The Role of Collaborative Observational Practice and Feedback-Discourse to Promote Remote Acquisition of Technical Surgical Skills

INTRODUCTION

Acquisition of technical skills remotely in a decentralized model requires an efficacious way of providing feedback. The primary objective was to test the efficacy of various forms of feedback on the acquisition of surgical skills by medical students.

METHODS

Forty volunteers were randomized to four experimental groups, differing from the nature of feedback (free text versus structured) and who provided the feedback (expert versus peer learners). They had to perform sutures and upload attempts on a learning management system to receive interactive feedback. The pretest and retention test performances were assessed.

RESULTS

All groups significantly improved from pretests to retention tests; however, participants using checklist showed statistically lower improvements than the other groups, which did not differ from each other.

CONCLUSIONS

Remote learners can acquire surgical skills, and most importantly, peers who provide feedback, are as effective as experts if they use open-ended comments and not checklists.

Application of Frailty Quantile Regression Model to Investigate of Factors Survival Time in Breast Cancer: A Multi-Center Study

Background

The prognostic factors of survival can be accurately identified using data from different health centers, but the structure of multi-center data is heterogeneous due to the treatment of patients in different centers or similar reasons. In survival analysis, the shared frailty model is a common way to analyze multi-center data that assumes all covariates have homogenous effects. We used a censored quantile regression model for clustered survival data to study the impact of prognostic factors on survival time.

Methods

This multi-center historical cohort study included 1785 participants with breast cancer from four different medical centers. A censored quantile regression model with a gamma distribution for the frailty term was used, and p-value less than 0.05 considered significant.

Results

The 10^th and 50^th percentiles (95% confidence interval) of survival time were 26.22 (23–28.77) and 235.07 (130–236.55) months, respectively. The effect of metastasis on the 10^th and 50^th percentiles of survival time was 20.67 and 69.73 months, respectively (all p-value < 0.05). In the examination of the tumor grade, the effect of grades 2 and 3 tumors compare with the grade 1 tumor on the 50^th percentile of survival time were 22.84 and 35.89 months, respectively (all p-value < 0.05). The frailty variance was significant, which confirmed that, there was significant variability between the centers.

Conclusions

This study confirmed the usefulness of a censored quantile regression model for cluster data in studying the impact of prognostic factors on survival time and the control effect of heterogeneity due to the treatment of patients in different centers.

Immediate Breast Reconstruction Using the Autologous Dermal Flap

INTRODUCTION

Despite the development of breast-conserving surgery in breast cancer treatment, there still remain indications for total mastectomy. Since mastectomy has a significant negative impact on the patients' quality of life, breast reconstruction is increasingly popular. However, for patients with large ptotic breasts who do not choose tissue-based reconstruction techniques and prefer implant-based breast reconstruction, there is no single-stage breast reconstruction technique other than the classic technique using Acellular Dermal Matrix (ADM).

METHODS

This study presents a novel technique for Nipple-Sparing Mastectomy (NSM) and Immediate Breast reconstruction (IBR) in 11 operations (in seven patients) whose treatment decision-making was based on NCCN guidelines. In this technique, the implant/tissue expander is covered by the pectoral muscle in the upper part and an autologous dermal flap in the lower part, replacing an ADM. The dermal flap is created from the de-epithelialized lower mastectomy flap in these large ptotic breasts. Maintaining the nipple-areola complex (NAC) is possible by re-implanting a free nipple split-thickness graft from the NAC of the ipsilateral breast prepared at the beginning of the operation.

RESULTS

All seven patients had large ptotic breasts ranging from C cup to double D in size and grade 2 and higher breast ptosis. The mean BMI of the patients was 28 (range: 26-33). No major complications occurred postoperatively. There were three minor complications, all managed conservatively. Surgical indications were risk reduction surgery in three patients with BRCA mutations and therapeutic in the remaining patients (three multifocal invasive ductal carcinomas and one diffused ductal carcinoma in situ). None of the patients had a previous reduction mammoplasty as preparation for NSM, and all the patients underwent a single operation. No breast tissue remained under the NAC, which is ideal with the NSM technique.

CONCLUSIONS

The proposed technique is excellent for implant-based IBR in patients with large ptotic breasts. It eliminates the use of ADM mesh and reduces the cost and postoperative complication rate associated with ADM. Furthermore, using a free nipple graft technique can eliminate the need for a preparatory mastopexy. This technique can also theoretically reduce the risk of recurrence or new primary breast cancer as there are no remaining ducts beneath the nipple-areola complex.

Real-time Detection of Cellular Metabolism: a New Trend for Intra-Operative Diagnosis of Cavity Margins

Not applicable

Expansion of the quality of care index on breast cancer and its risk factors using the global burden of disease study 2019

BACKGROUND

Breast cancer (BC), as the top neoplasm in prevalence and mortality in females, imposes a heavy burden on health systems. Evaluation of quality of care and management of patients with BC and its responsible risk factors was the aim of this study.

METHODS

We retrieved epidemiologic data of BC from the Global Burden of Disease (GBD) 1990-2019 database. Epidemiology and burden of BC and its risk factors were explored besides the Quality of Care Index (QCI) introduced before, to assess the provided care for patients with BC in various scales. Provided care for BC risk factors was investigated by their impact on years of life lost and years lived with disability by a novel risk factor quality index (rQCI). We used the socio-demographic index (SDI) to compare results in different socio-economic levels.

