A Preliminary Evaluation of Students' Learning and Performance Outcomes in an Accelerated 3-Year MD Pathway Program.

BACKGROUND: Little outcome data exist on 3-year MD (3YMD) programs to guide residency program directors (PDs) in deciding whether to select these graduates for their programs. OBJECTIVE: To compare performance outcomes of 3YMD and 4-year MD (4YMD) students at New York University Grossman School of Medicine. METHODS: In 2020, using the Kirkpatrick 4-level evaluation model, outcomes from 3 graduating cohorts of 3YMD students (2016-2018) were compared with the 4YMD counterparts. RESULTS: Descriptive statistics compared outcomes among consented student cohorts: 92% (49 of 53) 3YMD, 87% (399 of 459) 4YMD-G, and 84% (367 of 437) 4YMD-S. Student survey response rates were 93% (14 of 15), 74% (14 of 19), and 89% (17 of 19) from 2016 to 2018. PDs' response rates were 58% (31 of 53, 3YMD) and 51% (225 of 441, 4YMD). Besides age, 3YMD and 4YMD cohorts did not differ significantly in admissions variables. Other than small statistically significant differences in the medicine shelf examination (3YMD mean 74.67, SD 7.81 vs 4YMD-G mean 78.18, SD 7.60; t test=3.02; P=.003) and USMLE Step 1 (3YMD mean 235.13, SD 17.61 vs 4YMD-S mean 241.70, SD 15.92; t test=2.644; P=.009 and vs 4YMD-G mean 242.39, SD 15.65; t test=2.97; P=.003) and Step 2 CK scores (3YMD mean 242.57, SD 15.58 vs 4YMD-S mean 248.55, SD 15.33; t test=2.55; P=.01 and vs 4YMD-G mean 247.83, SD 15.38; t test=2.97; P=.03), other metrics and overall intern ratings did not differ by pathway. CONCLUSIONS: Exploratory findings from a single institution suggest that 3YMD students performed similarly to 4YMD students in medical school and the first year of residency.

Accelerated 3-Year MD Pathway Programs: Graduates' Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans.

PURPOSE: To compare perception of accelerated and traditional medical students, with respect to satisfaction with education quality, and the learning environment, residency readiness, burnout, debt, and career plans. METHOD: Customized 2017 and 2018 Medical School Graduation Questionnaires (GQs) were analyzed using independent samples t tests for means and chi-square tests for percentages, comparing responses of accelerated MD program graduates (accelerated pathway [AP] students) from 9 schools with those of non-AP graduates from the same 9 schools and non-AP graduates from all surveyed schools. RESULTS: GQ completion rates for the 90 AP students, 2,573 non-AP students from AP schools, and 38,116 non-AP students from all schools in 2017 and 2018 were 74.4%, 82.3%, and 83.3%, respectively. AP students were as satisfied with the quality of their education and felt as prepared for residency as non-AP students. AP students reported a more positive learning climate than non-AP students from AP schools and from all schools as measured by the student-faculty interaction (15.9 vs 14.4 and 14.3, respectively; P < .001 for both pairwise comparisons) and emotional climate (10.7 vs 9.6 and 9.6, respectively; P = .004 and .003, respectively) scales. AP students had less debt than non-AP students (P < .001), and more planned to care for underserved populations and practice family medicine than non-AP students from AP schools (55.7% vs 33.9% and 37.7% vs 9.4%; P = .002 and < .001, respectively). Family expectations were a more common influence on career plans for AP students than for non-AP students from AP schools and from all schools (26.2% vs 11.3% and 11.7%, respectively; P < .001 for both pairwise comparisons). CONCLUSIONS: These findings support accelerated programs as a potentially important intervention to address workforce shortages and rising student debt without negative impacts on student perception of burnout, education quality, or residency preparedness.

The New York State SARS-CoV-2 Testing Consortium: Regional Communication in Response to the COVID-19 Pandemic.

