Oncoplastic breast surgery with oxidized regenerated cellulose: appraisals based on five-year experience.

We have read with great interest the article by\r\nTanaka et al. reporting improved cosmetic outcomes\r\nafter breast conserving surgery with the use of oxidized\r\nregenerated cellulose (ORC) (1) in 94 breast\r\ncancer patients treated at the Osaka Medical College\r\nHospital (Osaka, Japan). Evaluation of cosmetic outcomes,\r\nperformed by three staff surgeons at least\r\n2 months after surgery using the scoring system (0–12\r\npoints) of the Japanese Breast Cancer Society, documented\r\nvery positive results, with a mean score of 9.5\r\n(3–12 points) and 71 patients (75.5%) categorized as\r\n“Excellent” (≥11 points) or “Good” (8–10 points),\r\nand only one patient (1.1%) as “Poor” (≤4 points).\r\nWe have previously reported our 5-year experience\r\nwith the use of ORC at the Catholic Breast Unit of\r\nRome and agree with the Authors that the use of this\r\nbiomaterial can improve the cosmetic results (Fig. 1)\r\nin patients undergoing an oncoplastic procedures for\r\nbreast cancer (2).\r\nHowever, as ORC is being increasingly utilized in\r\nbreast conserving surgery (1–3), we think that it is\r\nimportant to properly inform the patients not only\r\nabout the potential cosmetic advantages but also\r\nabout possible postoperative complications of this\r\ntechnique. Tanaka et al. report a 18% rate of allergic\r\nreaction with the use of ORC, mainly presenting as\r\nacute dermatitis and eczema, and one case of exudation\r\nfollowed by wound dehiscence.\r\nIn our series, we noted a 10% rate of allergic skin\r\nreactions with irritation, redness, itching, swelling,\r\nrash, and hives in the mammary region, successfully\r\nmanaged with steroids and antihistamine medications.\r\nIn addition, we experienced a significant seroma in the\r\nsite of ORC placement in 45% of our patients. This\r\nseroma that appears in the early postoperative period\r\nas consequence of redundant ORC digestion, normally\r\nresolved within few weeks with repeated percutaneous\r\naspirations, but in two cases it was followed by the\r\nformation of an abscess in the residual cavity that\r\nrequired surgical drainage.\r\nMoreover, we think it is important to call the\r\nattention of radiologists on the peculiar findings that\r\nORC determines on postoperative ultrasound (US)\r\nexamination, that often lead to undue alarmism.\r\nIn our series, peculiar fluid anechoic accumulation\r\ncontaining small hyperechoic, round components were\r\ndocumented on breast US examination (performed\r\n6 months after surgery) in all cases. This typical round\r\nimage (that we named “ile-flottante”; Fig. 2), is consequence\r\nof the fibrogenetic action induced by ORC and\r\nof the partial reabsorption of this biomaterial. It\r\nappears non-mobile, avascular, and adherent to the\r\nparenchymal tissue planes and is often misinterpreted\r\nin an alarming way by the radiologists. The diagnostic\r\ninterpretations in our patients varied from possible\r\nresidual disease to hematoma sequele, local abscess, or\r\narea of fat necrosis.\r\nIn conclusion, when using ORC as a filler to optimize\r\nesthetic outcomes, it is important to discuss with\r\nthe patient also about possible postoperative complications\r\nand to acquire an exhaustive informed consent.\r\nIt is also important that surgeons specify clearly\r\nthe use of this biomaterial in the report of the surgical\r\nprocedure, so that radiologists can properly interpret\r\nthe sonographic findings due to this biomaterial and\r\navoid misdiagnosis, and undue alarmism during the\r\nfollow-up of these patients.