Bridging the gap: unlocking the potential of emerging drug therapies for brain metastasis

Brain metastasis remains an unmet clinical need in advanced cancers with an increasing incidence and poor prognosis. The limited response to various treatments is mainly derived from the presence of the substantive barrier, blood-brain barrier (BBB) and brain-tumour barrier (BTB), which hinders the access of potentially effective therapeutics to the metastatic tumour of the brain. Recently, the understanding of the structural and molecular features of the BBB/BTB has led to the development of efficient strategies to enhance BBB/BTB permeability and deliver drugs across the BBB/BTB to elicit the anti-tumour response against brain metastasis. Meanwhile, novel agents capable of penetrating the BBB have rapidly developed and been evaluated in preclinical studies and clinical trials, with both targeted therapies and immunotherapies demonstrating impressive intracranial activity against brain metastasis. In this review, we summarize the recent advances in the biological properties of the BBB/BTB and the emerging strategies for BBB/BTB permeabilization and drug delivery across the BBB/BTB. We also discuss the emerging targeted therapies and immunotherapies against brain metastasis tested in clinical trials. Additionally, we provide our viewpoints on accelerating clinical translation of novel drugs into clinic for patients of brain metastasis. Although still challenging, we expect this review to benefit the future development of novel therapeutics, specifically from a clinical perspective.

Metastatic triple-negative breast cancer - current treatment strategies in the Nordics: a modified Delphi study

BACKGROUND AND PURPOSE

This study aimed to assess current treatment strategies for metastatic triple-negative breast cancer (mTNBC) and the perceptions of clinical experts in Sweden, Denmark, Norway, Finland, and Iceland, comparing them to international guidelines to provide insights into how these therapies are implemented and adapted to national Nordic guidelines.

METHODS

A three-round modified Delphi method was followed with consensus defined as 70% agreement. A steering committee selected 20 experienced oncologists as panellists and developed the questionnaires. Questions included items related to treatment preferences in different treatment lines with different clinical scenarios in mTNBC patients.

RESULTS

In the first round, eight out of 33 questions on clinical treatment reached consensus with 14 out of 27 in the second round reaching consensus. In round three, eight out of eight questions reached consensus. The preferred treatment for mTNBC patients with PD-L1 positive was checkpoint inhibitors (CPI) in combination with chemotherapy. For patients with germline BRCA mutation and PD-L1 negative disease, PARP-inhibitors were preferred as 1L and sacituzumab govitecan (SG) in both 2L and later lines. Disagreement was observed for chemotherapy in later lines where evidence is sparse or lacking.

INTERPRETATION

The high level of consensus for new treatment strategies, such as CPI and PARP-inhibitors in 1L and SG in 2L or later lines, in comparison with the limited consensus for older treatments, such as chemotherapy, may reflect the growing academic evidence for different treatment strategies. Understanding the treatment patterns across different countries contributes to gaining consensus on the upcoming therapeutic advances.

Novel De Novo BRCA2 Variant in an Early-Onset Ovarian Cancer Reveals a Unique Tumor Evolution Pathway

Ovarian cancer (OC) is a highly heterogeneous malignancy, often characterized by complex genomic alterations that drive tumor progression and therapy resistance. In this paper, we report a novel de novo BRCA2 germline variant NM_000059.3:c.(8693_8695delinsGT) associated with early-onset OC that featured two regions with differential MMR (Mismatch Repair) gene expression. To date, only six cases of de novo BRCA2 variants have been reported, none of which were associated with early-onset high-grade serous OC. The immunohistochemical analysis of MMR genes revealed two distinct tumor areas, separated by a clear topographic boundary, with the heterogeneous expression of MLH1 and PMS2 proteins. Seventy-five percent of the tumor tissue showed positivity, while the remaining 25% exhibited a complete absence of expression, underscoring the spatial variability in MMR gene expression within the tumor. Integrated comparative spatial genomic profiling identified several tumor features associated with the genetic variant as regions of loss of heterozygosity (LOH) that involved BRCA2 and MLH1 genes, along with a significantly higher mutational tumor burden in the tumor area that lacked MLH1 and PMS2 expression, indicating its further molecular evolution. The following variants were acquired: c.6572C>T in NOTCH2, c.1852C>T in BCL6, c.191A>T in INHBA, c.749C>T in CUX1, c.898C>A in FANCG, and c.1712G>C in KDM6A. Integrated comparative spatial proteomic profiles revealed defects in the DNA repair pathways, as well as significant alterations in the extracellular matrix (ECM). The differential expression of proteins involved in DNA repair, particularly those associated with MMR and Base Excision Repair (BER), highlights the critical role of defective repair mechanisms in driving genomic instability. Furthermore, ECM components, such as collagen isoforms, Fibrillin-1, EMILIN-1, Prolargin, and Lumican, were found to be highly expressed in the MLH1/PMS2-deficient tumor area, suggesting a connection between DNA repair deficiencies, ECM remodeling, and tumor progression. Thus, the identification of the BRCA2 variant sheds light on the poorly understood interplay between DNA repair deficiencies and ECM remodeling in OC, providing new insights into their dual role in shaping tumor evolution and suggesting potential targets for novel therapeutic strategies.

Healthcare metaverse in surgery: scoping review

BACKGROUND

The metaverse is an emerging concept in surgery, with much interest in its highly immersive and interactive virtual environment. Despite the growing interest and importance in healthcare, the metaverse is still very much in its early phase of evolution and adoption in surgery, with debate on its definition and components. This scoping review provides a summary of the evidence and current understanding for the use of the metaverse in surgery.

METHODS

Embase and MEDLINE were searched using scoping review methodology with a systematic search strategy, identifying any study examining the role of the metaverse in surgery without time limitation. After data extraction, a narrative synthesis was conducted to identify the components of the metaverse employed within surgery and the domains in which they were applied.

RESULTS

Of 97 articles found through the initial search, 15 studies were eligible for inclusion. Most of the studies were expert opinion pieces (46.6%), urology was the most common specialty (33.3%), and all studies were published after 2020. Studies were widely heterogeneous in study design and outcomes varied. The surgical metaverse was used across four main domains: education (53%), training (80%), operations (67%), and surgical care (53%).

CONCLUSION

Surgery is rapidly moving towards the age of the metaverse. There is great potential; however, evidence is lacking on its effectiveness and there are risks associated with its implementation. Institutions must learn how to understand and safely adopt the metaverse into their domains of education, training, operations, and surgical care.

Randomised controlled trial of music listening combined with progressive muscle relaxation for mood management in women receiving chemotherapy for cancer

AIMS

To evaluate the effects of passive music listening combined with progressive muscle relaxation on anxiety, depression, stress, coping, and quality-of-life in women with breast and gynaecological cancers receiving chemotherapy.

METHODS

This was an assessor-blinded, randomised wait-list controlled trial. A total of 120 participants were randomly allocated into an intervention group or a wait-list control group. The intervention group received an intervention comprising training on passive music listening and progressive muscle relaxation, with once-daily self-practice at home for 3 weeks. The wait-list control group received the same intervention after the outcome assessment at week 6. All outcome data were collected before (T0) and 3 weeks (T1), 6 weeks (T2), and 12 months (T3) after randomisation. A generalised estimating equations model was used to compare the changes in each outcome at different time points. Process evaluation was conducted using data from the patient's self-report forms and interviews.

RESULTS

The findings indicated that at T1 and T2, the intervention group's reductions in anxiety were significantly larger than those of the control group. Additionally, the intervention group exhibited significantly better decreases in depression at T2, stress at T1, and dysfunctional coping at T2, and a greater improvement in quality-of-life score at T1 and T2 when compared to the control group. Most of the interviewed participants provided positive feedback on the intervention.

CONCLUSIONS

The intervention was beneficial for lowering anxiety, depression, and stress and increasing the quality-of-life of women receiving chemotherapy for breast and gynaecological cancers.

TRIAL REGISTRATION

The trial was prospectively registered with ClinicalTrials.gov on 9 February 2022 (registration number: NCT05262621).

Primary Stereotactic Body Radiation Therapy for Breast Cancer Spinal Metastases

BACKGROUND

To present insights gained from a decade of employing stereotactic body radiation therapy (SBRT) as a primary intervention for spinal bone metastasis (SBM) originating from breast cancer (BC).

METHODS

We retrospectively examined the application of primary SBRT (the CyberKnife System) for BC SBMs between March 2012 and January 2023.

