Bile Spillage as a Prognostic Factor for Gall Bladder Cancer: A Systematic Review and Meta-Analysis.

INTRODUCTION: Biliary spillage (BS) is a common complication following initial cholecystectomy for gall bladder cancer (GBC). Few studies have explored the importance of BS as a long-term prognostic factor. We perform a meta-analysis of the association between BS and survival in GBC. METHODS: A systematic literature search was performed in February 2023. Studies evaluating the incidence of BS and its association with long-term outcomes in patients undergoing initial laparoscopic or open cholecystectomy for either incidental or resectable GBC were included. Overall survival (OS), disease-free survival (DFS), and rate of peritoneal carcinomatosis (RPC) were the primary end points. Forest plot analyses were used to calculate the pooled hazard ratios (HRs) of OS, DFS, and RPC. Metaregression was used to evaluate study-level association between BS and perioperative risk factors. RESULTS: Of 181 published articles, 11 met inclusion criteria with a sample size of 1116 patients. The rate of BS ranged between 9% and 67%. On pooled analysis, BS was associated with worse OS (HR = 1.68, 95% confidence interval [CI] = 1.32-2.14), DFS (pooled HR= 2.19, 95% CI = 1.30-3.68), and higher RPC (odds ratio = 9.37, 95% CI = 3.49-25.2). The rate of BS was not associated with higher T stage, lymph node metastasis, higher grade, positive margin status, reresection, or conversion rates. CONCLUSIONS: Our meta-analysis shows that BS is a predictor of higher peritoneal recurrence and poor survival in GBC. BS was not associated with tumor characteristics or conversion rates. Further research is needed to identify other potential risk factors for BS and investigate the ideal treatment schedule to improve survival.

Accuracy of the 'CUT' Score for Assessing Malignancy in Bethesda 3 and 4 Thyroid Nodules in North American Population: A Retrospective Study.

BACKGROUND: The CUT score is a thyroid nodule malignancy risk assessment scoring system intended to guide surgeons in treating Bethesda 3 and 4 thyroid nodules. It is based on clinical (C) and ultrasonographic (U) features and a five-tiered (T) representing cytology. PURPOSE: Our study aimed to assess the utility of the CUT score in predicting thyroid malignancy in the North American population. The main reason for creating this score is to reduce unnecessary surgeries on these challenging thyroid nodules. MATERIALS AND METHODS: A retrospective record review study applied the CUT score to 219 Bethesda 3 and 4 thyroid nodules. A total of 203 Bethesda 3 and 16 Bethesda 4 nodules from patients treated between January 2015 and December 2019 at a single institution were assessed. A receiver operating characteristic (ROC) curve analysis was performed to evaluate the CUT diagnostic test. Binary logistic regression analysis was performed. Iteration of analysis was performed after stratification according to body mass index to assess CUT score accuracy in obese and non-obese patients. RESULTS: Of 219 nodules analyzed, 148 were characterized as benign and 71 as malignant. Prevalence rates of malignancy were 29.6% (n = 60) and 68.8% (n = 11) in Bethesda 3 and 4 nodules, respectively. The mean CU (clinical, ultrasonography) score was 5.35 ± 1.38 in benign nodules versus 4.96 ± 1.5 in malignant nodules (p = 0.08). The area under the curve (AUC = 0.433) for the association of CUT scores with nodule malignancy was not significant (p = 0.13). The CUT score was insignificant as a diagnostic test for nodule malignancy in obese (AUC = 0.45; p = 0.72) and non-obese patients (AUC = 0.39; p = 0.08). CONCLUSION: The CUT score did not correlate with preoperative malignancy risk estimates in Bethesda 3 thyroid nodules and, therefore, may have limited utility as a predictor of malignancy in these thyroid nodules.

Preoperative Breast MRI for Newly Diagnosed Ductal Carcinoma in Situ: Imaging Features and Performance in a Multicenter Setting (ECOG-ACRIN E4112 Trial).

