Presentation and characteristics of breast cancer in young women under age 40.

PURPOSE: Although uncommon, breast cancer is the leading cause of cancer death in young women. There are limited studies on the presentation and characteristics of breast cancer in women under age 40. METHODS: This is a retrospective study investigating patient demographics, clinical presentations, imaging findings, and cancer characteristics of a cohort of 145 women under age 40 with breast cancer. RESULTS: Our cohort had more aggressive cancer subtypes than reported in older women; 33.1% triple negative, 80% high Ki-67, and 21.3% with stage 3+ disease. Most were referred from primary care or obstetrician/gynecologist, though 5.5% initially presented from the emergency department and another 2.1% were incidental findings. 16.6% of patients presented while pregnant or breastfeeding. Most patients presented with breast related symptoms. Of the 9.1% of patients diagnosed through our high-risk screening program, 84.6% of the cancers were identified on mammography or simultaneously with mammography and MRI. Most breast cancers presented with typically worrisome imaging (82.6%), though several cancers presented with findings that were typically benign. CONCLUSIONS: We recommend prompt breast imaging for young women presenting with breast-related symptoms or an incidental breast finding, as younger patients have more aggressive cancer subtypes and are of a higher grade at presentation compared to older women. We also recommend vigilance when distinguishing suspicious symptoms from pregnancy-related breast changes to minimize delays in diagnosis. Additionally, it is important to identify patients who qualify for high risk screening, since cancers in screening patients were found at a lower grade than those presenting with symptoms.

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.

The Role of Antifibrinolytics in Reducing Blood Loss During Craniofacial or Orthognathic Surgical Procedures: A Meta-Analysis.

PURPOSE: Use of antifibrinolytic drugs in craniofacial and orthognathic surgery seems quite promising and has strong advocates. However, supporting evidence is controversial and limited by a small sample of individual studies. We sought to systematically review and meta-analyze the available data regarding the role of preoperative or intraoperative antifibrinolytic drugs (eg, tranexamic acid, aprotinin, or aminocaproic acid) in craniofacial and orthognathic surgery. MATERIALS AND METHODS: We searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science through April 19, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included the volume of blood loss, volume of transfusions, and operative time. A meta-analysis was performed with a random-effects model using Review Manager (RevMan) software (The Cochrane Collaboration, Copenhagen, Denmark). RESULTS: We identified 32 eligible studies with 749 patients undergoing craniofacial surgery and 546 undergoing orthognathic surgery. Meta-analysis showed that antifibrinolytic use led to statistically significant decreases in blood loss and blood transfusions for craniofacial procedures in adult or pediatric patients and to significantly less blood loss during orthognathic surgical procedures. Operative time did not significantly differ for either type of surgery. CONCLUSIONS: Antifibrinolytics can significantly reduce blood loss in craniofacial surgical procedures including pediatric craniosynostosis and adult rhinoplasties and in orthognathic surgical procedures, as well as transfusion requirements in pediatric craniofacial surgical procedures. However, the clinical significance of the medications is still questionable because of the relative paucity of information on adverse effects and the usual small volume loss during those operations.

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis.

INTRODUCTION: Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals. METHODS: This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed. RESULTS: Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE. CONCLUSION: The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications.

BACKGROUND: Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane. METHODS: The authors retrospectively reviewed 348 patients that received 536 total immediate, prepectoral implant-based breast reconstructions between January 2018 and December 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients that received DTI versus TE reconstruction up to one year after surgery. RESULTS: Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction (p=0.1813), respectively. Overall infection rate was 16.4% (n=57). DTI patients had a significantly greater incidence of wounds (p<0.0001), including minor (p<0.0011) and major wounds (p<0.0053). Significantly greater mastectomy resection weights were found for DTI patients that experienced any complication (p<0.0076), postoperative wounds (p<0.0001), and major wounds specifically (p<0.0035). Compared to medium thickness, extra-thick acellular dermal matrix (ADM) was associated with significantly increased rates of infection (p<0.0408) and wounds (p<0.0001). CONCLUSIONS: Prepectoral DTI reconstruction in patients with adequate flap perfusion may have comparable complication rates to staged TE reconstruction apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infectious and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights that desire comparable or smaller implant volumes.

Image-guided Procedure Versus 2-year Follow-up for a BI-RADS 3 Probably Benign Lesion: A Cost Comparison Analysis.