RESULTS

We recruited 47 female patients with 82 SBMs affecting 104 vertebrae. The mean age was 53.2 ± 12.7 years. The overall local control (LC) rate of primary SBRT for BC SBMs was 84.1%. The median local progression (LP) occurred at 12 (3-66) months. The LP rates were 9.7%, 13.3%, and 18.3% at 1, 3, and 5 years following SBRT. We observed a lower LC rate in White patients than that in Asian patients. Factors associated with an increased risk of LP included SBMs from invasive lobular carcinoma, and patients with lower revised Tokuhashi scores. Additionally, the 1-, 3-, and 5-year LP rates of different SFED (≥20 Gy vs. <20 Gy) were 4.3% versus 19.1%, 7.2% versus 24.0%, and 11.5% versus 28.9%. The incidence of acute local adverse events (AEs) was 24.4% and was significantly associated with advanced age and prescribed target coverage of less than 95%.

CONCLUSIONS

We have demonstrated SBRT using the CyberKnife System as an effective primary intervention for BC SBMs. Our findings underscore the importance of treatment planning to optimize outcomes and minimize AEs in patients undergoing SBRT for SBMs.

Effects of Opioids in Cancer Pain: An Interplay Among Genetic Factors, Immune Response, and Clinical Outcomes-A Scoping Review

Background/Objectives: Managing cancer-related pain presents complex challenges involving the interplay between analgesic efficacy, immune system responses, and patient outcomes. Methods: Following the Scale for the Assessment of Narrative Review Articles (SANRA) criteria, we conducted a comprehensive literature search in Medline, Scopus, and Web of Science databases. The review synthesized evidence regarding opioid pain management modalities, genetic variations affecting pain perception, and associated drug metabolism. Results: The literature reveals significant associations between opioid administration and immune function, with potential implications for cancer progression and survival. Genetic polymorphisms in key genes influence individual responses to pain opioid metabolism and, finally, pain management strategies. The immunosuppressive effects of opioids emerge as a critical consideration in cancer pain management, potentially influencing disease progression and treatment outcomes. Conclusions: Genetic variants influence analgesic efficacy, while the interaction between opioid-induced immunosuppression and genetic factors impacts both pain control and survival outcomes. This emphasizes the need for personalized treatment approaches considering individual genetic profiles and immune function.

Predictors for Upgrade to Breast Cancer in Patients with B3 Lesions Diagnosed by Core Biopsy: A Retrospective Cohort Study

BACKGROUND

The optimal approach to B3 lesions is controversial, and the risk of malignant upgrade varies between studies. This study aimed to evaluate the factors affecting the risk of upgrading to breast cancer in patients diagnosed with B3 lesions by core biopsy.

METHODS

A total of 410 patients diagnosed with B3 lesions by core biopsy and subsequently undergoing surgical excision were evaluated. Patients who did not undergo surgical excision or were not followed up at our center were excluded. Patients were analyzed based on demographic, clinical, radiological, and pathological findings.

RESULTS

All 410 patients included in the study were women, with a median age of 47 years (range 21-78). An upgrade to in situ or invasive disease was observed in 117 of the 410 patients (28.5%). In univariate analysis, age, mammographic findings, histopathological type, and atypia in core biopsy were identified as significant factors affecting the upgrade rate (p = 0.046, p = 0.028, p < 0.001, and p < 0.001, respectively). In multivariate analysis, the presence of atypia (p < 0.001) and a diagnosis of atypical ductal hyperplasia (ADH) (p = 0.026) were determined to be independent variables that increase the upgrade rate.

CONCLUSION

Surgical excision or vacuum-assisted excision may be more appropriate for ADH and B3 lesions with atypia on core biopsy.

Recent advances in regulating the cell cycle through inhibiting CDKs for cancer treatment

The inhibition of cyclin-dependent kinases (CDKs) is considered a promising strategy for cancer treatment due to their role in cell cycle regulation. However, CDK inhibitors with no selectivity among CDK families have not been approved. A CDK inhibitor with high selectivity for CDK4/6 exhibited significant treatment effects on breast cancer and has become a heavy bomb on the market. Subsequently, resistance gradually decreased the efficacy of selective CDK4/6 inhibitors in breast cancer treatment. In this review, we first introduce the development of selective CDK4/6 inhibitors and then explain the role of CDK2 activation in inducing resistance to CDK4/6 inhibitors. Moreover, we focused on the development of CDK2/4/6 inhibitors and selective CDK2 inhibitors, which will aid in the discovery of novel CDK inhibitors targeting the cell cycle in the future.

Peptide receptor radionuclide therapy with somatostatin analogs beyond gastroenteropancreatic neuroendocrine tumors

First isolated by Brazeau et al. in 1972, somatostatin (SST) is a neuropeptide known for regulating various signaling pathways through its specific cell surface receptors. Somatostatin receptors (SSTRs) comprise a family of five G protein-coupled receptors that are widely distributed across the human body and are expressed by various tumor types. The growing understanding of their clinical potential led to the introduction of both cold and radiolabeled somatostatin analogs (SSAs), which have revolutionized the management of several cancers, especially neuroendocrine tumors. As a direct consequence, advances in peptide receptor radionuclide therapy (PRRT) over the last 30 years led to the approval of 177Lu-DOTATATE for the treatment of gastroenteropancreatic neuroendocrine tumors (GEPNETs). Theoretically, any cancer patients whose tumors express SSTR, as demonstrated in vivo through SSTR-based molecular imaging, could be candidates for PRRT, especially those with limited treatment options. However, evidence on the efficacy of PRRT in non-GEPNET SSTR-expressing tumors is limited, and mainly derived from small retrospective studies. Given the limited therapeutic options for advanced/metastatic patients, there is a clear need for randomized trials to formally approve PRRT with SSAs for patients who may benefit from this treatment, particularly in certain types of neuroendocrine neoplasms such as lung carcinoids, paragangliomas, and meningiomas, where high rates of disease control (up to 80%) can be achieved. In addition, emerging evidence supports the potential of combination therapies, alpha emitters, and non-SSTR-based radionuclide therapy in tumors beyond GEPNET. This review aims to provide a comprehensive overview of PRRT's role in cancers beyond GEPNET, exploring new possibilities and future directions for most SSTR highly expressing tumors.

Evaluation of normal tissue complications in breast cancer re-irradiation: a meta-analysis study

BACKGROUND

In recent years, evidence has accumulated that a second method of conserving the breast from cancer with re-irradiation as part of treatment may be feasible and safe. Many oncologists are skeptical of breast re-irradiation due to concerns about late complications, so access to quantitative data on the prevalence of breast re-irradiation complications is very important. In this meta-analysis, we determine the prevalence of complications in normal tissue after breast re-irradiation.

MATERIALS AND METHODS

A search was done to recognize qualified studies using EMBASE, MEDLINE, PUBMED, Google Scholar, and Cochrane Collaboration Library electronic databases from 2000 to 2023. In total, ten primary studies were applied in this meta-analysis to estimate the prevalence of complications of disorders, skin fibrosis, and chest pain. Heterogeneity was investigated using the I2 index and the meta-regression to evaluate variables suspected of causing heterogeneity. Statistical analysis and synthesis were performed using Stata 17.

RESULTS

The average dose received by patients who underwent radiation therapy in two stages was 100.32 Gy, and in these patients, the prevalence of skin fibrosis and disorders was 47% (95% CI 71-22%; I2 = 96.76%, P < 0.001) and the prevalence of chest pain was 35% (95% CI 68-8%; I2 = 98.13%, P < 0.001).

CONCLUSIONS

There is little clinical information about the incidence of complications in breast re-irradiation therapy. This meta-analysis presents the prevalence of complications after breast re-irradiation to help radiation oncologists and physicists make better decisions.

Validation of a breast cancer assay for radiotherapy omission: an individual participant data meta-analysis

BACKGROUND

There are currently no molecular tests to identify individual breast cancers where radiotherapy (RT) offers no benefit. Profile for the Omission of Local Adjuvant Radiotherapy (POLAR) is a 16-gene molecular signature developed to identify low-risk cancers where RT will not further reduce recurrence rates.

METHODS

An individual participant data meta-analysis was performed in 623 patients of node-negative estrogen receptor-positive and HER2-negative early breast cancer enrolled in 3 RT randomized trials for whom primary tumor material was available for analysis. A Cox proportional hazards model on time to locoregional recurrence was used to test the interaction between POLAR score and RT.

