PURPOSE: The nodal burden of patients with residual isolated tumor cells (ITCs) in the sentinel lymph nodes (SLNs) after neoadjuvant chemotherapy (NAC) (ypN0i+) is unknown, and axillary management is not standardized. We investigated rates of additional positive lymph nodes (LNs) at axillary lymph node dissection (ALND) and oncologic outcomes in patients with ypN0i+ treated with and without ALND. METHODS: The Oncoplastic Breast Consortium-05/ICARO cohort study (ClinicalTrials.gov identifier: NCT06464341 ) retrospectively analyzed data from patients with stage I to III breast cancer with ITCs in SLNs after NAC from 62 centers in 18 countries. The primary end point was the 3-year rate of any axillary recurrence. The rate of any invasive recurrence was the secondary end point. RESULTS: In total, 583 patients were included, of whom 182 (31%) had completion ALND and 401 (69%) did not. The median age was 48 years. Most patients (74%) were clinically node-positive at diagnosis and 41% had hormone receptor–positive/human epidermal growth factor receptor 2–negative tumors. The mean number of SLNs with ITCs was 1.2. Patients treated with ALND were more likely to present with cN2/3 disease (17% v 7%, P < .001), have ITCs detected on frozen section (62% v 8%, P < .001), have lymphovascular invasion (38% v 24%, P < .001), and receive adjuvant chest wall (89% v 78%, P = .024) and nodal radiation (82% v 75%, P = .038). Additional positive nodes were found at ALND in 30% of patients, but only 5% had macrometastases. The 3-year rates of any axillary and any invasive recurrence were 2% (95% CI, 0.95 to 3.6) and 11% (95% CI, 8 to 14), respectively, with no statistical difference by type of axillary surgery. CONCLUSION: The nodal burden in patients with ypN0(i+) was low, and axillary recurrence after ALND omission was rare in patients selected for this approach. These results do not support routine ALND in all patients with ypN0(i+).

Background: Breast-conserving surgery (BCS) still remains a blind surgery despite all available tumor localization methods. Intraoperative ultrasound (IOUS) allows real-time visualization during all resection phases. Methods: This was a prospective observational cohort study conducted at the Veneto Institute of Oncology between January 2021 and June 2022. Patients with ductal carcinoma in situ, T1-2 invasive cancer, or post-neoadjuvant tumors, suitable for BCS, were recruited. All breast cancer lesion types were included, i.e. solid palpable, solid non-palpable, non-solid non-palpable, and post-neoadjuvant treatment residual lesions. Eligible participants were randomly assigned to either IOUS or traditional surgery (TS) in a 1:1 ratio. The main outcomes were surgical margin involvement, reoperation rate, closest margin width, main specimen and cavity shaving margin volumes, excess healthy tissue removal, and calculated resection ratio (CRR). Results: Overall, 160 patients were enrolled: 80 patients were allocated to the TS group and 80 to the IOUS group. IOUS significantly reduced specimen volumes (16.8 cm ³ [10.5–28.9] vs. 24.3 cm ³ [15.0–41.3]; p = 0.015), with wider closest resection margin width (2.0 mm [1.0–4.0] vs. 1.0 mm [0.5–2.0] after TS; p < 0.001). Tumor volume to specimen volume ratio was significantly higher after IOUS (4.7% [2.5–9.1] vs. 2.9% [0.8–5.2]; p < 0.001). IOUS yielded significantly better CRR (84.5% [46–120.8] vs. 114% [81.8–193.2] after TS; p < 0.001), lower involved margin rate (2.5 vs. 15%; p = 0.009) and reduced re-excision rate (2.5 vs. 12.5%; p = 0.032). Conclusions: IOUS allows real-time resection margin visualization and continuous control during BCS. It showed clear superiority over TS in both oncological and surgical outcomes for all breast cancer lesion types. These results disfavor the paradigm of blind breast surgery.

Intraoperative ultrasound-guided breast-conserving surgery guarantees real-time direct visualization of tumor and resection margins. We compared surgical, oncologic, and cosmetic outcomes between intraoperative ultrasound-guided breast-conserving surgery and traditional (palpation- or wire-guided) surgery across all breast cancer lesion types. This prospective observational cohort study was conducted at the Veneto Institute of Oncology between January 2021 and October 2022. Patients with ductal carcinoma in situ, T1-2 invasive breast cancer, or post-neoadjuvant residual lesions, who were suitable for breast-conserving surgery were enrolled. A novel classification system categorized all breast cancer lesion types: solid palpable (type A); solid non-palpable (B); non-solid non-palpable (C); and post-neoadjuvant residual lesions (D). Main outcomes included involved margin rates, excision volumes, and cosmetic satisfaction. In total, 206 patients were enrolled, with 103 receiving traditional (palpation- or wire-guided) surgery and 103 undergoing intraoperative ultrasound-guided breast-conserving surgery. Despite similar tumor volumes, intraoperative ultrasound-guided breast-conserving surgery resulted in significantly smaller excised volumes (P = .024), greater tumor volume to specimen volume ratios (P = .002), and lower involved margin and reoperation rates (P = .002 and P = .01, respectively), in addition to a wider closest margin width (P < .001). Stratified analyses demonstrated superior performance of intraoperative ultrasound-guided breast-conserving surgery across all breast cancer lesion types, with notable improvements observed in the most challenging ones (types C and D). One-year follow-up assessments revealed significantly greater patient satisfaction levels after intraoperative ultrasound-guided breast-conserving surgery (P < .001), with specimen volume identified as the sole significant predictor of cosmetic satisfaction (P = .001). Intraoperative ultrasound-guided breast-conserving surgery showed clear superiority over traditional (palpation- or wire-guided) surgery in oncologic, surgical, and cosmetic outcomes, as demonstrated by a comprehensive stratified analysis encompassing all breast cancer lesion types. Intraoperative ultrasound-guided breast-conserving surgery represents the latest and most effective paradigm for precision breast-conserving surgery.