RESULTS

In 2019, 1,977,212 (95% UI: 1,807,615-2,145,215) new cases of BC in females and 25,143 (22,231-27,786) in males was diagnosed and this major cancer caused 688,562 (635,323-739,571) deaths in females and 12,098 (10,693-13,322) deaths in males, globally. The all-age number of deaths and disability-adjusted life years attributed to BC risk factors in females had an increasing pattern, with a more prominent pattern in metabolic risks. The global estimated age-standardized QCI for BC in females in 2019 was 78.7. The estimated QCI was highest in high SDI regions (95.7). The top countries with the highest calculated QCI in 2019 were Iceland (100), Japan (99.8), and Finland (98.8), and the bottom countries were Mozambique (16.0), Somalia (8.2), and Central African Republic (5.3). The global estimated age-standardized rQCI for females was 82.2 in 2019.

CONCLUSION

In spite of the partially restrained burden of BC in recent years, the attributable burden to risk factors has increased remarkably. Countries with higher SDI provided better care regarding both the condition and its responsible risk factors.

Ultrasound features of pregnancy-associated breast cancer: A retrospective observational analysis

Pregnancy-associated breast cancer (PABC) is a poor prognosis in women, and the mortality rate is higher in this subgroup of patients than in non-PABC. This study aims to assess clinicopathological and ultrasound features of patients with PABC. Of 75 patients with breast cancer, 31 cases were in lactating, or pregnancy phase and 44 patients had no recent history of pregnancy/lactation at the time of cancer detection. The available pathological characteristics and ultrasound findings of the PABC and non-PABC groups were compared. The analysis of ultrasound findings demonstrated that the percentages of antiparallel orientation (p = 0.04) and heterogeneous internal echo pattern (p = 0.002) were higher in the PABC group. The final Breast Imaging Reporting and Data System (BI-RADS) assessment in the two groups was significantly different (p = 0.008). In this study, most PABCs were BI-RADS 4c or 5; compared with age-matched non-PABC cases. There were significant differences in ER (p = 0.03), receptor groups (p = 0.007), and tumor grade (p = 0.02) in PABC compared to non-PABC group. To conclude, radiologists should be careful about ultrasound findings of PABC and recommend core needle biopsy in suspected cases.

Role of Corticosteroids along with Other Therapies for Treatment of Idiopathic Granulomatous Mastitis: A Narrative Review

Background: The use of oral corticosteroids to treat idiopathic granulomatous mastitis (IGM) has been a point of controversy for a long time. In addition, a wide diversity of combinations with other therapies have been reported so far. This study aims to review the usage of oral corticosteroids and their combinations in the published literature. Methods: PubMed and Scopus were searched using the key word “granulomatous mastitis.” Citations were filtered in two stages, considering the titles/abstracts and full texts. Papers reporting the treatment of IGM with corticosteroids with/without other treatments were included. Results: Fifty-eight citations were included in this study, 31 of which had at least a group of patients treated only with systemic corticosteroids. Combination therapy of systemic steroids with immunosuppressants, surgical interventions, and antibiotics were used in 6, 12, and 13 studies, respectively. Conclusion: Considering the inconsistency of studies in reporting the severity of the disease, administered treatments, outcome of treatment, side effects, and follow-up, our study failed to provide solid evidence for using corticosteroids as the first step in the management of idiopathic granulomatous mastitis. There is still a need for further studies emphasizing the homogenization of such reports. In this regard, preparing a questionnaire to help homogenize future reports on IGM is highly recommended.

Global Distribution of Idiopathic Granulomatous Mastitis: A Scoping Review

Background: Idiopathic granulomatous mastitis (IGM) is a challenging exclusion diagnosis for breast lesions, manifested as benign, chronic inflammation of the breast tissue. Although some evidence suggest that IGM cases are not uniformly distributed worldwide, few investigations have specifically addressed this topic. This study aims to examine the distribution of IGM cases among countries and races/ethnicities based on reported cases.Methods: A review of studies with a report of at least one IGM patient published from 2011 to 2020 inclusive was conducted. The search was performed in MEDLINE, and citations were filtered in two stages by title/abstract and full text. Those cases with a positive growth of pathogens, male granulomatous mastitis and review articles were excluded.Results: Among 365 retrieved publications, 218 were finally included based on the inclusion and exclusion criteria, comprising 7161 patients from 34 different countries. Turkey, the United States, and China were the countries where the most publications (including case reports) originated. Considering the number of patients within papers, Turkey, Iran, and China were the pioneers. Conclusion: Based on the published literature, some populations seem to be more prone to IGM. Further investigations may reveal the genetic and environmental factors associated with this disease in different geographic areas.

Human study on cancer diagnostic probe (CDP) for real-time excising of breast positive cavity side margins based on tracing hypoxia glycolysis; checking diagnostic accuracy in non-neoadjuvant cases

BACKGROUND

Cancer diagnostic probe (CDP) had been developed to detect involved breast cavity side margins in real-time (Miripour et al. Bioeng Transl Med. e10236.). Here, we presented the results of the in vivo human model CDP studies on non-neoadjuvant cases.

METHODS

This study is a prospective, blind comparison to a gold standard, and the medical group recruited patients. CDP and frozen data were achieved before the permanent pathology experiment. The main outcome of the study is surgical margin status. From November 2018 to April 2020, 202 patients were registered, and 188 were assigned for the study. Breast-conserving surgery at any age or gender, re-surgery due to re-currency, or involved margins are acceptable. Patients must be non-neoadjuvant. The reliability of CDP scoring had been evaluated by the pathology of the scored IMs. Then, three models of the study were designed to compare CDP with the frozen sections. Receiver operating characteristic (ROC) curves and AUC were measured based on the permanent postoperative pathology gold standard.

