Comparison of the Effect of 2 Virtual Education Methods: Family-based Versus Peer-Support on Perceived Stress and Stress Coping in Women with Breast Cancer: A Randomized Controlled Trial.

Background: Stress is an overwhelming feeling in patients with breast cancer (BC). However, The effect of virtual education has not been fully regulated. Hence, this study intends to compare the impact of 2 virtual education methods on perceived stress and stress coping in women with BC. Methods: A 3-armed randomized clinical trial was conducted among 315 women with BC who were referred to the Cancer Institute in Tehran. They were randomly assigned to 3 groups: (a) Family-based, receiving family-based training package; (b) peer-support, receiving peer-support educational package; and (c) control, receiving routine hospital care. Data were collected through demographic and disease characteristics, the Perceived Stress Scale (PSS-14), and Coping Inventory for Stressful Situations (CISS-21) questionnaires before and 3 months after the intervention. Results: The effect of the group factor after controlling the before-intervention scores in perceived stress, problem-oriented, emotion-oriented, and avoidance-oriented strategies were P < 0.0001, P = 0.015, P < 0.0001, and P = 0.111, respectively. Also, the effect of the confounding factor of BC disease stage in the dependent variables was P = 0.527, P = 0.275, P = 0.358, and P = 0.609, respectively. The effect size test showed that before the intervention, the mean scores of perceived stress, problem-oriented, emotion-oriented, and avoidance-oriented strategies were 32.00 ± 7.03, 19.36 ± 4.68, 25.10 ± 5.90, and 17.65 ± 6.64 respectively, but after the intervention showed a decrease in mean scores of perceived stress, emotion-oriented, and avoidance strategies. Conclusion: What is vibrant in virtual family-based education is far more effective than peer support when problem-oriented coping increases. Conversely, reducing perceived stress in women with BC receiving enough information and family support should be considered.

SBF2-AS1 and TreRNA: novel lncRNA players in triple-negative breast cancer pathogenesis.

BACKGROUND: Compared to other breast cancer subtypes, triple-negative breast cancer (TNBC) has always been challenging for clinicians due to its aggressive behavior and lack of a specific treatment. There is a confirmed association between invasive features of tumors and increased epithelial-mesenchymal transition (EMT) process, which is consistent with a higher rate of EMT in TNBC. METHODS AND RESULTS: We investigated the expression of EMT-related genes, SNAI1 and MMP7, and EMT-related lncRNAs, treRNA and SBF2-AS1, in 50 TNBC tumors and 50 non-TNBC tumors to reveal more regulators and effectors involved in TNBC malignancy. In the present study, we showed the overexpression of all the studied genes and lncRNAs in TNBC tumors compared to non-TNBC samples. Moreover, a significant association was observed between MMP7 and treRNA expression levels and larger tumor size. A positive correlation between SNAI1 and lncRNA treRNA expression levels was also detected. CONCLUSIONS: Due to the differential expression and the potential diagnostic power of the studied genes, SBF2-AS1 and treRNA can be proposed as new probable biomarkers and therapeutic targets in TNBC.

A pilot study of the use of human amniotic membrane as subcutaneous implants in a mouse model: a potential for temporary substitutes in two-stage breast reconstructions.

INTRODUCTION: Breast reconstruction by prosthesis is frequently performed in breast cancer treatments, and a temporary substitute is used in the first step of two-stage operations. AIM: Due to the advantageous biological features of the human amniotic membrane, we aimed to evaluate its use for temporary implants. METHOD: We prepared small spherical implants from human amniotic membranes and inserted them into BALB/c mice's subcutaneous flanks. Then, we compared the bulging they produced, the durability, and the host reaction with implants made from the chorionic membrane, folded membrane patches, and sterile plastic beads. RESULTS: All amionitic cases were healthy throughout the study and only mild inflammation occurred in them. Furthermore, the bulging of the implants was acceptable and faded gradually. However, moderate inflammation was observed in chorionic implant mice, and the bulging disappeared very soon. Finally, the control group had severe inflammation and the beads implant was rejected. CONCLUSION: Our study showed that the human amniotic membrane could represent a safe and valid tool for breast reconstruction, however, further studies on larger animals and more implants are suggested.

Clinical characteristics of breast cancer patients admitted to academic surgical wards in Tehran, Iran: an analytical cross-sectional study.