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, created an unprecedented need for comprehensive laboratory testing of populations, in order to meet the needs of medical practice and to guide the management and functioning of our society. With the greater New York metropolitan area as an epicenter of this pandemic beginning in March 2020, a consortium of laboratory leaders from the assembled New York academic medical institutions was formed to help identify and solve the challenges of deploying testing. This report brings forward the experience of this consortium, based on the real-world challenges which we encountered in testing patients and in supporting the recovery effort to reestablish the health care workplace. In coordination with the Greater New York Hospital Association and with the public health laboratory of New York State, this consortium communicated with state leadership to help inform public decision-making addressing the crisis. Through the length of the pandemic, the consortium has been a critical mechanism for sharing experience and best practices in dealing with issues including the following: instrument platforms, sample sources, test performance, pre- and post-analytical issues, supply chain, institutional testing capacity, pooled testing, biospecimen science, and research. The consortium also has been a mechanism for staying abreast of state and municipal policies and initiatives, and their impact on institutional and laboratory operations. The experience of this consortium may be of value to current and future laboratory professionals and policy-makers alike, in dealing with major events that impact regional laboratory services.

Antibody isotype diversity against SARS-CoV-2 is associated with differential serum neutralization capacities.

Understanding antibody responses to SARS-CoV-2 is indispensable for the development of containment measures to overcome the current COVID-19 pandemic. Recent studies showed that serum from convalescent patients can display variable neutralization capacities. Still, it remains unclear whether there are specific signatures that can be used to predict neutralization. Here, we performed a detailed analysis of sera from a cohort of 101 recovered healthcare workers and we addressed their SARS-CoV-2 antibody response by ELISA against SARS-CoV-2 Spike receptor binding domain and nucleoprotein. Both ELISA methods detected sustained levels of serum IgG against both antigens. Yet, the majority of individuals from our cohort generated antibodies with low neutralization capacity and only 6% showed high neutralizing titers against both authentic SARS-CoV-2 virus and the Spike pseudotyped virus. Interestingly, higher neutralizing sera correlate with detection of -IgG, IgM and IgA antibodies against both antigens, while individuals with positive IgG alone showed poor neutralization response. These results suggest that having a broader repertoire of antibodies may contribute to more potent SARS-CoV-2 neutralization. Altogether, our work provides a cross sectional snapshot of the SARS-CoV-2 neutralizing antibody response in recovered healthcare workers and provides preliminary evidence that possessing multiple antibody isotypes can play an important role in predicting SARS-CoV-2 neutralization.

Lessons Learned From an Anatomic Pathology Department in a Large Academic Medical Center at the Epicenter of COVID-19.

Many state-wide, city-wide, and hospital-wide changes have been implemented due to the ongoing COVID-19 crisis. We describe lessons learned in an anatomic pathology division at a tertiary care center during the peak of the COVID-19 pandemic in the hopes that knowledge of our experiences can benefit other pathology departments as they encounter this pandemic. Five categories that are critical in strategic planning for the COVID-19 pandemic are discussed: workload, departmental policy revisions, impact on faculty, workforce staffing, and impact on educational programs, including residency and fellowship training. Although the volume of COVID-19 testing had grown placing increased demands on the clinical pathology laboratory, the volume of anatomic pathology cases had declined during the COVID-19 peak. Lessons learned were widespread including changes in the anatomic pathology workflow due to declining surgical and cytologic case volumes and increases in autopsy requests. Modifications were required in gross room policies, levels of personal protective equipment, and workforce. Travel and meeting policies were impacted. Adaptations to residency and fellowship programs were vast and included innovations in didactic and interactive education. We must learn from our experiences thus far in order to move forward, and we hope that our experiences in an anatomic pathology department in the epicenter of the COVID-19 pandemic can help other pathology departments across the country.

Breaking Tradition to Bridge Bench and Bedside: Accelerating the MD-PhD-Residency Pathway.

PROBLEM: Physician-scientists are individuals trained in both clinical practice and scientific research. Often, the goal of physician-scientist training is to address pressing questions in biomedical research. The established pathways to formally train such individuals are mainly MD-PhD programs and physician-scientist track residencies. Although graduates of these pathways are well equipped to be physician-scientists, numerous factors, including funding and length of training, discourage application to such programs and impede success rates. APPROACH: To address some of the pressing challenges in training and retaining burgeoning physician-scientists, New York University Grossman School of Medicine formed the Accelerated MD-PhD-Residency Pathway in 2016. This pathway builds on the previously established accelerated 3-year MD pathway to residency at the same institution. The Accelerated MD-PhD-Residency Pathway conditionally accepts MD-PhD trainees to a residency position at the same institution through the National Resident Matching Program. OUTCOMES: Since its inception, 2 students have joined the Accelerated MD-PhD-Residency Pathway, which provides protected research time in their chosen residency. The pathway reduces the time to earn an MD and PhD by 1 year and reduces the MD training phase to 3 years, reducing the cost and lowering socioeconomic barriers. Remaining at the same institution for residency allows for the growth of strong research collaborations and mentoring opportunities, which foster success. NEXT STEPS: The authors and institutional leaders plan to increase the number of trainees who are accepted into the Accelerated MD-PhD-Residency Pathway and track the success of these students through residency and into practice to determine if the pathway is meeting its goal of increasing the number of practicing physician-scientists. The authors hope this model can serve as an example to leaders at other institutions who may wish to adopt this pathway for the training of their MD-PhD students.

