Long-Term Patient-Reported Outcomes Comparing Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery: A Propensity Score-Matched Analysis.

INTRODUCTION: Oncoplastic breast surgery (OBS) combines plastic surgery techniques with conventional breast-conserving surgery (BCS) and expands BCS eligibility. Limited data are available on patient-reported outcomes (PROs) after OBS. Here we compare long-term PROs after OBS and BCS utilizing the BREAST-Q. PATIENTS AND METHODS: Women undergoing OBS or BCS between 2006 and 2019 who completed ≥ 1 long-term BREAST-Q survey 3-5 years postoperatively were identified. Baseline characteristics were compared between women who underwent OBS/BCS. Women who underwent OBS were paired with those who underwent BCS using 1:2 propensity matching [by age, body mass index (BMI), race, T stage, and multifocality]. BREAST-Q scores were compared preoperatively and 3-5 years postoperatively. RESULTS: A total of 297 patients were included for analysis (99 OBS/198 BCS). Women who underwent OBS were younger (p < 0.001) and had higher BMI (p = 0.005) and multifocal disease incidence (p = 0.004). There was no difference between groups in nodal stage, re-excision rates, axillary surgery, chemotherapy, endocrine therapy, or radiotherapy. After propensity matching preoperatively, women who underwent OBS reported lower psychosocial well-being (63 versus 100, p = 0.039) but similar breast satisfaction and sexual well-being compared with women who underwent BCS; however, only three patients who underwent BCS had preoperative BREAST-Q scores available for review. In long-term follow-up, women who underwent OBS reported lower psychosocial scores (74 versus 93, p = 0.011) 4 years postoperatively, but not at 5 years (76 versus 77, p = 0.83). There was no difference in long-term breast satisfaction or sexual well-being. CONCLUSIONS: Women who undergo OBS present with a larger disease burden and may represent a group of non-traditional BCS candidates; they reported similar long-term breast satisfaction and sexual well-being compared with women who undergo BCS. While women who underwent OBS reported lower psychosocial well-being scores preoperatively and during a portion of the follow-up period, this difference was no longer seen at 5 years postoperatively.

Results of Magnetic Resonance Imaging (MRI) Screening in Patients at High Risk for Breast Cancer.

BACKGROUND: Screening MRI as an adjunct to mammography is recommended by the ACS for patients with a lifetime risk for breast cancer > 20%. While the benefits are clear, MRI screening is associated with an increase in false-positive results. The purpose of this study was to analyze our institutional database of high-risk patients and assess the uptake of screening MRI examinations and the results of those screenings. METHODS: Our institutional review board-approved High-Risk Breast Cancer Database was queried for patients enrolled from January 2017 to January 2023 who were at high risk for breast cancer in a comparative analysis between those who were screened versus not screened with MRIs. Variables of interest included risk factor, background, MRI screening uptake, and frequency and results of image-guided breast biopsies. RESULTS: A total of 254 of 1106 high-risk patients (23%) had MRI screening. Forty-six of 852 (5.3%) patients in the non-MRI-screened cohort and nine of 254 (3.5%) patients in the MRI-screened cohort were diagnosed with a malignant lesion after image-guided biopsy (p = 0.6). There was no significant difference between MRI and non-MRI guided biopsies in detecting breast cancer. All malignant lesions were T1 or in situ disease. The 254 patients in the MRI-screened group underwent 185 biopsies. Fifty-seven percent of MRI-guided biopsies yielded benign results. CONCLUSIONS: Although the addition of MRI screening in our high-risk cohort did not produce a significant number of additional cancer diagnoses, patients monitored in our high-risk cohort who developed breast cancer were diagnosed at very early stages of disease, underscoring the benefit of participation in the program.

Improving Information Extraction from Pathology Reports using Named Entity Recognition.

Pathology reports are considered the gold standard in medical research due to their comprehensive and accurate diagnostic information. Natural language processing (NLP) techniques have been developed to automate information extraction from pathology reports. However, existing studies suffer from two significant limitations. First, they typically frame their tasks as report classification, which restricts the granularity of extracted information. Second, they often fail to generalize to unseen reports due to variations in language, negation, and human error. To overcome these challenges, we propose a BERT (bidirectional encoder representations from transformers) named entity recognition (NER) system to extract key diagnostic elements from pathology reports. We also introduce four data augmentation methods to improve the robustness of our model. Trained and evaluated on 1438 annotated breast pathology reports, acquired from a large medical center in the United States, our BERT model trained with data augmentation achieves an entity F1-score of 0.916 on an internal test set, surpassing the BERT baseline (0.843). We further assessed the model's generalizability using an external validation dataset from the United Arab Emirates, where our model maintained satisfactory performance (F1-score 0.860). Our findings demonstrate that our NER systems can effectively extract fine-grained information from widely diverse medical reports, offering the potential for large-scale information extraction in a wide range of medical and AI research. We publish our code at https://github.com/nyukat/pathology_extraction.