RESULTS

A total of 429 (69%) patients' tumors had a high POLAR score, and 194 (31%) had a low score. Patients with high POLAR score had, in the absence of RT, a 10-year cumulative incidence of locoregional recurrence (20%, 95% confidence interval [CI] = 15% to 26%, vs 5%, [CI] 2% to 11%) for those with a low score. Patients with a high POLAR score had a large benefit from RT (hazard ratio [HR] for RT vs no RT = 0.37, 95% CI = 0.23 to 0.60; P < .001). In contrast, there was no evidence of benefit from RT for patients with a low POLAR score (HR = 0.92, 95% CI = 0.42 to 2.02; P = .832). The test for interaction between RT and POLAR was statistically significant (P = .022).

CONCLUSIONS

POLAR is not only prognostic for locoregional recurrence but also predictive of benefit from RT in selected patients. Patients aged 50 years and older with estrogen receptor-positive and HER2-negative disease and a low POLAR score could consider omitting adjuvant RT. Further validation in contemporary clinical cohorts is required.

The prognostic value of the tumor-stroma ratio compared to tumor-infiltrating lymphocytes in triple-negative breast cancer: a review

Previous literature extensively explored biomarkers to personalize treatment for breast cancer patients. The clinical need is especially high in patients with triple-negative breast cancer (TNBC) due to its aggressive nature and limited treatment modalities. This review aims to evaluate the value of tumor-infiltrating lymphocytes (TILs) and tumor-stroma ratio (TSR) as prognostic biomarkers in TNBC patients and assess their clinical potential. A literature search was conducted in PubMed, Embase, Emcare, Web of Science, and Cochrane Library. Papers comparing survival outcomes of TNBC patients with low/high or negative/positive TSR and immune cells were included. The most frequently mentioned subgroups of TILs were selected and reported in this review. Data from 43 articles on TILs and eight articles on TSR were included. Among TNBC patients, high CD8 expression was generally associated with better survival. Notable, the poor survival outcomes were related to high intra-tumoral PD-L1 expression, whereas high stromal PD-L1 expression more often was correlated with favorable outcomes. For the TSR, a high amount of stroma in the primary tumor of TNBC patients was consistently associated with worse survival. This review highlights that a high number of CD8-positive T-cells is a promising prognostic factor for TNBC patients. PD-L1 expression analyzed for intra-tumoral and stromal expression separately reports strong but contrasting information. Finally, the TSR shows potential to be an important prognostic marker, especially for TNBC patients. Utilizing both biomarkers, either on itself or combined, could enhance clinical decision-making and personalization of treatment.

Leveraging Digital Technology to Enhance Mind-Body Approaches in Cancer Treatment

PURPOSE

Cancer treatment involves significant psychological and emotional challenges. Conventional therapies often diminish quality of life, exacerbating stress, anxiety, and depression. Mind-body practices, such as sophrology, offer complementary solutions to improve well-being. Digital technology has expanded access to these practices, providing personalized tools to manage stress and emotional health remotely.

MATERIALS AND METHODS

This review examines digital applications in cancer care, focusing on sophrology and other mind-body techniques. Studies evaluating the efficacy of digital platforms and artificial intelligence-driven interventions for stress management, fatigue reduction, and psychological support are analyzed, highlighting their impact on patient outcomes.

RESULTS

Digital platforms integrating sophrology significantly alleviate cancer-related side effects. The ePAL app reduced pain scores by 30% over 8 weeks, and StressProffen improved fatigue scores by 20% and adherence to stress management (75% v 50% in controls). The PINK! app increased physical activity by 35% and reduced psychological distress by 30% over 12 weeks. During the COVID-19 pandemic, internet-based mindfulness programs reduced anxiety by 18% and depression by 22%. These tools enhance autonomy and promote community support through virtual sessions, reducing isolation.

CONCLUSION

Digital technology complements traditional cancer treatments, improving patient access, personalization, and adherence. Challenges such as digital literacy, data privacy, and regulatory oversight must be addressed. These tools provide holistic support and foster resilience, enhancing the cancer care continuum.

Oncogenic activation of PI K3 CA in cancers: Emerging targeted therapies in precision oncology

Phosphoinositide 3-kinases (PI3Ks) are heterodimers consisting of a p110 catalytic subunit and a p85 regulatory subunit. The PIK3CA gene, which encodes the p110α, is the most frequently mutated oncogene in cancer. Oncogenic PIK3CA mutations activate the PI3K pathway, promote tumor initiation and development, and mediate resistance to anti-tumor treatments, making the mutant p110α an excellent target for cancer therapy. PIK3CA mutations occur in two hotspot regions: one in the helical domain and the other in the kinase domain. The PIK3CA helical and kinase domain mutations exert their oncogenic function through distinct mechanisms. For example, helical domain mutations of p110α gained direct interaction with insulin receptor substrate 1 (IRS-1) to activate the downstream signaling pathways. Moreover, p85β proteins disassociate from helical domain mutant p110α, translocate into the nucleus, and stabilize enhancer of zeste homolog 1/2 (EZH1/2). Due to the fundamental role of PI3Kα in tumor initiation and development, PI3Kα-specific inhibitors, represented by FDA-approved alpelisib, have developed rapidly in recent decades. However, side effects, including on-target side effects such as hyperglycemia, restrict the maximum dose and thus clinical efficacy of alpelisib. Therefore, developing p110α mutant-specific inhibitors to circumvent on-target side effects becomes a new direction for targeting PIK3CA mutant cancers. In this review, we briefly introduce the function of the PI3K pathway and discuss how PIK3CA mutations rewire cell signaling, metabolism, and tumor microenvironment, as well as therapeutic strategies under development to treat patients with tumors harboring a PIK3CA mutation.

Expression and Subtype Discordance Between Core Needle Biopsy and Surgical Specimen in Breast Cancer

INTRODUCTION

Estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal growth factor receptors 2 (HER2s) are crucial for the molecular subtype classification and therapy decision-making in breast cancer. Core needle biopsy (CNB) serves as an essential preoperative diagnostic tool for biomarker evaluation, offering minimal invasiveness and convenience. However, CNB has limitations including insufficient sampling volume, sampling errors, underestimation and false results. This study evaluated the discordance of ER, PR, HER2, and molecular subtype between CNB and surgical specimen (SS) in breast cancer, explored the factors associated with discordance and discussed which specific breast cancer cases were recommended for retesting.

MATERIALS AND METHODS

Medical records of invasive breast cancer patients admitted to Fujian Medical University Union Hospital from January 2014 to January 2020 were retrospectively collected. Immunohistochemistry and fluorescence in situ hybridization were used to assess the status of ER, PR, and HER2 in both CNB and SS. The agreement analyses were performed using the Kappa test. Univariable and multivariable logistic regressions were employed to identify factors associated with discordance of biomarkers and molecular subtypes.

RESULTS

A total of 2099 patients were included in the study. Discordance rates were 3.9% (n = 82) for the ER, 4.8% (n = 101) for PR and 1.2% (n = 25) for HER2. High agreement was observed between CNB and SS for ER (κ=0.899), PR (κ=0.896) and HER2 (κ=0.972). There were 344 cases of molecular typing discordance, with the majority (n = 226, 65.7%) occurring between Luminal A and Luminal B (HER2-). Factors of ER discordance were large tumor size (OR = 8.715, P < 0.001), ER-low biopsy status (OR = 49.959, P < 0.001) and PR-high biopsy status (OR = 0.046, P < 0.001. Factors of molecular subtype discordance were carcinoma in situ (OR = 1.930, P = 0.007), ER-low biopsy status (OR = 40.527, P < 0.001) and Ki67-high biopsy status (OR = 0.332, P < 0.001).

CONCLUSIONS

CNB showed good accuracy in evaluating ER, PR, HER2, and molecular subtypes in breast cancer. However, concerning the factors associated with discordance, we recommend retesting for three CNB cases (1) ER-negative and PR-positive, (2) ER low-expression and PR-negative, and (3) Luminal A subtype with tumors ≤2 cm, which might offer a valuable reference for clinical decision-making.

Patient-reported and surgical outcomes of profunda artery perforator (PAP) flap breast reconstructions compared to deep inferior epigastric perforator (DIEP) using BREAST-Q

BACKGROUND

Autologous breast reconstruction patients require thorough assessment, with the profunda femoris artery perforator (PAP) flap having become an important autologous reconstruction option alongside the deep inferior epigastric perforator (DIEP) flap. Breast reconstruction impacts patients psychologically, physically and mentally. The BREAST-Q aids in the assessment of patient-reported outcome measures (PROMs). We aim to critically compare postoperative clinical outcomes, aesthetic results, morbidity and patient satisfaction between patients undergoing DIEP and PAP flap reconstructions using clinical follow-up and PROMs.

METHODS

A non-blinded two-armed prospective cohort study was performed. Patients undergoing PAP or DIEP flap reconstructions between January 2021 and February 2022 were included and followed up for at least one-year postoperatively. Demographic and per-operative data were acquired. BREAST-Q data were collected preoperatively and at 2-week, 3-month and 1-year intervals postoperatively.