Early Results from Severe Acute Respiratory Syndrome Coronavirus 2 Polymerase Chain Reaction Testing of Healthcare Workers at an Academic Medical Center in New York City.

Coronavirus disease 2019 (COVID-19) reverse-transcription polymerase chain reaction employee testing was implemented across New York University Langone Health. Over 8 weeks, 14 764 employees were tested; 33% of symptomatic employees, 8% of asymptomatic employees reporting COVID-19 exposure, and 3% of employees returning to work were positive. Positivity rates declined over time, possibly reflecting the importance of community transmission and efficacy of personal protective equipment.

Evolution of an Accelerated 3-Year Pathway to the MD Degree: The Experience of New York University Grossman School of Medicine.

The revision of the curriculum at New York University Grossman School of Medicine in 2010, with a reduction of the preclerkship curriculum to 18 months, made it possible to offer an accelerated 3-year pathway in 2013 for students who know their career path. The goals of the program include individualizing education, reducing student debt, and integrating undergraduate and graduate medical education. This accelerated 3-year doctor of medicine (3YMD) pathway is the first program of its kind in the United States to offer conditional acceptance to residency programs in all specialties through the National Resident Matching Program. Since inception of the pathway 6 years ago, 81 students have graduated. Critical components to successfully launch and implement the program are described.Unwavering commitment to the program as a high institutional priority by the dean and vice dean for education facilitated the support required by department chairs and residency program directors and the flexibility needed for success. Alignment between the 3- and 4-year pathways has made it possible to add points of entry into the 3-year pathway during the second and third years and to shift back into the 4-year pathway, as warranted. Modifications to how 3YMD students are mentored included changing the role of the departmental advisor and adding a dedicated 3YMD pathway advisor who serves as an advocate for both the students and the program. Having a relatively large number of 3YMD students has contributed to the success of the program and facilitated acceptance by the residencies.

Application of GATA 3 and TTF-1 in differentiating parathyroid and thyroid nodules on cytology specimens.

BACKGROUND: Differentiating parathyroid from thyroid lesions can be difficult on fine-needle aspiration (FNA) due to overlapping cytomorphologic features. While the traditional parathyroid hormone (PTH) assays can help in the distinction, these tests may be cumbersome, particularly when the lesion is unexpected clinically and a needle wash is not collected at the time of FNA. Therefore, we chose to investigate the application of immunohistochemical staining (IHC) with GATA 3 and thyroid transcription factor-1 (TTF-1) on air-dried cytology smears to distinguish parathyroid and thyroid lesions. METHODS: Air-dried touch preparation (TP) slides were prepared from consecutively selected parathyroid and thyroid specimens. Thirteen FNA cases with the clinical concern for parathyroid lesions were also included in the study. IHC was performed on unstained and ultrafast Papanicolaou (UFP) stained air-dried slides. RESULTS: On TP slides, GATA 3 expression was observed in all cases of parathyroid origin but no immunoreactivity was present in thyroid lesions. TTF-1 expression was observed in all cases of thyroid origin but not in parathyroid lesions. GATA 3 and TTF-1 expression of 13 FNA cases were consistent with the clinical impression or concurrent PTH tests. CONCLUSIONS: IHC with GATA 3 and TTF-1 on air-dried cytology smears is a simple and effective way to differentiate parathyroid vs thyroid lesions on FNA. Air-dried unstained and UFP-stained slides perform equally well with IHC, but UFP-stained slides provide the added benefit of morphologic evaluation and assessment of smear cellularity prior to IHC.

Does Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features (NIFTP) Have a Unique Molecular Profile?

