Successful and safe treatment of severe steroid depended eosinophilic asthma with mepolizumab in a woman during pregnancy.

A 26-year-old female with steroid dependent eosinophilic asthma and nasal polyps who had successfully been treated with mepolizumab for 17 consecutive months with complete steroid withdrawal and symptoms control, stopped biologic treatment due to pregnancy efforts. Mepolizumab discontinuation resulted in frequent exacerbations and daily symptoms despite high dose ICS/LABA and re-initiation of oral steroids. Mepolizumab was initiated again, followed by improvement of asthma control and gradual withdrawal of steroids within 2 months. The patient became pregnant during the fourth month of mepolizumab re-initiation. The patient presented two asthma exacerbations during pregnancy treated with short course (3 days) oral steroids and delivery was uneventful (female, Apgar 9, weight 2750 g, length 59 cm) in week 40 by caesarean section.

Isolated colonic metastasis two years after resection of stage IA primary adenocarcinoma of the lung: A case report.

Colonic metastasis from lung cancer is rare, generally asymptomatic and usually develop at advanced cancer stages. Here, we report a case with a resected stage IA lung adenocarcinoma in a 51yo male patient that presented two years later with mild abdominal pain due to intestinal obstruction caused by a metastatic colon tumor. The patient underwent colonoscopy followed by surgical resection and the pathologic report was adenocarcinoma which was the same as that from a lung nodule that was excised two years earlier. Immunohistochemistry was cytokeratin 7 (CK7) positive, thyroid transcription factor 1 (TTF1) focally positive and cytokeratin 20 (CK20), caudal-related homeobox transcription factor 2 (CDX2) negative on both lung biopsy and colon surgical specimens. Interestingly there was no obvious lung cancer recurrence both at the time of metastasis and one year following chemotherapy.

Prophylactic mastectomy: an appraisal.

The main indication of prophylactic mastectomy pertains to BRCA1 or BRCA2 mutation carriers. Prophylactic mastectomy includes the simple method and the subcutaneous method. Both methods can be followed by breast plastic reconstruction either at the same time or later. This review examines key issues regarding prophylactic mastectomy: the selection of patients, its effectiveness, its limitations, convergence/divergence in existing guidelines, and future perspectives.

Vacuum-assisted breast biopsy: more cores, more hematomas?

BACKGROUND: Vacuum-assisted breast biopsy (VABB) is used for the diagnosis of non-palpable breast lesions. Hematoma has been recognized as the main complication of the procedure. Its main disadvantage is the underestimation rate. Generally speaking, approximately up to 24 cores are excised in most published series. It has been suggested that excision of more cores per lesion can reduce the underestimation rate. The present study aims to evaluate hematoma formation with regard to the number of cores excised. PATIENTS AND METHODS: A total of 660 women underwent VABB; 232 women were allocated to the standard protocol (24-36 cores excised, 2-3 offsets) and 428 women were allocated to the extended protocol (96 cores excised, 8 offsets). Cases were derived from a double blind study, as well as from the periods before (standard protocol) and after (mainly extended protocol) the study. In all cases, the occurrence of organized hematomas within the subsequent 20 days was followed up by ultrasound. RESULTS: In the standard protocol, the frequency of clinically significant and subsequently organized hematomas was 3.5%. However, in the extended protocol the respective hematoma percentage was 7.5%. Clinically significant and subsequently organized hematomas were significantly more frequent in the extended protocol (Pearson's chi-squared=4.29, p=0.038). CONCLUSION: Despite the superiority of the extended protocol in terms of underestimation, the approximately two-fold increase in hematoma occurrence prompts the need for careful patient selection prior to its performance.

Downgrading BIRADS 3 to BIRADS 2 category using a computer-aided microcalcification analysis and risk assessment system for early breast cancer.

This paper explores the potential of a computer-aided diagnosis system to discriminate the real benign microcalcifications among a specific subset of 109 patients with BIRADS 3 mammograms who had undergone biopsy, thus making it possible to downgrade them to BIRADS 2 category. The system detected and quantified critical features of microcalcifications and classified them on a risk percentage scale for malignancy. The system successfully detected all cancers. Nevertheless, it suggested biopsy for 11/15 atypical lesions. Finally, the system characterized as definitely benign (BIRADS 2) 29/88 benign lesions, previously assigned to BIRADS 3, and thus achieved a reduction of 33% in unnecessary biopsies.

Volume of blood suctioned during vacuum-assisted breast biopsy predicts later hematoma formation.

