the gold standard for treatment for most women with breast cancer, advances in materials, mastectomy and reconstructive surgery techniques, now give us the possibility to perform on our patients a great outcome with oncological security. Both advances, in plastic and oncologic surgery, created a new discipline, called oncoplastic breast surgery, that allow surgeons to resect large breast specimens preventing subsequent deformities with the correct previous planning. This is particularly important when more than 30% of the breast volume will be resected because it allows for planning CS depending on the site of the lesion and for establishing the limits between CS and mastectomy.

Introduction Oncoplastic breast surgery has evolved the surgical treatment of breast cancer over the past two decades. This practice still lacks validation and poses several dilemmas in terms of safety, local and systemic control, timing of adjuvant treatments and cost-effectiveness. Our case series investigates the effects of a reduced surgical complexity on cosmetic results and quality of life. Methods We treated 76 consecutive patients affected by early stage breast cancer from January 2016 to April 2017. We employed a decision support system to assist the final shared decision making. The communication process before surgery included new specific information on recent evidence about local control of disease and outcomes after multimodality treatment. In order to estimate the oncoplastic complexity, we created a new score based on scars, bilateral procedures and type and timing of reconstructions. We compared the outcomes of this series to that of a previous one from the same institution. Results The medium complexity score (CS) in the current series was significantly lower compared to that of the previous series (medium CS cohort 1 = 3.1 vs medium CS cohort 2 = 1.51; p = 0.001). Complications according to Clavien-Dindo classification did not vary significantly between the two series (p = 0.7). The increased use of primary systemic treatment did not translate into a significantly lower mastectomy rate (cohort 1 = 20% vs cohort 2 = 16%; p = n.s.). There was no significant difference in breast deformities after breast conserving surgery (p = 0.2). The BCCT.Core demonstrated a 67.1% occurrence of “good” results. Quality of life in patients who underwent breast-conserving surgery measured using the Breast-Q demonstrated similar results in the pre-post-op assessment. Conclusions This study hypothesizes that a proper information may impact on patient's decisions and may reduce surgical complexity. This reduction likely has no effects on the main surgical outcomes estimated using standard tools. More investigations should be performed on a larger multi-institutional scale to confirm these conclusions.

SUMMARY: The authors reviewed the available evidence on revision surgery following implant-based breast surgery with the aim of investigating whether any difference in the surgical approach should be proposed if the patient has a textured device. They included in their review 31 studies presenting different approaches for revision surgery following implant-based breast surgery (both aesthetic and reconstructive), with a level of evidence ranging from 4 to 5. None of the included studies proposed different surgical approaches for revision surgery in patients carrying textured devices. The authors conclude that no different surgical attitudes in revision surgery following implant-based breast surgery should be adopted if the patient has a textured device according to the available evidence, when a correct approach is performed to face the complication or adverse event, following a thorough preoperative study of the patient with the proper diagnostic tools.

Growing numbers of asymptomatic women who become aware of carrying a breast cancer gene mutation (BRCA) mutation are choosing to undergo risk-reducing bilateral mastectomies with immediate breast reconstruction. We reviewed the literature with the aim of assessing the oncological safety of nipple-sparing mastectomy (NSM) as a risk-reduction procedure in BRCA-mutated patients. Nine studies reporting on the incidence of primary breast cancer post NSM in asymptomatic BRCA mutated patients undergoing risk-reducing bilateral procedures met the inclusion criteria. NSM appears to be a safe option for BRCA mutation carriers from an oncological point of view, with low reported rates of new breast cancers, low rates of postoperative complications, and high levels of satisfaction and postoperative quality of life. However, larger multi-institutional studies with longer follow-up are needed to establish this procedure as the best surgical option in this setting.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the effects of implants versus autologous tissue flaps for breast reconstruction following mastectomy for breast cancer treatment or risk reduction, on women’s level of satisfaction, and quality of life, and surgical short- and long-term complications.

Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) is a distinctive type of T-cell lymphoma arising around breast implants. We performed a review of the existing literature with the aim of providing an evidence-based overview of the available data on BIA-ALCL with a standardized evaluation of the quality of the studies and investigating the potential association between textured breast implants and BIA-ALCL.We analyzed the literature reporting estimates of relative or absolute risks of BIA-ALCL in case-control, cohort studies and case series studies. The total number of BIA-ALCL cases reported in literature is very low. Furthermore, most of the reported cases have been reported in case-control studies or case series. This means that our knowledge is based on a low level of evidence. Moreover, low-medium quality scores were observed in the included case series studies. In relation to the rarity of the event, better information could only derived by international cooperation to pool together data deriving from all over the world, with the clear need of better reporting patients and implant characteristics in case series and when adding data to public registries. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Decisions in healthcare usually rely on the goodness and completeness of data that could be coupled with heuristics to improve the decision process itself. However, this is often an incomplete process. Structured interviews denominated Delphi surveys investigate experts' opinions and solve by consensus complex matters like those underlying surgical decision-making. Natural Language Processing (NLP) is a field of study that combines computer science, artificial intelligence, and linguistics. NLP can then be used as a valuable help in building a correct context in surgical data, contributing to the amelioration of surgical decision-making.We applied NLP coupled with machine learning approaches to predict the context (words) owning high accuracy from the words nearest to Delphi surveys, used as input.The proposed methodology has increased the usefulness of Delphi surveys favoring the extraction of keywords that can represent a specific clinical context. It permits the characterization of the clinical context suggesting words for the evaluation process of the data.

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities. Three key recommendations emerged from the meeting. First, the effect of oncoplastic breast-conserving surgery on quality of life and the optimal type and timing of reconstruction after nipple-sparing or skin-sparing mastectomy with planned radiotherapy should be addressed by prospective cohort studies at an international level. Second, the role of adjunctive mesh and the positioning of implants during implant-based breast reconstruction should ideally be investigated by randomised controlled trials of pragmatic design. Finally, the BREAST-Q questionnaire is a suitable tool to assess primary outcomes in these studies, but other metrics to measure patient-reported outcomes should be systematically evaluated and quality indicators of surgical morbidity should be further assessed.

A generalized lack of evidence is associated to mastectomies and reconstructions with dermal flaps. However these technique may warrant good cosmetic results in women with macromastia who can benefit from contralateral adjustment with symmetrical scarring. When performing DTI (direct to implant) breast reconstructions, the complication rates may be rather high with skin necrosis especially at the junction of the inverted T. For this reason a two-stage breast reconstruction would be advisable especially for patients at high risk (smokers, overweight, diabetic). Nipple preservation is related to the nipple to sternal notch distance. For more than 24 cm, a preservation on a double pedicle could be performed safely with few necrotic complications and predictable final results. When the nipple to sternal notch is higher than 29 cm, nipple saving is not recommended as a standard.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

It has been widely reported that breast reconstruction improves the quality of life of women who undergo mastectomy for breast cancer. This approach provides many psychological advantages. Today, different techniques are available for the breast oncoplastic surgeon that involve the use of breast implants and autologous tissues, also offering interesting results in terms of aesthetic and patient-reported outcomes. On the other hand, advanced technologies and design strategies (i.e. design for additive manufacturing, reverse engineering) may allow the development of customised porous structures with tailored morphological, mechanical, biological, and mass transport properties. For this reason, the current study deals with the challenges, principles, and methods of developing 3D additive manufactured structures in breast reconstructive surgery. Specifically, the aim was to design 3D additive manufactured poly(ε-caprolactone) scaffolds with different architectures (i.e. lay-down patterns). Preliminary mechanical and biological analyses have shown the effect of the lay-down pattern on the performances of the manufactured structures.

Oncoplastic breast surgery encompasses both displacement and replacement techniques following breast-conserving surgery and conservative mastectomies 3 (i.e., skin sparing (SSM) and nipple-areola complex-sparing mastectomies (NSM)) followed by breast reconstruction. In this chapter, we will offer an overview on complications following oncoplastic breast-conserving surgery (OPBCS) and implant-based breast reconstruction following NSM and SSM conservative mastectomies and how to treat them properly.

The Breast Surgery theoretical and practical knowledge curriculum comprehensively describes the knowledge and skills expected of a fully trained breast surgeon practicing in the European Union and European Economic Area (EEA). It forms part of a range of factors that contribute to the delivery of high quality cancer care. It has been developed by a panel of experts from across Europe and has been validated by professional breast surgery societies in Europe. The curriculum maps closely to the syllabus of the Union of European Medical Specialists (UEMS) Breast Surgery Exam, the UK FRCS (breast specialist interest) curriculum and other professional standards across Europe and globally (USA Society of Surgical Oncology, SSO). It is envisioned that this will serve as the basis for breast surgery training, examination and accreditation across Europe to harmonise and raise standards as breast surgery develops as a separate discipline from its parent specialties (general surgery, gynaecology, surgical oncology and plastic surgery). The curriculum is not static but will be revised and updated by the curriculum development group of the European Breast Surgical Oncology Certification group (BRESO) every 2 years.