RESULTS

157 patients had autologous breast reconstruction (207 flaps), with 129 (82.1%) DIEP patients and 21 (13.3%) PAP patients. 37 (28.6%) patients underwent bilateral DIEP reconstructions, and 1 (5%) PAP case was bilateral. The remaining PAP cases used stacked flaps for unilateral breast reconstruction. Mean ischaemia time for PAP was 55.29 (±15.59 minutes) compared to 69.52 (±21.74 minutes) for DIEP (p = 0.014). Donor site wound dehiscence was significantly higher with PAP reconstructions (p = 0.014).

CONCLUSIONS

At one-year follow-up, no significant differences in PROMs across all domains between DIEP and PAP flap reconstructions were noted. This reflects that PAP flap reconstructions, despite having a more challenging donor site and higher donor site complications, provide an excellent reconstructive option with similar patient-reported outcomes when compared to the gold-standard DIEP flap reconstruction.

Paediatric breast disease and developmental breast cysts - reflection on 20 years of experience

INTRODUCTION

Presentation with breast symptoms in the paediatric population is common but there is little existing literature on the workup and management of breast disease in this population.

METHODS

Retrospective series of 140 cases of breast disease in the paediatric population managed by a single surgeon in Adelaide, South Australia between 2004 and 2024. Review of patient demographics, presentation, investigation, management and outcomes of various breast symptoms and pathologies using descriptive analysis.

RESULTS

We reviewed 140 cases including 135 females and 5 males, aged 8-18 years (median = 15). The most common reason for presentation was breast lump (n = 86, 61%), followed by large breasts (n = 13, 9%), asymmetry (n = 11, 8%), abnormal development (n = 8, 6%). Most patients were investigated with ultrasound (n = 101, 71%) and FNA biopsy was performed in cases of non-diagnostic ultrasound or to distinguish fibroadenoma from phyllodes tumour (n = 17, 12%). There was a single case of malignancy and the most common diagnoses were developmental breast cyst (n = 36, 26%) and fibroadenoma (n = 33, 24%). Gynaecomastia was the only diagnosis in males (n = 5, 4%). Majority of patients were managed non-operatively (n = 101, 72%), indications for surgery included fibroadenoma (n = 18, 13%), breast hypertrophy (n = 8, 6%) or abnormal breast development (n = 4, 3%).

CONCLUSION

We reviewed 140 cases of breast disease in the paediatric population over a 20-year period. Malignancy in this population is rare but requires exclusion with history, examination and ultrasound where appropriate. Developmental breast cysts are the most common pathology, require early identification to avoid unnecessary invasive investigation and should be managed expectantly where possible.

[Prophylactic breast surgery in high-risk breast cancer patients]

INTRODUCTION

Breast cancer associated with pathogenic variants of BRCA1 and BRCA2 genes requires specific management. This review examines the prognostic benefits, prophylactic surgical strategies, and impact on quality of life of patients at very high risk of breast cancer. Breast surgical prophylaxis concerns women at high risk of breast cancer with a risk assessment based on their personal and family history, or by diagnosis of pathogenic variants in high-risk genes. Personalized management is based on enhanced clinical and radiological monitoring, the use of predictive tools such as BOADICEA, and surgical options such as prophylactic bilateral mastectomy, which can reduce the risk of cancer by over 90 %. Although its impact on overall survival is still debated, advances in surgical techniques have significantly improved aesthetic results and patient satisfaction, thanks to modern reconstruction methods. The surgical strategy, whether primary or secondary, must be individualized, considering the patient's history, therapeutic needs, and preferences. Mastectomy with preservation of the skin envelope, often performed in one or two stages, offers significant psychosocial benefits, although radiotherapy may increase the risk of complications. Options include immediate reconstruction, by implant or autologous technique, adapted to the patient's morphology and any adjuvant treatments.

CONCLUSION

Prophylactic bilateral mastectomy is an effective strategy for reducing the risk of breast cancer, particularly in patients with pathogenic BRCA gene variants. Personalized assessment, detailed information on risks and impacts, and the use of decision-support tools are essential to enable informed choices tailored to individual patient needs.

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications.

RESULTS

Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence.

CONCLUSIONS

This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictive Model Based on Texture Analysis of Noncontrast Cardiac Magnetic Resonance Images for the Prognostic Evaluation of Cardiac Amyloidosis

OBJECTIVES

We aimed to develop a predictive model based on textural features of noncontrast cardiac magnetic resonance (CMR) imaging for risk stratification toward adverse events in patients with cardiac amyloidosis (CA).

METHODS

A cohort of 78 patients with CA was grouped into training (n = 54) and validation (n = 24) sets at a ratio of 7:3. A total of 275 textural features were extracted from the CMR images. MaZda and a support vector machine (SVM) were used for feature selection and model construction. An SVM model incorporating radiological and textural features was built to predict endpoint events by evaluating the area under the curve.

RESULTS

In the entire cohort, 52 patients experienced major adverse cardiovascular events and 26 patients did not. By combining 2 radiological features and 8 texture features, extracted from cine and T2-weighted imaging images, the SVM model achieved area under the curves of the receiver operating characteristic and precision-recall curves of 0.930 and 0.962 in the training cohort and that of 0.867 and 0.941 in the validated cohort, respectively. The Kaplan-Meier curve of this SVM model criterion significantly stratified the CA outcomes (log-rank test, P  < 0.0001).

CONCLUSIONS

The SVM model based on radiological and textural features derived from noncontrast CMR images can be a reliable biomarker for adverse events prognostication in patients with CA.

Neratinib derivative 7A induces apoptosis in colon cancer cells via the p53 pathway

Colorectal cancer remains a significant health threat, with its incidence continuously rising, underscoring the urgent need for the development of new therapeutic agents. In our previous research, we identified 7A, a derivative of Neratinib, as having pronounced antitumor activity. However, its specific effects and mechanisms in colorectal cancer have not been thoroughly investigated. Therefore, this study employed in vivo and in vitro experiments, utilizing techniques such as RNA sequencing, Western blotting, and PCR, to provide a comprehensive analysis of 7A's mechanism of action in colorectal cancer. The results indicate that 7A induces DNA damage and activates the P53 pathway, thereby promoting apoptosis in colorectal cancer cells. Additionally, 7A treatment significantly reduced angiogenesis and tumor weight. Our findings suggest that 7A, a Neratinib derivative, holds promise as a novel candidate for colorectal cancer therapy.

Contrast-Enhanced Digital Mammography for the Diagnosis and Determination of Extent of Disease in Invasive Lobular Carcinoma: Our Experience and Literature Review

OBJECTIVE

Contrast-enhanced imaging, including magnetic resonance imaging and, more recently, contrast-enhanced digital mammography (CEM), is indicated for the precise diagnosis of invasive lobular carcinoma (ILC). The aim of our study was to further validate the use of CEM for evaluation of extent of disease in ILC cases, with digital breast tomosynthesis (DBT) as an adjunct.

METHODS

A retrospective, institutional review board approved study was conducted in a tertiary medical center. All CEM examinations performed on ILC patients between 2017 and 2023 were reread by 2 dedicated breast radiologists. Clinical data and pathology reports were retrieved from electronic medical records. The longest diameter of the enhancing lesion was correlated to pathology findings. In addition, for each case, the readers provided brief commentary on the added value of DBT.

RESULTS

Twenty-four CEM examinations were evaluated. The subjects in the study cohort were on average older than expected for ILC patients (74 vs 63 years) and were unable to undergo breast magnetic resonance imaging due to advanced age and comorbidities. Three subjects were treated with neoadjuvant therapy and thus were excluded from the correlation to pathology analysis. Enhancing lesions, ranging from 4-75 mm, strongly correlated to pathology results, with statistical significance. This was demonstrated for mass and nonmass lesions ( r  = 0.94, P  < 0.001 and r  = 0.99, P  = 0.002, respectively). For most lesions (17/24, 71%), readers remarked that the addition of DBT allowed for improved characterization of lesion margins, mainly detecting architectural distortion.

CONCLUSIONS

When compared with the pathology findings, ILC was accurately diagnosed and assessed using CEM. The addition of DBT was reported by the interpreting radiologists as a valuable adjunct for margin analysis.

Allies not enemies-creating a more empathetic and uplifting patient experience through technology and art

OBJECTIVE

To understand whether art and technology (mainly conversational agents) may help oncology patients to experience a more humanized journey.

