Periareolar Skin-Sparing Mastectomy and Immediate Implant-Based Reconstruction: A Reappraisal.

INTRODUCTION: Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the nipple-areolar complex (NAC) and an X-shaped purse string closure after implant-based reconstruction. METHODS: A retrospective review was performed on patients undergoing periareolar SSM and immediate implant-based reconstruction from January 2015 through December 2022, specifically identifying those patients who had square NAC excision and skin closure. RESULTS: Twenty-nine patients met the inclusion criteria. They underwent 54 periareolar SSM and immediate implant-based reconstruction (bilateral 25, unilateral 4). Indications for surgery were cancer (30) and prophylactic (24; 2 patients had bilateral cancer). Reconstructive methods included tissue expander (TE) (36 [66.7%]) and direct-to-implant (DTI) (18 [33.3%]). The mean mastectomy weights and final implant sizes were similar between the 2 groups. Overall wound complications occurred in 13 (24.1%) of the breasts: mastectomy skin flap necrosis (MSFN; 10 [18.5%]) and infection (3 [5.6%]). Reconstructive failure occurred in 3 cases: TE, 1 (infection); DTI, 2 (MSFN/exposure). MSFN by reconstructive method: TE, 4 (11.1%); DTI, 6 (33.3%) (P = 0.05, comparing MSFN rates between TE and DTI methods). The mean initial TE fill volume was 247.1 cc; mean implant size in the DTI group was 417.8 cc (P < 0.0001). CONCLUSIONS: The square NAC excision and closure can minimize the surgical incision in implant reconstruction. Two-stage TE reconstruction permits lower initial fill volumes, which reduces the risk of MSFN after box to X closure of SSM and implant-based reconstruction. It is useful in small- to moderate-sized breasts with mild ptosis in patients who are not candidates for NSM.

Machine learning approaches in the prediction of positive axillary lymph nodes post neoadjuvant chemotherapy using MRI, CT, or ultrasound: A systematic review.

Background and objective: Neoadjuvant chemotherapy is a standard treatment approach for locally advanced breast cancer. Conventional imaging modalities, such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound, have been used for axillary lymph node evaluation which is crucial for treatment planning and prognostication. This systematic review aims to comprehensively examine the current research on applying machine learning algorithms for predicting positive axillary lymph nodes following neoadjuvant chemotherapy utilizing imaging modalities, including MRI, CT, and ultrasound. Methods: A systematic search was conducted across databases, including PubMed, Scopus, and Web of Science, to identify relevant studies published up to December 2023. Articles employing machine learning algorithms to predict positive axillary lymph nodes using MRI, CT, or ultrasound data after neoadjuvant chemotherapy were included. The review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, encompassing data extraction and quality assessment. Results: Seven studies were included, comprising 1502 patients. Four studies used MRI, two used CT, and one applied ultrasound. Two studies developed deep-learning models, while five used classic machine-learning models mainly based on multiple regression. Across the studies, the models showed high predictive accuracy, with the best-performing models combining radiomics and clinical data. Conclusion: This systematic review demonstrated the potential of utilizing advanced data analysis techniques, such as deep learning radiomics, in improving the prediction of positive axillary lymph nodes in breast cancer patients following neoadjuvant chemotherapy.

The Utility of Preoperative HbA1c as a Standardized Protocol in Elective Carpal Tunnel Release: A Retrospective Review of Clinical Outcomes.

Background: In an effort to reduce surgical complications, some institutions have implemented universal hemoglobin A1c (HbA1c) screening for all preoperative patients. However, the value of HbA1c screening for predicting clinically meaningful complications after elective carpal tunnel release (CTR) remains unclear. The purpose of this study was to investigate the clinically meaningful predicative value of HbA1c screening on postoperative complications following elective CTR. Methods: A retrospective cohort study of 790 patients who underwent CTR was performed. All patients had an HbA1c screening performed, regardless of whether they underwent the diagnosis for diabetes or not. Primary outcomes were overall complication rate, rates of major complications (readmission or reoperation), and rates of minor complications (surgical site infection and wound dehiscence). Patients were stratified into 3 groups based on HbA1c: HbA1c <7, HbA1c 7-8, and HbA1c >8. Results: The overall complication rate for all groups was 4.8%. Rates of major complications were 0.4% for readmission and 0.1% for reoperation. For minor complications, the odds ratio (OR) for the HbA1c 7-8 group was 0.6 (95% confidence interval [CI], 0.14-1.77), and for the HbA1c >8 group, the OR was 1.6 (95% CI, 0.66-3.60). All minor complications resolved with outpatient treatment. There were no statistically significant differences between the groups for any comparisons. Conclusions: Elective CTR has a low complication rate. Routine preoperative screening of HbA1c is of little value in predicting clinically meaningful complications.

