Comment on: Off-the-shelf volume replacement in breast-conserving surgery: oxidized regenerated cellulose for upper inner quadrant defects.

Dear Editor,

Celene W Q Ng and colleagues report that oxidized regenerated cellulose (ORC) could be used as effective filler in breast conserving surgery (BCS) to improve aesthetic results¹.

However, the possible problems related to the use of ORC should also be carefully underlined in order to optimize the outcomes in clinical practice.

ORC, like other biomaterials, can cause allergic skin reactions, seromas and foreign-body reactions with the risk of extrusion due to its inadequate and suboptimal absorption; a high rate of red syndrome with eczema and acute dermatitis, significant postoperative seromas and some cases of foreign body reaction, requiring surgical removal, have been reported in the literature; these surgical complications could compromise clinical outcomes and lead to delayed oncological treatments with a consequent negative impact on patient survival, quality of life and overall hospital costs.

In addition, ORC-induced fibrogenetic reaction can determine a granulomatous reaction that may simulate an abscess, hematoma, fat necrosis or also cancer recurrence, creating a difficult challenge in differential diagnosis and sometimes diagnostic mistakes during follow-up.

Compliance with standardized recommendations is essential to prevent the aforementioned problems: appropriate selection of candidates to BCS with ORC; skin incision performed away from cancer site to minimize the risk of ORC extrusion; preservation of an adequate subcutaneous thickness to provide a secure coverage of ORC; calibrated use of ORC to prevent overdose and avoid excessive fibrosis and foreign-body reaction; prophylactic administration of antibiotic therapy in the postoperative time to prevent infections; detailed description in the surgical report about use of ORC to ensure a correct interpretation of the imaging by radiologists.

In conclusion, a trained and aware breast surgeon should handle ORC as filler with due caution; further high-quality studies should be performed to confirm the promising preliminary data and definitively launch ORC in BCS.