METHODS

This narrative review encompasses a comprehensive examination of the existing literature in this field by a multicenter, multidisciplinary, and multiprofessional team aiming to analyze the current developments and potential future directions of using art and technology for patient engagement.

RESULTS

We identified three major themes of patient engagement with art and three major themes of patient engagement with technologies. Two real-case scenarios are reported from our experience to practically envision how findings from the literature can be implemented in different contexts.

CONCLUSION

Art therapy and technologies can be ancillary supports for healthcare professionals but are not substitutive of their expertise and responsibilities. Such tools may help to convey a more empathetic and uplifting patient journey if properly integrated within clinical practice, whereby the humanistic touch of medicine remains pivotal.

Alkaloid fraction of Achyranthes aspera Linn triggers breast cancer apoptosis in mice (Mus musculus) model

Background

Breast cancer affects women of various ages, and its recurrence is a significant cause of death. The search for potent anticancer compounds of herbal origin with well-defined mechanisms of action is an essential focus of current research.

Aim

This study aimed to investigate the effects of alkaloids in Achyranthes aspera Linn (AAL) leaf extract on necrosis, apoptosis, and related molecular markers, namely, cyclin-dependent kinase 1, Bcl-2 associated X-protein (Bax), rat sarcoma virus (Ras), cytochrome (Cyt) c, and apoptotic activating factor-1 (Apaf-1), in mice models.

Methods

Thirty mice with breast cancer were randomly divided into five groups. The negative control group only received distilled water daily. Mice in the positive control group (PCG) were administered methotrexate (15 mg/Kg) daily. The T1, T2, and T3 groups received oral orally at 75, 100, and 125 mg/Kg body weight daily for 30 days, respectively. On day 31, all mice were euthanized for the preparation of histological specimens of the mammary glands. The negative control group had the lowest number of apoptotic cells, Apaf-1, Cyt C, and Bax expression, and the highest number of viable cancer cells and Ras expression.

Results

The percentages of necrotic cells and breast cancer-expressed CDK-1 were not significantly (p > 0.05) different among groups. The percentage of apoptotic cells, Apaf-1, and Cyt c, was highest in T3. Conversely, the percentage of viable cells and breast cancer-expressing Ras was lowest in T3.

Conclusion

Treatment with 125 mg/Kg AAL suppressed cancer cell growth in breast cancer-bearing mice. Further research is necessary to determine the complete signaling mechanism.

Management of B3 breast lesions: Potential clinical implications from a retrospective study conducted in an accredited Breast Unit following the 2024 EUSOMA guidelines

B3 breast lesions present significant challenge in breast surgery. Despite their relatively low risk of malignancy without cellular atypia, overtreatment remains common. We retrospectively evaluate the management of B3 lesions in an accredited-EUSOMA Breast Unit, comparing 10-years practices with 2016 and 2019 international Consensus Conferences and with 2024 EUSOMA guidelines. The study included 354 patients diagnosed with B3 lesions, evaluating guideline adherence, malignancy risk in non-adherent cases, and biopsy-to-final pathology concordance. Adherence to guidelines varied by lesion type, with 46.3 % of cases potentially involving avoidable surgeries, 9.1 % of which were found to be malignant. Additionally, discrepancies between biopsy and final histology were significant, with 43.2 % of lesions showing different histological types. These findings emphasize the importance of updated guidelines to reduce overtreatment, encourage minimally invasive treatments and highlight the need of multidisciplinary discussions in managing B3 lesions, especially when there is a discrepancy between imaging and preoperative biopsy.

Managing pregnancy-associated breast cancer: A practical approach

Pregnancy-Associated Breast Cancer (PABC) is a rare but complex condition that presents both professional and ethical challenges. Diagnosis is often delayed due to breast changes associated with pregnancy and puerperium, which can mask malignant findings. Management requires a multidisciplinary approach that carefully balances maternal and fetal risks. Chemotherapy is generally reserved for the second and third trimesters to avoid teratogenicity, with anthracyclines being the most well-studied and safest agents in this setting. Surgical decisions are influenced by factors such as cancer stage, gestational age, and the timing of potential radiation therapy. Notably, radiation therapy, endocrine therapy, and most targeted therapies are contraindicated during pregnancy due to potential harm to the fetus. Comprehensive care should include robust social and mental health support for the mother and her family to help navigate the physical and emotional challenges during this period.

Acetylsalicylic acid and cancer: updates on the new potential of a nature-inspired drug

Acetylsalicylic acid (ASA), commonly known as aspirin, is an organic compound with the formula C9H8O4 obtained from the natural compound salicylic acid, recognized for its analgesic, anti-inflammatory, antipyretic, and anticancer properties. Its role in medicine and plant biology is well-established, but its emerging potential in cancer treatment has garnered increased attention. This review aims to provide a comprehensive overview of the therapeutic applications of ASA as an anticancer agent, focusing on its mechanisms, effectiveness, and role as an adjuvant therapy, preventive compound, and radioprotective agent. Recent research papers, including mechanistic studies, preclinical investigations, and clinical trials related to the effects of ASA on various cancer types, were reviewed. The review places particular emphasis on the enhancement of traditional chemotherapy drugs by ASA and considers toxicological aspects. The analysis of recent studies highlights the potential of ASA to improve the effectiveness of chemotherapy and its role in cancer inhibition through specific molecular pathways. Mechanistic insights suggest that ASA may influence cellular processes that contribute to cancer growth suppression and increased sensitivity to conventional treatments. ASA exhibits promising potential as an adjunct therapy in cancer treatment, with evidence supporting its benefits in improving therapeutic outcomes when used alongside conventional chemotherapy. Further studies are needed to clarify its mechanisms and ensure its safe and effective application in clinical settings.

Navigating heme pathways: the breach of heme oxygenase and hemin in breast cancer

Breast cancer remains a significant global health challenge, with diverse subtypes and complex molecular mechanisms underlying its development and progression. This review comprehensively examines recent advances in breast cancer research, with a focus on classification, molecular pathways, and the role of heme oxygenases (HO), heme metabolism implications, and therapeutic innovations. The classification of breast cancer subtypes based on molecular profiling has significantly improved diagnosis and treatment strategies, allowing for tailored approaches to patient care. Molecular studies have elucidated key signaling pathways and biomarkers implicated in breast cancer pathogenesis, shedding light on potential targets for therapeutic intervention. Notably, emerging evidence suggests a critical role for heme oxygenases, particularly HO-1, in breast cancer progression and therapeutic resistance, highlighting the importance of understanding heme metabolism in cancer biology. Furthermore, this review highlights recent advances in breast cancer therapy, including targeted therapies, immunotherapy, and novel drug delivery systems. Understanding the complex interplay between breast cancer subtypes, molecular pathways, and innovative therapeutic approaches is essential for improving patient outcomes and developing more effective treatment strategies in the fight against breast cancer.

Multidisciplinary Management of Pregnancy-Associated Breast Cancer

Breast cancer during pregnancy is uncommon; however, it is one of the most common malignancies affecting pregnant women. Pregnancy-associated breast cancer (PABC) is a complex entity characterized by unique risk factors, presentation, and pathology. Furthermore, although management generally aims to mirror that for nonpregnant patients, there are distinct aspects of oncologic care delivery specific to PABC. The focus is on optimizing maternal outcomes while maximizing maternal and fetal safety. A multidisciplinary approach is key, and the timing of various treatment modalities is critical. Postdelivery care and counseling are also imperative to address issues such as contraception, breastfeeding, and future fertility. In the present review, we discuss the current knowledge base and the diagnostic and treatment landscape for PABC, including recent literature and practice pattern updates.

Clinical impact of the Z0011 trial on axillary surgical management in Australia and New Zealand from the BreastSurgANZ Quality Audit

BACKGROUND

The clinical management of the axilla in early breast cancer has changed since the Z0011 trial, which showed that axillary lymph node dissection (ALND) is not necessary in select patients with a positive sentinel lymph node biopsy (SLNB). Studies have shown a significant decrease in the rates of completion ALND (cALND) since Z0011. The aims of this study were to investigate the effect of the Z0011 trial on the management of positive axillary sentinel nodes and the trends in axillary surgical management since 2005 in Australia and New Zealand.

METHODS

This study utilized prospectively maintained data from the BreastSurgANZ Quality Audit (BQA). Patients with early breast cancer between 2005 and 2023 satisfying the Z0011 trial inclusion criteria undergoing SLNB or SLNB followed by cALND were identified.