Background There are limited data from clinical trials describing preoperative MRI features and performance in the evaluation of mammographically detected ductal carcinoma in situ (DCIS). Purpose To report qualitative MRI features of DCIS, MRI performance in the identification of additional disease, and associations of imaging features with pathologic, genomic, and surgical outcomes from the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E4112 trial. Materials and Methods Secondary analyses of a multicenter prospective clinical trial from the ECOG-ACRIN Cancer Research Group included women with DCIS diagnosed with conventional imaging techniques (mammography and US), confirmed via core-needle biopsy (CNB), and enrolled between March 2015 and April 2016 who were candidates for wide local excision (WLE) based on conventional imaging and clinical examination results. DCIS MRI features and pathologic features from CNB and excision were recorded. Each woman without invasive upgrade of the index DCIS at WLE received a 12-gene DCIS score. MRI performance metrics were calculated. Associations of imaging features with invasive upgrade, dichotomized DCIS score (<39 vs ≥39), and single WLE success were estimated in uni- and multivariable analyses. Results Among 339 women (median age, 60 years; interquartile range, 51-66 years), most DCIS cases showed nonmass enhancement (NME) (195 of 339 [58%]) on MRI scans with larger median size than on mammograms (19 mm vs 12 mm; P < .001). Positive predictive value of MRI-prompted CNBs was 32% (21 of 66) (95% CI: 22, 44), yielding an additional cancer detection rate of 6.2% (21 of 339) (95% CI: 4.1, 9.3). MRI false-positive rate was 14.2% (45 of 318) (95% CI: 10.7, 18.4). No imaging features were associated with invasive upgrade or DCIS score (P = .05 to P = .95). Smaller size and focal NME distribution at MRI were linked to single WLE success (P < .001). Conclusion Preoperative MRI depicted ductal carcinoma in situ (DCIS) diagnosed with conventional imaging most commonly as nonmass enhancement, with larger median span than mammography, and additional cancer detection rate of 6.2%. MRI features of this subset of DCIS did not enable prediction of pathologic or genomic outcomes. Clinical trial registration no. NCT02352883 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Kuhl in this issue. An earlier incorrect version of this article appeared online. This article was corrected on August 4, 2021.

Hashimoto's Thyroiditis Minimizes Lymph Node Metastasis in BRAF Mutant Papillary Thyroid Carcinomas.

Hashimoto's thyroiditis (HT) (autoimmune thyroiditis) is a clinicopathological entity associated with chronic lymphocytic infiltration resulting in hypothyroidism. HT is a double-edged sword that increases the risk of papillary thyroid cancer (PTC), yet it serves as a protective factor for PTC progression. BRAF mutation in PTCs is associated with rapid cell growth, aggressive tumor characteristics, and higher mortality rates. Here, we aimed to analyze the influence of HT in patients with PTCs and its effect on lymph node metastasis (LNM) in BRAF mutant tumors. Adults diagnosed with PTC between 2008 and January 2021 were retrospectively included. A total of 427 patients, 128 of whom had underlying HT, were included. The HT group had significantly higher rates of microcarcinoma (49.2% vs. 37.5%, p = 0.025) and less lateral LNM (8.6% vs. 17.1%, p = 0.024). Interestingly, BRAF-mutated PTCs were found to have significantly less overall LNM (20.9% vs. 51%, p = 0.001), central LNM (25.6% vs. 45.1%, p = 0.040) and lateral LNM (9.3% vs. 29.4%, p = 0.010) in patients with HT when compared to those without underlying HT. HT was found to be an independent protective predictor of overall and lateral LNM. Altogether, HT was able to neutralize the effect of BRAF mutation and was determined to be an independent protective factor against LNM. Specifically, our work may influence treatment-aggressiveness decision making for endocrinologists, oncologists and surgeons alike.

Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging: An Ancillary Study of the ECOG-ACRIN Cancer Research Group (E4112).

