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Surgery for breast cancer has changed in the last few decades in favor of more conservative approaches, without compromising loco‐regional control and survival. Common immediate complications fol ‐lowing breast surgery are hematoma, seroma, and wound infection.1Traditionally, surgeons have implemented the use of closed‐suction drains in this setting with the aim of preventing these complications, which can cause discomfort, morbidity, increased follow‐up visits,and possible delay in the beginning of adjuvant therapies.2 On the other hand, potential benefits of performing breast procedures without using a drain have been increasingly considered.3 There is lack of modern and official guidelines on use of drains in breast sur ‐gery, with no consensus regarding their management and the appro‐priate use of antibiotics in this setting. Almost all reports agree withthe use of drains after breast procedures, especially if they are asso‐ciated with reconstruction or axillar lymph node dissection (ALND), but an extreme variability is reported regarding practice patterns.4A national survey regarding the management of drains afterbreast cancer surgery was sent by email on January 2018 to all Breast Centers (BC) registered with Senonetwork Italia. Data col ‐lected by the administrative office of Senonetwork were de‐iden‐tified and exported for statistical analysis. A Steering Committeecomposed of general surgeons and plastic surgeons was appointedto coordinate the survey, which consisted of 22 multiple choicequestions, designed to inquire about surgeons' demographics, use of drains after breast procedures with and without reconstructionand/or ALND, antibiotic use and to characterize drain managementin their clinical practice.

Available evidence on axillary surgery has accumulated dramatically in the last two decades in favor of less invasive care. The aim of this paper is to study 16-years trends in the surgical management of the axilla in a large population-based data set of screen-detected breast cancers in Italy and to document at what extent recommendations have been adopted in actual clinical care.This is a retrospective cohort study documenting the surgical management of the axilla in primary breast cancer patients over time. We retrieved from the Italian database of screen-detected cancers 41213 cases diagnosed in women aged 50-69 between years 2000 and 2015 in twelve Italian Regions.In pN0 cases, an increasing trend (p 0.001) in the number of patients who received sentinel lymph node biopsy (SLNB) as the only axillary staging procedure was observed. In pN + cases SLNB was the only staging procedure in an increasing number of patients (p 0.001) especially since the publication of the ACOSOG-Z0011 paper. In ductal carcinoma in situ (DCIS) SLNB was more frequent in mastectomies and in high grade and large lesions. However, 45% of low grade, small DCIS over the whole time period had some form of axillary surgery.This large series of screen-detected cases documents a strong time trend in the direction of reducing axillary surgery and hence potential harms from treatment. The continuing practice of SLNB in low risk DCIS is of concern in an era of increasing awareness towards overdiagnosis and overtreatment.

Women who were previously treated for breast cancer (BC) are an important particular subgroup of women at intermediate BC risk. Their breast follow-up should be planned taking in consideration a 1.0-1.5 % annual rate of loco-regional recurrences and new ipsilateral or contralateral BCs during 15-20 years, and be based on a regional/district invitation system. This activity should be carried out by a Department of Radiology integrating screening and diagnostics in the context of a Breast Unit. We recommend the adoption of protocols dedicated to women previously treated for BC, with a clear definition of responsibilities, methods for invitation, site(s) of visits, methods for clinical and radiological evaluation, follow-up duration, role and function of family doctors and specialists. These women will be invited to get a mammogram in dedicated sessions starting from the year after the end of treatment. The planned follow-up duration will be at least 10 years and will be defined on the basis of patient's age and preferences, taking into consideration organizational matters. Special agreements can be defined in the case of women who have their follow-up planned at other qualified centers. Dedicated screening sessions should include: evaluation of familial/personal history (if previously not done) for identifying high-risk conditions which could indicate a different screening strategy; immediate evaluation of mammograms by one or, when possible, two breast radiologists with possible addition of supplemental mammographic views, digital breast tomosynthesis, clinical breast examination, breast ultrasound; and prompt planning of possible further workup. Results of these screening sessions should be set apart from those of general female population screening and presented in dedicated reports. The following research issues are suggested: further risk stratification and effectiveness of follow-up protocols differentiated also for BC pathologic subtype and molecular classification, and evaluation of different models of survivorship care, also in terms of cost-effectiveness.