Computerized Diagnosis of Liver Tumors From CT Scans Using a Deep Neural Network Approach.

The liver is a frequent site of benign and malignant, primary and metastatic tumors. Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) are the most common primary liver cancers, and colorectal liver metastasis (CRLM) is the most common secondary liver cancer. Although the imaging characteristic of these tumors is central to optimal clinical management, it relies on imaging features that are often non-specific, overlap, and are subject to inter-observer variability. Thus, in this study, we aimed to categorize liver tumors automatically from CT scans using a deep learning approach that objectively extracts discriminating features not visible to the naked eye. Specifically, we used a modified Inception v3 network-based classification model to classify HCC, ICC, CRLM, and benign tumors from pretreatment portal venous phase computed tomography (CT) scans. Using a multi-institutional dataset of 814 patients, this method achieved an overall accuracy rate of 96%, with sensitivity rates of 96%, 94%, 99%, and 86% for HCC, ICC, CRLM, and benign tumors, respectively, using an independent dataset. These results demonstrate the feasibility of the proposed computer-assisted system as a novel non-invasive diagnostic tool to classify the most common liver tumors objectively.

How Much Pain Will I Have After Surgery? A Preoperative Nomogram to Predict Acute Pain Following Mastectomy.

INTRODUCTION: Acute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate-severe pain following mastectomy. METHODS: Demographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1-5, with moderate-severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate-severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients. RESULTS: In the training cohort, 297 patients reported no-mild pain and 659 reported moderate-severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate-severe pain. The resulting nomogram accurately predicted moderate-severe pain in the validation cohort (AUC =  0.735). CONCLUSIONS: This nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate-severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.

Addressing the problem of overtreatment in breast cancer.

INTRODUCTION: As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance. AREAS COVERED: Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment. EXPERT OPINION: The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.

Machine learning radiomics can predict early liver recurrence after resection of intrahepatic cholangiocarcinoma.

BACKGROUND: Most patients recur after resection of intrahepatic cholangiocarcinoma (IHC). We studied whether machine-learning incorporating radiomics and tumor size could predict intrahepatic recurrence within 1-year. METHODS: This was a retrospective analysis of patients with IHC resected between 2000 and 2017 who had evaluable computed tomography imaging. Texture features (TFs) were extracted from the liver, tumor, and future liver remnant (FLR). Random forest classification using training (70.3%) and validation cohorts (29.7%) was used to design a predictive model. RESULTS: 138 patients were included for analysis. Patients with early recurrence had a larger tumor size (7.25 cm [IQR 5.2-8.9] vs. 5.3 cm [IQR 4.0-7.2], P = 0.011) and a higher rate of lymph node metastasis (28.6% vs. 11.6%, P = 0.041), but were not more likely to have multifocal disease (21.4% vs. 17.4%, P = 0.643). Three TFs from the tumor, FD1, FD30, and IH4 and one from the FLR, ACM15, were identified by feature selection. Incorporation of TFs and tumor size achieved the highest AUC of 0.84 (95% CI 0.73-0.95) in predicting recurrence in the validation cohort. CONCLUSION: This study demonstrates that radiomics and machine-learning can reliably predict patients at risk for early intrahepatic recurrence with good discrimination accuracy.

Surgical Treatment After Neoadjuvant Systemic Therapy in Young Women With Breast Cancer: Results From a Prospective Cohort Study.