RESULTS

There were 91 196 patients who underwent breast-conserving surgery and SLNB of which 12 035 were node positive therefore satisfying the Z0011 trial inclusion criteria, of which 8194 (68.1%) received SLNB only with no cALND. There has been a 55.4% reduction in the rate of cALND after 2010 when the Z0011 trial was published (P < 0.001). There was a significant downward trend in the number of cALND performed per year (R2 = 0.890, P < 0.001).

CONCLUSION

The Z0011 trial was a practice changing trial and since its publication in 2010 has been correlated with de-escalation in surgical management of the axilla and decline in the rates of cALND in Australia and New Zealand.

Is an Online Asynchronous Progressive Resistance Training Programme Feasible for Individuals With Down Syndrome?

BACKGROUND

Online exercise programming reduces transportation and scheduling barriers. This study explored the feasibility of online resistance training for individuals with Down syndrome.

METHOD

Thirteen individuals (3 M/10 F, age: 21.7 ± 5.9 years) began a 10-week programme delivered using a website with pre-recorded exercise videos (45-60 min each) for 3 days/week. Surveys were used to obtain feedback and track adherence. At baseline and after 10 weeks, participants completed the 30-s sit-to-stand, modified push-ups and 30-s bicep curl tests.

RESULTS

11 (85%) participants completed the programme, and 8 participants (73%) met the ≥ 20 sessions goal. Participants rated (n = 267 ratings) most exercises easy to somewhat easy and exercise videos as fun to a lot of fun (n = 220 ratings, 86.2%). After 10 weeks, participants completed more push-ups (8 ± 6 vs. 12 ± 6; p = 0.031) and biceps curls (7 ± 3 vs. 11 ± 3; p < 0.001).

CONCLUSION

Remote resistance training programmes may be feasible and should be further evaluated.

Ovarian stimulation response and fertility outcomes in patients with breast cancer across different stages, grades, and hormone receptor status for fertility preservation

BACKGROUND

This study aimed to explore the potential impact of stage, grade, and hormone receptor profile on ovarian stimulation response and fertility preservation outcomes.

METHODS

This retrospective cohort study evaluated data from breast cancer patients who underwent fertility preservation at a tertiary medical center between 2014 and 2022. The outcomes of women with low-stage cancer (stages I and II) were compared with those of women with high-stage disease (stages III and IV or lymph node metastasis). Similarly, we compared those with low-grade (grades 1 and 2) and high-grade (grade 3) malignancies. In addition, we compared different hormone statuses of breast cancer (1) estrogen receptor (ER) positive vs. ER-negative and (2) triple-negative breast cancer (TNBC) vs. non-TNBC. The primary outcome measured was the number of mature oocytes, while the secondary outcomes included the numbers of total oocytes retrieved, peak estradiol levels, and subsequent fertility preservation outcomes.

RESULTS

A total of 47 patients were included. Patients with high-grade tumors had a comparable number of mature oocytes (8 vs. 10, p = 0.08) compared to patients with low grade cancers. The stage-based analysis revealed a similar number of mature oocytes (8 vs. 10, p = 0.33) between high/low stage patients. In the hormone receptor-based analysis, no differences were seen in mature oocytes collected between the ER-positive/ER-negative group (9 vs. 9, p = 0.87) and the TNBC/non-TNBC group (11 vs. 9, p = 0.13). The utilization rate was 27.6% (13/47).

CONCLUSION

Our study showed similar ovarian stimulation response and fertility preservation outcomes among breast cancer patients with different prognostic factors.

Interval breast cancer rates for tomosynthesis vs mammography population screening: a systematic review and meta-analysis of prospective studies

OBJECTIVES

We aimed to synthesise evidence from prospective studies of digital breast tomosynthesis (DBT) screening to assess its effectiveness compared to digital mammography (DM). Specifically, we examined whether DBT reduces interval cancer rates (ICRs) in population breast cancer screening.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of DBT screening studies (identified from January 2013 to March 2024). We included both RCTs and non-randomised prospective studies that used an independent comparison for our primary outcome ICRs. The risk of bias was assessed with QUADAS-2. We compared the ICR, cancer detection rate (CDR), and recall rate of DBT and DM screening using random effects meta-analysis models. Subgroup analyses estimated outcomes by study design. Sensitivity analyses estimated absolute effects from relative effects.

RESULTS

Ten prospective studies (three RCTs, seven non-randomised) were eligible; all had a low risk of bias. There were 205,245 DBT-screened and 306,476 DM-screened participants with follow-up for interval cancer data. The pooled absolute ICR did not significantly differ between DBT and DM: -2.92 per 10,000 screens (95% CI: -6.39 to 0.54); however subsequent subgroup analysis indicated certain study designs may have biased this ICR estimate. Pooled ICR from studies that only sampled groups from the same time and region indicated DBT led to 5.50 less IC per 10,000 screens (95% CI: -9.47 to -1.54). Estimates from subgroup analysis that compared randomised and non-randomised trials did not significantly differ.

CONCLUSION

This meta-analysis provides suggestive evidence that DBT decreases ICR relative to DM screening; further evidence is needed to reduce uncertainty regarding ICR differences between DBT and DM.

KEY POINTS

Question Does DBT have long-term benefits over standard DM? Finding We find suggestive evidence in our primary analysis and stronger evidence in a follow-up analysis that DBT reduces interval cancers. Clinical relevance This meta-analysis provides the first indication that DBT may detect additional cancers that are clinically meaningful, based on suggestive evidence of a reduction in ICR. This finding does not preclude the simultaneous possibility of overdiagnosis.

Efficacy of Modified Triple Assessment in Diagnosing Breast Lesions: A Prospective Observational Study

BACKGROUND

Breast lumps are a common clinical presentation, often causing significant anxiety due to the risk of malignancy. Early and accurate differentiation between benign and malignant breast lesions is essential for optimal patient management. The modified triple test (MTT), which replaces mammography with ultrasound in the traditional triple assessment test (TAT), offers a more effective diagnostic approach, particularly in younger women with dense breast tissue. This study evaluates the efficacy of MTT in diagnosing breast lesions.

METHODS

A prospective observational study was conducted on 100 female patients aged 15 years and above presenting with palpable breast lumps at South Central Railway Hospital, Secunderabad, India. Patients underwent clinical examination, ultrasound (USG), and fine-needle aspiration cytology (FNAC), with histopathological examination (HPE) as the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each modality.

RESULTS

The majority of participants were in the 41-50 years age group (38%). Clinical examination demonstrated a sensitivity of 73.08% and specificity of 98.65%. Ultrasound exhibited a sensitivity of 57.69% and specificity of 98.64%. FNAC showed a sensitivity of 84.62% and specificity of 98.65%. MTT demonstrated 100% sensitivity, 98.65% specificity, and 96.30% PPV, significantly outperforming individual modalities.

CONCLUSION

The MTT is a highly accurate and reliable diagnostic approach for breast lump evaluation, reducing the need for unnecessary biopsies. Its high sensitivity and specificity make it a valuable tool for early breast cancer detection, especially in resource-limited settings.

Spectral Power Analysis of Delta Waves in Neonatal Electroencephalography: A Tool for Assessing Brain Maturation and Injury

Recent advances in neonatal care have improved survival rates of preterm infants but highlighted the persistent challenge of neurological impairments. This study focuses on delta wave analysis in neonatal electroencephalography (EEG) as a marker for brain maturation and injury. Using quantitative EEG methods, including spectral power analysis, we examined 399 EEG recordings from infants with gestational ages spanning 23-42 weeks. Results demonstrated significant maturation-related changes in delta wave spectral power across cortical regions, particularly in lower-frequency bands. Suppression of delta wave power correlated with visual assessments of brain injury severity. These findings suggest that delta wave spectral power analysis enhances the precision of brain function evaluation, providing a valuable complement to conventional methods such as amplitude-integrated EEG (aEEG). This approach holds potential for improving early diagnosis and guiding therapeutic interventions for neonatal brain injuries.

Surgical Second Opinion for Pancreatic Cancer Patients

BACKGROUND

Due to the complexity of pancreatic surgery, patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) may seek out the opinion of more than 1 surgeon. Little is known regarding how second surgical opinions impact the likelihood of pancreatectomy and perioperative outcomes. Our study aimed to determine the impact of obtaining second surgical opinions on pancreatectomy rates and to assess its impact on surgical outcomes.

STUDY DESIGN

Patients who were diagnosed with PDAC between 2013 and 2020 were identified using 100% Medicare Inpatient and Outpatient Standard Analytic Files. Data collected included the number of surgeons consulted and geographic region. Receipt of pancreatectomy and perioperative outcomes were compared between patients who received only 1 and more than 1 surgical consultation.

