Does Nipple-Ward Positive Margin Contribute to a Higher Rate of Re-Excision Procedures After a Lumpectomy with Pathology-Confirmed Positive Margins? A Retrospective Study

Background

Positive margins on lumpectomy specimens are associated with a twofold increased risk of local breast tumor recurrence. Prior literature has demonstrated various techniques and modalities for assessing margin status to reduce re-excision rates. However, there is paucity of literature analyzing which margin contributes to the highest re-excision rates. Therefore, the primary aim of the study was to investigate whether the nipple-ward margins resulted in a higher rate of re-excision in our patient population.

Methods

 A retrospective chart review was performed on patients who had re-excision surgery. Nipple-ward margin was identified by correlating radiological and pathological reports. A cut-off of more than 25% was used to demonstrate correlation between nipple-ward margin and re-excision rate.

Results

A total of 98 patients' data were analyzed, with 41 (41.8%), 14 (14.3%), 5 (5.1%), and 38 (38.8%) diagnosed with DCIS, IDC, ILC, and mixed pathology on their margins, respectively. Overall, 48% (n=47) of the positive margins were nipple-ward, with 44.7% (n=21) reporting DCIS. Upon stratification, 45 (45.9%) cases were single-margin positive, with 26 (57.8%) being nipple-ward. Furthermore, the remaining 53 (54.1%) patients had multiple positive margins, with 21 (39.6.7%) nipple-ward cases.

Conclusion

Positive nipple-ward margins significantly contribute to a higher re-excision rate p < 0.001; 48% of re-excision surgeries had positive nipple-ward margins, and 57.8% of positive single-margin cases were nipple-ward. Taking an additional shave during initial lumpectomy decreases re-excision rates. However, planning a lumpectomy procedure with a more elliptical rather than a spherical resection with additional cavity shave (ie, larger volume) in the nipple-ward direction and minimizing the remaining cavity shaves so the total volume resected remains unchanged. Nevertheless, future studies with larger sample sizes are required to bolster our findings.

Elevated Calcitonin Levels in a Patient With a Pheochromocytoma: A Case Report

Elevated calcitonin and catecholamine levels in patients with adrenal masses and thyroid nodules are suspicious for multiple endocrine neoplasia type 2A. Here, we present an interesting case with elevated catecholamines, thyroid nodules, and hypercalcitoninemia. A 46-year-old woman with complaint of abdominal pain was recently hospitalized. Abdominal computed tomography elicited a 7 cm left adrenal mass. Upon presentation to our clinic, the patient complained of abdominal pain, nausea, and diaphoresis. Laboratory studies showed elevated catecholamines, and a pheochromocytoma was subsequently diagnosed. Further evaluation elicited elevated calcitonin levels and a suspicious 3 cm left thyroid nodule, inciting concern for medullary thyroid carcinoma. The patient underwent an uneventful robot-assisted laparoscopic left adrenalectomy. Surgical pathology confirmed a pheochromocytoma. Post-operative calcitonin levels resolved to within normal range. The patient elected to undergo a left hemithyroidectomy. Surgical pathology confirmed calcitonin-negative nodular hyperplasia, negative for malignancy. The patient's diagnosis was confined to a pheochromocytoma. Clinicians should investigate high calcitonin levels associated with a pheochromocytoma as it may not always be ascribed to the thyroid.

Case Report: Bilateral targeted intraoperative radiotherapy: a safe and effective alternative for synchronous bilateral breast cancer

Background

The incidence of bilateral breast cancer (BBC) ranges from 1.4% to 11.8%. BBC irradiation is a challenge in current clinical practice due to the large target volume that must be irradiated while minimizing the dose to critical organs. Supine or prone breast techniques can be used, with the latter providing better organ sparing; both, however, result in lengthy treatment times. The use of Intra-operative radiotherapy (IORT) in breast cancer patients who choose breast conservation has been highlighted in previous studies, but there is a scarcity of literature analyzing the utility and applicability of IORT in BBC. This case series aims to highlight the applicability of administering bilateral IORT in patients with BBC.

Case reports

Five patients with bilateral early-stage breast cancer (or DCIS) were treated with breast-conserving surgery followed by bilateral IORT. Of the 10 breast cancers, 8 were diagnosed as either DCIS or IDC, while the other 2 were diagnosed as invasive lobular carcinoma and invasive carcinoma, respectively. During surgery, all patients received bilateral IORT. Furthermore, 1 patient received external beam radiation therapy after her final pathology revealed grade 3 DCIS. The IORT procedure was well tolerated by all five patients, and all patients received aromatase inhibitors as adjuvant therapy. Additionally, none of these patients showed evidence of disease after a 36-month median follow-up.

Conclusion

Our findings demonstrate the successful use of IORT for BCS in patients with BBC. Furthermore, none of the patients in our study experienced any complications, suggesting the feasibility of the use of IORT in BBC. Considering the benefits of improved patient compliance and a reduced number of multiple visits, IORT may serve as an excellent patient-centered alternative for BBC. Future studies are recommended to reinforce the applicability of IORT in patients with BBC.

Can the Clinical Utility of iBreastExam, a Novel Device, Aid in Optimizing Breast Cancer Diagnosis? A Systematic Review

PURPOSE

A portable, cost-effective, easy-to-use, hand-held Intelligent Breast Exam (iBE), which is a wireless, radiation-free device, may be a valuable screening tool in resource-limited settings. While multiple studies evaluating the use of iBE have been conducted worldwide, there are no cumulative studies evaluating the iBE's performance. Therefore this review aims to determine the clinical utility and applicability of iBE compared with clinical breast examinations, ultrasound, and mammography and discuss its strengths and weaknesses when performing breast-cancer screening.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four electronic databases were searched: PubMed, Cochrane Library, Web of Science, and Google Scholar.

