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

We have read with great interest the article by Tanaka et al. reporting improved cosmetic outcomes after breast conserving surgery with the use of oxidized regenerated cellulose (ORC) (1) in 94 breast cancer patients treated at the Osaka Medical College Hospital (Osaka, Japan). Evaluation of cosmetic outcomes, performed by three staff surgeons at least 2 months after surgery using the scoring system (0–12 points) of the Japanese Breast Cancer Society, documented very positive results, with a mean score of 9.5 (3–12 points) and 71 patients (75.5%) categorized as “Excellent” (≥11 points) or “Good” (8–10 points), and only one patient (1.1%) as “Poor” (≤4 points). We have previously reported our 5-year experience with the use of ORC at the Catholic Breast Unit of Rome and agree with the Authors that the use of this biomaterial can improve the cosmetic results (Fig. 1) in patients undergoing an oncoplastic procedures for breast cancer (2). However, as ORC is being increasingly utilized in breast conserving surgery (1–3), we think that it is important to properly inform the patients not only about the potential cosmetic advantages but also about possible postoperative complications of this technique. Tanaka et al. report a 18% rate of allergic reaction with the use of ORC, mainly presenting as acute dermatitis and eczema, and one case of exudation followed by wound dehiscence. In our series, we noted a 10% rate of allergic skin reactions with irritation, redness, itching, swelling, rash, and hives in the mammary region, successfully managed with steroids and antihistamine medications. In addition, we experienced a significant seroma in the site of ORC placement in 45% of our patients. This seroma that appears in the early postoperative period as consequence of redundant ORC digestion, normally resolved within few weeks with repeated percutaneous aspirations, but in two cases it was followed by the formation of an abscess in the residual cavity that required surgical drainage. Moreover, we think it is important to call the attention of radiologists on the peculiar findings that ORC determines on postoperative ultrasound (US) examination, that often lead to undue alarmism. In our series, peculiar fluid anechoic accumulation containing small hyperechoic, round components were documented on breast US examination (performed 6 months after surgery) in all cases. This typical round image (that we named “ile-flottante”; Fig. 2), is consequence of the fibrogenetic action induced by ORC and of the partial reabsorption of this biomaterial. It appears non-mobile, avascular, and adherent to the parenchymal tissue planes and is often misinterpreted in an alarming way by the radiologists. The diagnostic interpretations in our patients varied from possible residual disease to hematoma sequele, local abscess, or area of fat necrosis. In conclusion, when using ORC as a filler to optimize esthetic outcomes, it is important to discuss with the patient also about possible postoperative complications and to acquire an exhaustive informed consent. It is also important that surgeons specify clearly the use of this biomaterial in the report of the surgical procedure, so that radiologists can properly interpret the sonographic findings due to this biomaterial and avoid misdiagnosis, and undue alarmism during the follow-up of these patients.