Landscape of HER2-low breast cancer: Insights from a six-year study on prevalence and clinicopathological characteristics.

Human epidermal growth factor receptor 2 (HER2)-low breast cancer has emerged as a subtype of breast cancer, defined by HER2 1+/2+ in immunohistochemistry (IHC) and absence of ERBB2 gene amplification on fluorescence in situ hybridization (FISH). Recent trials showed marked response of HER2-low breast cancer to novel anti-HER2 antibody-drug-conjugates. Data on characteristics of HER2-low breast cancer subtype is limited. Real-world data from the Anatomic Pathology Department of Hotel-Dieu de France, spanning 2017-2023, was retrospectively collected. HER2-positive patients were excluded to compare HER2-low to HER2-zero breast cancer subtypes. Clinicopathological characteristics between the groups were compared using a Chi-Squared test. Out of 1195 patients, we observed 341 (28.5 %) HER2-low breast cancers cases. HER2-positive breast cancer cases (n = 178; 14.9 %) were excluded. There was no significant difference in age and sex between HER2-low and HER2-zero group (p = 0.33 and 0.79, respectively). HER2-low breast cancer was associated with positive estrogen receptor status and positive progesterone receptor status (p < 0.001 and p = 0.01, respectively). Ductal adenocarcinomas were more commonly observed in HER2-low group (p < 0.001). When stratified by hormone (HR) status, 87.4 % of patients had HR-positive status and 12.6 % were HR-negative. Among the HR-negative group, HER2-low tumors tended to show lower proliferation index compared to HER2-zero tumors (25%vs.10 %, p = 0.04). This study showed that HER2-low is distinct from HER2-zero and is common among patients with breast cancer. Clinicopathological features such as histological type differ between HER2-zero and HER2-low breast cancer. Within HR-negative breast cancer, those with low HER2 expression exhibit a less aggressive profile compared to HER2-zero tumors.

The Lebanese percreta group: A retrospective cohort study of both radical and conservative management outcomes of abnormally invasive placenta.

OBJECTIVE: The aim of the present study was to illustrate the outcomes of abnormally invasive placenta (AIP) cases managed in three leading centers in Lebanon. METHODS: We conducted a retrospective multicenter cohort study. Patients managed conservatively (cesarean delivery with successful placental separation) or radically (cesarean hysterectomy) were included in the study. Data included patient characteristics, surgical outcomes (blood loss, operative time, transfusion, partial bladder resection), maternal outcomes (death, length of stay, ICU admission, postoperative hemoglobin level) and neonatal outcomes (Apgar score, neonatal weight, admission to neonatal intensive care unit, neonatal death). RESULTS: The study included 189 patients. In the radical treatment subgroup (141/189), patients were para 3 and delivered at 34 4/7 weeks in average, bled 1.5 L and were transfused with three packed red blood cells, with operative time averaging 160 min. A total of 36% were admitted to the ICU and patients stayed on average for 1 week despite partial bladder resection in 19% of cases. Unscheduled radical delivery occurred at a lower gestational age, was associated with more blood loss, higher rate and volume of transfusion, and risk of maternal and neonatal death. In addition, patients delivered in an unscheduled fashion experienced higher rates of partial bladder resection and longer interventions. In the conservative treatment subgroup, on average patients were para 2 and delivered at 36 weeks, bled 800 mL on average with low rates of transfusion (35%) and ICU admission (22.9%). With regard to neonatal outcomes, the average neonatal birth weight was 2.4 kg in the radical subgroup and 2.5 kg in the conservative subgroup. Neonatal death occurred in 5.4% of cases requiring radical management while it occurred in 2% of patients treated conservatively. CONCLUSION: Through their multidisciplinary approach, the three centers demonstrated that management of AIP in Lebanon has led to excellent outcomes with no maternal mortality occurring in scheduled radical treatment. By comparison of the three leading centers, pitfalls in each center were identified and addressed.

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

OBJECTIVE: To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS: A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS: The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION: The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification.

OBJECTIVE: To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut. METHODS: Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group. RESULTS: The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic. CONCLUSION: More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Validation of the Human Papillomavirus Impact Profile in Lebanese Women With Human Papillomavirus or Associated Lesions.

