title: Value of an intraoperative real time tissue perfusion assessment system following a nipple-sparing radical mastectomy for advanced breast cancer.
abstract: BACKGROUND
  Standard surgical approach for advanced breast cancer is a modified radical mastectomy with a periareolar elliptical incision. Here a unique surgical approach is presented utilizing intraoperative real time tissue perfusion technology.
  
  
  METHODS
  A 65-year old African American female was diagnosed with grade 3 papillary carcinoma on biopsy of a palpable 3.7cm left breast mass at 12 o'clock position. Pathology showed a T2N0M0 invasive ductal carcinoma, triple negative disease, with clear margins. Patient opted for naturopathic treatment. Six months later, cancer recurred at the local site; the patient persisted with natural remedies. Nine months later, the mass had progressed to 14.5cm with smaller adjacent nodules and nodular thickening of breast with no metastatic disease. Patient received neoadjuvant chemoradiation. Ten months later, patient underwent a nipple-sparing radical mastectomy given the persistent pectoral muscle involvement of this mass.
  
  
  CONCLUSIONS
  An elliptical incision was made in the superior aspect of the breast wall at least 6cm above the areola. After tumor removal, the skin edges were approximated. It was decided preoperatively to use the SPY Elite™ system to assess perfusion of the flap edges. Angiography with indocyanine green showed poor perfusion of the inferior flap and an additional 2cm of skin was resected. Final pathology showed that all margins were clear of disease and patient recovered well from surgery.
  
  
  CONCLUSIONS
  This case study shows that an individualized approach resulted in an optimal outcome for the patient. The infrequent procedure of a nipple-sparing radical mastectomy was done in coordination with SPY Elite™ to achieve good wound healing.
authors.affiliation: Cancer Treatment Centers of America(®) (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Avenue, Zion, IL 60099, USA. Electronic address: Brenten.popiel@ctca-hope.com.
authors.forename: Brenten
authors.initials: B
authors.lastname: Popiel
authors.affiliation: Cancer Treatment Centers of America(®) (CTCA) at Midwestern Regional Medical Center, 2520 Elisha Avenue, Zion, IL 60099, USA. Electronic address: Digant.gupta@ctca-hope.com.
authors.forename: Digant
authors.initials: D
authors.lastname: Gupta
authors.affiliation: Texas Tech University Health Sciences Center School of Medicine at Amarillo, 1400 S. Coulter, Amarillo, TX 79106, USA. Electronic address: Subhasis.misra@ttuhsc.edu.
authors.forename: Subhasis
authors.initials: S
authors.lastname: Misra
keywords: Breast cancer; Elliptical incision; Indocyanine green; Intraoperative real time tissue perfusion technology; Nipple-sparing radical mastectomy