Importance: Guiding treatment decisions for women with ductal carcinoma in situ (DCIS) requires understanding patient preferences and the influence of preoperative magnetic resonance imaging (MRI) and surgeon recommendation. Objective: To identify factors associated with surgery preference and surgery receipt among a prospective cohort of women with newly diagnosed DCIS. Design, Setting, and Participants: A prospective cohort study was conducted at 75 participating institutions, including community practices and academic centers, across the US between March 25, 2015, and April 27, 2016. Data were analyzed from August 2 to September 24, 2021. This was an ancillary study of the ECOG-ACRIN Cancer Research Group (E4112). Women with recently diagnosed unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. Participants who had documented surgery and completed the baseline patient-reported outcome questionnaires were included in this substudy. Exposures: Women received preoperative MRI and surgeon consultation and then underwent wide local excision or mastectomy. Participants will be followed up for recurrence and overall survival for 10 years from the date of surgery. Main Outcomes and Measures: Patient-reported outcome questionnaires assessed treatment goals and concerns and surgery preference before MRI and after MRI and surgeon consultation. Results: Of the 368 participants enrolled 316 (86%) were included in this substudy (median [range] age, 59.5 [34-87] years; 45 women [14%] were Black; 245 [78%] were White; and 26 [8%] were of other race). Pre-MRI, age (odds ratio [OR] per 5-year increment, 0.45; 95% CI, 0.26-0.80; P = .007) and the importance of keeping one's breast (OR, 0.48; 95% CI, 0.31-0.72; P < .001) vs removal of the breast for peace of mind (OR, 1.35; 95% CI, 1.04-1.76; P = .03) were associated with surgery preference for mastectomy. After MRI and surgeon consultation, MRI upstaging (48 of 316 [15%]) was associated with patient preference for mastectomy (OR, 8.09; 95% CI, 2.51-26.06; P < .001). The 2 variables with the highest ORs for initial receipt of mastectomy were MRI upstaging (OR, 12.08; 95% CI, 4.34-33.61; P < .001) and surgeon recommendation (OR, 4.85; 95% CI, 1.99-11.83; P < .001). Conclusions and Relevance: In this cohort study, change in patient preference for DCIS surgery and surgery received were responsive to MRI results and surgeon recommendation. These data highlight the importance of ensuring adequate information and ongoing communication about the clinical significance of MRI findings and the benefits and risks of available treatment options.

Multicentric Breast Abscesses in a Patient Who Had COVID-19.

Background: Coronavirus disease 2019 (COVID-19) is recognized as a multisystem disease affecting the whole body, with new complications from the disease being described on an almost-daily basis. Case Report: We report the case of a 50-year-old female with a medical history of diabetes and silicone breast implants who developed right-sided, multicentric breast masses after a prolonged hospitalization for COVID-19 infection complicated by renal failure requiring dialysis. The patient noted an onset of breast pain and masses, and subsequent imaging demonstrated multiple similar oval masses. She underwent biopsy and operative debridement of the lesions and recovered appropriately. Results were consistent with sterile abscesses that were considered secondary to a vasculitis-like process associated with COVID-19 infection. Conclusion: To our knowledge, this case is the first account of breast pathology associated with a diagnosis of COVID-19 in the medical literature and encourages systematic evaluations of patients with coronavirus infections, including breast examinations.

Prevalence and mortality of cardiovascular events in patients with hyperthyroidism: a nationwide cohort study in the United States.

BACKGROUND: Little is known about the implications of hyperthyroidism on cardiovascular diseases like myocardial infarctions (MI), ischemic strokes, and hemorrhagic strokes. Previous studies implicate hyperthyroidism as a risk factor for MI and ischemic stroke. Cardiovascular disease is the leading cause of death in the US, and the possibility of hyperthyroidism contributing to this disease burden warrants investigation in a US patient population. METHODS: The National Readmission Database (NRD) from 2010 to 2017 was used to identify adults who had a new-onset diagnosis of MI, ischemic stroke, or hemorrhagic stroke. Risk factors for mortality, prolonged hospital stay, and hospital cost were analyzed with binary logistic regression. RESULTS: A total of 278,609,748 hospital records were reviewed. Of these, 15,685,461 were hospitalized for adverse cardiovascular events with concomitant hyperthyroidism, roughly 4.5 per 1,000 cases. Patients with MI and hemorrhagic stroke with thyrotoxicosis had a lower mortality rate than euthyroid patients (OR 0.81, 95% CI: 0.78-0.84, P<0.001 and OR 0.72, 95% CI: 0.67-0.77, P<0.001, respectively). Thyrotoxicosis was associated with increased hospital stay (MI: OR 1.35, 95% CI: 1.32-1.38, P<0.001; ischemic: OR 1.38, 95% CI: 1.35-1.41, P<0.001; hemorrhagic: OR 1.33, 95% CI: 1.25-1.40, P<0.001), expenditures in ischemic (OR 1.31, 95% CI: 1.28-1.34, P<0.001) and hemorrhagic stroke patients (OR 1.18, 95% CI: 1.12-1.24, P<0.001). CONCLUSIONS: Patients that experienced MI or hemorrhagic stroke with concomitant thyrotoxicosis were observed to have a lower mortality rate than euthyroid patients but had with an increased length of hospital stay. Patients who had ischemic or hemorrhagic stroke with thyrotoxicosis had a significantly higher hospital cost. The hyperdynamic state underlying hyperthyroidism may be protective in these adverse events. Further studies into these physiological changes are warranted.