RESULTS

A matched clinical diagnostic categorization between the pathological results of the tested IMs and response peaks of CDP on 113 cases, was reported (sensitivity = 97%, specificity = 89.3%, accuracy = 92%, positive predictive value (PPV) = 84.2%, and negative predictive value (NPV) = 98%). Study A showed the independent ability of CDP for IM scoring (sensitivity = 80%, specificity = 90%, accuracy = 90%, PPV = 22.2%, and NPV = 99.2%). Study B showed the complementary role of CDP to cover the missed lesions of frozen sections (sensitivity = 93.8%, specificity = 91%, accuracy = 91%, PPV = 55.6%, and NPV = 99.2%). Study C showed the ability of CDP in helping the pathologist to reduce his/her frozen miss judgment (specificity = 92%, accuracy = 93%, PPV = 42.1%, and NPV = 100%). Results were reported based on the post-surgical permanent pathology gold standard.

CONCLUSION

CDP scoring ability in intra-operative margin detection was verified on non-neoadjuvant breast cancer patients. Non-invasive real-time diagnosis of IMs with pathological values may make CDP a distinct tool with handheld equipment to increase the prognosis of breast cancer patients.

Evaluation of the indication of BRCA1/2 genetic tests in Iranian women and acceptance rate of risk-reducing surgeries in BRCA mutation carriers

BACKGROUND

A higher risk for breast and ovarian cancer has been reported in BRCA carriers and prophylactic surgeries are proposed to reduce this risk. This retrospective cohort study has evaluated the indication of BRCA1/2 genetic tests in Iranian women and the rate of women's acceptance of prophylactic surgeries recommended by the surgeon.

METHODS

Medical records of 147 high-risk women according to NCCN clinical practice guidelines who referred for BRCA mutations testing were assessed. Individual information, indications for BRCA1/2 genetic testing and their results, physician recommendations, and type of accepted surgery were registered. To evaluate the current status of women an active visit follow-up every six months was conducted.

RESULTS

The mean age of women was 43.40 ± 10.94 and the median follow-up time was 1.92 years. Genetic test results showed 49(33.3%) women were positive for either BRCA1/2 mutations. Although the occurrence of breast cancer younger than 40 was the most common indication for genetic tests (26.5%), positive breast cancer history in first-degree relatives and two relatives younger than 50 was the most common indications with positive results. The rate of acceptance of prophylactic mastectomy and bilateral salpingo-oophorectomy was (14.3% and 34.7%) in BRCA mutation carriers.

CONCLUSION

If the onset of breast cancer at a young age (less than 40) will be the only indication for a BRCA analysis, the rate of a positive result (12.8%) is very low. Further studies are warranted to evaluate the age limit for genetic testing in our country. Prophylactic mastectomy acceptance is very low in BRCA1/2 carriers in our centers.

Prediction of Local Recurrence After Oncoplastic Breast Surgery: Analysis of a Large Cohort

BACKGROUND

Oncoplastic breast surgery (OBS) is becoming an acceptable procedure for the surgical treatment of breast cancer; however, its safety and recurrence rate still need further clarification. This study evaluates the rate of local recurrence and its predictive factors after OBS in a large series of patients. Materials and methods This study was conducted between January 2008 and June 2018 in two centers in Iran. Patients underwent OBS, and baseline characteristics were recorded. Patients underwent regular follow-up; local recurrence rate, median time, and the hazard ratio of predictive factors were calculated. Also, a multivariate analysis was performed. Results A total of 676 patients with a mean age of 48 ± 10.7 y were included. The median follow-up time was 26.4 (first, third IQR: 13.2, 45.6) mo, and 37 (5.5%) patients were diagnosed with local recurrence. The median time to local recurrence was 22.0 (first, third IQR: 16.0, 32.8) mo. Pathological N stage, neoadjuvant chemotherapy, overexpression of HER2, and one surgery technique was associated with a higher risk of recurrence, while the expression of estrogen receptor and progesterone receptor (PR) decreased the risk of recurrence. PR status, neoadjuvant chemotherapy, and pathological N stage remained significant in the final model for recurrence on multivariate analysis. Conclusion OBS is a safe technique with an acceptable risk of local recurrence. PR status, neoadjuvant chemotherapy, and pathological N stage can predict recurrence in these patients with an acceptable power.

Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis

Introduction

Targeted axillary dissection (TAD) is a novel technique in the field of surgical oncology. During TAD, patients with node-positive breast cancer who clinically responded to neoadjuvant chemotherapy undergo resection of a previously proven metastatic node together with sentinel lymph node dissection (SLND). We aimed to assess the success rates of seed insertion and seed retrieval in the Canadian setting, as well as hospital costs of the procedure.

Methods

Patients converted to clinically node-negative status post-neoadjuvant chemotherapy underwent TAD. Before surgery, an iodine-125 radioactive seed was inserted in the previously proven metastatic node. The seed node was resected together with an SLND. Axillary lymph node dissection (ALND) was performed in all patients with residual metastases.