RESULTS

Of 116,072 patients diagnosed with PDAC, 10,640 (9.2%) underwent pancreatectomy. A total of 4,913 (4.2%) patients received a second surgical opinion, of whom 1,906 (17.9%) patients underwent pancreatectomy after the second opinion visit. Patients receiving a second surgical opinion were more likely to undergo pancreatectomy (adjusted odds ratio 6.17; 95% CI 5.78 to 6.59). Patients who received a second opinion and underwent surgery had equivalent length of stay and complication rates compared to those who underwent surgery without seeking a second opinion (both p > 0.05).

CONCLUSIONS

Among Medicare patients who underwent pancreatectomy for pancreatic cancer, approximately 1 in 7 patients received a second surgical opinion. Further research is needed to determine how patient motivations, referral patterns, disease characteristics, and treatments all interplay to affect clinical outcomes for patients undergoing pancreatectomy for PDAC.

Low-Invasive Biomarkers of Canine Mammary Tumours

Canine mammary tumours (CMTs) are the most common type of tumours in older bitches. An early, precise and low-invasive diagnosis is essential, due to some CMTs being malignant and having a poor prognosis. Fine needle aspiration cytology (FNAC) and blood tests are both low-invasive diagnostic methods that have been used in veterinary medicine. However, the perfect biomarkers should be identified to diagnose and evaluate the prognosis of CMTs. This review focuses on biomarkers that can be tested by FNA or blood samples based on current literature. Until now, the most studied biomarkers of FNAC, such as Ki-67, human epidermal growth factor receptor 2 (HER-2), oestrogen receptor (ER), progesterone receptor (PR), P53, E-cadherin and cyclooxygenase-2 (COX-2). Some common blood biomarkers that have been widely studied include lactate dehydrogenase (LDH), C-reactive protein (CRP), carbohydrate antigen 15-3 (CA15-3) and carcinoembryonic antigen (CEA). The novel biomarkers will also be mentioned: cancer stem cells (CSCs), circulating tumour cells (CTCs), miRNAs and circulating cell-free DNA (cfDNA); they are all useful markers. Copper ion and serum ferritin (SF) are good markers of human breast cancer; they may be candidates of CMTs biomarkers, too. In conclusion, many biomarkers are suitable for diagnosing and/or prognosing CMTs; combining a couple of them can increase the specificity; more detailed research should be done.

MRI-Guided Near-Infrared Spectroscopic Tomography (MRg-NIRST) Imaging System With Wearable Breast Optical Interface for Breast Cancer Imaging

OBJECTIVE

To develop a novel Magnetic Resonance Imaging (MRI)-guided Near-Infrared Spectroscopic Tomography (MRg-NIRST) imaging system with an MRI-compatible breast optical interface for breast imaging.

METHODS

The breast interface consists of eight flexible opto-electronic circuit strips, each equipped with six photodetectors and six side-firing fiber-probes. Concurrent MRI and NIRST data were acquired from a total of 2,304 source-detector positions at six wavelengths, enabling 3D MRg-NIRST image reconstruction of the entire breast. The system was validated through a series of phantom and normal subject studies.

RESULTS

Reconstructed images of phantoms with inclusions ranging 10-25 mm in diameter showed errors in the estimated inclusion diameter and contrast of total hemoglobin (HbT) within the inclusion relative to the background were ranged in [-7%, 12%] and [7%, 28%], respectively. HbT estimates from reconstructed images of nine normal subjects ranged between 8.0-l25.2 μM, align with previous imaging studies.

CONCLUSION

Results from both phantom and normal subject studies indicate that this system has the potential to be easily integrated into clinical practice for acquiring 3D MRg-NIRST images of the entire breast.

SIGNIFICANCE

The flexibility of the wearable breast optical interface, along with the increased number of sources and detectors, has improved the optical accessibility for breasts of various sizes, shapes, and tumor locations. 3D MRg-NIRST image reconstruction, based on optical data collected from multiple source-detector layers across the entire breast, demonstrates that MRg-NIRST is ready to be tested clinically for its potential to enhance breast cancer detection alongside MRI.

Breast cancer in Bulgaria prior implementation of a national breast cancer screening program and certified breast centers

INTRODUCTION

Breast cancer (BC) survival has improved globally in the past years. Eastern Europe is a region with lack of epidemiological data and traditionally lower BC overall survival (OS). We aimed to investigate the epidemiology of BC in Bulgaria between 2012 and 2022 and the readiness of the state for implementing population based organized screening program.

METHODS AND MATERIALS

This is a retrospective study of 38 576 invasive BC cases registered in Bulgarian National Cancer Registry. We obtained data from publicly available sources - national institutes and regulatory agencies. We report descriptive statistics of distribution of cases and mammography units among the country and the compared survival of patient's groups.

RESULTS

75 % of patients are treated in the 9 biggest cities. They are younger, diagnosed earlier and have significantly better OS than the rest of the patients. Patients over 75 years represent 18.7 % of all. The 211 installed mammography systems can secure the implementation of organized BC screening.

DISCUSSION

The survival gap between cities can be due to the limited access to care of older patients living in smaller cities. The model of collaboration between private and state centers can be highly effective in implementing of organized screening since in Bulgaria both can be reimbursed by the National Insurance Fund.

CONCLUSION

Further centralization of care probably would not have such an impact on treatment outcomes as improvement and monitoring the quality of the provided treatment. Organized BC screening in Bulgaria is needed and technically possible step towards improving survival.

Multi-locus inherited neoplasia alleles syndromes in cancer: implications for clinical practice

The popularity of multi-gene testing has identified more families with two or more pathogenic variants (PV) in cancer predisposition genes, also known as 'MINAS' (multilocus inherited neoplasia alleles syndromes). They are at risk of suboptimal treatment and management as little on this topic is known. We conducted a systematic review of published MINAS cases within cancer predisposition genes to understand their association with more severe presentations. We analysed 413 MINAS carriers, which included 33 novel cases from the Cancer Genetics Service, National Cancer Centre Singapore. Statistical tests were conducted to assess association between carrier characteristics and the number PV identified. Results suggest that MINAS carriers have more malignancies (31.7% vs 21.5% vs 10.3% %; p < 0.001), a younger median age of first cancer diagnosis (40.0 vs. 44.0 vs. 49.0 years; p < 0.001) and an early onset of cancer (defined as <5% PV-associated cancer risk at age of diagnosis) (24.9% vs 7.7% vs 4.7%; p < 0.001) compared to monoallelic and non-carriers. We also studied the association of clinical characteristics by the dominant or recessive nature of PV harboured, where more dominant-dominant (D-D) carriers reported multiple malignancies (34.0%), compared to dominant-recessive (D-R) (23.9%) and recessive-recessive (R-R) carriers (20%;) (p = 0.051). Our findings suggest that MINAS carriers are prone to more and younger malignancies and the dominant or recessive nature of PV within double carriers can affect clinical presentation. We suggest a framework to guide management based on the dominant or recessive nature of PV within double PV carriers.

The Autoimmune Profiles in the Etiopathogenesis of Granulomatous Lobular Mastitis

OBJECTIVES

Granulomatous lobular mastitis (GLM) is a chronic breast inflammation with low remission and high recurrence. This study aimed to investigate GLM patients' autoimmune profiles and their correlation with GLM etiopathogenesis.

METHODS

Samples from GLM patients and fibroadenoma (FA) controls admitted to Shuguang Hospital between July 2021 and July 2022 were analyzed. Patients (107 GLM, 73 FA) underwent humoral immunity (C3, C4, IgG, IgM, IgE and IgA), cellular immunity (CD3+CD4+ T cells, CD3+CD8+ T cells, regulatory T cells and CD4/CD8 ratio) and cytokines (IL-1β, IL-6, IL-8, IL-10, IL-12 and TNF-α) tests. Immunohistochemical staining (10 GLM, 10 FA normal tissues) detected IL-1β, IL-6, CD86 and CD206, and immunofluorescence (3 GLM, 3 FA normal tissues) evaluated CD86 and CD206 expression. Multivariate analysis was done using logistic regression.

RESULTS

GLM featured granulomas with non-caseation necrosis and inflammatory cell infiltration. GLM patients showed higher C3 (P < 0.001), C4 (P < 0.001), IgE (P < 0.05), IgA (P < 0.05), IL-6 (P < 0.001), and IL-8 levels (P < 0.05). M1 (CD86) and M2 (CD206) macrophage markers were significantly higher in GLM than controls in both immunohistochemical and immunofluorescent staining (P < 0.05). The multivariate logistic regression analysis revealed that reproductive history (OR = 7.011, P < 0.01) and C3 expression level (OR = 5565.570, P < 0.001) were independent factors of GLM.