OBJECTIVES: Recognizing preoperative characteristics of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is important for clinical management. Therefore, we assessed presurgical NIFTP molecular profiles using fine-needle aspiration (FNA) material. METHODS: Presurgical FNA reports of 39 surgically confirmed NIFTP cases from January 2013 through May 2017 were assessed for Afirma and ThyroSeq results. RESULTS: Twenty-one of 39 NIFTP nodules were preoperatively tested with Afirma with two benign and 19 suspicious results. Twenty-seven of 39 nodules were tested with ThyroSeq (nine of 39 had both Afirma and Thyroseq): 18 (67%) had RAS mutations (13 NRAS, four HRAS, one KRAS), and three of 18 had multiple alterations (NRAS + TP53, n = 1; NRAS + PTEN, n = 2). BRAF T599_R603 + EIF1AX mutation (n = 1), PTEN mutation (n = 1), MET overexpression (n = 1), PAX8/PPARG fusion (n = 3), and THADA/IGF2BP3 fusion (n = 3) comprised the remainder. CONCLUSIONS: NIFTP cases most commonly displayed suspicious Afirma results and RAS mutations on ThyroSeq, lacking aggressive/BRAF-V600E-like mutations. While NIFTP remains a surgical entity, the lack of aggressive/BRAF-V600E-like mutations can aid in determining the extent of surgery.

Self-clotting method improves cell block preparation.

BACKGROUND: The success of cell block preparation is crucial for ancillary diagnostic tests in cytology. However, achieving an optimal cell block can be challenging. The current study describes a self-clotting-based technique for fine-needle aspiration (FNA) cell block preparations and evaluates its usefulness in comparison with the conventional needle wash technique. METHODS: The clinical data, FNA procedure, and cellularity of cell blocks of the self-clotting group (37 cases) and the conventional needle wash group (33 cases) were compared. The cellularity was evaluated using a scoring system (0 indicated acellular, 1 indicated 1-50 cells, and 2 indicated >50 cells). RESULTS: Approximately 76% of cases in the self-clotting group received a score of 2 versus 36% in the conventional needle wash group. Approximately 14% received a score of 1 in the self-clotting group compared with 9% in the conventional needle wash group, whereas 11% in the self-clotting group received a score of 0 versus 55% in the conventional needle wash group. The differences between the 2 methods were statistically significant. CONCLUSIONS: The results of the current study demonstrate that the self-clotting method is superior to the conventional needle wash method for FNA samples. Cancer Cytopathol 2018;126:190-9. © 2017 American Cancer Society.

Frequency and outcomes of biopsy-proven fibroadenomas recommended for surgical excision.

Our aim was to investigate the outcomes of fibroadenomas recommended for surgical excision due to large size (>2cm) or interval growth. A retrospective review of our institutional radiology database from 2007 to 2015 was performed. We identified 167 biopsy-proven fibroadenomas recommended for surgical consultation. Of these, 75 (45%) cases actually underwent excision, 7 (9%, 95% CI: 4-18%) of which were upgraded to phyllodes tumors upon histopathological examination. Our results support the current recommendation to surgically excise breast lesions diagnosed as fibroadenomas with size >2cm or with interval growth due to the considerable risk of finding phyllodes tumors.

Does noninvasive follicular thyroid neoplasm with papillary-like nuclear features have distinctive features on sonography?

BACKGROUND: The noninvasive encapsulated follicular variant of papillary carcinoma (nEFVPTC) has recently been reclassified to "noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)," removing this entity from the malignant category. This re-categorization has had major implications for clinical management. NIFTP has overlapping cytohistologic features with papillary thyroid carcinoma (PTC) and with follicular adenomas (FA), but sonographic data comparing NIFTP to PTC and FA is lacking. Our study examines the sonographic features of NIFTP as compared with PTC and FA. METHODS: Ultrasound scans and Doppler blood flow from subjects who had pre-surgical sonograms and fine needle aspiration biopsies with final surgical pathology diagnoses of NIFTP/nEFVPTC, classical PTC, and FA between 01/2013-08/2016 were assessed. Sonographic and Doppler features as well as Bethesda System (TBS) diagnoses were recorded and analyzed. RESULTS: 40 NIFTP, 58 classical PTC, and 23 FA cases were included. The most common NIFTP pre-surgical TBS cytology diagnosis was Atypia of Undetermined Significance (AUS/FLUS) (40%). NIFTP cases predominantly displayed wider-than-tall shape (100%), smooth borders (75%), occurrence in multinodular glands (82.5%), heterogeneous echogenicity (50%), both perinodular and intranodular Doppler flow patterns (70%), minimal Doppler flow grade (62.5%), and no calcifications (90%). CONCLUSIONS: Our study demonstrates that NIFTP, PTC, and FA display several distinguishing and overlapping sonographic and Doppler features. Sonographic features appear to complement cytology findings and may help raise pre-operative concern for NIFTP in the proper clinical setting, potentially leading to a more conservative management approach.