Benign Feminizing Adrenal Tumor in an Adult Male.

Background: Feminizing adrenal tumors are rare and generally malignant tumors usually seen in male adults and children. We report the case of a benign feminizing adrenal tumor in a male patient. To our knowledge, only 2 other cases of benign, estrogen-only-secreting adrenal tumors have been reported. Case Report: A 44-year-old male with a history of hypertension presented to his primary care physician with chest tenderness, fatigue, and erectile dysfunction. Hormonal workup and imaging identified an estrogen-only-secreting adrenal adenoma. The adenoma was removed via laparoscopic adrenalectomy, and the patient had a normal postoperative course. Pathologic findings were an adrenal cortical adenoma with a Weiss score of 0 and a Ki-67 score of 0%. At 6-month follow-up, the patient's symptoms had significantly improved, and his previously abnormal sex hormone levels were within normal limits. Conclusion: Given the ambiguity in distinguishing between malignant and benign feminizing adrenal tumors, we suggest that radiologic (via Hounsfield units), clinical (via trending hormone levels), and histopathologic (via Weiss and Ki-67 scores) findings are sufficient to confirm the benign nature of this commonly malignant tumor.

Factors That Predict Biological Aggressiveness in Estrogen Receptor-Positive / Human Epidermal Growth Factor Receptor 2-Negative / Lymph Node-Negative Breast Cancer.

Background: Traditionally, breast cancer is staged using TNM criteria: tumor size (T), nodal status (N), and metastasis (M). The Oncotype DX assay provides a recurrence score (RS) based on genomics that predicts the likelihood of distant recurrence in estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-)/lymph node-negative (LN-) tumors. Methods: We retrospectively reviewed the medical records of patients with ER+/HER2-/LN- breast cancer tumors who were evaluated between 2007 and 2017 with Oncotype DX RS. We compared the RS to tumor size, patient age, progesterone receptor (PR) status, and LN immunohistochemistry to assess for factors that may independently predict recurrence risk. We also compared tumor size to tumor grade. Results: The data set included 296 tumors: 248 ER+/PR-positive (PR+)/HER2- and 48 ER+/PR-negative (PR-)/HER2-. RS ranged from 0 to 66, patient age ranged from 33 to 77 years, and tumor size ranged from 1 to 65 mm. No significant correlation was found between age and RS (r=-0.073, P=0.208). PR- tumors had a significantly higher RS regardless of size (PR- mean RS 30.8 ± 12.7; PR+ mean RS 16.3 ± 7.3; t(53)=7.6, P<0.0001). No significant correlation was seen between tumor size and RS for all tumors (r=-0.028, P=0.635), and this finding remained true for the PR+ tumor subgroup (r=0.114, P=0.072). However, a significant negative correlation was seen between tumor size and RS in the PR- subgroup (r=-0.343, P=0.017). Further analysis to ensure that differences in tumor grade did not account for this correlation showed equal distribution of well differentiated, moderately differentiated, and poorly differentiated tumors with no significant correlation between tumor size and grade. Conclusion: Increasing tumor size may not be associated with increasing biological aggressiveness. Traditionally, smaller tumors are thought to be lower risk and larger tumors higher risk, with a tendency to use chemotherapy with large tumors. However, our data showed a negative correlation between tumor size and RS in the PR- subgroup. A tumor with PR negativity that reaches a large size without metastasizing may suggest a favorable tumor biology. These tumors may not receive as much benefit from chemotherapy as previously thought. Also, the higher RS seen in smaller PR- tumors may demonstrate PR- status as a predictor for higher risk of distant recurrence. We propose that all tumors meeting the ER+/PR-/LN- criteria, regardless of size, should be considered for genotyping, with the RS used to guide chemotherapy benefit.