Results

Radioactive seeds were successfully inserted in 34/35 patients. In 34 patients, the targeted node was successfully resected with the radioactive probe during TAD. In one patient, the seed was retrieved inferiorly in the axilla during surgery. There was no adverse event. In total, 50% (17/34) of patients had no residual metastases and were able to avoid ALND. Eight out of 17 patients who underwent ALND did not have any residual disease in their specimen. The mean cost of TAD was 25% superior to the mean cost of ALND (p = 0.02). However, the mean total cost of the hospital stay for TAD was 20% superior to the mean cost of ALND (p = 0.11). The mean cost of TAD was 4,322 Can$ (Canadian dollars), similar to the mean cost of both ALND and SLND performed during the same procedure (4,479 Can$).

Conclusions

TAD was successful in 97% of patients. Despite increased procedural costs, with a lesser impact on total hospital stay costs, TAD was beneficial in 50% of patients. These patients avoided the unnecessary morbidity associated with ALND.

Expression of SCUBE2 and BCL2 Predicts Favorable Response in ERα Positive Breast Cancer

BACKGROUND

The study aimed at evaluating steroid biomarker genes (ERα, PGR, ERβ) and determining the expression level of estrogen-regulated genes (SCUB2 and BCL2) and growth factors receptors (HER2 and IGFR1) in cancer tissue samples obtained from Iranian patients with breast cancer. Moreover, relationships with clinicopathologic aspects of tumor and response to treatment were studied.

METHODS

The current study was conducted on 246 breast tissue samples. The expression levels of these genes and their relationships with clinicopathologic aspects and treatment response were evaluated.

RESULTS

Based on immunohistochemistry (IHC) results, 12% of the ER negative patients expressed ERα. Comparing the effects of ERα and coexpression of BCL2 and SCUBE2 on the survival of the patients demonstrated remarkably poorer survival in ERα positive, SCUBE2, and BCL2 negative groups in comparison with other patients, which was statistically significant in the log-rank analysis (P = 0.01). Evaluation of the effects of coexpression of HER2 and IGFR1 on patients' survival demonstrated a worse survival rate in patients with positive expression of both receptors, which was insignificant.

CONCLUSION

Many studies suggest that PGR alone is not enough for the functional evaluation of ERα. Evaluation of the progesterone receptor expression as well as other genes such as BLC2, SCUBE2, and IGFR1, seems necessary to evaluate functionality.

Classification of the Clinical Presentation, Severity, and Response to Treatment in Idiopathic Granulomatousis Mastitis

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Accurate Estimation of Breast Tumor Size: A Comparison Between Ultrasonography, Mammography, Magnetic Resonance Imaging, and Associated Contributing Factors

Objective

This study aimed to provide further evidence on the accuracy of tumor size estimates and influencing factors.

Materials and Methods

In this cross-sectional study, patients with a biopsy-proven diagnosis of breast cancer referred to our hospital to obtain a preoperative magnetic resonance imaging (MRI) between 2015 and 2016 were included. Data from 76 breast cancer patients with 84 lesions were collected. All participants underwent ultrasonography and MRI, and their mammograms (MGMs) were reevaluated for tumor size estimation. Measurements by the three imaging modalities were compared with the pathologically determined tumor size to assess their accuracy. Influencing factors such as surgical management, molecular and histopathological subtypes, and Breast Imaging Reporting and Data System enhancement types in MRI were also assessed.

Results

The rates of concordance with the gold standard were 64.3%, 76.2%, and 82.1% for MGM, ultrasound (US), and MRI measurements, respectively. Therefore, the highest concordance rate was observed in MRI-based estimates. Among the discordant cases, US and MGM underestimation were more prevalent (70%); nevertheless, MRI showed significant overestimation (80%). Tumor size estimates in patients whose MRIs presented with either non-mass enhancement [p=0.030; odds ratio (OR)=17.2; 95% confidence interval (CI): 1.3-225.9] or mass lesion with non-mass enhancement (p=0.001; OR=51.0; 95% CI: 5.0-518.4) were more likely to be discordant with pathological measurements compared with those in cases with only mass lesion on their MRIs.

Conclusion

MRI was more accurate than either US or MGM in estimating breast tumor size but had the highest overestimation rate. Therefore, caution should be practiced in interpreting data obtained from subjects whose MRIs present with non-mass enhancement or mass lesion with non-mass enhancement.

Oncoplastic Repair in Breast Conservation: Comprehensive Evaluation of Techniques and Oncologic Outcomes of 937 Patients

BACKGROUND

Breast-conserving surgery, especially with oncoplastic breast surgery (OBS), is becoming the standard of care in the surgical management of breast cancer. We investigated the applied technique of OBS and oncologic outcomes in a large series of patients.

PATIENTS AND METHODS

This study was conducted between January 2008 and June 2018 in two centers in Iran. Patients underwent OBS. Early and late postoperative complications, oncologic outcomes, and follow-up data were documented.

RESULTS

Nine hundred thirty-seven patients with a mean ± standard deviation age of 48.1 ± 11.3 underwent OBS. Most of the patients were diagnosed with early-stage disease, of which the most common pathology was invasive ductal carcinoma (83.3%). Lateral oncoplasty was the most commonly used OBS technique (324 cases, 34.6%). The most common complication was seroma formation. Reduction-type OBS technique had the highest rate of complications (13.1%). Thirty-four patients (5.4%) experienced local recurrence, with a median recurrence time of 26.4 months. Nine patients (1.3%) died from cancer recurrence.

CONCLUSION

OBS is a safe procedure with minor complications and good oncologic outcomes. These techniques can be applied to most patients who are candidates for breast-conserving surgery.