OBJECTIVES: Human papillomavirus (HPV) is responsible for a multitude of lesions with high psychosocial burden. The "HPV Impact Profile" (HIP) questionnaire is one of the first and most specific tools evaluating the emotional impact of HPV. This study aimed to translate this questionnaire into Arabic and to validate it, in a sample of Lebanese female patients. MATERIALS AND METHODS: The HIP questionnaire was translated to Arabic. It was then administered to 118 Lebanese women infected with HPV or screened for HPV-associated lesions, in parallel with the Hospital Anxiety and Depression Scale questionnaire. The psychometric properties of the questionnaire were studied in our sample population. RESULTS: The internal consistency of the HIP questionnaire was weak as Cronbach α coefficients of most of the domains were low. The study of the composite matrix resulted in the improvement of the internal consistency after the elimination of some items. Moreover, the "adapted domains" were created by reverse-scoring items with positive implications.The composite reliability and the average variance extracted of all the domains were analyzed. Analysis of discriminate validity through heterotrait-monotrait ratio of correlation ratio analyses of corresponding Hospital Anxiety and Depression Scale domains was also performed along with reliability analysis. There results were satisfying for the adapted domains. CONCLUSIONS: The adapted domains of the 27 items questionnaire with reverse scoring of 8 items presented with good psychometric properties, allowing their use in clinical trials and in clinical practice.

Does Social and Religious Background Matter? A Study of the Psychosocial Impact of Human Papillomavirus on Lebanese Women.

OBJECTIVE: The human papillomavirus (HPV) has been associated with an important psychosocial impact. This impact has been poorly evaluated in developing countries, mostly because of the lack of instruments to quantify it. The HIP questionnaire aims to measure HPV-associated affective burden. Our team has previously translated this questionnaire to Arabic and used it to assess the impact of HPV on Lebanese women. MATERIALS AND METHODS: While the HIP is a specific tool to evaluate the emotional impact of HPV, the Hospital Anxiety and Depression Scale questionnaire consists of 2 scales, anxiety and depression, and assess the psychological distress in nonpsychiatric patients. The HPV impact profile and Hospital Anxiety and Depression Scale questionnaires were administered to 118 Lebanese women with an HPV-related presentation, aiming to determine which aspect of these women's lives was mostly affected. The association with different sociodemographic factors was also assessed. RESULTS: Feelings of "concerns and worries" were mostly strongly felt in our population except for women with genital warts who were more concerned with the risk of transmission and the impact on their partners. All women had predominant feelings of anxiety.Religion was a statistically significant influencing factor and employment a protective factor. Muslim women demonstrated significant adverse affects on HPV impact profile domains that included: "sexual impact," "self-image," "interaction with doctors," and "health control/life impact." CONCLUSIONS: Different women perceive the diagnosis of HPV and HPV-related lesions differently. In this study, employment was found to play a protective role, but the biggest influencers were social and religious beliefs.

Predictive factors of lymph node metastasis and pattern of repartition in patients with epithelial ovarian cancer.

Aim: To determine the rate, repartition and risk factors of lymph node (LN) metastasis in patients with epithelial ovarian cancer. Methods: We reviewed retrospectively the pathological and clinical data of 184 patients with epithelial ovarian cancer at a tertiary care center in Beirut, Lebanon. Results: 88% of patients received a pelvic and para-aortic lymphadenectomy. 70% of patients presented LN metastases at both pelvic and para-aortic levels, while isolated pelvic or para-aortic LN metastases were seen in 16 and 14% of cases, respectively. In a univariate analysis, the rate of positive LNs was higher in patients with serous histology (65 vs 33%; p < 0.001), high-grade tumors (68 vs 26%; p < 0.001), bilateral adnexal involvement (74 vs 27%; p < 0.001), advanced clinical stage (p < 0.001), interval debulking surgery (63.2 vs 36.8%; p = 0.003) and positive peritoneal cytology (79 vs 26%; p < 0.001). In a multivariate analysis, the rate of LN involvement was significantly higher in patients with higher grade, advanced clinical stage and positive peritoneal cytology. Conclusion: Serous histology, grade 3 tumors, positive peritoneal cytology, advanced clinical stage, interval surgery and bilateral adnexal involvement can predict LN metastasis in patients with epithelial ovarian cancer.

The use of hysteroscopic endometrectomy in the conservative treatment of early endometrial cancer and atypical hyperplasia in fertile women.