Do rural patients with operable breast cancer fare worse than urban patients in Louisiana? Results of the Louisiana cancer consortium.

BACKGROUND: It is unknown whether rural patients with operable breast cancer do worse than urban patients in Louisiana. We performed an analysis of breast cancer based on rural versus urban residencies and evaluate factors associated with worse survival. METHODS: Data on women diagnosed with stages I to III breast cancer from 2004 to 2016 were obtained from the Louisiana Tumor Registry. Overall survival and cancer-specific survival were compared between rural and urban residencies by sociodemographic, clinical-pathologic, and treatment variables. Kaplan-Meier method and the log-rank test were used to compare the survival curves. Cox regression model was used to assess independent factors associated with overall survival and cancer-specific survival. RESULTS: Of the 27,780 patients, 2,441 patients (8.7%) resided in rural areas. Compared with urban patients, rural patients tended to be older, underinsured, more impoverished, less likely to be treated at an American College of Surgeons accredited institution, and more likely to be treated at a low-volume center (P < .005 each). For stages I and II diseases, there was a statistically significant difference in overall survival favoring urban regions, but no difference in cancer-specific survival. For stage III disease, there was no difference in either overall survival or cancer-specific survival between the 2 cohorts. Overall survival and cancer-specific survival curves for the entire cohort were not different at the 5-year mark, but become statistically significant with greater time; although rural patients had a lower long-term overall survival (P = .0001) and cancer-specific survival (P = .049) compared with urban patients, the rural-urban differences in overall survival and cancer-specific survival were no longer different after adjusting for other covariates, indicating the observed differences in univariate analysis were attributable to sociodemographic, clinicpathologic, and treatment factors. CONCLUSION: Despite rural patients with operable breast cancer having an overall lesser overall survival and cancer-specific survival than their urban counterpart, rural residence itself was not an independent predictor of outcome. In fact, particular socioeconomic factors increased the risk of death among patients residing in rural areas. Additional analysis at the patient-level is needed to understand the interactions between rurality and breast cancer outcomes in Louisiana.

Peritoneal Encapsulation With Incarcerated Meckel Diverticulum Contributing to Small Bowel Obstruction.

Background: Meckel diverticulum is the most common congenital gastrointestinal malformation, but it is rarely symptomatic. Peritoneal encapsulation is a rare abnormality of embryonic development and may present with obstruction, although it too is usually asymptomatic. Case Report: We report the case of an 82-year-old male who presented with symptoms and imaging findings consistent with small bowel obstruction. During laparotomy, a peritoneal encapsulation was observed containing the majority of the small bowel. A Meckel diverticulum was discovered tethered to the small bowel mesentery by a mesodiverticular band, preventing egress from the accessory peritoneal membrane and appearing to be the cause of the obstruction. Conclusion: This patient had 3 rare findings-peritoneal encapsulation, Meckel diverticulum, and a mesodiverticular band-contributing to cause an acute small bowel obstruction. The presence of all of these features in one patient is extremely rare, and we believe this is the first description of such a phenomenon.

Use of Postmastectomy Radiation in Patients Treated for Invasive Breast Cancer with Mastectomy and Immediate Reconstruction.

Immediate reconstruction after mastectomy helps women manage the psychological impact of deforming surgery. Postmastectomy radiation therapy (PMRT) can negatively impact the aesthetic result after breast reconstruction. We performed this study to achieve a better understanding of how PMRT is used after reconstruction in our institution. We conducted a retrospective review of a prospectively maintained database of all women who underwent mastectomy for invasive breast cancer followed by immediate reconstruction from 2006 to 2017. Patients were divided into two groups depending on whether PMRT was included in their treatment, and we compared clinical and pathologic characteristics to determine which factors were likely to lead to PMRT. A total of 315 women treated with mastectomy and immediate reconstruction were identified. A total of 96 were treated with PMRT; 219 had mastectomy and immediate reconstruction without radiotherapy. Tumor characteristics, tumor stage, demographics, and comorbidities did not predict the use of PMRT. Neoadjuvant chemotherapy (NAC) was the most powerful predictor for using PMRT. In 47 of 81 (58%) patients treated with NAC, PMRT was used. Whereas 49 of 234 (21%) patients who did not receive NAC were treated with PMRT (P = 0.0001, risk ratio 2.77, 95 per cent confidence interval 2.03-3.77). In our institution, patients treated with NAC followed by mastectomy and immediate reconstruction are significantly more likely to receive PMRT. The increased use of PMRT after NAC should be factored into the preoperative discussion with patients choosing mastectomy and immediate reconstruction.