Conflict of Interest: Are Iranian Breast Cancer Specialists Prone to it?

Introduction:

Giving gifts is a common way to promote and encourage the use of products of trading companies and increase the patient referrals to diagnostic centers. The present study aimed to assess the practice of physicians of different (sub) specialties/educational levels engaged in breast cancer management in some conflict of interest (COI) situations in their relation with pharmaceutical companies and paraclinical centers.

Methods:

A self-administered online questionnaire including questions on demographic and professional information as well as the attitude of physicians toward COI by answering the questions in three different practical scenarios was developed. Respondents were asked to answer each question by selecting one of the five options: strongly agree, agree, undecided/neutral, disagree, and strongly disagree in their own practices as well as the same questions asking the same subject for what they think of the other physicians. Descriptive statistical analysis was used to report qualitative and quantitative variables.

Result:

The response rate was 66.24%. In general, physicians considered their performance better than that of other physicians in the situations asked. More than 90% stated that they would participate in the sponsorship congress for introducing new drugs. One fifth of the physicians stated that they would accept the 30% financial proposition for the referral of every single patient to other clinics. More than half of the physicians stated that they had considered the risks resulted from the COI for referring patients to private radiobiological centers.

Conclusion:

This study indicated that physicians in the field of breast cancer were at the risk of COI. Even within the medical field, there is not sufficient trust in the proper functioning of doctors in dealing with COI situations.

Idiopathic granulomatous mastitis: Management and predictors of recurrence in 474 patients

Idiopathic Granulomatous Mastitis (IGM) is an uncommon inflammatory disease of the breast, with similar presentations as breast cancer and a relatively high recurrence rate. We reviewed the demographics, clinical presentations, and treatment modalities of a large cohort of patients in Iran. Most of the patients had history of pregnancy and breastfeeding. The most common clinical finding was pain and a palpable mass, respectively. Most of the patients received medical treatment, and about half of the patients had surgery. The recurrence rate was 24.8%, and breast skin lesions were associated with a significantly higher odds of recurrence.

Modifications in Breast Cancer Guidelines in COVID19 Pandemic; An Iranian Consensus

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Oncoplastic and Reconstructive Breast Surgery: Who Is in Charge to Do It?

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The Persian Version of the Fear of Cancer Recurrence Inventory (FCRI): Translation and Evaluation of Its Psychometric Properties

Background: This study aimed to translate and validate the Fear of Cancer Recurrence Inventory (FCRI) questionnaire into Persian and to investigate its psychometric properties. Methods: The FCRI was translated to Persian using a linguistic methodology according to WHO guidelines. A total of 450 breast cancer survivors who had the following inclusion criteria were included: time elapse of more than six months after the treatment prior to the study; absence ofobjective markers of recurrence, fluency in the Persian language, and signing the informed consent. Internal consistency was estimated with Cronbach's α coefficient and test-retest reliability with Interclass correlation.  Concurrent validity was estimated through Pearson’s correlation between the FCRI and Hospital Anxiety and Depression Scale (HADS). Principal component analysis (PCA) and confirmatory factor analysis (CFA) were employed to evaluate dimensionality. Results: The Persian version was acceptable for patients. The content validity index (CVI) was 0.80.  The instrument had good test-retest reliability (ICC= 0.96) and internal consistency (Cronbach’s α=0.86).  PCA and CFA indicated that the factor structure of the Persian version was similar to the original questionnaire and had acceptable goodness of fit.  Correlations between the FCRI and HADS was remarkable (r= 0.252 – 0.639), indicating acceptable concurrent validity. Conclusions: The Persian version of FCRI could be considered a good cross-cultural equivalent for the original English version. The questionnaire was a reliable and valid instrument in terms of internal consistency, test-retest reliability, and dimensionality.

Investigation of Prognostic Factors of Survival in Breast Cancer Using a Frailty Model: A Multicenter Study

Background

Using data from different health centers can provide more accurate knowledge of the survival prognostic factors and their effect on the patient's survival. In this multicenter study, we aimed to investigate the role of prognostic factors on breast cancer survival with large data set.

Methods

This historical cohort study was carried out using data from 1785 participants with breast cancer. Data were gathered from medical records of patients referring to 4 breast cancer research centers in Tehran, Iran, between 1997 and 2013. Age at diagnosis (year), size of the tumor, involve lymph nodes, tumor grade, type of surgery, auxiliary treatment of chemotherapy, radiotherapy, recurrence, and metastasis were the prognosis factors considered in this study. A shared frailty model with a gamma distribution for frailty term was used.

Results

The median follow-up period was 29.71 months with the interquartile range of 19 to 61 months. During the follow-up period, 337 (18.9%) patients died from breast cancer and 1448 (81.1%) survived. The 1-, 3-, 5-, and 10-year survival rates were 96%, 84%, 76%, and 58%, respectively. In the Cox model by centers, in Center A, the type of surgery, number of nodes involved, and the grade 3 tumor; in center B, age, radiotherapy, metastasis, and between 1 and 3 involved nodes; in center C, age, radiotherapy, recurrence, metastasis, tumor size, and grade 3 tumor; and in center D, chemotherapy, metastasis, and lymph nodes involved were significant. Shared frailty model showed that type of surgery, number of lymph nodes involved, metastasis, radiotherapy, and the tumor grade are the prognostic factors survival in breast cancer. The frailty variance was significant, and it affirmed there was significant variability between centers.