CONCLUSIONS

The results highlighted the crucial role of elevated M1 and M2 macrophages in GLM inflammation. GLM was associated with reproductive history, C3, C4, IgE, IgA, IL-6, and IL-8, with reproductive history and C3 as independent risks.

Sisters But Not Twins: A Critical Appraisal of Long-Term Results in Breast Asymmetry Correction

BACKGROUND

Breast asymmetry is a common disorder, which can lead to significant emotional distress. Despite this, there is currently no widely accepted approach for managing this prevalent condition. Due to the high dimorphism of the breast, despite a satisfactory result in the short-term post-op, the recurrence of asymmetry is one of the most common weak points of breast recontouring. The purpose of this paper is to investigate the long-lasting maintenance of breast symmetry in women who have undergone surgical correction of asymmetric breasts through mastopexy or reduction mammoplasty and to try to identify some specific elements to achieve more stable outcomes in the long term.

METHODS

A retrospective study was conducted on 1,984 breast surgical procedures carried out between 2002 and 2020 to evaluate patient satisfaction and the recurrence rate of asymmetry disorders. All the patients enrolled in this study were given a questionnaire to evaluate their satisfaction level. A retrospective iconographic-chart review was investigated by the same senior surgeon, who recorded the presence or the absence of recurring breast asymmetry.

RESULTS

In total, 1984 patients were enrolled who respected the minimum standard of the study; 596 showed up at post-op follow-up longer than three years. Most of the patients showed great satisfaction with the results, even if several recurrences of asymmetry were reported.

CONCLUSIONS

The recurrence of asymmetry is one of the most common weak points of breast asymmetry correction procedures due to the high dimorphism of the breasts. In order to fully assess the results of asymmetric breast correction, patients should be required to attend a post-op follow-up examination after a long time frame. Indeed, the strength of this paper lies in the focus on long-term postoperative follow-up.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nomograms Integrating MRI-derived Apparent Diffusion Coefficient and Clinicopathologic Features for Prediction of Axillary Lymph Node Metastasis in Breast Cancer

Purpose To develop three nomograms integrating apparent diffusion coefficients (ADCs) derived from diffusion-weighted imaging to predict the status of pretreatment axillary lymph nodes (ALNs) (task 1), nonsentinel lymph nodes (task 2), and ALNs after neoadjuvant chemotherapy treatment (task 3) in patients with breast cancer. Materials and Methods Pretreatment MRI scans, including diffusion-weighted images, were retrospectively acquired from patients with breast cancer at multiple centers from May 2019 to May 2023. ADC values and clinicopathologic features were measured. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of ALN metastasis. These predictors were incorporated into nomogram models for each of the three tasks. Model performance was assessed with area under the receiver operating characteristic curve (AUC) analysis in training and two external testing datasets. Results The study included 961 female patients (mean age ± SD, 50 years ± 10) with breast cancer from three hospitals. In the three tasks, the ADC values of the ALN metastasis groups were lower than those of the nonmetastasis groups (all P < .05). The nomogram models combining ADC values and clinicopathologic features demonstrated high predictive performance for each task in the training cohort (task 1: AUC, 0.90; task 2: AUC, 0.74; task 3: AUC, 0.75), external testing cohort 1 (task 1: AUC, 0.86; task 3: AUC, 0.82), and external testing cohort 2 (task 1: AUC, 0.90; task 3: AUC, 0.84). Conclusion Nomograms incorporating ADCs and clinicopathologic features demonstrated good performance in predicting ALN metastasis in patients with breast cancer. Keywords: Breast, MR-Functional Imaging, MR-Diffusion Weighted Imaging, Apparent Diffusion Coefficient, Axillary Lymph Node Metastasis, Nonsentinel Lymph Node Metastasis, Neoadjuvant Chemotherapy, Nonogram Supplemental material is available for this article. © RSNA, 2025.

From Breast to Eye: A Rare Case of Ocular Metastasis From Luminal Breast Cancer in a Nicaraguan Patient

Ocular metastases from breast cancer are rare but significant, with invasive lobular carcinoma (ILC) showing a higher tendency for ocular involvement than invasive ductal carcinoma (IDC). Radiotherapy is the main treatment, but the prognosis is poor. This case involves a 37-year-old woman with a history of bilateral breast cancer, initially treated with surgery, chemotherapy, and radiotherapy. She later developed pulmonary progression, bone metastases, and other complications. The patient experienced worsening vision loss, headaches, tinnitus, and systemic decline. Imaging showed brain lesions and choroidal metastasis. Extensive metastasis was confirmed, including in the pleura, liver, and bones. Ophthalmologic evaluation revealed increased intraocular pressure, requiring medical management and planned cyclophotocoagulation. Due to the advanced disease, a palliative care approach was initiated, with radiotherapy planned for ocular metastasis. This case highlights the aggressive nature of metastatic luminal B breast cancer with ocular involvement and underscores the importance of early detection and a multidisciplinary approach to patient care.

Association of tumor-infiltrating lymphocytes with clinical outcomes in patients with triple-negative breast cancer receiving neoadjuvant chemotherapy: a systematic review and meta-analysis

OBJECTIVE

Triple-negative breast cancer (TNBC) presents a clinical challenge as an aggressive tumor, correlated with unfavorable prognosis. Tumor-infiltrating lymphocytes (TILs) have garnered interest as a potential prognostic biomarker. However, the disparity in outcomes between varying TILs rates remains inadequately explored.

METHODS

PubMed, Scopus, Web of Science, and Cochrane databases were searched for studies about the prognostic value of TILs in patients with TNBC receiving neoadjuvant chemotherapy. The hazard ratios (HRs) or odds ratios (ORs) were computed for binary endpoints, with 95% confidence intervals (CIs).

RESULTS

Twenty-nine studies were included, involving a population of six thousand one hundred sixty-one (80.41%) with TNBC. The cut-off TILs value ranged from 10 to 60%, with 50% being the most related value. Compared with the low-TIL expression group, the disease-free survival (DFS) (HR 0.71; 95% CI 0.61-0.82; p < 0.00001) and overall survival (OS) (HR 0.76; 95% CI 0.63-0.90; p = 0.002) rates showed significant improvement with higher TIL infiltrations. In the subgroup analyses of the lymphocyte subtypes CD4 + and CD8 + , there was statistical significance favoring higher TILs rates in both subtypes, each associated with improved DFS (HR 0.48; 95% CI 0.33-0.71; p = 0.0002) and OS (HR 0.53; 95% CI 0.36-0.78; p = 0.001), regardless of which cell subtype was predominantly infiltrated. The complete pathological response analysis showed better rates for the higher TIL group than the control for both the TIL (OR 1.29; 95% CI 1.13-1.48; p = 0.0003) and Ki-67 (OR 2.74; 95% CI 2.01-3.73; p < 0.00001) analyses.

CONCLUSION

Higher expressions of TILs in patients with TNBC were associated with improved significantly DFS, OS, and pCR outcomes.

Gene expression associated with endocrine therapy resistance in estrogen receptor-positive breast cancer

Despite endocrine therapy (ET), approximately 20-40% of Stage I-III estrogen receptor-positive breast cancer (ER + BC) patients experience recurrence. Recurrence while on ET is indicative of ET resistance. This study aimed to identify differentially expressed genes (DEGs) associated with recurrence during ET (ET resistance) and to explore gene expression differences across PAM50 molecular subtypes. Eighty tumor specimens from 79 patients treated at the City of Hope Comprehensive Cancer Center (2012-2016) were analyzed using NanoString technology. Fourteen patients (17.7%) experienced recurrence over a median follow-up of 68 months (range 35-104 months). Key upregulated DEGs in the recurrence group included EZH2 (log2 fold change[log2FC]: 0.67, p = 0.0017), WNT11 (log2FC: 1.08, p = 0.0088), ITGB6 (log2FC: 0.80, p = 0.0312), and TOP2A (log2FC: 0.79, p = 0.0381). Downregulated DEGs included SNAI2 (log2FC: - 0.63, p = 0.0055), ITPR1 (log2FC: - 0.75, p = 0.0083), CD10 (log2FC: - 0.70, p = 0.0092), PTEN (log2FC: - 0.29, p = 0.0163), VRD (log2FC: - 0.46, p = 0.0184), and WNT5A (log2FC: - 0.76, p = 0.0272). EZH2 and TOP2A were positively correlated with proliferation scores, while WNT11 and ITGB6 emerged as potential biomarkers independently associated with recurrence. These findings suggest novel biomarker candidates that could help overcome ET resistance, reduce recurrence, and improve outcomes in ER + BC.