Could ductoscopy alleviate the need of microdochectomy in pathological nipple discharge?

BACKGROUND: Microdochectomy is the gold-standard for definitive diagnosis for pathological nipple discharge (PND); however, problem of over-treating exists since majority of PND are self-limiting and due to benign causes. Ductoscopy may assist diagnosis, and triage patients for intervention or expectant management. This study aimed to evaluate if ductoscopy could reduce unnecessary microdochectomy but not compromising the diagnosis of malignancy. METHOD: A multicenter, retrospective study was conducted in consecutive patients of PND without a suspected malignancy on routine diagnostic evaluation. Ductoscopy was performed with attempts to remove intraductal lesions if they were found. Microdochectomy was carried out if there were positive intraductal lesions, but failed endoscopic extraction, or failed ductoscopy and persistent PND. Efficacy of ductoscopy was determined by cannulation success rate, number of avoided surgery and number of missed malignancy. RESULTS: In a 3-year period between 2016 and 2018, a total of 223 ductoscopy were performed and 94.2% had successful cannulation. Within such, 59.5% (N = 125) had intraductal mass identified, and 82 microdochectomy were carried out. The final histology showed 15 malignancy, making the overall malignancy rate 6.7%. Ductoscopy successful and negative patients (N = 85, 37.8%) were triaged for surveillance and the malignancy rate is 0% in a median follow-up of 2 years; hence, microdochectomy was avoided. CONCLUSION: PND with non-suspicious conventional imaging and negative ductoscopy have rare malignancy rate which makes subsequent microdochectomy unnecessary. However, intraductal mass in ductoscopy is a predictor for malignancy so definitive histology diagnosis is mandatory.

Conversion rate from mastectomy to breast conservation after neoadjuvant dual target therapy for HER2-positive breast cancer in the Asian population.

BACKGROUND: Dual HER2 blockade with transtuzumab and pertuzumab is known to be associated with improved oncologic outcome, however, its evidence on the impact of surgical decision remains limited. This study aims to evaluate the efficacy of dual HER2 blockade, when compared to single blockade, in improving breast conservation rate in an Asian cohort. METHODS: Retrospective study was performed on a prospectively-maintained database in our tertiary academic-based hospital, including patients with non-metastatic, HER2-positive breast cancer receiving neoadjuvant systemic therapy (NST) between January 2014 and December 2018. RESULTS: 142 patients were analyzed: 75 received Herceptin (H)-based NST and 67 received H + Pertuzumab (P)-based NST. Before NST, 65 patients (45.8%) were eligible for breast conserving therapy (BCT); and this increased to 103 (72.5%) after NST. Thirty-seven out of 75 patients (49.3%) who were deemed not BCT candidate converted to BCT-eligible after NST. More than half of the patients who were BCT-eligible opted for mastectomy. PH-based comparing to H-based NST did not differ significantly in BCT rate (35.5% vs 32.0%, P = 0.72); but there was a trend of increase in conversion to BCT-eligible rate (43.9-52.8%), reducing tumor diameter (40.2-53.1% reduction) and volume (69.5-80.0% reduction). CONCLUSION: The conversion rate from mastectomy to BCT-eligible was more than 50% after dual target therapy, which was slightly higher than single target agent. However the actual BCT rate was not significantly increased, and more than half of the BCT-eligible patients opted for mastectomy.

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

INTRODUCTION: Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results. METHODS: Over 46 months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfth months post-operatively until VCP recovered. RESULTS: In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125 days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027). CONCLUSION: The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

The impact of indocyanine-green fluorescence angiogram on colorectal resection.

BACKGROUND: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. METHOD: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. RESULTS: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1-17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09-11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01-1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. CONCLUSION: ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon.

To identify or not to identify parathyroid glands during total thyroidectomy.