Conclusions

This study showed it is necessary to consider the frailty term in modeling multicenter survival studies and confirmed the importance of early diagnosis of cancer before the involvement of lymph nodes and the onset of metastasis and timely treatment could lead to longer life and increased quality of life for patients.

Novel Uses of Radioactive Seeds in Surgical Oncology: A Case Series

The localization of nonpalpable axillary metastatic lymph nodes has been achieved using several techniques in the past. Amongst these techniques, the use of radioactive iodine seeds is increasingly spread, and was initially reserved to breast-conserving surgery. Many studies have assessed the use of radioactive seed localization for the surgical management of breast cancer patients diagnosed with lymph node metastases. However, few articles have reported their utilization in other cancer subtypes and in complex clinical situations. This case series describes the innovative use of radioactive seeds in the axilla in five patients, including one case of squamous cell carcinoma skin cancer, one case of malignant melanoma, and three cases of invasive breast cancer.

Cross Oncoplastic Breast Surgery Technique; A Good Choice for Tumors Located Far From Nipple Areola Complex

Background: Although various Oncoplastic Breast Surgery (OBS) techniques have been introduced for varied sizes of the breast and locations of tumors , surgeons are still faced with serious challenges for tumors which have developed in special anatomic part of the breast. A good instance of these challenges is the tumors located far from Nipple Areola Complex (NAC) especially in the upper inner quadrant. We aimed to assess the application of newly introduced OBS technique (Cross Technique) in these situations. Methods: The data of 95 patients who suffered from breast cancer and operated with Cross method were assessed in this prospective survey. Data was gathered regarding demographic variables, the size, location, and pathologic characteristics of tumors, patients' BMI and breast circumference and cup size. The patients were recruited to the study according to inclusion and exclusion criteria and the study protocol which was approved by the research deputy of department of surgery, Tehran University of Medical Sciences. Data was presented in a descriptive method.Results: Nighty-five patients underwent oncoplastic breast surgery using the Cross method from November 2015 to May 2018. Patients had a mean age of 48.2 ranging from 25 to 70 years. The patients had a wide range of breast circumference and cup size (70 to 95 for the breast circumference and A to E for the cup size). Clear surgical margin was obtained in 93 cases according to the permanent pathology reports. The complications were seen in 5 patients all managed conservatively (2 slight hematoma and three ischemic skin flaps). The most common histologic type was insitu and invasive ductal carcinoma (DCIS-IDC). Mean tumor size was 22.7 mm with standard deviation of 9.2mm, most of which were positive for estrogen receptor (ER)/progesterone receptor (PR). As the surgery of axilla, six lymph nodes were excised on average and 22 patients had axillary lymph node involvement.Conclusion: The Cross method is not only a reliable choice for tumors located in the UIQ, but it can also be applied safely for tumors in UOQ and upper central part of the breast, although the best application for the technique is the tumors located far from nipple areola complex.

Breast Cancer Patients' Preferences When Receiving Bad News: A Qualitative Study from a Middle Eastern Country

Background: Telling bad news to the patients after a diagnosis of breast cancer is one of the most important duties of a physician. The aim of this study was to explore breast cancer patient's preferences regarding how to receive bad news. Methods: A group of 15 women with breast cancer were purposively recruited to this qualitative study. Semi-structured in-depth interviews were conducted to identify the patients' preferences through content analysis. Results: The age of participants ranged between 28 and 58 years. Nine patients had undergone mastectomy and the remaining 6 had received conservative surgery. The minimum time between the diagnosis and receiving the news of cancer was 1 month, the maximum 15. Altogether, 250 codes were extracted after content analysis and categorized into 7 categories and 43 subcategories. The main categories were the method of disclosure of bad news, medical information, communication skills, emotional support, family involvement, the setting, psycho-spiritual care, and the word “cancer.” Conclusion: Knowing about patients' preferences regarding the methods of breast cancer diagnosis disclosure can help physicians to effectively deliver bad news. Therefore, it is necessary that the clinicians be informed about the themes that the patients consider important while delivering bad news to patients.

Idiopathic granulomatous mastitis: Looking for the most effective therapy with the least side effects according to the severity of the disease in 374 patients in Iran

The goal of this study is to compare the response rate and the recurrence rate of available therapeutic modalities in the treatment of Idiopathic Granulomatous Mastitis (IGM). 374 patients with pathologically confirmed IGM, were included. They were subdivided into three levels of severity. Close observation had the best response rate with the lowest recurrence rate in mild to moderate cases. Severe cases were mostly treated by prednisolone or underwent surgery. The outcome of prednisolone use in severe cases was comparable to NSAIDs. Overall 9% were resistant to treatment and surgical intervention is still an option among them.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown. Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin. Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.

Patient Satisfaction and Body Image Following Mastectomy, Breast-Conserving Therapy, and Mastectomy With Reconstruction: A Study in Iran

Background: Breast cancer is considered a chronic disease owing to the increases in survival rate. Thus, better body image and patient satisfaction with the surgery have become more important factors to be considered when choosing the surgical approach. The aim of this study was to compare body image and patient satisfaction following three different approaches. Methods: We evaluated 183 consecutive patients who had undergone three different surgeries including breast-conserving surgery (BCS), mastectomy, or mastectomy followed by reconstruction (M-R). Body image was evaluated using the BICI questionnaire, and patient satisfaction was rated using a multiple-choice question and a scale ranging from 1 to 10. Results: A significantly better body image was observed in the M-R and BCS groups compared with mastectomy (P = 0.02). In body image subscale analysis, social functioning scores were higher in the M-R and BCS groups than in the mastectomy group (P = 0.01), but no differences were obtained between surgery groups in appearance dissatisfaction subscale. Patients were more satisfied with BCS than the other two surgeries (P = 0.008). Conclusion: Based on the results of this study, it could be proposed that both oncoplastic BCS and implant reconstruction could provide patients with acceptable body image, while BCS could bring about better satisfaction with the surgery. Reconstruction may be an alternative for the patients to improve body image and satisfaction when BCS is not applicable.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown. Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin. Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.