Background: Intraoperative ultrasound-guided breast-conserving surgery (IOUS) combined with chest wall perforator flaps (CWPFs) is a promising approach to avoid mastectomy, especially for patients with high anticipated resection-to-breast volume ratios (ARR) who would otherwise be ineligible for breast conservation. Methods: This study prospectively analyzed surgical, oncologic, and cosmetic outcomes for consecutive patients with stages 0 to III breast cancer who underwent IOUS with CWPF-based partial breast reconstruction at a single institution between 2022 and 2024. Results: The study enrolled 73 female patients. The median age was 57 years, and the median tumor size was 32 mm, with 43.8% of lesions being multifocal/multicentric. The median ARR was 30.2%. The flap types included lateral intercostal artery perforator (LiCAP, 53.4%), anterior intercostal artery perforator (AICAP, 8.2%), medial intercostal artery perforator (MICAP, 19.2%), lateral thoracic artery perforator (LTAP, 16.4%), and thoracodorsal artery perforator (TDAP, 2.7%). The median flap volume was 90 cm³ (interquartile range [IQR], 47–140.5 cm), corresponding to 127% of the median specimens’ volume (71.1 cm³). The median operation time was 112 min. The 30-day global complication rate was 16.4%. No flap losses occurred. The positive margin rate was 9.6%, requiring re-excisions (5.5%) and mastectomies (4.1%). Adjuvant radiotherapy was administered to 95.9% of the patients, with no flap-related complications. During a median follow-up period of 14 months, only one distant recurrence was experienced, and no deaths occurred. Both patient- and surgeon-assessed evaluations demonstrated excellent cosmetic outcomes. Lower scores were associated with postoperative complications, re-excisions, and horizontal scars. None of the patients would have preferred mastectomy, and 89% underwent CWPF-based surgery to avoid it. Conclusions: The combination of IOUS and CWPFs yielded favorable surgical, cosmetic, and short-term oncologic outcome. This approach effectively and safely expands the indications for breast conservation, avoiding mastectomies, particularly for patients with small-to-medium breasts and an unfavorable ARR.

Background/Objectives: Male breast cancer (MBC) is a rare malignancy with a globally rising incidence. Due to the paucity of specific evidence, therapeutic strategies are often extrapolated from female breast cancer guidelines. The quality of life (QoL) among MBC patients remains underexplored. Methods: This single-institution retrospective study analyzed male patients who underwent surgery for newly diagnosed breast cancer at our institution from 1998 to 2020. The primary aim was to assess QoL after surgical and medical treatments using a newly developed 12-item dedicated questionnaire. Clinicopathological features were recorded, and oncological and survival outcomes were evaluated, with a specific focus on identifying factors influencing QoL. Results: A total of 109 consecutive MBC patients who underwent surgery were included, with 96.3% undergoing total mastectomy. The median global QoL score was 28.5 out of 36, where scores above 24 indicated a low impact of BC treatments on QoL. Multivariate analyses identified adjuvant chemotherapy (p < 0.001) and postoperative complications (p < 0.001) as significant predictors of poorer QoL. Patients reported significantly lower scores on medical treatment-related items compared to surgery-related items (p < 0.001). The 10-year overall survival rate was 79.1%, with a 10-year BC-specific mortality of 3.5%. Advanced age, higher stage disease, and receiving adjuvant chemotherapy were independently associated with poorer overall survival. Conclusions: Despite elevated mastectomy rates, MBC patients self-reported high levels of satisfaction with their treatment outcomes. Medical therapies showed a more pronounced negative impact on QoL than surgery. These findings provide novel insights into the QoL of MBC patients, highlighting the need for future prospective studies and tailored treatments.

Pure pleomorphic (PLCIS) and florid (FLCIS) lobular carcinoma in situ, without concurrent invasive carcinoma (IC) or ductal carcinoma in situ (DCIS), are rare. We collected the largest and most comprehensive single-institution cohort to analyze oncological outcomes and management strategies. Consecutive patients diagnosed with pure PLCIS and/or FLCIS and treated at our institution between 2012 and 2021 were identified. Clinical, radiological, and pathological characteristics, along with recurrence risk, were analyzed. A total of 303 patients were diagnosed with PLCIS and/or FLCIS on surgical specimens. Among them, 144 PLCIS and 116 FLCIS cases were associated with IC or DCIS, leaving 43 (14.2 %) pure P-/FLCIS cases (20 PLCIS, 17 FLCIS, and six mixed cases). Pure P-/FLCIS diagnosed on core-biopsy had a 31.3 % upgrade ratio on surgical specimens to IC (86.7 %) or DCIS (13.3 %). Median lesion size was 15 mm. Mastectomy was performed in four cases, while 90.7 % underwent wide local excision, with 14 % positive margin rate. Sentinel lymph node biopsy was performed in four cases, with no positive nodes. No adjuvant treatment was administered, as per multidisciplinary decision. After a median follow-up of 53 months, local recurrence (LR) occurred in 14 % of cases. Margin involvement strongly predicted LR, which was higher in patients with final positive margins (5/6, 83.3 % vs. 0/31, 0 % in patients with clear margins, p < 0.001). The 31.3 % upgrade ratio from pure P-/FLCIS to IC/DCIS recommends surgical excision. Axillary surgery should be omitted. Positive margins are strongly associated with LR. Surgery with negative margins is the mainstay of treatment. Larger multicentric studies are needed.