BACKGROUND: To evaluate whether the volume of blood suctioned during vacuum-assisted breast biopsy (VABB) is associated with hematoma formation and progression, patient's age and histology of the lesion. FINDINGS: 177 women underwent VABB according to standardized protocol. The volume of blood suctioned and hematoma formation were noted at the end of the procedure, as did the subsequent development and progression of hematoma. First- and second-order logistic regression was performed, where appropriate. Cases with hematoma presented with greater volume of blood suctioned (63.8 +/- 44.7 cc vs. 17.2 +/- 32.9 cc; p < 0.001, Mann-Whitney-Wilcoxon test for independent samples, MWW); the likelihood of hematoma formation was increasing till a volume equal to 82.6 cc, at which the second-order approach predicts a maximum. The volume of blood suctioned was positively associated with the duration of the procedure (Spearman's rho = 0.417, p < 0.001); accordingly, hematoma formation was also positively associated with the latter (p = 0.004, MWW). The volume of blood suctioned was not associated with patients' age, menopausal status and histopathological diagnosis. CONCLUSION: The likelihood of hematoma is increasing along with increasing amount of blood suctioned, reaching a plateau approximately at 80 cc of blood lost.

Comparison of molecular markers expression in vacuum-assisted biopsies and surgical specimens of human breast carcinomas.

In this study, we examined whether vacuum-assisted breast biopsy (VABB) specimens provide an accurate immunohistochemical assessment of estrogen receptors (ER), progesterone receptors (PR), c-erbB-2, and p53 proteins. Thirty-seven consecutive cases with a VABB diagnosis of ductal carcinoma in situ (DCIS) were included. The immunohistochemical expression of ER and PR, c-erbB-2, and p-53 was assessed in VABB and in surgical specimens with pathological concordance. The "clinically relevant concordance rate" (CRCR) was calculated. The CRCRs were 77.8%, 77.8%, and 89% for ER, PR, and c-erbB-2, respectively. Concerning both ER and PR, the clinically relevant expression was higher in VABB specimens. A difference in borderline significance arose concerning c-erbB-2 expression, pointing to more intense expression in the surgical specimens. The p53 percentage did not differ between the two groups. VABB specimens provide an accurate immunohistochemical assessment of molecular markers. However, bioptical-surgical discrepancies persisted even in this context of a larger quantity of tissue removed.

Biopsy method: a major predictor of adherence after benign breast biopsy?

OBJECTIVE: Adopting a longitudinal approach to assess women after breast biopsy with a benign result, this study aimed to comparatively evaluate the effect of the biopsy method on compliance with clinical recommendations for follow-up. MATERIALS AND METHODS: For this study, 410 patients who underwent biopsy of a breast lesion were included: fine-needle aspiration biopsy, n = 95 patients; core biopsy, n = 84; local excision under local anesthesia, n = 72; vacuum-assisted breast biopsy, n = 100; and hookwire localization, n = 59. Information about patient age, place of residence, whether complications occurred, and type of lesion was collected. RESULTS: Compliance was higher among women who had undergone vacuum-assisted breast biopsy than those who had undergone one of the other biopsy methods. The superiority (carryover effect) of vacuum-assisted breast biopsy persisted for 18 months after the biopsy procedure. Patient compliance for all of the other biopsy methods followed an M pattern, with the peaks corresponding to the follow-up mammography sessions. In patients who had undergone vacuum-assisted breast biopsy, a gradual decrease in compliance over time was observed. Older women were more compliant than younger women with follow-up recommendations regardless of biopsy method. A subanalysis of the vacuum-assisted breast biopsy group indicated that complications are associated with better compliance. CONCLUSION: Women more often adhere to clinical recommendations for follow-up sessions comprising mammography. Patient age and whether biopsy complications occurred also seem to modify compliance. Further studies should assess whether superior compliance after vacuum-assisted breast biopsy persists in other settings, such as with stereotactic or ultrasound guidance, different numbers of cores, and procedures of various durations.

Breast ductal endoscopy: how many procedures qualify?

BACKGROUND: Breast ductal endoscopy is a relatively new diagnostic method with ever growing importance in the work-up of patients with bloody nipple discharge. The ability to perform ductal endoscopy is very important and useful for breast fellows. Learning curve in breast ductal endoscopy remains a terra incognita, since no systematic studies have addressed this topic. The purpose of this study is to determine the point (number of procedures during training) beyond which ductal endoscopy is successfully performed. FINDINGS: Ten breast fellows received training in our Breast Unit. For the training process, an ex vivo model was adopted. Fellows were trained on 20 surgical specimens derived from modified radical mastectomy for breast cancer. The target of the education program was to acquire proficiency in performing ductoscopy. The achievement of four consecutively successful ductal endoscopies was determined as the point beyond which proficiency had been achieved. The number of procedures needed for the achievement of proficiency as defined above ranged between 9 and 17 procedures. The median value was 13 procedures; i.e. 50% of trainees had achieved proficiency at the 13th procedure or earlier. CONCLUSION: These pilot findings point to approximately 13 procedures as a point beyond which ductal endoscopy is successfully performed; studies on a larger number of fellows are nevertheless needed. Further research, focusing on the learning curves of different training models of ductal endoscopy, seems desirable.

Excisional breast biopsy under local anesthesia: stress-related neuroendocrine, metabolic and immune reactions during the procedure.