Roadmap for creating an accelerated three-year medical education program.

Medical education is undergoing significant transformation. Many medical schools are moving away from the concept of seat time to competency-based education and introducing flexibility in the curriculum that allows individualization. In response to rising student debt and the anticipated physician shortage, 35% of US medical schools are considering the development of accelerated pathways. The roadmap described in this paper is grounded in the experiences of the Consortium of Accelerated Medical Pathway Programs (CAMPP) members in the development, implementation, and evaluation of one type of accelerated pathway: the three-year MD program. Strategies include developing a mission that guides curricular development - meeting regulatory requirements, attaining institutional buy-in and resources necessary to support the programs, including student assessment and mentoring - and program evaluation. Accelerated programs offer opportunities to innovate and integrate a mission benefitting students and the public. ABBREVIATIONS: CAMPP: Consortium of accelerated medical pathway programs; GME: Graduate medical education; LCME: Liaison committee on medical education; NRMP: National residency matching program; UME: Undergraduate medical education.

"Low-grade squamous intraepithelial lesion, cannot exclude high-grade:" TBS says "Don't Use It!" should I really stop it?

BACKGROUND: The Bethesda System uses a two-tiered approach in the diagnosis of cervical squamous intraepithelial lesions (SILs). Occasionally, Papanicolaou (Pap) tests with evident low-grade SIL (LSIL) also have some features suggestive but not diagnostic of high-grade SIL (HSIL). This study reviews our experience with "Low-grade Squamous Intraepithelial Lesion, Cannot Exclude High-grade" (LSIL-H) and discusses the best approach to report such Paps if the LSIL-H interpretation is abandoned. METHODS: Abnormal Paps were identified between January and December 2014 that had surgical follow-up within 6 months. Their biopsy outcomes were compared. Statistical analysis was performed using Pearson's Chi-square and McNemar tests in SPSS software version 23. Statistical significance was defined as P ≤ 0.05. RESULTS: There were a total of 1049 abnormal Paps with follow-up. High-grade dysplasia/carcinoma (HGD+) was found in 8% of LSIL, 30% of LSIL-H, 52% of atypical squamous cells (ASCs), cannot rule out HSIL (ASC-H), and 77% of HSIL Paps. The detection rate of HGD+ for LSIL-H was between that of LSIL (Pearson's Chi-square test, P = 0.000) and ASC-H (P = 0.04). If LSIL-H cases are reported as ASC-H, the rate of HGD+ for the ASC-H category would decrease from 51.5% to 37.4% (McNemar test, P = 0.000). Alternatively, if LSIL-H cases are downgraded to LSIL, the rate of HGD+ for the LSIL category would rise from 7.7% to 10.4% (McNemar test, P = 0.000). Nearly 86.7% of LSIL-H cases were positive for high-risk HPV (HR-HPV) in comparison to 77.5% of LSILs, 100% of ASC-Hs, and 75% of HSILs. The sample size for HR-HPV and LSIL-H was too small for meaningful statistical analysis. CONCLUSIONS: "LSIL-H" category detects more HGD+ than LSIL, and fewer than ASC-H and HSIL. If LSIL-H is eliminated, Paps with this finding are best reported as ASC-H to ensure that women with potential HGD+ undergo colposcopy in a timely manner. Reporting LSIL-H as LSIL may delay colposcopy since management of LSIL Paps depends on multiple factors (age, HPV status, etc.).

Can p40 (Polyclonal) Replace p63 (Clone 4A4) in the Cytologic Diagnosis of Pulmonary Non-Small Cell Carcinoma?