OBJECTIVE: To illustrate the effectiveness of hysteroscopic endometrial resection in conservative treatment of early endometrial cancer/atypical hyperplasia in women of reproductive age. METHODS: Review of outcomes of women of reproductive age who underwent fertility sparing treatment (hysteroscopic superficial endometrectomy followed by progestin therapy) in early endometrial cancer. RESULTS: Eight women with Stage I endometrial cancer and three with atypical endometrial hyperplasia underwent hysteroscopic superficial endometrial resection, followed by 1-year treatment with oral megestrol acetate. One patient had a synchronous endometrioid ovarian carcinoma. One patient with Grade 2 carcinoma opted for conservative treatment and had hysterectomy 3 months later for persisting disease. Ten patients showed no evidence of residual disease during a 12-month follow-up period with regular hysteroscopy. Five patients had seven pregnancies without assisted reproductive technology. One patient got pregnant after one attempt of in-vitro fertilization and oocyte donation. Pregnancy rate was 54.5%; two patients had two successful pregnancies and deliveries. Average time to pregnancy was 16 months from the end of treatment. All babies were delivered vaginally. CONCLUSION: Total superficial endometrial resection followed by progestin can be considered in patients with early endometrial cancer/atypical hyperplasia who still want to conceive. It does not seem to impair fertility nor pregnancy outcomes in women of reproductive age.

Periductal stromal tumor of the breast in a young lady: A case report.

We present the case of a 30-year-old lady who underwent a core needle biopsy for a BIRADS 4 lesion of her left breast and was diagnosed as having a cellular fibroadenoma. The final diagnosis after excision returned to be a periductal stromal tumor (PST). An extremely rare entity, the PST is actually classified as a subtype of phyllodes tumor, with specific criteria that are only found upon histological examination of the specimen. Care should be taken when considering the diagnosis of fibroadenoma based only on clinical, radiological, and biopsy findings. Any nonclassical, clinical, or radiological findings should prompt a wide excision. Prognosis is generally good when clear margins are obtained and in the absence of malignant heterologous elements.

Breast and tumor volumes on 3D-MRI and their impact on the performance of a breast conservative surgery (BCS).

Breast conservation rate is being increasingly used nowadays as a marker of breast cancer care among hospitals. Searching for the ideal technique to predict the feasibility of BCS is ongoing. For this matter, the preoperative MRIs of 169 patients operated with radical or conservative surgery were reviewed. We estimated the tumor volume (TV) and breast volume (BV) on enhanced 3D-MRI and compared the tumor-to-breast volume ratio (TV/BV) in both groups. The mean ratio was 9.5% in the mastectomy group and 1.7% in the BCS group. A tumor-to-breast volume ratio less than 4% seemed to favor the adoption of a conservative option. Our data suggest that preoperative 3D-MRI can orient the surgical approach by assessing the TV/BV ratio, increasing lumpectomy rates with clear margins and good cosmetic outcome.

MRI-based predictive factors of axillary lymph node status in breast cancer.

To evaluate the diagnostic value of diffusion-weighted imaging (DWI) in combination with conventional MRI in predicting metastatic axillary lymph nodes (ALN) in breast cancer (BC). We reviewed pathological findings and clinical breast MRI examinations of 169 patients with invasive BC who were evaluated at the Hôtel-Dieu de France Hospital in 2009-2015. Morphological parameters and apparent diffusion coefficient (ADC) value were compared with pathological nodal status. Independent t-test/chi-square test and a Pearson correlation analysis were used. With pathological diagnosis as reference, MRI-based interpretations were 87.5% specific and 70.3% sensitive. On conventional MRI, the round shape of lymph nodes (LNs), loss of fatty hilum, irregular margins and hypo-intensity/heterogeneous intensity on T2-weighted sequence were statistically significantly different between metastatic and nonmetastatic groups (P < .001, each). Mean size of metastatic ALN was larger compared with negative ALN (13.9 mm vs. 10.9 mm, P < .001). LNs ≥ 12 mm were associated with higher risk of metastasis (P < .001). ADC value was not significantly different between both groups (P = .862). Conventional MRI using the ALN shape, signal intensity in T2-weighted sequences, loss of fatty hilum, regularity of the margins and size of the LNs can evaluate the axilla with high specificity. ADC value could not be used as a reliable parameter.

Clinical research ethics review process in Lebanon: efficiency and functions of research ethics committees - results from a descriptive questionnaire-based study.