Association of Magnetic Resonance Imaging and a 12-Gene Expression Assay With Breast Ductal Carcinoma In Situ Treatment.

IMPORTANCE: Advanced diagnostics, such as magnetic resonance imaging (MRI) and gene expression profiles, are potentially useful to guide targeted treatment in patients with ductal carcinoma in situ (DCIS). OBJECTIVES: To examine the proportion of patients who converted to mastectomy after MRI and the reasons for those conversions and to measure patient adherence to radiotherapy guided by the 12-gene DCIS score. DESIGN, SETTING, AND PARTICIPANTS: Analysis of a prospective, cohort, nonrandomized clinical trial that enrolled women with DCIS on core biopsy who were candidates for wide local excision (WLE) from 75 institutions from March 25, 2015, to April 27, 2016, through the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network trial E4112. INTERVENTIONS: Participants underwent breast MRI before surgery, and subsequent management incorporated MRI findings for choice of surgery. The DCIS score was used to guide radiotherapy recommendations among women with DCIS who had WLE as the final procedure and had tumor-free excision margins of 2 mm or greater. MAIN OUTCOMES AND MEASURES: The primary end point was to estimate the conversion rate to mastectomy and the reason for conversion. RESULTS: Of 339 evaluable women (mean [SD] age, 59.1 [10.1] years; 262 [77.3%] of European descent) eligible for WLE before MRI, 65 (19.2%; 95% CI, 15.3%-23.7%) converted to mastectomy. Of these 65 patients, conversion was based on MRI findings in 25 (38.5%), patient preference in 25 (38.5%), positive margins after attempted WLE in 10 (15.4%), positive genetic test results in 3 (4.6%), and contraindication to radiotherapy in 2 (3.1%). Among the 285 who had WLE performed after MRI as the first surgical procedure, 274 (96.1%) achieved successful breast conservation. Of 171 women eligible for radiotherapy guided by DCIS score (clear margins, absence of invasive disease, and score obtained), the score was low (<39) in 82 (48.0%; 95% CI, 40.6%-55.4%) and intermediate-high (≥39) in 89 (52.0%; 95% CI, 44.6%-59.4%). Of these 171 patients, 159 (93.0%) were adherent with recommendations. CONCLUSIONS AND RELEVANCE: Among women with DCIS who were WLE candidates based on conventional imaging, multiple factors were associated with conversion to mastectomy. This study may provide useful preliminary information required for designing a planned randomized clinical trial to determine the effect of MRI and DCIS score on surgical management, radiotherapy, overall resource use, and clinical outcomes, with the ultimate goal of achieving greater therapeutic precision. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02352883.

Rosai-Dorfman disease of the breast and parotid gland.

Rosai-Dorfman disease or sinus histiocytosis with massive lymphadenopathy (SHML) is a histiocytic proliferative disorder that typically involves the cervical lymph nodes with or without extranodal involvement of the skin, soft tissues, respiratory tract, or virtually any other site of the body. We present a case report of SHML involving the cervical lymph nodes, parotid gland and breast. There is only one other Rosai-Dorfman registered case that involves both breast and parotid disease and no previously published case reports. The patient presented atypically with breast masses found on screening mammogram rather than massive cervical lymphadenopathy. We describe the subsequent radiographic and surgical pathologic evidence that led to the diagnosis of this rare disease.

A Case of Malignant Pheochromocytoma Presenting 7 Years After the Initial Surgery.