OBJECTIVES: Differentiating squamous cell carcinoma from adenocarcinoma (ACA) in cytology specimens can be challenging. Recent literature showed p40 had higher specificity than p63 for this purpose. METHODS: We identified 190 cytology cases with p40 (polyclonal) and p63 (monoclonal clone 4A4) immunohistochemistry, including specimens from fine-needle aspirations (FNAs) and effusions. RESULTS: ACAs of lung origin stained for p40 and p63 in 21% and 20% of cases, respectively, regardless of specimen site. Among lung FNAs of primary pulmonary ACAs (n = 42), 14% were positive for p40 and 24% were positive for p63. Of the 20 pulmonary ACAs in effusions, more cases showed p40 positivity (40%) compared with FNAs, whereas p63 were positive in 15%. Among metastatic ACAs from other sites (n = 14), more cases were positive for p40 than p63. CONCLUSIONS: Polyclonal p40 yields a level of false positivity in ACAs similar to p63, which is highest in effusions and is not limited to lung origin.

Three-Year MD Programs: Perspectives From the Consortium of Accelerated Medical Pathway Programs (CAMPP).

In the last decade, there has been renewed interest in three-year MD pathway programs. In 2015, with support from the Josiah Macy Jr., Foundation, eight North American medical schools with three-year accelerated medical pathway programs formed the Consortium of Accelerated Medical Pathway Programs (CAMPP). The schools are two campuses of the Medical College of Wisconsin; McMaster University Michael G. DeGroote School of Medicine; Mercer University School of Medicine; New York University School of Medicine; Penn State College of Medicine; Texas Tech University Health Sciences Center School of Medicine; University of California, Davis School of Medicine; and University of Louisville School of Medicine. These programs vary in size and medical specialty focus but all include the reduction of student debt from savings in tuition costs. Each school's mission to create a three-year pathway program differs; common themes include the ability to train physicians to practice in underserved areas or to allow students for whom the choice of specialty is known to progress more quickly. Compared with McMaster, these programs are small, but most capitalize on training and assessing competency across the undergraduate medical education-graduate medical education continuum and include conditional acceptance into an affiliated residency program. This article includes an overview of each CAMPP school with attention to admissions, curriculum, financial support, and regulatory challenges associated with the design of an accelerated pathway program. These programs are relatively new, with a small number of graduates; this article outlines opportunities and challenges for schools considering the development of accelerated programs.

Accelerating medical education: a survey of deans and program directors.

BACKGROUND: A handful of medical schools in the U.S. are awarding medical degrees after three years. While the number of three-year pathway programs is slowly increasing there is little data on the opinions of medical education leaders on the need for shortening training. PURPOSE: To survey deans and program directors (PDs) to understand the current status of 3-year medical degree programs and to elicit perceptions of the need for shortening medical school and the benefits and liabilities of 3-year pathway programs (3YPP). METHODS: Online surveys were emailed to the academic deans of all U.S. medical schools and to a convenience sample of residency and fellowship PDs. Frequency distributions are reported for key survey items and content analysis was used to describe open-ended responses. RESULTS: Of the respondents, 7% have a 3YPP, 4% were developing one, and 35% were considering development. In 2014, 47% of educational deans and 32% of PDs agreed that there may be a need to shorten medical school. From a list of benefits, both deans and PDs agreed that the greatest benefit to a 3YPP was debt reduction (68%). PDs and deans felt reduced readiness for independence, reduced exposure to complementary curricula regarding safety and quality improvement, premature commitment to a specialty, and burnout were all potential liabilities. From a list of concerns, PDs were concerned about depth of clinical exposure, direct patient care experience, ability to assume increased responsibility, level of maturity, and certainty regarding career choice. CONCLUSIONS: Over one-third of medical schools are considering the development of a 3YPP. While there may be benefits for a select group of students, concerns regarding maturity, depth of clinical exposure, and competency must be addressed for these programs to be well received.

Primary large cell neuroendocrine carcinoma of the breast, a case report with an unusual clinical course.

Large cell neuroendocrine carcinoma of the breast (NECB) is an extremely rare type of breast cancer; little is known about effective chemotherapies, and data on pathologic response to treatment are unavailable. We report the case of a 34-years-old woman with large cell NECB with initial clinical and pathologic evidence of treatment response to anthracycline-containing neo-adjuvant therapy. Histologic reassessment early during anthracycline chemotherapy revealed cell death with necrosis of 50% of the tumor cells seen in the biopsy specimen. After completing neo-adjuvant chemotherapy, the patient underwent breast-conserving surgery. Pathologic evaluation of the surgical specimen showed a partial response but margins were positive for residual carcinoma. Despite repeated neo-adjuvant chemotherapy, radiotherapy, and surgical resection, the tumor grew rapidly between surgeries and recurred systemically. Therefore, we review the literature on large cell NECB and its treatment options.