RESULTS

The review included 11 studies with a total sample size of 16,052 breasts. The mean age ranged from 42 to 58 years. The sensitivity and specificity of the iBE ranged from 34.3% to 86% and 59% to 94%, respectively. For malignant lesions, iBE demonstrated a moderate to higher diagnostic capacity ranging from 57% to 93% and could identify tumor sizes spanning from 0.5 cm to 9 cm.

CONCLUSION

Our findings underscore the potential clinical utility and applicability of iBE as a prescreening and triaging tool, which may aid in reducing the burden of patients undergoing diagnostic imaging in lower- and middle-income countries. Furthermore, iBE has shown to diagnose cancers as small as 0.5 cm, which can be a boon in early detection and reduce mortality rates. However, the encouraging results of this systematic review should be interpreted with caution because of the device's low sensitivity and high false-positive rates.

Radiofrequency ablation as a novel modality in the USA for treating toxic thyroid nodules: case series and literature review

Background

Radiofrequency ablation (RFA) is widely accepted as a treatment for non-functioning benign thyroid nodules, mainly to reduce compressive symptoms. In addition to potential compressive symptoms, autonomously functioning thyroid nodules (AFTNs) can cause palpitations, weight loss, diarrhea, increased appetite, flushing, irritability, tiredness, poor sleep, and long-term cardiovascular and musculoskeletal consequences. Currently, there are no United States based RFA practice guidelines for the treatment of AFTNs. However, several reports from Asia and Europe have described the resolution of hyperthyroidism secondary to AFTNs with RFA.

Case Description

Three patients with toxic thyroid nodules presented with symptomatic hyperthyroidism, suppressed thyroid-stimulating hormone (TSH), and increased uptake on nuclear medicine thyroid scan. These patients were treated with RFA. At 3 months following ablation, TSH normalized to 2.09, 1.91, and 1.34 mIU/mL respectively. However, temporary hypothyroidism was encountered at 1 month following ablation. All patients discontinued their antithyroid medications following ablation. Nodules exhibited significant volume reductions of 38%, 32%, and 54% from the baseline at 1-month follow-up.

Conclusions

RFA potentiates as a safe and effective treatment of toxic thyroid nodules. Though it carries a risk of temporary hypothyroidism following ablation, long-term consequences appear to be minimal. Future study with larger sample size and longer follow-up are encouraged to identify factors predicting response.

Excess of cesarean births in pregnant women with COVID-19: A meta-analysis

BACKGROUND

Studies have suggested that cesarean birth in pregnant women with COVID-19 may decrease maternal adverse events and perinatal transmission. This systematic review aimed to evaluate variations in clinical presentation, laboratory findings, and maternal/neonatal outcomes in COVID-19 patients who delivered vaginally versus via cesarean.

METHODS

A comprehensive search following PRISMA guidelines was performed for studies published up to May 23, 2020, using PubMed, Web of Science, Scopus, Embase, Cochrane, Science Direct, and clinicaltrials.gov. Original retrospective and prospective studies, case reports, or case series with sufficient data for estimating the association of COVID-19 with different pregnancy outcomes with no language restriction and published in peer-reviewed journals were included. Pooled mean and arcsine transformation proportions were applied. Next, a two-arm meta-analysis was performed comparing the perinatal outcomes between the study groups.

RESULTS

Forty-two studies with a total of 602 pregnant women with COVID-19 were included. The mean age was 31.8 years. Subgroup analysis showed that Americans had the lowest gestational age (mean = 32.7, 95%CI = 27.0-38.4, P < 0.001) and the highest incidence of maternal ICU admission (95%CI = 0.45%-2.20, P < 0.001) of all nationalities in the study. There was no significant difference in perinatal complications, premature rupture of membrane, placenta previa/accreta, or gestational hypertension/pre-eclampsia between women who delivered vaginally versus by cesarean. Importantly, there were also no significant differences in maternal or neonatal outcomes.

CONCLUSION

Vaginal delivery was not associated with worse maternal or neonatal outcomes when compared with cesarean. The decision to pursue a cesarean birth should be based on standard indications, not COVID-19 status.

COVID-19 and liver dysfunction: A systematic review and meta-analysis of retrospective studies

Recently, Coronavirus Disease 2019 (COVID‐19) pandemic is the most significant global health crisis. In this study, we conducted a meta‐analysis to find the association between liver injuries and the severity of COVID‐19 disease. Online databases, including PubMed, Web of Science, Scopus, and Science direct, were searched to detect relevant publications up to 16 April 2020. Depending on the heterogeneity between studies, a fixed‐ or random‐effects model was applied to pool data. Publication bias Egger's test was also performed. Meta‐analysis of 20 retrospective studies (3428 patients), identified that patients with a severe manifestation of COVID‐19 exhibited significantly higher levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin values with prolonged prothrombin time. Furthermore, lower albumin level was associated with a severe presentation of COVID‐19. Liver dysfunction was associated with a severe outcome of COVID‐19 disease. Close monitoring of the occurrence of liver dysfunction is beneficial in early warning of unfavorable outcomes.

Liver dysfunction was associated with a severe outcome of COVID‐19

Sever cases of COVID‐19 patients have high serum levels of ALT, AST and bilirubin with prolonged prothrombin time.

Low serum albumin is associated with a severe presentation of COVID‐19

Close monitoring of the occurrence of liver dysfunction is beneficial in early warning of unfavorable COVID‐19 outcomes.