As reported in the scientific literature and mentioned in building energy performance legislation, the thermal inertia of the opaque building envelope can have a significant positive impact on the reduction of summer indoor overheating, of space cooling peak load and of electricity consumption. At the early stages of the envelope design, there is a need to use simplified as well as effective parameters to correctly characterize the thermal performance of the opaque envelope under dynamic conditions. In this work, a new methodology to describe the dynamic thermal behavior of opaque components is proposed. The approach is based on the harmonic parameters specified in ISO 13786 but it also takes into account realistic boundary conditions for different orientations and solar absorptance values. New equivalent thermal parameters are determined by means of dynamic simulations. The use of these parameters to assess the conduction heat flow rate by means of a simplified model is validated through a comparison with the results of a dynamic simulation. The method presented in the article represents an improvement with respect to the parameters usually applied at the early design stage to thermally characterize the opaque envelope of the building under dynamic conditions. In fact, it allows simplified but reliable performance parameters referring to actual boundary conditions to be obtained. The application potential of the proposed methodology lies in the drawing-up of catalogues and technical standards that supply the values of the new equivalent thermal parameters for different technical solutions.

Directive 2010/31/EU establishes that Member States must ensure that minimum energy performance requirements for buildings as well as for individual building elements are set with a view to achieve cost-optimal levels. The comparative methodology is here applied to two reference buildings; different energy efficiency measures are considered one at a time in order to find the optimality in terms of costs/benefits; results are then discussed. The definition of the individual building elements refurbishment cost/benefits effectiveness wants to address building administrations to define suitable energy requirements as well as economic incentives, as to promote the energy consumption reduction according to EU requirements.

The article presents the fundamental steps of building refurbishment toward the nZEB target; it is based on a detailed energy audit and on a financial analysis. The methodology starts from the set-up of a numerical model of the building, calibrated through actual data on operation, climate and energy consumption. Then, a cost-optimisation procedure is applied to identify the energy efficiency measures that determine the minimum global cost in 30 years lifetime. Finally, the measures are improved as to comply with the nZEB requirements and to be cost-effective as well. The methodology was applied to a high school in Torino.

A cross-country comparison of the RePublic_ZEB project results is presented. The paper reports on the energy efficiency measures and on the options considered for the refurbishment of the public buildings taken as representative of the building stock in the countries involved in the project. The nZEB solutions are compared in terms of adopted energy efficiency measures; moreover, the nZEBs are quantitatively defined through a set of energy, economic and environmental parameters. The paper aims at giving an overview on the meaning of nZEB in the European context, and on its energy and economic feasibility for real public existing buildings.

The European residential building stock is largely composed of buildings with poor energy performance, therefore basic retrofit actions could lead to significant energy savings. However, energy refurbishment measures should be identified in accurate way, taking into account the technical viability and aiming both to increase the building energy performance and to restrain the costs. The present article investigates the effects of different measures applied to the Italian residential building stock by using the building typology, which consists of 120 building types, representative of six construction ages, four building sizes and five climatic zones. A quasi-steady state model has been used to calculate the energy performance; the economic evaluation has been carried out as specified in the EU cost-optimal comparative methodology (Directive 2010/31/EU). The most effective measures and packages of measures, in terms of energy saving and global cost reduction, are identified and discussed. The results are addressed to important purposes for energy policy, as for instance: (a) to provide political authorities with the most effective energy efficiency measures as to encourage retrofit processes through the allocation of financial incentives, (b) to offer a knowledge-base for developing energy refurbishment scenarios of residential building stocks and forecasting future energy resource demand.