AIM: The aim of this study was to evaluate three axes: the sympathetic system (adrenaline and noradrenaline), surgical stress-related endocrine factors (prolactin, cortisol, insulin, glucose and growth hormone) and inflammatory cytokines (IL-1alpha, IL-1beta and IL-6) during excisional breast biopsy under local anesthesia (EBBLA). PATIENTS AND METHODS: On 14 women undergoing EBBLA, all the aforementioned molecules were measured in peripheral venous blood samples prior (baseline), during (at 10 and 30 minutes), at the end of EBBLA (46+/-9 minutes) and one hour after its end. RESULTS: Serum growth hormone glucose and cortisol were found elevated at the 10th and 30th minute and at the end of EBBLA. Serum prolactin increased only at the 30th minute. Of notice, none of the measured parameters was found elevated one hour after the end of biopsy. Concerning adrenaline, noradrenaline and interleukins, no significant changes were documented. CONCLUSION: During EBBLA, significant stress-related endocrine events arise. However, no significant sympathetic / cytokine triggering was noted.

Psychiatric disorder associated with vacuum-assisted breast biopsy clip placement: a case report.

INTRODUCTION: Vacuum-assisted breast biopsy is a minimally invasive technique that has been used increasingly in the treatment of mammographically detected, non-palpable breast lesions. Clip placement at the biopsy site is standard practice after vacuum-assisted breast biopsy. CASE PRESENTATION: We present the case of a 62-year-old woman with suspicious microcalcifications in her left breast. The patient was informed about vacuum-assisted breast biopsy, including clip placement. During the course of taking the patient's history, she communicated excellently, her demeanor was normal, she disclosed no intake of psychiatric medication and had not been diagnosed with any psychiatric disorders. Subsequently, the patient underwent vacuum-assisted breast biopsy (11 G) under local anesthesia. A clip was placed at the biopsy site. The pathological diagnosis was of sclerosing adenosis. At the 6-month mammographic follow-up, the radiologist mentioned the existence of the metallic clip in her breast. Subsequently, the woman presented complaining about "being spied [upon] by an implanted clip in [her] breast" and repeatedly requested the removal of the clip. The patient was referred to the specialized psychiatrist of our breast unit for evaluation. The Mental State Examination found that systematized paranoid ideas of persecutory type dominated her daily routines. At the time, she believed that the implanted clip was one of several pieces of equipment being used to keep her under surveillance, the other equipment being her telephone, cameras and television. Quite surprisingly, she had never had a consultation with a mental health professional. The patient appeared depressed and her insight into her condition was impaired. The prevalent diagnosis was schizotypal disorder, whereas the differential diagnosis comprised delusional disorder of persecutory type, affective disorder with psychotic features or comorbid delusional disorder with major depression. CONCLUSION: This is the first report of a psychiatric disorder being brought to the fore using a vacuum-assisted breast biopsy clip. Vacuum-assisted breast biopsy, and breast biopsy in general, represent a significant experience, encompassing anxiety and pain; it may thus aggravate psychiatric conditions. Apart from these well-established factors, other aspects, such as the clip, may occasionally become significant. In a modern breast unit, the evaluation of patients should be multidisciplinary. A psychiatrist may be needed for optimal management of anxiety-related issues, as well as for the detection of psychiatric disorders.

Vacuum-assisted breast biopsy in close proximity to the skin: a case report.

INTRODUCTION: Vacuum-assisted breast biopsy is a minimally invasive technique used increasingly for the assessment of mammographically detected, non-palpable breast lesions. The effectiveness of vacuum-assisted breast biopsy has been demonstrated on lesions both with and without microcalcifications. Given that the position of the lesion represents a major factor in stereotactic vacuum-assisted breast biopsy, targeting lesions in close proximity to the skin (superficial lesions) has been described as a problematic issue. CASE PRESENTATION: A 53-year-old woman presented with a newly developed, non-palpable lesion in her left breast. The lesion consisted of widely spread microcalcifications located approximately 5 mm from the skin. The lesion was isoechoic on ultrasound examination. Vacuum-assisted breast biopsy was scheduled (on the Fischer's table, using 11-gauge probes, under local anaesthesia). The vacuum-assisted breast biopsy probe was inserted antidiametrically into the breast, the probe reached the lesion and effort was made to excise the microcalcifications. As only a small proportion of the microcalcifications were excised an accurate diagnosis could not be expected. However, with the probe having entered the breast antidiametrically, the probe tip underlying the skin could be palpated. Following the palpation of the tip, the exact point was marked by a pen, the probe was removed and the patient was transferred to the surgery room to have the remaining lesion removed by a spindle-form excision under local anaesthesia. The mammogram of the removed specimen confirmed the total excision of the suspicious microcalcifications. CONCLUSION: Isoechoic superficial lesions can be localized with a hook-wire and open breast biopsy under general or local anaesthesia can be performed. However, vacuum-assisted breast biopsy might offer an alternative solution and serve as an alternative approach to localize the lesion. The clinical significance of the present exploratory effort remains to be assessed in the future.