OBJECTIVE: We aimed to investigate eligibility for breast conserving surgery (BCS) pre- and post-neoadjuvant systemic therapy (NST), and trends in the surgical treatment of young breast cancer patients. BACKGROUND: Young women with breast cancer are more likely to present with larger tumors and aggressive phenotypes, and may benefit from NST. Little is known about how response to NST influences surgical decisions in young women. METHODS: The Young Women's Breast Cancer Study, a multicenter prospective cohort of women diagnosed with breast cancer at age ≤40, enrolled 1302 patients from 2006 to 2016. Disease characteristics, surgical recommendations, and reasons for choosing mastectomy among BCS-eligible patients were obtained through the medical record. Trends in use of NST, rate of clinical and pathologic complete response, and surgery were also assessed. RESULTS: Of 1117 women with unilateral stage I-III breast cancer, 315 (28%) received NST. Pre-NST, 26% were BCS eligible, 17% were borderline eligible, and 55% were ineligible. After NST, BCS eligibility increased from 26% to 42% (P < 0.0001). Among BCS-eligible patients after NST (n = 133), 41% chose mastectomy with reasons being patient preference (53%), BRCA or TP53 mutation (35%), and family history (5%). From 2006 to 2016, the rates of NST (P = 0.0012), clinical complete response (P < 0.0001), and bilateral mastectomy (P < 0.0001) increased, but the rate of BCS did not increase (P = 0.34). CONCLUSION: While the proportion of young women eligible for BCS increased after NST, many patients chose mastectomy, suggesting that surgical decisions are often driven by factors beyond extent of disease and treatment response.

A Modified T-Stage Classification for Gastric Neuroendocrine Tumors.

BACKGROUND: The eighth edition of the American Joint Committee on Cancer (AJCC) staging manual's TNM staging classification for gastric neuroendocrine tumors has been shown to have poor prognostic discriminability. The aim of present study was to propose a modified T-stage classification, and externally validate its performance in a separate population data registry. METHODS: A modified T-stage classification with tumor size and extent of tumor invasion was generated from the National Cancer Database between 2004 and 2014 (n = 1249). External validation was performed using the Surveillance, Epidemiology, and End Results registry between 1973 and 2013 (n = 539). RESULTS: In the National Cancer Database population, using the AJCC T-stage classification, the 5-y survival rates were 85.7%, 80.8%, 64.5%, and 46.1% in T1, T2, T3, and T4 patients respectively (P < 0.001). These rates were more contrasting with the modified T-stage (mT) classification at 87.0%, 78.2%, 59.0%, and 40.3% respectively (P < 0.001). When patients within each of the AJCC T stages were stratified by mT stages, significant survival heterogeneity was observed within each of the AJCC T2 to T4 stages (P < 0.01). Conversely, when mT stages were stratified by AJCC T stage, no survival difference was observed in any of the mT stages (P > 0.05). The same analyses were performed using Surveillance, Epidemiology, and End Results data, and all the observed results were validated. CONCLUSION: The current AJCC T stage classification categorizes patients into groups with heterogenous prognosis, thus failing to serve as an effective staging tool. A modified T-stage classification demonstrated significantly improved stratification for patients with gastric neuroendocrine tumors.

Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program.

BACKGROUND: India has an estimated incidence of more than one million cancers annually. Breast, oral, and cervical cancers account for over one-third of newly diagnosed cases. With the introduction of pilot cancer screening programs in India, little is known about current sociocultural barriers that may hinder acceptance of screening and treatment. We sought to identify knowledge gaps, misconceptions, and stigmas surrounding cancer diagnosis. PATIENTS AND METHODS: A baseline survey was conducted in Assam, India, as part of the Detect Early and Save Her/Him program, a mobile screening program for breast, oral, and cervical cancer. Data were collected on participants' cancer knowledge, and attitudes towards screening, diagnosis, and treatment. RESULTS: Of the 923 residents who participated, a large majority (92.9%; n = 858) were neither aware of cancer screening availability nor had prior screening. Low-medium awareness was demonstrated regarding the carcinogenic effects of betel nuts (n = 433, 47%). Only one-third of participants recognized oral ulcers and dysphagia as cancer symptoms. Approximately 10% of respondents had misconceptions about cancer etiologies, and 42-57% endorsed statements reflecting a negative stigma towards cancer, including its long-term detrimental effects on personal, occupational, and familial life. However, the majority (68-96%) agreed with statements endorsing positive community support and medical care for cancer patients. CONCLUSIONS: This study identifies actionable targets for intervention in cancer education and awareness within a large rural Indian population. Education to address preventable causes of cancer and to correct misconceptions and stigma is a critical component in ensuring the successful implementation of cancer screening programs.

Genetic Determinants of Outcome in Intrahepatic Cholangiocarcinoma.