BACKGROUND: Breast cancer (BC) is the most commonly diagnosed cancer and the leading cause of cancer death among women. Knowledge of the clinical characteristics of BC in a population may be informative for disease prediction or diagnosis and for developing screening and diagnostic guidelines. This study aimed to evaluate the clinical characteristics of female patients with BC who were admitted to academic surgical wards in Tehran, Iran. METHODS: In this cross-sectional study, demographic information and clinical characteristics of Iranian females with BC who had undergone breast surgery from 2017-2021 in four academic Breast Surgery Units were extracted from medical files and recorded via a pre-designed checklist. RESULTS: A total of 1476 patients with a mean age of 48.03 (± 11.46) years were enrolled. Among them, 10.4% were aged less than 35. In younger patients, Triple-negative and Her2-enriched subtypes of BC were significantly higher compared to older ones. Overall, 85.7% of tumors were invasive ductal carcinoma, 43.3% were grade 2, 41.4% were located in the UOQ, and 65.2% had presented with mass palpation. The mean pathologic tumor size was 28.94 mm, and the most common subtype was luminal B. CONCLUSIONS: Many characteristics of breast cancer in this study were similar to other countries and previous studies in Iran. However, a higher proportion of young BC compared with Western countries, and even with older studies in Iran, suggest a trend toward lower age for BC in recent years. These results indicate the need for preventive measures and screening in Iranian women at a younger age.

The role of FOXC1/FOXCUT/DANCR axis in triple negative breast cancer: a bioinformatics and experimental approach.

BACKGROUND: Triple-negative breast cancer (TNBC) is the most challenging subtype of breast cancer and does not benefit from the existing targeted therapies. In the present study, we used bioinformatics and experimental approaches to assess the genes that are somehow involved in the epithelial-mesenchymal transition (EMT) pathway which may explain the invasive features of TNBC. METHOD AND RESULTS: We analyzed five GEO datasets consisting of 657 breast tumors by GEO2R online software to achieve common differentially expressed genes (DEGs) between TNBC and non-TNBC tumors. The expression of the selected coding and non-coding genes was validated in 100 breast tumors, including fifty TNBC and fifty non-TNBC samples, using quantitative Real-Time PCR (qRT-PCR). The bioinformatics approach resulted in a final DEG list consisting of ten upregulated and seventeen downregulated genes (logFC ≥|1| and P < 0.05). Co-expression network construction indicated the FOXC1 transcription factor as a central hub node. Considering the notable role of FOXC1 in EMT, the expression levels of FOXC1-related lncRNAs, lnc-FOXCUT and lnc-DANCR, were also evaluated in the studied tumors. The results of qRT-PCR confirmed notable upregulation of FOXC1, lnc-FOXCUT, and lnc-DANCR in TNBC tissues compared to non-TNBC samples (P < 0.0001, P = 0.0005, and P = 0.0008, respectively). Moreover, ROC curve analysis revealed the potential biomarker role of FOXC1 in TNBC samples. CONCLUSION: Present study suggested that the deregulation of FOXC1/lnc-FOXCUT/lnc-DANCR axis may contribute to the aggressive features of triple-negative breast tumors. Therefore, this axis may be considered as a new probable therapeutic target in the treatment of TNBC.

Use of Inguinal Hernia Mesh (DynaMesh-ENDOLAP) in Immediate Implant-based Breast Reconstruction.

INTRODUCTION: The rate of immediate implant-based breast reconstruction after mastectomy is increasing, and providing enough coverage for the implant is mandatory; however the choice of appropriate mesh for implant coverage is controversial. Considering the high cost and the limited availability of breast-dedicated meshes in our country, we conducted this study to investigate the consequences of using a polyvinylidene fluoride (PVDF) mesh designed for endoscopic and laparoscopic hernia repair (ENDOLAP) as a coverage for breast prostheses in breast reconstruction. MATERIALS AND METHODS: A retrospective cross-sectional study was performed on data of patients who had underwent immediate implant-based breast reconstruction between 2012 and 2019. After skin sparing mastectomy and subpectoral implant insertion, the exposed lower and lateral parts were covered with the mesh. RESULTS: Seventy-nine reconstructions were performed on 62 patients. The average follow-up was 31.9 months (ranges 6-102 months). Postoperative complications including small flap necrosis (3.8%), seroma (8.9%), infection (5.1%), hematoma (3.8%), malposition (1.3%), rippling (1.3%), grade two and three capsular contracture (2.5%), and chronic pain (1.3%) occurred in 19% of the operated breasts. The complication rate requiring intervention was 5.3%, and no implant loss was observed. None of the patients who received radiation developed complications. CONCLUSION: ENDOLAP mesh is a cost-effective and safe option for implant coverage in immediate implant-based breast reconstruction, with an acceptable complication rate. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Air pollution exposure and mammographic breast density in Tehran, Iran: a cross-sectional study.