Background Breast shape is defined utilizing mainly qualitative assessment (full, flat, ptotic) or estimates, such as volume or distances between reference points, that cannot describe it reliably. Objectives The authors quantitatively described breast shape with two parameters derived from a statistical methodology denominated by principal component analysis (PCA). Methods The authors created a heterogeneous dataset of breast shapes acquired with a commercial infrared 3-dimensional scanner on which PCA was performed. The authors plotted on a Cartesian plane the two highest values of PCA for each breast (principal components 1 and 2). Testing of the methodology on a preoperative and posttreatment surgical case and test-retest was performed by two operators. Results The first two principal components derived from PCA characterize the shape of the breast included in the dataset. The test-retest demonstrated that different operators obtain very similar values of PCA. The system is also able to identify major changes in the preoperative and posttreatment stages of a two-stage reconstruction. Even minor changes were correctly detected by the system. Conclusions This methodology can reliably describe the shape of a breast. An expert operator and a newly trained operator can reach similar results in a test/re-testing validation. Once developed and after further validation, this methodology could be employed as a good tool for outcome evaluation, auditing, and benchmarking. Level of Evidence: 4

The evolution of breast reconstructive surgery keeps pace with the evolution of breast oncologic surgery. The reconstructive choice should always balance the optimal local control of disease and the best cosmetic result, reflecting an informed decision that is shared with the patient, who is always at the center of the decision-making process. Implant-based breast reconstruction following mastectomy represents a complex choice. In order to obtain optimal results, the following considerations are mandatory: thorough preoperative planning, a complete knowledge of the devices that are used, accurately performed surgery, and appropriate follow-up.

Background: Many techniques have been described for mastopexy, with several types of skin incisions and parenchymal rearrangements. We present a parenchymal rearrangement technique allowing better upper pole fullness and nipple-areola-complex (NAC) projection when performing a mastopexy, with a combination of a superior pedicle for the NAC and an inferiorly-based parenchymal flap, the so-called “autoprosthesis”. Methods: From January 2008 to June 2015, 184 patients underwent “autoprosthesis” mastopexy. Patients’ mean ages was 42 years. The mean follow-up period was 39 months. Results: We reported no major complications. All the patients were satisfied with their post-operative unclothed and clothed appearance and overall body image as reported by our questionnaire. Conclusions: The autoprosthesis technique for mastopexy is a simple and safe, technique, allowing longlasting results for breast projection and upper pole fullness.

This abstract was withdrawn by the authors.

Supplemental Digital Content is available in the text., Background: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). Methods: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 “key questions” that were used for the Survey. The authors prepared a set of 10 “key statements” that have been discussed in a dedicated face-to-face session during the meeting. Results: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. Conclusions: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Patients undergoing mastectomy for breast cancer have nowadays many options for breast reconstruction, that will help in re-establishing patient's self confidence in her own body image. Implant-based reconstruction remains the most common form of post-mastectomy reconstruction, but it could also present some complications, the most common being capsular contracture. Accordingly, a novel breast mound may be perfectly designed using the reverse engineering approach and additive manufacturing methods combined with autologous fat grafting. A 3D hierarchical structure with autologous adipose-derived stem cells may be used as a construct for tissue regeneration. The 3D morphologically controlled scaffold may be placed in the subcutaneous position at the level of the conservative mastectomy side. The scaffold will be colonized with autologous fat tissue in some sessions. The biodegradable customized structure will help to maintain the breast shape and the natural consistency may be obtained with the fat grafting, also considering adequate enhancement techniques (Stromal Vascular Fraction derived growth factors). The principles of regenerative medicine may be combined and integrated with those of reverse engineering (3D image capture, 3D modelling and rapid prototyping) to design custom-made and high functional hierarchical structures with tailored properties and 3D complex geometry. The current study will focus on the basic principles and strategies in designing 3D advanced and complex structures for breast repair and regeneration.

Ductal carcinoma in situ (DCIS) has been the subject of much controversy since the advent of population based breast screening programs. An increasing number of asymptomatic women are being diagnosed with this condition and there is uncertainty over the best treatment algorithm for this condition if treatment is to be considered at all. Different subtypes of DCIS show innate differences in developmental pathways and biological behavior. This is not only determined by pathological subtypes but there is increasing understanding of molecular biomarkers related to DCIS progression. The ultimate management aim is to identify a subgroup of patients in whom DCIS will not progress to invasive disease such that they can avoid morbidity from surgical and adjuvant therapies. This has to be balanced by the potential risk of undertreatment of patients in whom DCIS is likely to progress to invasive cancer and hence a reduced life expectancy. Results of current ongoing prospective randomized trials assessing the safety of omitting surgery for what is considered to be low risk DCIS are eagerly awaited for by patients and clinicians. However the definition of what is considered to be "low risk" DCIS is still to be ascertained.