BACKGROUND AND AIM: Genetic alterations in intrahepatic cholangiocarcinoma (iCCA) are increasingly well characterized, but their impact on outcome and prognosis remains unknown. APPROACH AND RESULTS: This bi-institutional study of patients with confirmed iCCA (n = 412) used targeted next-generation sequencing of primary tumors to define associations among genetic alterations, clinicopathological variables, and outcome. The most common oncogenic alterations were isocitrate dehydrogenase 1 (IDH1; 20%), AT-rich interactive domain-containing protein 1A (20%), tumor protein P53 (TP53; 17%), cyclin-dependent kinase inhibitor 2A (CDKN2A; 15%), breast cancer 1-associated protein 1 (15%), FGFR2 (15%), polybromo 1 (12%), and KRAS (10%). IDH1/2 mutations (mut) were mutually exclusive with FGFR2 fusions, but neither was associated with outcome. For all patients, TP53 (P < 0.0001), KRAS (P = 0.0001), and CDKN2A (P < 0.0001) alterations predicted worse overall survival (OS). These high-risk alterations were enriched in advanced disease but adversely impacted survival across all stages, even when controlling for known correlates of outcome (multifocal disease, lymph node involvement, bile duct type, periductal infiltration). In resected patients (n = 209), TP53mut (HR, 1.82; 95% CI, 1.08-3.06; P = 0.03) and CDKN2A deletions (del; HR, 3.40; 95% CI, 1.95-5.94; P < 0.001) independently predicted shorter OS, as did high-risk clinical variables (multifocal liver disease [P < 0.001]; regional lymph node metastases [P < 0.001]), whereas KRASmut (HR, 1.69; 95% CI, 0.97-2.93; P = 0.06) trended toward statistical significance. The presence of both or neither high-risk clinical or genetic factors represented outcome extremes (median OS, 18.3 vs. 74.2 months; P < 0.001), with high-risk genetic alterations alone (median OS, 38.6 months; 95% CI, 28.8-73.5) or high-risk clinical variables alone (median OS, 37.0 months; 95% CI, 27.6-not available) associated with intermediate outcome. TP53mut, KRASmut, and CDKN2Adel similarly predicted worse outcome in patients with unresectable iCCA. CDKN2Adel tumors with high-risk clinical features were notable for limited survival and no benefit of resection over chemotherapy. CONCLUSIONS: TP53, KRAS, and CDKN2A alterations were independent prognostic factors in iCCA when controlling for clinical and pathologic variables, disease stage, and treatment. Because genetic profiling can be integrated into pretreatment therapeutic decision-making, combining clinical variables with targeted tumor sequencing may identify patient subgroups with poor outcome irrespective of treatment strategy.

Tumor phenotype and concordance in synchronous bilateral breast cancer in young women.

PURPOSE: Synchronous bilateral breast cancer is uncommon, and its pattern and incidence among younger women is unknown. Here we report the incidence, phenotypes, and long-term oncologic outcomes of bilateral breast cancer in women enrolled in the Young Women's Breast Cancer Study (YWS). METHODS: The YWS is a multi-center, prospective cohort study of women with breast cancer diagnosed at age ≤ 40 years. Those with synchronous bilateral breast cancer formed our study cohort. Tumor phenotypes were categorized as luminal A (hormone receptor (HR)+/HER2-/grade 1/2), luminal B (HR+ /HER2+ or HER2- and grade 3), HER2-enriched (HR-/HER2+), or basal-like (HR-/HER2-). Descriptive statistics were used to evaluate tumor phenotypes of bilateral cancers for concordance. RESULTS: Among 1302 patients enrolled in the YWS, 21 (1.6%) patients had synchronous bilateral disease. The median age of diagnosis was 38 years (range 18-40 years). Seventeen (81.0%) underwent genetic testing with 6 found to have pathogenic germline mutations in BRCA1, BRCA2, or TP53. The majority of patients (76.2%) underwent bilateral mastectomy. On pathology, 2 patients had bilateral in-situ disease, 6 had unilateral invasive and contralateral in-situ disease, and 13 had bilateral invasive disease. Of those with bilateral invasive disease, 10 (76.9%) had bilateral luminal tumors and, when fully characterized, 6 were of the same luminal subtype. Only 1 patient had bilateral basal-like breast cancer. At median follow-up of 8.2 years, 14 patients are alive with no recurrent disease. CONCLUSIONS: Bilateral breast cancer is uncommon among young women diagnosed with breast cancer at age ≤ 40. In our cohort, the majority of invasive tumors were of the luminal phenotype, though some differed by grade or HER2 status. These findings support the need for thorough pathologic workup of bilateral disease when it is found in young women with breast cancer to determine risk and tailor treatment.