This position paper, issued by ICBR/SIRM and GISMa, summarizes the evidence on DBT and provides recommendations for its use. In the screening setting, DBT in adjunct to digital mammography (DM) increased detection rate by 0.5-2.7‰ and decreased false positives by 0.8-3.6% compared to DM alone in observational and double-testing experimental studies. The reduction in recall rate could be less prominent in those screening programs which already have low recall rates with DM. The increase in radiation exposure associated with DM/DBT protocols has been solved by the introduction of synthetic mammograms (sDM) reconstructed from DBT datasets. Thus, whenever possible, sDM/DBT should be preferred to DM/DBT. However, before introducing DBT as a routine screening tool for average-risk women, we should wait for the results of randomized controlled trials and for a statistically significant and clinically relevant reduction in the interval cancer rate, hopefully associated with a reduction in the advanced cancer rate. Otherwise, a potential for overdiagnosis and overtreatment cannot be excluded. Studies exploring this issue are ongoing. Screening of women at intermediate risk should follow the same recommendations, with particular protocols for women with previous BC history. In high-risk women, if mammography is performed as an adjunct to MRI or in the case of MRI contraindications, sDM/DBT protocols are suggested. Evidence exists in favor of DBT usage in women with clinical symptoms/signs and asymptomatic women with screen-detected findings recalled for work-up. The possibility to perform needle biopsy or localization under DBT guidance should be offered when DBT-only findings need characterization or surgery.

Directive 2010/31/EU establishes that Member States must ensure that minimum energy performance requirements for buildings are set with a view to achieve cost-optimal levels. The paper presents a methodology for identifying the cost-optimal levels for the Italian residential building stock, following the Guidelines accompanying the Commission Delegated Regulation No. 244/2012. The methodology is applied to a reference building of the IEE-TABULA project and considering different energy efficiency measures. The energy performance and the global cost calculations are performed according to UNI/TS 11300 and UNI EN 15459, respectively. A new cost optimisation procedure based on a sequential search-optimisation technique considering discrete options is applied.

The study presents some results of the on-going European Project, RePublic_ZEB, on the refurbishment of the public building stock towards nearly Zero Energy Building (nZEB). The work is focused on the application of the nZEB requirements to two existing public buildings representative of the 1960s in Northern Italy. Many packages of energy efficiency measures that comply with nZEB requirements are identified and evaluated. The aim is to promote energy efficient but also cost-effective solutions for the Italian building stock refurbishment. The results are presented in terms of «package of measures», energy consumption, global costs, actualized pay-back period and CO2 emission.

In the last decades, governments worldwide have promoted energy efficiency improvements in order to reduce the building energy consumptions and CO2 emissions. In many geographical contexts, the largest and most cost-effective energy saving potential is in the existing housing stock renovation. For this reason, many energy efficiency policies are focused on the energy refurbishment of the existing buildings. Though the energy consumption of buildings is supposed to decrease after a retrofit, several studies show that the energy performance does not increase as much as it would be expected and that a significant gap between the estimated and the real energy savings - called rebound effect - occurs. This deviation can partly depend on the model used for the energy performance evaluation, but changes in the occupants’ behavior after a thermal retrofit of an existing dwelling are also revealed. The present paper examines the influences of occupant behavior on the energy savings for some retrofitted Italian residential representative buildings. Some typical use patterns are defined according to statistics of the national census of population and dwellings and the expectations of the building occupants are specified before and after the retrofit. The main objective is to investigate the elasticity of the energy consumption in function of the occupancy parameters before and after the application of high energy efficiency improvements. The analysis is carried out by means of a simplified energy performance assessment model. The outcomes of this study consist in defining synthetic indicators for the quantitative assessment of the rebound effect.

In the preoperative setting of breast cancer, fine-needle aspiration biopsy (FNAB) guided by ultrasonography can be used to detect axillary lymph node metastases. The aim of the current study was to determine whether measurement in needle washouts of CYFRA 21-1, a soluble fragment of cytokeratin 19 (CK19), can improve the diagnosis of lymph node tumor deposits.Our prospective study included 329 breast cancer patients eligible for a sentinel node procedure. Eighty-two patients had a ultrasonography-guided FNAB of an abnormal or suspicious axillary node and were included in the current analysis. Samples were processed with smears and cell-block histology; afterwards, needles were washed with saline solution, and the CYFRA 21-1 content in the washouts was measured. The cutoff value for positive samples that expressed CK19, as shown by their immunohistochemistry, was determined by a receiver operating characteristic curve. On the basis of this value, the specificity and the sensitivity, as well as the positive and negative predictive values, were then calculated using cytology results as a reference standard.Of the 82 axillary lymph nodes sampled, 61 were positive on cytology and were metastatic for breast cancer, as confirmed by surgery. The median CYFRA 21-1 concentration of positive samples was 88.94 ng/mL, whereas in the 21 negative nodes, its median concentration was 1.02 ng/mL (P0.0001). A CYFRA 21-1 cutoff value of 1.98 ng/mL, obtained by the receiver operating characteristic curve, was able to clearly separate negative from positive samples and gave the test a sensitivity of 0.98 and a specificity of 1.00. Positive and negative predictive values were 1.00 and 0.95, respectively.The measurement of CYFRA 21-1 levels in needle washouts after axillary lymph node FNABs represents an accurate, sensitive, and highly predictive procedure in detecting metastatic deposits of breast cancer and is fit to complement cytology and CK19 immunohistochemistry as a diagnostic tool.