Hypoparathyroidism is one of the most common complications after total thyroidectomy and may impose a significant burden to both the patient and clinician. The extent of thyroid resection, surgical techniques, concomitant central neck dissection, parathyroid gland (PG) autotransplantation and inadvertent parathyroidectomy have long been some of the risk factors for postoperative hypoparathyroidism. Although routine identification of PGs has traditionally been advocated by surgeons, recent evidence has suggested that perhaps identifying fewer number of in situ PGs during surgery (i.e., selective identification) may further lower the risk of hypoparathyroidism. One explanation is that visual identification may often lead to subtle damages to the nearby blood supply of the in situ PGs and that may increase the risk of hypoparathyroidism. However, it is worth highlighting the current literature supporting either approach (i.e., routine vs. selective) remains scarce and because of the significant differences in study design, inclusions, definitions and management protocol between studies, a pooled analysis on this important but controversial topic remains an impossible task. Furthermore, it is worth nothing that identification of PGs does not equal safe preservation, as some studies demonstrated that it is not the number of PGs identified, but the number of PG preserved in situ that matters. Therefore a non-invasive, objective and reliable way to localize PGs and assess their viability intra-operatively is warranted. In this aspect, modern technology such as the indocyanine green (ICG) as near-infrared fluorescent dye for real-time in situ PG perfusion monitoring may have a potential role in the future.

Assessing the Validity of Transcutaneous Laryngeal Ultrasonography (TLUSG) After Thyroidectomy: What Factors Matter?

INTRODUCTION: Although transcutaneous laryngeal ultrasound (TLUSG) is an excellent, noninvasive way to assess vocal cord (VC) function after thyroidectomy, some patients simply have "un-assessable" or "inaccurate" examination. Our study evaluated what patient and surgical factors affected assessability and/or accuracy of postoperative TLUSG. METHODS: Five hundred eighty-one consecutive patients were analyzed. All TLUSGs were done by one operator using standardized technique, whereas direct laryngoscopies (DL) were done by an independent endoscopist to confirm TLUSG findings. Their findings were correlated. TLUSG was "unassessable" if ≥1 VC could not be clearly visualized, whereas it was "inaccurate" if the TLUSG and DL findings were discordant. Demographics, body habitus, neck anthropometry, and position of incision were correlated with assessability and accuracy of TLUSG. RESULTS: Twenty-nine (5.0 %) patients had "unassessable" VCs; among the "assessable" patients, 29 (5.3 %) patients had "inaccurate" TLUSG. More than one-third (38.5 %) of VC palsies (VCPs) were "inaccurate." Older age (odds ratio [OR] = 1.055, 95 % confidence interval [CI] 1.016-1.095, p = 0.005), male sex (OR = 13.657, 95 % CI 2.771-67.315, p = 0.001), taller height (OR = 1.098, 95 % CI 1.008-1.195, p = 0.032), and shorter distance from cricoid cartilage to incision (OR = 0.655, 95 % CI 0.461-0.932, p = 0.019) were independent factors for "unassessable" VCs, whereas older age (OR = 1.028, 95 % CI 1.001-1.056, p = 0.040) was the only factor of incorrect assessment. CONCLUSIONS: Older age, male sex, tall in height, and incision closer to the thyroid cartilage were independent contributing factors for unassessable VCs, whereas older age was the only contributing factor for inaccurate postoperative TLUSG. Because more than one-third of VCPs were actually normal, patients labeled as such on TLUSG would benefit from laryngoscopic validation.

Genome-wide association study in Asian populations identifies variants in ETS1 and WDFY4 associated with systemic lupus erythematosus.

Systemic lupus erythematosus is a complex and potentially fatal autoimmune disease, characterized by autoantibody production and multi-organ damage. By a genome-wide association study (320 patients and 1,500 controls) and subsequent replication altogether involving a total of 3,300 Asian SLE patients from Hong Kong, Mainland China, and Thailand, as well as 4,200 ethnically and geographically matched controls, genetic variants in ETS1 and WDFY4 were found to be associated with SLE (ETS1: rs1128334, P = 2.33x10(-11), OR = 1.29; WDFY4: rs7097397, P = 8.15x10(-12), OR = 1.30). ETS1 encodes for a transcription factor known to be involved in a wide range of immune functions, including Th17 cell development and terminal differentiation of B lymphocytes. SNP rs1128334 is located in the 3'-UTR of ETS1, and allelic expression analysis from peripheral blood mononuclear cells showed significantly lower expression level from the risk allele. WDFY4 is a conserved protein with unknown function, but is predominantly expressed in primary and secondary immune tissues, and rs7097397 in WDFY4 changes an arginine residue to glutamine (R1816Q) in this protein. Our study also confirmed association of the HLA locus, STAT4, TNFSF4, BLK, BANK1, IRF5, and TNFAIP3 with SLE in Asians. These new genetic findings may help us to gain a better understanding of the disease and the functions of the genes involved.