Patient Satisfaction and Body Image Following Mastectomy, Breast-Conserving Therapy, and Mastectomy With Reconstruction: A Study in Iran

Background: Breast cancer is considered a chronic disease owing to the increases in survival rate. Thus, better body image and patient satisfaction with the surgery have become more important factors to be considered when choosing the surgical approach. The aim of this study was to compare body image and patient satisfaction following three different approaches. Methods: We evaluated 183 consecutive patients who had undergone three different surgeries including breast-conserving surgery (BCS), mastectomy, or mastectomy followed by reconstruction (M-R). Body image was evaluated using the BICI questionnaire, and patient satisfaction was rated using a multiple-choice question and a scale ranging from 1 to 10. Results: A significantly better body image was observed in the M-R and BCS groups compared with mastectomy (P = 0.02). In body image subscale analysis, social functioning scores were higher in the M-R and BCS groups than in the mastectomy group (P = 0.01), but no differences were obtained between surgery groups in appearance dissatisfaction subscale. Patients were more satisfied with BCS than the other two surgeries (P = 0.008). Conclusion: Based on the results of this study, it could be proposed that both oncoplastic BCS and implant reconstruction could provide patients with acceptable body image, while BCS could bring about better satisfaction with the surgery. Reconstruction may be an alternative for the patients to improve body image and satisfaction when BCS is not applicable.

Neutrophil-Lymphocyte Ratio in Different Stages of Breast Cancer

Despite many advances in the treatment of breast cancer, it is still the second most common cause of death in women in the United States. It has been shown that inflammation plays a major role in the treatment of these cancers and inflammatory factors enhance tumor growth, invasion, metastasis, and vascularization. In this study, we would like to analyze peripheral blood neutrophil-lymphocyte ratio (NLR) in breast cancer patients and its correlation with disease staging. This cross-sectional analytic study was conducted in Imam Hospital, affiliated with Tehran University of Medical Sciences; a total of 195 female patients with breast cancer met the inclusion criteria. All of the patients had a complete blood count with leukocyte differential performed before chemotherapy. Medical records including pathology reports were also available. Data for all patients were collected prior to any surgical intervention. Exclusion criteria included clinical evidence of active infection, presence of hematological disorders, acute as well as chronic inflammatory or autoimmune diseases, or prior steroid therapy. Higher platelet count was significantly associated with the higher stage. The stage was not associated with the hemoglobin level. There was no association between the tumor size and age of patients with NLR. There was a significant relationship between NLR and IDC. There was a significant relationship between IDC and NLRs of less than 8.1 and greater than 3.3. There was a significant relationship between NLR and vascular invasion. There was no association between NLR and estrogen receptor and HER2. There was no significant relationship between the PLR and the cancer stage. In this study, NLR showed a significant relation with the disease staging. As the NLR increases the stage increases as well. Therefore, this ratio may be helpful in the preoperative evaluation of patients with breast cancer.

Celecoxib Versus Diclofenac in Mild to Moderate Depression Management Among Breast Cancer Patients: A Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Depression is a well-known complication of breast cancer, which is known to adversely affect quality of life, prognosis, and survival in breast cancer patients. Celecoxib, a nonsteroidal anti-inflammatory drug, which acts via the selective inhibition of cyclo-oxygenase (COX)-2, has been shown to have antidepressive effects.

OBJECTIVES

Here, we aimed to compare the efficacy and safety of celecoxib, a selective inhibitor of COX-2, with diclofenac, a nonselective inhibitor of both COX-1 and COX-2 in reducing depressive symptoms and pain in breast cancer patients.

METHODS

A total of 52 outpatients with breast cancer with mild to moderate depression, who suffered from pain and needed analgesics, participated in the trial and underwent 6 weeks of treatment with either celecoxib (200 mg twice daily) or diclofenac (50 mg twice daily). Participants were investigated using the Hamilton Depression Rating Scale (HDRS). The primary outcome measure was to compare the antidepressant effects of celecoxib and diclofenac.

RESULTS

Repeated-measures analysis demonstrated significant effect for Time × Treatment interaction on the HDRS scores: F(1.76, 87.85) = 9.66; P < 0.001. By study conclusion, greater improvement was observed in the HDRS score of the celecoxib group compared with the diclofenac group (P = 0.002). No one experienced remission (HDRS ≤ 7) in either group. Frequencies of adverse events were not significantly different between groups.

CONCLUSION

Celecoxib seems to possess superior antidepressive effects compared with diclofenac in breast cancer patients with mild to moderate depression.

Oncoplastic surgery in breast conservation: a prospective evaluation of the patients, techniques, and oncologic outcomes

BACKGROUND

The oncologic efficacy of breast-conserving therapies has been established in recent decades. Oncoplastic breast surgery (OBS), as a leap forward in breast conservation, offers concomitant techniques of oncologic and plastic surgeries that grant better esthetic results. The outcomes of our oncoplastic surgeries from 2007 to 2012 are reported.