Non-clinical Drivers of Variation in Preoperative MRI Utilization for Breast Cancer.

BACKGROUND: Preoperative magnetic resonance imaging (MRI) utilization in breast cancer treatment has increased significantly over the past 2 decades, but its use continues to have interprovider variability and disputed clinical indications. OBJECTIVE: The aim of this study was to evaluate non-clinical factors associated with preoperative breast MRI utilization. METHODS: This study utilized TRICARE claims data from 2006 to 2015. TRICARE provides health benefits for active duty service members, retirees, and their dependents at both military (direct care with salaried physicians) and civilian (purchased care under fee-for-service structure) facilities. We studied patients aged 25-64 years with a breast cancer diagnosis who had undergone mammogram/ultrasound (MMG/US) alone or with subsequent breast MRI prior to surgery. Facility characteristics included urban-rural location according to the National Center for Health Statistics classification. Adjusted multivariable logistic regression tests were used to identify independent factors associated with preoperative breast MRI utilization. RESULTS: Of the 25,392 identified patients, 64.7% (n = 16,428) received preoperative MMG/US alone, while 35.3% (n = 8964) underwent additional MRI. Younger age, Charlson Comorbidity Index score ≥ 2, active duty or retired beneficiary category, officer rank (surrogate for socioeconomic status), Air Force service branch, metropolitan location, and purchased care were associated with an increased likelihood of preoperative MRI utilization. Non-metropolitan location and Navy service branch were associated with decreased MRI use. CONCLUSION: After controlling for expected clinical risk factors, patients were more likely to receive additional MRI when treated at metropolitan facilities or through the fee-for-service system. Both associations may point toward non-clinical incentives to perform MRI in the treatment of breast cancer.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population.

BACKGROUND: In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS: Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS: Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS: In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

Neoadjuvant Therapy is Associated with Improved Survival in Borderline-Resectable Pancreatic Cancer.

BACKGROUND: Neoadjuvant therapy has shown value in various cancer types. The role of neoadjuvant therapy in pancreatic ductal adenocarcinoma (PDAC), however, remains unknown. The aim of the present work is to evaluate the effect of neoadjuvant therapy on the survival of patients with borderline-resectable PDAC. PATIENTS AND METHODS: Between 2004 and 2015, 7730 patients with resectable PDAC and 1980 patients with borderline-resectable PDAC were identified from the National Cancer Database (NCDB). Survival was compared between resectable and borderline-resectable patients. Survival and pathologic characteristics were also compared within borderline-resectable patients who received neoadjuvant therapy and those who received adjuvant therapy alone. Kaplan-Meier method and Cox proportional-hazard models were used for analysis. RESULTS: Median overall survival (mOS) of all patients with resectable PDAC was similar to that of patients with borderline-resectable disease treated with neoadjuvant therapy (26.5 versus 25.7 months, p = 0.78). Patients with borderline-resectable disease treated with neoadjuvant therapy had improved mOS compared with borderline-resectable patients treated with adjuvant therapy alone (25.7 versus 19.6 months, p < 0.0001). When comparing patients with borderline-resectable disease who received neoadjuvant therapy versus those who received adjuvant therapy alone, the former less often had node-positive pancreatic cancer (40.6% versus 76.3%, p < 0.001) and margin-positive resections (17.8% versus 44.4%, p < 0.001). CONCLUSION: Neoadjuvant therapy is associated with enhanced survival in patients with borderline-resectable pancreatic cancer, which may be attributed to tumor downstaging.

Noncirrhotic hyperammonemia after deceased donor kidney transplantation: A case report.

A 72-year-old woman with end-stage kidney disease due to recurrent urinary tract infections and obstructive uropathy of a solitary kidney presented to our hospital for renal transplantation. She underwent successful transplantation of a deceased donor allograft, but developed acute mental status deterioration on the fifth postoperative day. Her serum ammonia was found to be markedly elevated to 447 µmol/L in the setting of normal hepatic function. She was treated with emergent dialysis and empiric antibiotics targeting urea-splitting organisms, and ultimately made a full neurologic recovery with stable renal allograft function. Noncirrhotic hyperammonemia (NCH) is an exceedingly rare clinical entity but seems to have a predilection for patients who have undergone solid organ transplantation. This report emphasizes the importance of rapid diagnosis and initiation of treatment for NCH, which is associated with a high rate of mortality and irreversible neurological morbidity. We outline the successful workup and management approach for this patient.