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Breast cancer (BC) metastasis accounts for the majority of deaths from BC. The rate of metastasis to uncommon sites is on the rise due to the more effective therapy prolonging survival and to the early detection on imaging. The evaluation of patient-reported symptoms is essential in detecting a recurrence as early as possible, which may impact survival. Hence, the knowledge of even the rare sites of BC metastasis is of paramount importance for the clinical interpretation of new symptoms in BC survivors. The term “unusual metastasis” defines a systemic failure with a frequency of ≤1% at each site and according to this unusual metastasis involve the central nervous system, secretory/endocrine organs and glands, internal organs and structures, and gynecological organs. The literature search was performed using the electronic database PubMed up to December 2018, with the following key words: {[rare(Title/Abstract)] OR [ unusual (Title/Abstract)] OR [ unconventional (Title/Abstract)]} AND {[ metastases (Title/Abstract)] OR [ metastasis (Title/Abstract)]} AND {[ breast (Title/Abstract)]} AND {[ cancer (Title/Abstract)] OR [ tumor (Title/Abstract)] OR [ tumour (Title/Abstract)] OR [neoplasm(Title/Abstract)]}. The search was limited to papers in English language. Of the 3,086 papers found, 757 were excluded as reporting animal models, 378 were not in English language, 1 was a duplicate of the same research, 1,414 did not report on BC metastases, 108 were previous review reviews on BC or tumour to tumour metastases; 428 papers were included in this review. Despite the improvements in BC management, most deaths from cancer result from metastases that are resistant to conventional therapies. In general, it is uncommon to find isolated rare metastases, the vast majority of these develops together with metastases in other sites, thus highlighting a worsening systemic disease. However, the early detection of even rare metastases represents the only chance to control the disease and prolong survival while waiting for the development of more effective systemic therapies.

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Women carrying a BRCA mutation have an increased risk of developing breast and ovarian cancer. The most effective strategy to reduce this risk is the bilateral salpingo-oophorectomy, with or without additional risk-reducing mastectomy. Risk-reducing bilateral salpingo-oophorectomy (RRBSO) is recommended between age 35 and 40 and between age 40 and 45 years for women carriers of BRCA1 and BRCA2 mutations, respectively. Consequently, most BRCA mutation carriers undergo this procedure prior to a natural menopause and develop an anticipated lack of hormones. This condition has a detrimental impact on various systems, affecting both the quality of life and longevity; in particular, women carrying BRCA1 mutation, who are likely to have surgery earlier as compared to BRCA2. Hormonal replacement therapy (HRT) is the only effective strategy able to significantly compensate the hormonal deprivation and counteract menopausal symptoms, both in spontaneous and surgical menopause. Although recent evidence suggests that HRT does not diminish the protective effect of RRBSO in BRCA mutation carriers, concerns regarding the safety of estrogen and progesterone intake reduce the use in this setting. Furthermore, there is strong data demonstrating that the use of estrogen alone after RRBSO does not increase the risk of breast cancer among women with a BRCA1 mutation. The additional progesterone intake, mandatory for the protection of the endometrium during HRT, warrants further studies. However, when hysterectomy is performed at the time of RRBSO, the indication of progesterone addition decays and consequently its potential effect on breast cancer risk. Similarly, in patients conserving the uterus but undergoing risk-reducing mastectomy, the addition of progesterone should not raise significant concerns for breast cancer risk anymore. Therefore, BRCA mutation carriers require careful counselling about the scenarios following their RRBSO, menopausal symptoms or the fear associated with HRT use.

The utilization of delayed hypersensitivity response (DHR) for the identification of high-risk patients with regard to postoperative septic complications is still discussed. The aim of this study was to clarify how much DHR may improve the prognostic capacity of nutritional assessment (NA). Nutritional and immunological evaluations were performed at admission on 405 patients undergoing elective general surgical procedures. Subjects with serum albumin less than or equal to 3.0 g/dl or total iron-binding capacity less than or equal to 220 micrograms/dl or weight loss greater than or equal to 10% with respect to usual body weight were classified as malnourished. DHR was assessed by performing skin tests with four recall antigens: PPD, candida, trichophyton, sk-sd. The incidence of postoperative complications resulted higher among the 187 malnourished patients (31.0%) than in the 218 well-nourished ones (14.2%) (p less than 0.001), and among the 213 anergic patients (29.6%) than in the 192 normal responders (13.5%) (p less than 0.001). To determine how much skin tests may improve the prognostic ability of NA, the relationship between DHR and postoperative complications was also studied in the malnourished and in the well-nourished patients, separately. In the malnourished group, the patients with an impairment of DHR had a higher incidence of postoperative infections than normal responders (p less than 0.05). In the well-nourished group, no significant differences were found between anergic patients and normal responders. In our study, DHR slightly improved the prognostic capacity of NA. Therefore, the first approach to identify the high-risk patients seems to be the unexpensive, quick and available determination of nutritional status.

In a retrospective study postoperative septic complications were evaluated in 140 insulin-dependent diabetic patients who underwent surgery. The data collected were matched with those of a group of non-diabetic patients, homogeneous for sex, age, and type of surgical procedure. Patients of each group were further divided into 3 subgroups according to the risk of intraoperative contamination (clean-, clean-contaminated, and contaminated procedures). Diabetic patients had a significantly (p less than 0.01) higher rate of septic complications in clean- and clean-contaminated procedures particularly of wound infections. Our experience suggests that diabetes represents an important risk factor.

Corrigendum to "Sentinel node biopsy after primary systemic therapy in node positive breast cancer patients: Time trend, imaging staging power and nodal downstaging according to molecular subtype" [Eur. J. Surg. Oncol. 45, (6) (2019) 969e975]

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