BACKGROUND: Clinical trials conducted in Lebanon are increasing. However, little is known about the performance of research ethics committees (RECs) in charge of reviewing the research protocols. This study aimed to assess the level of adherence to the ethics surrounding the conduct of clinical trials and perceptions of team members regarding roles of the RECs during the conduct of clinical trials in Lebanon. The research question was: Are RECs adherent to the ethics surrounding the conduct of clinical trials (chapters II and IV in 'Standards and Operational Guidance for Ethics Review of Health-related Research with Human Participants' in Lebanon?' METHODS: This was a quantitative and descriptive questionnaire-based study conducted among RECs of university hospitals in Lebanon. The questionnaire had to be completed online and included general questions in addition to items reflecting the different aspects of a REC performance and effectiveness. All the questionnaire was assigned a total score of 175 points. General information and questions assigned point values/scores were analysed using descriptive statistics: frequency and percentage, mean score ± standard deviation. RESULTS: Ten RECs participated in the study (52 persons: four chairs, one vice-president, 47 ordinary members). Forty-seven (90.4%) had previous experience with clinical research and 30 (57.7%) had a diploma or had done a training in research ethics. Forty-one percent confirmed that they were required to have a training in research ethics. All RECs had a policy for disclosing and managing potential conflicts of interest for its members, but 71.8% of participants reported the existence of such a policy for researchers. Thirty-three point three percent reported that the RECs had an anti-bribery policy. The questionnaire mean score was 129.6 ± 22.3/175 points reflecting thus an excellent adherence to international standards. CONCLUSION: Inadequate training of REC members and the lack of anti-bribery policies should be resolved to improve their performance.

Case series of outcomes of a standardized surgical approach for placenta percreta for prevention of ureteral lesions.

OBJECTIVE: To report the outcomes of women with placenta percreta who were surgically treated by a specialized technique based on gynecologic oncology experience, and to demonstrate its safety in preventing ureteral lesions and reducing blood loss. METHODS: In the present retrospective study, data from patients with placenta percreta radically treated at Hôtel-Dieu de France, Beirut, Lebanon, between December 2012 and January 2017 were reviewed. Demographic, pathology, and delivery data, medical history, per-operative and postoperative information, and neonatal data were assessed. Operative and postoperative outcomes were compared between emergency and scheduled cases. RESULTS: Data from 35 patients were reviewed. Median gestational age at delivery was 34 weeks. Cesarean hysterectomy was scheduled in 20 (60%) cases. No ureteral lesions were noted. The median estimated blood loss was 1 L and a median of 3 units of red blood cells units was transfused. Emergency and scheduled cases presented comparable estimated blood loss, intra-operative transfusion, bladder injury incidence, and surgery duration (all P>0.05). The mean delivery weight was 2100 g; admission to the neonatal intensive care unit was needed for 30 (86%) neonates. CONCLUSION: The surgical technique developed for placenta percreta was found to be effective (operative and postoperative outcomes) and safe (prevention of ureteral lesions).

Breast Density and Breast Cancer Incidence in the Lebanese Population: Results from a Retrospective Multicenter Study.

PURPOSE: To study the distribution of breast mammogram density in Lebanese women and correlate it with breast cancer (BC) incidence. METHODS: Data from 1,049 women who had screening or diagnostic mammography were retrospectively reviewed. Age, menopausal status, contraceptives or hormonal replacement therapy (HRT), parity, breastfeeding, history of BC, breast mammogram density, and final BI-RADS assessment were collected. Breast density was analyzed in each age category and compared according to factors that could influence breast density and BC incidence. RESULTS: 120 (11.4%) patients had BC personal history with radiation and/or chemotherapy; 66 patients were postmenopausal under HRT. Mean age was 52.58 ± 11.90 years. 76.4% of the patients (30-39 years) had dense breasts. Parity, age, and menopausal status were correlated to breast density whereas breastfeeding and personal/family history of BC and HRT were not. In multivariate analysis, it was shown that the risk of breast cancer significantly increases 3.3% with age (P = 0.005), 2.5 times in case of menopause (P = 0.004), and 1.4 times when breast density increases (P = 0.014). CONCLUSION: Breast density distribution in Lebanon is similar to the western society. Similarly to other studies, it was shown that high breast density was statistically related to breast cancer, especially in older and menopausal women.

PREGNANCY AND RENAL TRANSPLANTATION.

Pregnancy is common nowadays in kidney transplant female patients because of medical and surgical advances. However, pregnancy is a high risk one in these patients. Fertility is rapidly restored after the transplantation; thus, contraception is a good option in the first year. Adding to that, pregnancy can endanger the allograft function in the presence of hypertension, a moderate to severe kidney disease and proteinuria. Medical complications are more prevalent in kidney transplant population, such as infections, gestational hypertension and diabetes and anemia. Low birth weight infants and premature delivery are two other major concerns in this population. Acute rejection of the allograft is another major complication that can be avoided with close monitoring of the graft and convenient immunosuppression. Immunosuppressive drugs must be continued during pregnancy except for mycophenolic acid and sirolimus that can be teratogen. Delivery of kidney transplant patients should be vaginal and spontaneous. Cesarean section should be reserved for obstetrical indications. Prophylactic antibiotics should be administered for every invasive procedure. Patients treated with corticosteroids can breastfeed their babies. Kidney donating women can have a safe pregnancy but with a slight risk of gestational diabetes and hypertension. In summary, a multidisciplinary medical team should follow pregnant kidney transplant patients in a tertiary center. International and national registries are a must to collect data concerning this particular high-risk population in order to solve unanswered questions.