Local and distant tumor dormancy during early stage breast cancer are associated with the predominance of infiltrating T effector subsets.

BACKGROUND: Although breast cancer mortality is a result of distant recurrences associated with the establishment of tumor dormancy, current clinical practice guidelines recommend a wait and watch approach for tumor recurrences. This is because of our limited understanding of tumor dormancy and insufficient evidence in support of immunological control of tumor dormancy. METHODS: We used FVBN202 transgenic mice expressing rat neu oncogene in the mammary glands, and their parental FVB strain lacking neu expression. These models allowed the detection of tumor dormancy at distant sites using the rat neu protein as a tumor marker. We also used Ki67 for the detection of the indolent and quiescent types of tumor dormancy. Multicolor flow cytometry was used to detect dormant tumor cells and T cell subsets. Co-culture studies were performed to determine the role of T cells in preventing regrowth of dormant cells. RESULTS: We demonstrated that dormant tumor cells were present at the site of primary breast cancer and at distant sites in the lungs and in the liver very early in the course of early stage breast cancer when no distant metastasis was evident. Dormant tumor cells were characterized as neu expressing Ki67- and Ki67low fractions associated with the induction of local immune responses predominated by CD4+ and CD8+ T effector cell subsets. The presence of neu-autoreactive T cells from FVBN202 mice only prevented regrowth of dormant cells. On the other hand, presence of neu-alloreactive anti-tumor T cells in FVB mice prior to tumor challenge resulted in the protection of mice from the dissemination of dormant tumor cells to distant organs. CONCLUSION: Our results suggest that immunotherapeutic targeting of semi-allogeneic mutant neoantigens during tumor dormancy might prevent distant recurrence of the disease.

COVID-19 as an Acute Inflammatory Disease.

The 2019 coronavirus disease (COVID-19) pandemic caused by the virus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has created an unprecedented global crisis for the infrastructure sectors, including economic, political, healthcare, education, and research systems. Although over 90% of infected individuals are asymptomatic or manifest noncritical symptoms and will recover from the infection, those individuals presenting with critical symptoms are in urgent need of effective treatment options. Emerging data related to mechanism of severity and potential therapies for patients presenting with severe symptoms are scattered and therefore require a comprehensive analysis to focus research on developing effective therapeutics. A critical literature review suggests that the severity of SARS-CoV-2 infection is associated with dysregulation of inflammatory immune responses, which in turn inhibits the development of protective immunity to the infection. Therefore, the use of therapeutics that modulate inflammation without compromising the adaptive immune response could be the most effective therapeutic strategy.

Immunotherapy of cancer: targeting cancer during active disease or during dormancy?

Immunotherapeutic targeting of advanced stage cancers has prolonged the survival of cancer patients, yet its curative efficacy is limited due to tumor immunoediting and escape. On the other hand, human vaccines have been able to eradicate smallpox and control several other infectious diseases. The success has resulted from the administration of vaccines in prophylactic settings, or during latency periods in order to protect an individual during future exposure to the disease rather than curing an established disease. Therefore, administration of immunotherapy at the right time is the key to success. However, instead of focusing on the prevention of cancer, current cancer immunotherapies are often being used in a therapeutic setting with the goal of eliminating tumor cells. The present review of evidence related to cancer immunotherapeutics suggests that immunotherapeutic targeting of tumor dormancy could be more promising than targeting of advanced stage disease to achieve a cure for cancer.