METHODS

A series of 258 cases with breast masses (18 benign and 240 carcinomas) were operated on by OBS techniques and prospectively followed. Neoadjuvant and adjuvant oncologic treatments were also delivered as indicated.

RESULTS

Free margins were obtained in 95% of cancer patients. During the 26 months of follow-up, local recurrence happened in 7 (2.9%) patients, of which 1 underwent oncologic therapies and 6 underwent completion mastectomy. Complications postponed adjuvant therapies in 3 (1.2%) patients. Postsurgically, metastases were diagnosed in 8 (3.3%) patients. Two patients (.8%) died of cancer.

CONCLUSIONS

Outcomes of OBS are oncologically acceptable with low frequencies of positive margins and recurrence, while cosmetic results are much improved by OBS.

Do the different reasons for lactation discontinuation have similar impact on future breast problems?

BACKGROUND

Breast feeding is considered to be mutually beneficial for both mothers and infants, though the effect of lactation problems on development of breast lesions (whether benign or malignant) is not clear.

OBJECTIVES

This study was conducted to identify possible relations between lactation problems and benign and malignant breast disease.

MATERIALS AND METHODS

308 patients referred to two referral breast clinics in Tehran, the capital city of IR Iran, between January 2008 and January 2011, were recruited. They were interviewed by a standard questionnaire regarding breast feeding problems. The study population was classified in 3 major groups; breast feeding without any problem, unwillingness to breast feed according to whether mothers' preference not to feed or some breast problems like mastitis, and finally insufficient milk that caused the mothers to feed their babies with formula.

RESULTS

Recruiting binary logistic regression method, mother's unwillingness to feed her child by breast milk, and also breast problems such as mastitis and abscess during lactation period showed significant relation with both benign and malignant breast diseases (p value<0.01). Surprisingly, inadequate milk was not associated with any of these conditions.

CONCLUSIONS

We concluded that lactation problems which involve normal milk drainage from the breast may play an important role in whether the mother wll subsequently develope both benign and malignant pathologies. In contrast in the situation that the production of the milk is not sufficient and there are no intentional or unintentional problems in drainage of the produced milk, future problems would not be more common.

Effects of obesity on presentation of breast cancer, lymph node metastasis and patient survival: a retrospective review

BACKGROUND

As data on the relation between obesity and lymph node ratio are missing in the literature, we here aimed to assess the impact of obesity on this parameter and other clinicopathological features of breast cancer cases and patient survival.

MATERIALS AND METHODS

Medical data of 646 patients, all referred to two centers in Tehran, Iran, were reviewed. Factors that showed significant association on univariate analysis were entered in a regression model. Kaplan-Meier and Cox-regression were employed for survival analysis.

RESULTS

Obesity was correlated with the expression of estrogen and progesterone receptor (p=0.004 and p=0.039, respectively), metastasis to axillary lymph nodes (p=0.017), higher lymph node rate (p<0.001) and larger tumor size (p<0.001). The effect of obesity was stronger in premenopausal women. There was no association between obesity and expression of human epidermal growth factor receptor. Three factors showed independent association with BMI on multivariate analysis; tumor size, estrogen receptor and lymph node ratio. Obesity was predictive of shorter disease-free survival with a hazard ratio of 3.324 (95%CI: 1.225-9.017) after controlling for the above-mentioned variables.

CONCLUSIONS

The findings of this study support the idea that obese women experience more advanced disease with higher axillary lymph node ratio, and therefore higher stage at the time of diagnosis. Furthermore, obesity was associated with poorer survival independent of lymph node rate.

Orbital Doppler evaluation of blood flow velocities in patients with diabetic retinopathy

BACKGROUND

There have been conflicting results in relation to impaired ocular hemodynamics in the orbital vessels of patients with diabetic retinopathy (DR). Clarification of the early signs of retinopathy in diabetic patients is urgently needed.

AIMS

We aimed to evaluate orbital blood flow velocities using Doppler and gray-scale sonography in patients with DR, and to compare the results with those of their non-diabetic and diabetic peers without retinopathy.

METHODS

Orbital Doppler and gray-scale sonography were performed in 123 patients aged 29-77 who had been divided into 3 groups: non-diabetic controls (n = 25), diabetes and impaired glucose tolerance with minimal clinical retinopathy (n = 74), and diabetes with untreated non-proliferative retinopathy (n = 24). Retinopathy was diagnosed by an ophthalmologist on the basis of fundoscopic examination. The peak systolic (PSV) and end-diastolic (EDV) blood flow velocities, and the resistivity and pulsatile indices, of the ophthalmic artery, central retinal artery, posterior ciliary artery, and central retinal vein were measured.

RESULTS

Compared with healthy controls, the age-adjusted resistivity and pulsatile indices of the ophthalmic artery were significantly higher in patients with DR (p < 0.05). PSV and EDV of the posterior ciliary arteries were significantly lower in diabetic patients with DR. After further adjustment for age, gender, HbA1c, fasting plasma glucose, blood pressure, BMI, cholesterol, HDL, LDL, and triglycerides, only the resistivity index of the ophthalmic artery and the central retinal vein remained significantly higher in patients with DR compared with healthy controls (p < 0.005 after Bonferroni adjustment).

CONCLUSIONS

Resistivity index alteration of the ophthalmic artery and central retinal vein may be prevalent among patients with early changes in DR.