[Infertility and kidney transplantation]. / INFERTILITÉ ET GREFFE RÉNALE.

Renal failure impairs the endocrine system, especially in women, due to hyperprolactinemia, altering fertility, ovulatory cycles, libido and growth in adolescents. Renal transplantation is considered the best solution to the problems of renal failure and and of dialysis, as evidenced by comparing the rate of hyperprolactinemia (100% in chronic renal failure, 60% in patients on dialysis and 35% in post-transplantation). Kidney transplant is less efficient for restoring perfect function of the hypothalamic-pituitary-gonadal axis due in part to the immunosuppressant regimens prescribed. When these drugs are properly managed, transplantation will restore near normal sexual function.

CEREBRAL ANEURISMAL RUPTURE WITH SUBARACHNOID HEMORRHAGE DURING PREGNANCY: A CASE REPORT.

BACKGROUND: Intracranial hemorrhage due to arteriovenous malformation or intracranial aneurysm is a rare but severe complication of pregnancy with maternal and fetal mortality of 20% and 33% respectively. Whether to deliver the patient first, or to treat the aneurysm first is still controversial, but an emergency cesarean section followed by aneurismal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications. CASE: A 38-year-old patient, G3P2A0, presented at 36 gestational weeks with a diffuse bilateral subarachnoid hemorrhage with fourth ventricle bleeding and hydrocephalus. She had a cerebral aneurysm of the left posterior communicating artery on arteriography. A cesarean section was performed on the first day of admission, and an external ventricular derivation with clipping of the aneurysm on the left posterior communicating artery were done immediately after the cesarean section. Mother and newborn were discharged from hospital in a good health status except Broca's aphasia in the mother. CONCLUSION: In the absence of categorical recommendations, we stress the role of combined care by both neurosurgeons and obstetricians, on a case to case basis according to gestational age, mother neurological status and experience of caregivers.

[Urinary functional complications following radical uterine surgery]. / Complications urinaires fonctionnelles après chirurgie utérine radicale.

BACKGROUND AND STUDY OBJECTIVE: Radical hysterectomy is the surgery of reference for cervical cancer at an early stage. However, it causes functional urinary complications. The purpose of this article is to review the literature recalling the anatomy of the pelvic nerves and their relation to the various viscera, to better understand the etiology of urinary functional disorders associated with pelvic autonomic nerve section, and their prevention techniques. METHODOLOGY AND FINDINGS: A systematic search of the medical literature and PubMed from 1950 to 2013 showed that urinary complications are mainly a decreased sensation of need, urine output and bladder compliance, an increase in residual urine volume, and a urinary incontinence. Causes include a vegetative denervation, anatomical changes causing loss of the support of the urethra and the vesical neck as well as the local trauma. The severity of vesico-ureteral dysfunction is associated with the degree of radical hysterectomy. Radiotherapy can increase associated urinary morbidity of radical hysterectomy. These complications can be avoided with conservative surgery for pelvic nerves initiated by the Japanese Yabuki. In the postoperative course of a radical hysterectomy, it is important to avoid and treat bladder overdistensions, diagnose and treat any urinary tract infections that are often asymptomatic. CONCLUSION: Knowledge of the surgical anatomy of the nerves and their relation to other pelvic structures, allows the improvement of postoperative functional urinary outcomes.

Mycobacterial infection of breast prosthesis--a conservative treatment: a case report.

BACKGROUND: Bacterial infection is a well-known risk of breast implant surgery. It is typically caused by bacterial skin flora, specifically Staphylococcus aureus and the coagulase negative staphylococci. There have been infrequent reports of breast implant infection caused by the atypical mycobacteria, of which Mycobacterium canariasense not yet reported in the literature. CASE PRESENTATION: This report summarizes the case of a female patient who underwent mastectomy followed by bilateral breast augmentation and presented approximately three years later with clinical evidence of infected breast prosthesis by Mycobacterium canariasense. One year after thoroughly follow-up, appropriate antibiotherapy and the change of the infected prosthesis, the patient presented no signs of reinfection. CONCLUSION: Our case demonstrates that Mycobacterium canariasense should be considered as a new potential cause of infected breast prosthesis.