evaluation of a centralised collection of clinical data (Service) within cancer screening programmes in Piedmont based on a hubspoke model and its impact on process indicators.assessment of an organisational intervention, through a non-controlled pre-post design.organised screening programmes within the Piedmont Region, divided into 9 departments.clinical data (extracted from medical charts for mammography screening and from excision histology reports for cervical screening) obtained through the Service were quantified and their completeness was assessed. The Service impact on the detection rate (DR) was evaluated, comparing the DR pre- (2005-2008) and post-Service (2009- 2012) within breast screening; the DR was computed through histological diagnosis made during colposcopy (pre-Service method) or through the worst diagnosis between the latter and that reported from excision histology (post-Service method) within cervical screening (data available for department 1, year 2013). Some hints on human resources employed in pre- and post-Service periods were reported.within mammography screening, the Service obtained 53.1% of extra-department medical charts and 45.8% of extra-region ones; the percentage of missing diagnoses changed from 5.5% (pre- Service) to 3.7% (post-Service). The age standardised DR for malignant tumours in the post-Service period is 1.3 times the DR of the pre-Service period per 1,000 screening tests. Within cervical screening, 51.7% of histological reports was recorded. Crude DR for high-grade lesions changed from 3.9 (pre-Service) to 4.7 (post-Service) per 1,000 screened women. The system centralisation did not imply an increase in the dedicated personnel.the Service is an operational core which coordinates the collection of clinical data, impacting on process indicators without an increase in human resources at departmental level.

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Aims and BackgroundThe DIANA (Diet and Androgens)-5 study is a multi-institutional randomized controlled trial of the effectiveness of a diet based on Mediterranean and macrobiotic recipes and principles, associated with moderate physical activity, in reducing additional breast cancer events in women with early stage invasive breast cancer at high risk of recurrence because of metabolic or endocrine milieu. The intervention is expected to reduce serum insulin and sex hormones, which were associated with breast prognosis in previous studies.MethodsBetween 2008 and 2010, the study randomly assigned 1208 patients to an intensive diet and exercise intervention or to a comparison group, to be followed-up through 2015. General lifestyle recommendations for the prevention of cancer are given to both groups, and the intervention group is being offered a comprehensive lifestyle intervention, including cooking classes, conferences, common meals and exercise sessions. Adherence assessments occurred at baseline and at 12 months and are planned at 36 and 60 months. They include food frequency diaries, anthropometric measures, body fat distribution assessed with impedance scale, one week registration of physical activity with a multisensor arm-band monitor, metabolic and endocrine blood parameters. Outcome breast cancer events are assessed through self report at semi annual meetings or telephone interview and are validated through medical record verification.ResultsThe randomized groups were comparable for age (51.8 years), proportion of ER-negative tumors (22%), axillary node metastasis (42%), reproductive variables, tobacco smoking, blood pressure, anthropometric measurements and hormonal and metabolic parameters.ConclusionsDIANA-5 has the potential to establish whether a Mediterranean-macrobiotic lifestyle may reduce breast cancer recurrences. We will assess evidence of effectiveness, first by comparing the incidence of additional breast cancer events (local or distant recurrence, second ipsilateral or contralateral cancer) in the intervention and in the control group, by an intention-to-treat analysis, and second by analyzing the incidence of breast cancer events in the total study population by compliance assessment score.