BACKGROUND: Pheochromocytoma (PHEO) is a rare tumor of the adrenal medulla and sympathetic ganglion that produces the catecholamines norepinephrine and epinephrine. Traditionally, approximately 10% of PHEOs were thought to be malignant, but recent developments in PHEO research have noted that specific genetic mutations are associated with higher risk of metastatic spread. CASE REPORT: We report the case of a 71-year-old female who presented with abdominal pain in September 2009 when she was 64 years old. Evaluation at that time revealed cholelithiasis and bilateral adrenal masses. Workup showed elevated free normetanephrines, and positron emission tomography-computed tomography demonstrated bilateral adrenal hypermetabolic lesions concerning for malignancy. She underwent open bilateral adrenalectomies and cholecystectomy. The right adrenal mass was identified as a PHEO with nonaggressive features and negative margins, and the left adrenal mass was an adrenal cortical adenoma without dysplasia. In April 2016, the patient was referred by her endocrinologist for elevated blood pressure and 16-lb weight loss. The patient reported weakness, headaches, hot flashes, cold sweats, and fatigue. Laboratory workup revealed elevated plasma free normetanephrine, and imaging showed a recurrence of the PHEO in both the right adrenal bed and the head of the right humerus. CONCLUSION: Current predictors of PHEO recurrence failed to identify the original tumor as aggressive or likely to return as a metastatic lesion. Because of the rarity of these tumors, few consistent laboratory or radiologic predictors of malignancy based on initial presentation have been identified; predictors of malignancy in PHEO warrant further investigation.

A Potential Additional Variable to Consider in the Surgical Treatment of Ductal Carcinoma in Situ.

BACKGROUND: HER2/neu is a potentially interesting variable that has been demonstrated to have a profound impact on the management of invasive breast carcinoma, and we performed this study to evaluate the differences between HER2-positive and HER2-negative ductal carcinoma in situ. The impetus for this study was our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial that was designed to evaluate the potential role of trastuzumab in breast conservation therapy for patients with HER2-positive ductal carcinoma in situ. METHODS: All patients with ductal carcinoma in situ and an assessment for the HER2/neu receptor were identified. Patients with HER2-positive and HER2-negative ductal carcinoma in situ were compared to determine differences in demographic, hormone receptor status, nuclear grade, presence of necrosis, surgical procedure (lumpectomy or mastectomy), tumor size, and extent of margins. Quantitative variables were analyzed with t test, and nominal variables were assessed by chi square analysis. RESULTS: A total of 177 patients were identified with a mean age of 61.0 years. A total of 101 patients (57.1%) were treated with lumpectomy, and 76 had mastectomy (42.9%). Forty-four (24.9%) patients were positive, and 133 (75.1%) were negative for the HER2/neu receptor. HER2-positive tumors were larger (23.6 vs 13.8 mm, P=0.001) and more likely to undergo mastectomy (61.4% vs 36.8%, P=0.01). CONCLUSION: Based on these results, an HER2-positive ductal carcinoma in situ is likely to be larger than an HER2-negative tumor, leading to more frequent use of mastectomy. This finding would explain our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial.

Omental torsion mimicking acute appendicitis: a case report.

Primary omental torsion is an uncommon cause of an acute abdomen that can mimic acute appendicitis. Herein we report a case of suspected acute appendicitis that proved to be a distal segment of infarcted omentum secondary to primary torsion.

An Assessment of Margins after Lumpectomy in Breast Cancer Management.

We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen (P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant (P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.

The Impact of Chemotherapy on Complications Associated with Mastectomy and Immediate Autologous Tissue Reconstruction.

We performed this study to evaluate the impact of chemotherapy on the outcomes associated with immediate autologous tissue reconstruction (IATR) in the treatment of breast cancer. Patients were divided into two groups: Group 1 received chemotherapy before surgery and Group 2 did not receive chemotherapy. Records were reviewed to identify demographics, comorbidities, histology, and wound healing complications. Groups were compared using Kruskal-Wallis and Fisher exact tests as appropriate. A total of 128 patients were identified: 29 received chemotherapy before surgery (Group 1) and 99 did not receive chemotherapy (Group 2). Group 1 patients were more likely to have diabetes 27 per cent versus 6 per cent (P = 0.005) despite both groups having a mean body mass index of 30. Group 2 patients had less advanced stage disease as expected because they did not receive chemotherapy; 37 per cent of Group 2 patients had stage 0 breast cancer (P < 0.001). The incidence of wound complications was 17 per cent in Group 1 and 12 per cent in Group 2 (P = NS). Preoperative chemotherapy for breast cancer followed by IATR was associated with no increased risk of healing complications. IATR can be offered to patients who require preoperative chemotherapy, and their healing will not be impaired as a result of the chemotherapy.