BACKGROUND: Air pollution is one of the major public health challenges in many parts of the world possibly has an association with breast cancer. However, the mechanism is still unclear. This study aimed to find an association between exposure to six criteria ambient air pollutants (PM2.5, PM10, SO2, NO2, O3, and CO) and mammographic breast density (MBD), as one of the strongest predictors for developing breast cancer, in women living in Tehran, Iran. METHODS: Participants were selected from women attending two university hospitals for screening mammography from 2019 to 2021. Breast density was rated by two expert radiologists. Individual exposures to 3-year ambient air pollution levels at the residence were estimated. RESULTS: The final analysis in 791 eligible women showed that low and high breast density was detected in 34.8 and 62.2 of participants, respectively. Logistic regression analysis after considering all possible confounding factors represented that an increase in each unit of NO2 (ppb) exposure was associated with an increased risk of breast density with an OR equal to 1.04 (95CI: 1.01 to 1.07). Furthermore, CO level was associated with a decreasing breast density (OR = 0.40, 95CI = 0.19 to 0.86). None of the other pollutants were associated with breast density. CONCLUSION: Higher MBD was associated with an increased level of NO2, as a marker of traffic-related air pollution. Furthermore, CO concentration was associated with a lower MBD, while other criteria air pollutants were not related to MBD. Further studies are needed to evaluate the association between ambient air pollutants with MBD.

Association study of miR-22 and miR-335 expression levels and G2 assay related inherent radiosensitivity in peripheral blood of ductal carcinoma breast cancer patients.

Identifying patient's cellular radiosensitivity before radiotherapy (RT) in breast cancer (BC) patients allows proper alternations in routinely used treatment programs and reduces the adverse side effects in exposed patients. This study was conducted on blood samples taken from 60 women diagnosed with Invasive Ductal Carcinoma (IDC) BC (mean age: 47±9.93) and 30 healthy women (mean age: 44.43±6.7). The standard G2 assay was performed to predict cellular radiosensitivity. To investigate miR-22 and miR-335 expression levels in peripheral blood mononuclear cells (PBMCs), qPCR was performed. The sensitivity and specificity of the mentioned miRNAs were assessed by plotting the Receiver Operating Characteristic (ROC) curve. Binary logistic regression was performed to identify the miRNA involvement in BC and cellular radiosensitivity (CR) of BC patients. The frequency of spontaneous and radiation-induced chromatid breaks (CBs) was significantly different between control and patient groups (p<0.05). A cut-off value was determined to differentiate the patients with and without cellular radiosensitivity. miR-22 and miR-335 were significantly downregulated in BC patients. miRNAs expression levels were directly associated with CR. ROC curve assessment identified that both miRNAs had acceptable specificity and sensitivity in the prediction of BC and CR of BC patients. Binary logistic regression showed that both miRNAs could also predict BC successfully. Although only miR-22 was shown potent to predict CR of BC patients, both miR-22 and miR-335 might act as tumor suppressor miRNAs in BC. miR-22 and miR-335 may be promising potential biomarkers in BC prediction along with other important biomarkers. Moreover, mirR-22 might be a potential biomarker for the prediction of CR in BC patients.

The effect of fibrin glue on the postoperative lymphatic leakage after D2-lymphadenectomy and gastrectomy in patients with gastric cancer.

INTRODUCTION: Disturbance in the lymphatic drainage during D2 dissection is associated with significant morbidity. We aimed to assess the effect of fibrin glue on the reduction of postoperative lymphatic leakage. METHODS: Prospective double-blinded randomized clinical trial with forty patients in each study arm was conducted. All patients diagnosed, staged, and became a candidate for D2 dissection based on NCCN 2019 guideline for gastric cancer. The intervention group received 1 cc of IFABOND® applied to the surgical bed. RESULTS: The difference between study groups regarding age, gender, tumor stage was insignificant. (All p-values > 0.05). The median daily drainage volume was 120 ml with the first and the third interquartile being 75 and 210 ml, respectively for the intervention group. The control group had median, the first, and the third interquartile of 350, 290, and 420 ml. The difference between daily drainage volumes was statistically significant (p-value < 0.001). The length of hospital stay was significantly different between the two groups. Notably, the intervention group was discharged sooner (median of 7 Vs 9 days, p-value: 0.001). CONCLUSION: This study showed the possible role of fibrin glue in reducing postoperative lymphatic leakage after gastrectomy and D2 dissection. Registration trial number: IRCT20200710048071N1, 2020.08.16.

