Delayed nipple-sparing modified subcutaneous mastectomy: Rationale and technique

The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective

Cystic Echinococcosis of the Breast - Diagnostic Dilemma or just a Rare Primary Localization

Introduction: Although the liver and lung are the most frequently affected organs in cystic echinococcosis, the cysts may develop in any viscera and tissues. Breast is a rare primary localization with few cases described in the literature. We present an updated and systematic review and discuss the possible mechanisms of spreading, diagnostic and treatment options.Materials and methods: We performed a literature search in PUBMED using the key words ‘hydatid disease’, ‘cystic echinococcosis’ and ‘breast echinococcosis’ without time limitation. Only studies reporting breast cystic echinococcosis were included.Results: Overall, 121 cases with cystic echinococcosis and 2 with alveolar echinococcosis were reported. A total of 52 cases were included in the analysis. The mean size of cysts was 5.5 cm (range 1.7-12). The most common clinical presentation was painless lump presented from 4 months to 19 years before the final diagnosis. Most cases had isolated breast CE, few cases had synchronous localizations – femoral, thigh and lung, and previous liver CE. Most were active CL and CE1-2 cysts (72%). Ultrasound was used in 83%, followed by mammography (35%). Fine needle aspiration was reported in 27 cases with positive finding in 59%.Conclusions: In cases with cystic breast lesions from endemic regions we recommend the US as a gold standard. CT and MRT are more accurate but expensive tools without the potential to change the surgical tactic. In contrast to the other localizations of CE, complete excision of the cysts is the best diagnostic and treatment approach

SPECT-CT in breast cancer

The most important prognostic factors for breast cancer are the size of primary tumor and axillary lymph node status. Role of scintimammography with the cationic lipophilic 99mTc-Tetrofosmin and 99mTc-Sestamibi in preoperative evaluation and post-treatment follow-up of patients with breast cancer is well known. The added diagnostic value of SPECT-CT has recently been investigated. Scintigraphy provides a description of function or process whereas CT depicts the precise localization and type of morphological changes that have occurred in the lesions. Combined SPECT-CT imaging enables to localize positive primary tumors and/or loco-regional lymph nodes; to evaluate effect of neoadjuvant chemotherapy in locally advanced and non-operable breast tumors. SPECT-CT studies are useful in post-therapeutic follow-up of patients to visualize suspicious local recurrence, lymphadenopathy and disease extension. CT part of the study can increase the specificity of SPECT by more accurate anatomical assessment of the sites of abnormal activity with unclear character such as radiation pulmonitis, postoperative parenchymal changes, fibrocystic changes etc. According to the results reported in literature, all the axillary metastatic nodes that were false negative on SPECT image were non-palpable, small lesion size (<10 mm) with partial metastatic involvement or micrometastases in most cases. Lymphatic mapping of SLNs is now routinely done in breast cancer patients for correct N-staging. SPECT-CT has been used for clear depiction of the SLNs to provide the useful information for intraoperative gamma-probe detection in cases that are difficult to interpret planar images, in cases with unusual drainage or in cases of nonvisualization. SPECT-CT scintimammogarphy is preferable in terms of physical characteristic, execution time and cost-effectiveness, thus suggesting wider application of this procedure. SPECT-CT is a potential new tool for LN localization and radioguided surgery in the coming years