OBJECTIVE: Perform a comparison between the costs of image-guided breast procedures versus 2-year imaging follow-up for findings classified as BI-RADS assessment category 3-probably benign. METHODS: The national payment amount costs at non-facility locations were obtained from the Centers for Medicare and Medicaid Services physician fee schedule for breast imaging-related Current Procedural Terminology codes. Total costs were calculated and compared for management algorithms of 2-year imaging follow-up of a BI-RADS 3 lesion from 2018 through 2019 versus performing an image-guided procedure of the lesion in 2018 after the initial diagnostic imaging. RESULTS: Two-year mammographic follow-up of a BI-RADS 3 finding costs $484. This was less than a stereotactic-guided breast biopsy, which cost at least $1055. Two-year follow-up for a probably benign US finding cost $615 compared to $1173 for the least expensive US-guided breast biopsy scenario. For breast MRI, 2-year imaging follow-up cost $1510, which was also less than most MRI-guided breast biopsy scenarios. The one exception in which biopsy costs less than 2-year imaging follow-up was in the setting of an MRI-guided biopsy in the average-risk population without a post-benign biopsy follow-up breast MRI; in this setting, MRI biopsy cost $1235. CONCLUSION: In 2018-2019, 2-year imaging follow-up of a BI-RADS 3 finding continues to be less costly than an immediate procedure, except for MRI-guided breast biopsy in the average-risk population without a post-benign biopsy follow-up MRI.

Breast Reconstruction for Medicaid Beneficiaries: A Systematic Review of the Current Evidence.

Introduction: Medicaid beneficiaries are a generally disadvantaged population with access to elective specialty services. We sought to better understand utilization of breast reconstruction by Medicaid beneficiaries.Methods: We systematically searched PubMed, Scopus, Web of Science, and CINAHL databases for studies comparing breast reconstruction rates by insurance type. We extracted the information of interest to qualitatively and quantitatively synthesize the results of the studies.Results: We identified seven eligible studies. Overall, the rates of breast reconstruction have increased across insurance groups. However, our results show that Medicaid beneficiaries were on average less likely to receive breast reconstruction in comparison to patients with private insurance. Although, Medicaid patients again were more likely to receive breast reconstruction in comparison to Medicare beneficiaries.Conclusion: There is wide disparity in reconstruction rates by insurance status. However, with continued increase in the adult Medicaid population due to widening eligibility expansion, disparities involving this vulnerable population should be examined for causes and solutions.

Estrogen Receptor Positive and Progesterone Receptor Negative Breast Cancer: the Role of Hormone Therapy.

ER+/PR- (estrogen receptor positive and progesterone receptor negative) tumors constitute only a small portion of the breast cancer population. Patients with ER+/PR- tumors, however, are characterized by worse survival compared to patients with ER+/PR+ (estrogen receptor positive and progesterone receptor positive) tumors. Controversy exists regarding the efficacy of hormone blocking therapy for patients with ER+/PR- tumors. The NCDB was queried between 2004 and 2015, and patients with invasive ER+/PR- tumors were identified. We employed univariate Cox proportional hazards to compare outcomes among patients that did or did not receive hormone blocking therapy. We identified 138,398 patients with invasive ER+/PR- tumors, 32,044 (23%) of whom did not receive hormone blocking therapy. The reasons for not receiving hormone blocking therapy included contraindications to treatment, death, patient refusal, and unknown. There were no significant differences in race, income quartile, or education quartile between patients who did and did not receive hormone blocking therapy. Patients who did not receive hormone blocking therapy underwent surgical assessment of the axilla more frequently than those who did receive hormone therapy. Our analysis demonstrated that hormone blocking therapy administration was associated with increased overall survival for up to 10 years of follow up (HR: 0.58; 95% CI: 0.56-0.59, p < 0.001). Hormone blocking therapy may be associated with increased survival for breast cancer patients with ER+/PR- tumors. Although this benefit may last for years after completion of the course, up to 25% of patients do not receive this treatment. Strategies to increase the utilization and adherence to hormone blocking therapy regimens may improve patient survival outcomes.

Inroads Toward Robot-Assisted Internal Fixation of Bone Fractures Using a Bendable Medical Screw and the Curved Drilling Technique.

Internal fixation is a common orthopedic procedure in which a rigid screw is used to fix fragments of a fractured bone together and expedite the healing process. However, the rigidity of the screw, geometry of the fractured anatomy (e.g. femur and pelvis), and patient's age can cause an array of complications during screw placement, such as improper fracture healing due to misalignment of the bone fragments, lengthy procedure time and subsequently high radiation exposure. To address these issues, we propose a minimally invasive robot-assisted procedure comprising of a continuum robot, called ortho-snake, together with a novel bendable medical screw (BMS) for fixating the fractures. We describe the implementation of a curved drilling technique and focus on the design, manufacturing, and evaluation of a novel BMS, which can passively morph into the drilled curved tunnels with various curvatures. We evaluate the performance and efficacy of the proposed BMS using both finite element simulations as well as experiments conducted on synthetic bone samples.