Residency training amid the COVID-19 pandemic: exploring the impact on mental health and training, a lesson from Iran.

BACKGROUND: COVID-19 has affected the training programs and the clinical schedules of surgical wards in many countries, including Iran. Also, the continuous involvement with COVID-19 patients has caused stress in health care workers; among them, residents are on the frontlines of care delivery. Therefore, we designed a study to assess the mental effects of these circumstances, and the effects on General Surgery and Obstetrics & Gynecology residency training in the busiest surgical departments of our university. METHODS: Participants of this cross-sectional study were residents of General Surgery and Obstetrics & Gynecology of Tehran University of Medical Sciences, and the conventional sampling method was used. We used a questionnaire consisting of 47 questions (mostly using multiple choice questions and answers on the Likert scale) about personal, familial, and demographic characteristics; training activities, and mental effects of COVID-19. RESULTS: The response rate was 63.5%. (127 filled questionnaires). Around 96% of the residents had emotional problems, 85.9% were highly stressed about contracting COVID-19, 81.3% were worried about transferring it to their families; and 78% believed that their residency training had been impaired. CONCLUSION: Overall, our study shows the negative impact of COVID-19 on mental health and the training of residents. We propose that appropriate emotional support and suitable planning for compensation of training deficits is provided for residents.

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.

Surgery for Pregnancy-Associated Breast Cancer.

Surgery in the form of both mastectomy and breast conservation is the main step in the treatment of breast cancer. Numerous studies have shown an equivalent long-term survival for breast conserving surgery (BCS) and mastectomy . Patients desire and tumor characteristics, especially size and multicentricity, are the key factors that affect the decision between these two types of surgery . Patients with any contraindication for radiotherapy or previous history of radiation to the breast field are not suitable for BCS . There are few absolute contraindications for BCS , and early pregnancy is listed among them; mastectomy is preferred in the first trimester of pregnancy to avoid the impact of delaying radiation therapy on outcome of the cancer.

Mastitis, Breast Abscess, and Granulomatous Mastitis.

Breastfeeding is immunoprotective and World Health Organization recommends exclusive breastfeeding for about six months with continuation of breastfeeding for one year or longer as mutually desired by mother and infant. But the target for duration of exclusive breastfeeding has not been reached in a significant number of women. It may be due to inflammatory breast disease such as milk stasis or lactational mastitis.In this chapter we discuss the most common complications of breastfeeding including milk stasis, mastitis, and breast abscess. Also idiopathic granulomatous mastitis, a less common condition, is discussed due to its confusing characteristics and not universally-accepted treatment strategies .Breastfeeding mastitis is inflammation of the breast that can be infectious or non-infectious. With proper diagnosis and treatment of this condition, more severe complications like breast abscess could be avoided, so that breastfeeding could be continued in some circumstances.

Premalignant Disorders of the Breast in Pregnancy and Lactation.

Papillomas, atypical hyperplasias, and lobular carcinoma in situ of the breast are not malignant tumors, but present serious management challenges when they are diagnosed in a breast biopsy . Upgrading after excision and increased possibility of future cancer are risks that accompany these lesions. While some features have been defined as high-risk for upgrading, many practitioners now recommend conservative non-surgical treatment and vacuum-assisted biopsy . However, the challenge gets worse when the patient is pregnant or breastfeeding because of the limitations in imaging and treatment in relation to the fetus. This chapter deals with these problems, although the best management strategy cannot be defined because of lack of evidence at present.

A randomized, controlled, phase II clinical trial of ß-D-mannuronic acid (M2000) in pre-surgical breast cancer patients at early stage (T1-T2).

