I. Kenolov, K. Kenolov
This is a 43-year-old female patient with metastatic bilateral triple-negative breast cancer who was treated at the Burgas Cancer Center between 2022 and 2026. The disease dates back to December 1, 2022, when she felt a lump in her left breast. The examination revealed a 1.5 cm × 1.5 cm mass with a firm consistency and slight retraction of the overlying skin; no enlarged axillary lymph nodes were detected on palpation. A mammogram was performed, which visualized a dense oval shadow with occasionally blurred contours and clustered microcalcifications in the lower medial quadrant —the finding is highly suspicious for a neoplastic process and requires further evaluation with a Tru-Cut biopsy. Histological examination revealed G-2 invasive ductal carcinoma, and immunohistochemistry showed a triple-negative tumor. A PET/CT scan was performed—no evidence of regional lymph node or distant metastasis. The patient was staged as cT1 N0 M0—Stage IA.
On January 12, 2023, she was admitted for surgical treatment. The following preoperative tests were performed: a breast ultrasound showing a hypoechoic mass with microcalcifications, polycystic contours, and dimensions of 29/18/25 mm in the right breast, with no enlarged lymph nodes in the right axilla and fibrocystic mastopathy in the left breast; chest X-ray—no evidence of parenchymal changes; laboratory and imaging tests—within normal limits. A skin-sparing mastectomy was performed with subpectoral placement of an expander, inverted-T skin reconstruction with a dermal sling covering the lower pole of the temporary prosthesis, and axillary lymph node dissection at levels I–II. Histological results confirmed the diagnosis of invasive ductal carcinoma; clear resection margins were achieved, and the lymph nodes were free of metastases—pT1 N0 M0. The postoperative period was uneventful; the patient was discharged in good general condition and referred to an oncology committee, which decided to administer adjuvant chemotherapy. She underwent 3 courses of a regimen with epirubicin and cyclophosphamide, followed by 3 cycles of paclitaxel, between March 1, 2023, and June 16, 2023, without any side effects. A PET/CT scan was performed, showing no evidence of active disease, and she remains under follow-up.
Preoperative status:
- bilateral mastoptosis (Regnault II-III)
- Preoperative marking using the Wise pattern (inverted T)
Postoperative status:
- Right-sided skin-sparing mastectomy with immediate reconstruction and resection of the axillary lymph nodes.
- The contralateral breast exhibits marked ptosis and is significantly larger in volume than the reconstructed breast, necessitating a second-stage procedure to achieve symmetry.
- Surgical wounds dressed; Redon drain placed in the axillary dissection area
On September 4, 2023, the patient was admitted for a prophylactic nipple-sparing mastectomy of the left breast and simultaneous reconstruction with an implant using an inverted-T skin flap, replacement of the temporary prosthesis with a permanent one, and reconstruction of the areola-nipple complex of the right breast. The left mammary gland, sent for histology, showed fibrocystic mastopathy. The patient was discharged in good general condition.
- Anatomical features: differences in breast size and ptosis
- Preoperative Plan: The new position of the AMK on the right breast has been determined (yugulum–nipple = 18 cm; 10 cm from the midline); The Wise pattern was used for the left breast, which is suitable for excising excess skin following a nipple-sparing mastectomy in cases of such severe ptosis (Regnault II–III).
- Intraoperatively:
- Right: removal of the tissue expander, capsuloplasty, and subpectoral implantation of a 375cc MOTIVA Ergonomix Round Silksurface implant. Reconstruction of the AMK was performed using a free composite graft from the contralateral AMK, thereby achieving excellent color and texture matching between the two and minimizing the donor AMK.
- Left: nipple-sparing mastectomy, subpectoral placement of a 375cc MOTIVA Ergonomix Round Silksurface implant, and skin flap reconstruction using the inverted T technique.
- Result: Symmetry has been achieved despite the different reconstructive techniques—the inframammary folds are at the same level; the breasts have a relatively natural contour, with some flattening at the lower pole, which is characteristic of the early postoperative period; Good positioning of the areola-nipple complexes; the free graft used to reconstruct the areola-nipple complex is viable, and the donor site shows no signs of complications; the skin margins have healed well with no signs of dehiscence or infection.
On June 17, 2025, a routine PET/CT scan revealed a metabolically active area in the residual parenchyma behind the areola-nipple complex of the left breast. The local examination revealed a mass above the upper pole of the AMC, with no evidence of lymphadenopathy in the ipsilateral axilla. A local excision of the suspicious lesion was performed, and a specimen with a diameter of 5.5 cm was sent for histological examination, which revealed a new invasive triple-negative ductal carcinoma with low differentiation and clear margins of 2 cm in the surrounding soft tissues.
On August 17, 2025, a left-sided axillary lymph node dissection (levels I–II) was performed, during which 11 lymph nodes were removed; no histological evidence of metastasis was found. The stage was determined as pT1N0M0. The postoperative period was uneventful; the patient was discharged in good general condition and referred to an oncology committee, which decided to administer adjuvant chemotherapy. She underwent 4 courses of docetaxel between October 8, 2025, and December 12, 2025, without any side effects, and remains under follow-up care.
Late postoperative finding from a routine examination: 
Conclusion:
The presented case demonstrates the possibility of successfully combining modern oncological and reconstructive techniques in a patient with metachronous bilateral triple-negative breast cancer. Despite the good aesthetic outcome and the prophylactic nipple-sparing mastectomy performed, the development of carcinoma in residual retroareolar parenchyma underscores the need for careful patient selection, strict intraoperative assessment of the retroareolar tissues, and long-term oncological follow-up.