Abstract: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. Key Words: delayed nipple-sparing modified subcutaneous mastectomy, mastectomy, nipple-areola complex preservation T he inheritable breast cancer recently detectable by evidence of the BRCA-1 / BRCA-2 gene mutation, lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ are currently faced on a preventive basis with selective screening and follow-up, chemoprevention, and /or prophylactic mastectomy (1-4). The surgical options of simple mastectomy and subcutaneous mastectomythe former excising the nipple-areola complex (NAC) together with the gland, the latter leaving intact the NACprovides 95 -99% and 90 -95% breast tissue removal, respectively, and thus being inadequate as to oncologic radicality (5). Therefore when risk of breast cancer is high, total mastectomy is the golden standard.A 13% increase (from 81% to 94%) of total mastectomies in cohorts of women with a family history of breast malignancy has been observed since 1995, followed by an high rate of reconstruction. Metcalfe et al. (6) report breast restoration in 60% of these patients, compared with 6 -13% of nonprophylactic mastectomies.Our study addresses the hypothesis of a new radical approach to subcutaneous mastectomy while retaining the integrity of the NAC, without leaving any gland stalk or parenchyma underneath, and thus obtaining complete clearance of the breast tissue. Primary reconstruction with subpectoralis prosthesis or two-stage replacement with an expander are the surgical options to complete the procedure in order to achieve satisfactory cosmetic results. This procedure addresses both cancer prophylaxis and stage I cancer treatment.

The aim of this study was to investigate the clinical and morphological aspects of drug diffusion and efficacy after perioperative locoregional application of mitoxantrone in patients with early breast cancer. Mitoxantrone was injected at a dose of 0.5 ml (1.0 mg) in two sites around the tumor in 37 patients. Intraoperative inspection of mitoxantrone diffusion in breast and axillary tissues was carried out by blue color of the chemotherapeutic drug. Investigations of reactive morphological changes in axillary nodes were determined intraoperatively by blue stained lymph capillaries identified 2-4 cm laterally from the application sites and in 30 patients a mean of 1.5 stained axillary nodes was found. The light microscopy in the metastatic blue lymph nodes showed circulatory changes, dilatation of marginal sinus and inflammatory alterations. It was concluded that lymphotropic locoregional application of mitoxantrone results in diffusion of the drug in the regional lymph drainage and in cytotoxic effects on axillary nodes.

Touch imprint cytology is a simple and quick method of intraoperative screening of SLNs for the presence of metastases in patients with breast cancer. Results may be improved by an appropriate enlargement of the surface sampled and the use of rapid CK-IHC on the touch preparations.

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

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