Following the potent efficacy of ß-D-Mannuronic acid in a breast cancer murine model, we evaluated the efficacy of this novel non-steroidal anti-inflammatory drug in breast cancer patients in the present clinical trial. The study was an 8-week randomized, controlled, phase II clinical trial (IRCT: 2017012213739N7 (in 48 pre-surgical breast cancer patients. Patients who had breast cancer at early stage, with invasive ductal carcinoma, were placed on a waiting-list for surgery and were allocated to the study. ß-D-Mannuronic was administrated at a dose of two capsules (1000 mg/d) orally during a period of 8 weeks. The end point of this study was when the patients were admitted for surgery. Moreover, the patients' well-being status was followed up on for safety. There were no statistically significant differences between treatment and non-treatment groups at baseline. ß-D-Mannuronic acid therapy, from 20 patients, showed that in one patient (5%) tumour size was decreased; in five patients (25%) tumour growth was stopped; and in 14 patients (70%) the growth rate in the treatment group did not show significant change, compared to the non-treatment group. Evaluation of two tumour markers (carcinoembryonic antigen and cancer antigen 15-3) showed that there was no significant difference between before and after treatment. Although the use of some non-steroidal anti-inflammatory drugs in a long time period has shown a prophylactic effect in breast cancer, their therapeutic efficacy in a short time period is unknown, whereas treatment with ß-D-Mannuronic acid during 8 weeks could show 30% therapeutic effects in pre-surgical breast cancer 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.

Health-related quality of life and the predictive role of sense of coherence, spirituality and religious coping in a sample of Iranian women with breast cancer: a prospective study with comparative design.

BACKGROUND: There is disagreement among studies of health-related quality of life (HRQoL) changes in breast cancer patients over time. Reportedly, assessment of HRQoL prior to diagnosis may be crucial to provide a clear point of comparison for later measurements. The aims of this study were (1) to investigate changes in HRQoL, sense of coherence (SOC), spirituality and religious coping in a group of women with breast cancer from the pre-diagnosis phase to 6 months later in comparison with a control group, and (2) to explore the predictor role of SOC, spirituality, and religious coping within the breast cancer group at the 6-month follow-up. METHODS: A sample of women with breast cancer (n = 162) and a matched control group (n = 210) responded to the following instruments on both occasions: the European Organization for Research and Treatment of Cancer QLQ-C30, the SOC Scale, the Spiritual Perspective Scale and the Brief Religious Coping Scale. A series of General Linear Model (GLM) Repeated Measures was used to determine changes between the groups over time. Also, Multiple Linear Regression analyses were applied to each of the HRQoL dimensions, as dependent variable at the 6 months follow-up. RESULTS: Physical and role function, fatigue, and financial difficulties were rated worse by the women with breast cancer during the first 6 months in comparison to the controls, which was both a statistically (p < 0.001) and clinically significant difference. Women had better scores for global quality of life (p < 0.001), and emotional functioning (p < 0.01) during the same period of time. The degree of SOC (p < 0.01) and baseline ratings of several dimensions of HRQoL (p < 0.05) were the most important predictors of HRQoL changes. CONCLUSIONS: Collecting HRQoL data before a final diagnosis of breast cancer is important to identify women at risk of deterioration in HRQoL during and after treatment. Special attention should be paid to physical and role functioning impairment, fatigue, and financial difficulties experienced by these women. These results underscore that the degree of SOC may be more important as a predictor for HRQoL changes in this sample than spirituality and religious coping.

Effective Ki-67 Reduction by Pre-Surgery Short-Term Administration of Letrozole in (Hormone-Positive) Breast Cancer.

Background & Objective: Antigen Ki-67 (histone-based nuclear protein) is a static marker of tumor cell proliferation and growth and is commonly measured to indicate the effect of treatment in breast cancer patients. This single-arm trial study aimed to evaluate the effect of short-term endocrine therapy (letrozole) on Ki-67 levels in menopausal women with early hormone-positive breast cancer who were referred to two university hospitals. Methods: Patients with a pre-treatment Ki67 of 5% or less were excluded from the study. Participants (n=25) received oral letrozole (2.5 mg daily) seven days before surgery. Ki-67% on both biopsies and the surgical specimens were measured and compared. Results and Conclusion: The mean age of patients was 62±9.4 (48-83 years). Our result indicated that pre-surgery consumption of letrozole for hormone-positive breast cancer can significantly decrease the of Ki-67 labeling index (23.24±9.74 vs. 16.92±9.55, P=0.001 by paired t-test), with no drug-related adverse events.

Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy.

INTRODUCTION: Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS: Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS: Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS: This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.