A 1-Day-Old Girl With Infantile Hemangioma and Sternal Cleft.

CASE PRESENTATION: A newborn girl presented to the hospital on the first day of life because of respiratory failure. She was born at home at 37 weeks' gestation with minimal prenatal care and was found to be small for gestational age. The patient was found to have partial sternal agenesis and sternal cleft, cutis aplasia, left facial hemangioma, micrognathia, wide-spaced nipples, and low-set ears. The mother's and baby's urine toxicology screening were positive for amphetamines. Chest radiographs on admission showed bilateral hazy opacities. CT scan of the chest showed an absent sternum with midline chest wall concavity. The patient was monitored preoperatively in the cardiac ICU for risks of arrythmia, respiratory failure, altered cardiac output, and acute cardiopulmonary decompensation.

Perineural Invasion in Papillary Thyroid Cancer: A Rare Indicator of Aggressive Disease.

BACKGROUND: Perineural invasion (PNI) is associated with aggressive tumor behavior, increased locoregional recurrence, and decreased survival in many carcinomas. However, the significance of PNI in papillary thyroid cancer (PTC) is incompletely characterized. METHODS: Patients diagnosed with PTC and PNI from 2010-2020 at a single, academic center were identified and matched using a 1:2 scheme to patients without PNI based on gross extrathyroidal extension (ETE), nodal metastasis, positive margins, and tumor size (±4 cm). Mixed and fixed effects models were used to analyze the association of PNI with extranodal extension (ENE)-a surrogate marker of poor prognosis. RESULTS: In total, 78 patients were included (26 with PNI, 52 without PNI). Both groups had similar demographics and ultrasound characteristics preoperatively. Central compartment lymph node dissection was performed in most patients (71%, n = 55), and 31% (n = 24) underwent a lateral neck dissection. Patients with PNI had higher rates of lymphovascular invasion (50.0% vs. 25.0%, p = 0.027), microscopic ETE (80.8% vs. 44.0%, p = 0.002), and a larger burden [median 5 (interquartile range [IQR] 2-13) vs. 2 (1-5), p = 0.010] and size [median 1.2 cm (IQR 0.6-2.6) vs. 0.4 (0.2-1.4), p = 0.008] of nodal metastasis. Among patients with nodal metastasis, those with PNI had an almost fivefold increase in ENE [odds ratio [OR] 4.9 (95% confidence interval [CI] 1.5-16.5), p = 0.008] compared with those without PNI. More than a quarter (26%) of all patients had either persistent or recurrent disease over follow-up (IQR 16-54 months). CONCLUSIONS: PNI is a rare, pathologic finding that is associated with ENE in a matched cohort. Additional investigation into PNI as a prognostic feature in PTC is warranted.

Metagenomic Sequencing of the Gallbladder Microbiome: Bacterial Diversity Does Not Vary by Surgical Pathology.

INTRODUCTION: Alterations in the microbiome contribute to the pathogenesis of many gastrointestinal diseases. However, the composition of the microbiome in gallbladder disease is not well described. METHODS: We aimed to characterize the biliary microbiome in cholecystectomy patients. Bile and biliary stones were collected at cholecystectomy for a variety of surgical indications between 2017 and 2019. DNA was extracted and metagenomic sequencing was performed with subsequent taxonomic classification using Kraken2. The fraction of bacterial to total DNA reads, relative abundance of bacterial species, and overall species diversity were compared between pathologies and demographics. RESULTS: A total of 74 samples were obtained from 49 patients: 46 bile and 28 stones, with matched pairs from 25 patients. The mean age was 48 years, 76% were female, 29% were Hispanic, and 29% of patients had acute cholecystitis. The most abundant species were Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pasteurianus. The bacterial fraction in bile and stone samples was higher in acute cholecystitis compared to other non-infectious pathologies (p < 0.05). Neither the diversity nor differential prevalence of specific bacterial species varied significantly between infectious and other non-infectious gallbladder pathologies. Multivariate analysis of the non-infectious group revealed that patients over 40 years of age had increased bacterial fractions (p < 0.05). CONCLUSIONS: Metagenomic sequencing permits characterization of the gallbladder microbiome in cholecystectomy patients. Although a higher prevalence of bacteria was seen in acute cholecystitis, species and diversity were similar regardless of surgical indication. Additional study is required to determine how the microbiome can contribute to the development of symptomatic gallbladder disease.

Split Inferior Pedicle: The 1-Stage Augmentation Mastopexy for Grade 3 Ptosis.

In this article, the authors describe the 1-stage surgical technique that has been used by the senior author since 1990 for all his primary grade 2 and grade 3 augmentation-mastopexies. The article provides a safe, simple, and reproducible approach to a challenging procedure, one that tends to be the most litigious in aesthetic breast surgery. The key points of this technique are simple preoperative markings; the augmentation is performed with a true submuscular placement of smooth implants; and the mastopexy is performed with an inferior pedicle technique with unlimited skin flap undermining and no limitation of nipple elevation. Seventy-eight consecutive cases of augmentation mastopexy performed since 1999 by a single surgeon (V.S.) using the same technique were reviewed. The age range was 26-62 years old; the range of implant volume was 150-375 cc; and the follow-up time period was from 1 year to 22 years. After an extensive patient case review, the authors enforce true extended submuscular augmentation (TESMA) as a reliable augmentation technique that can be used as the first procedure in any grades 2 and 3 ptosis, 1-stage augmentation-mastopexies including bariatric cases. The authors believe that the split inferior pedicle for the mastopexy in combination with the TESMA is a breakthrough approach that eliminates the second stage for any augmentation mastopexy procedure. No major complications such as nipple necrosis, implant bottoming, malpositioning, or extrusions were observed. It is a safe, simple, and reproducible procedure.

Association of Adrenal Venous Sampling With Outcomes in Primary Aldosteronism for Unilateral Adenomas.

Importance: Adrenal venous sampling is recommended prior to adrenalectomy for all patients with hyperaldosteronism; however, cross-sectional imaging resolution continues to improve, while the procedure remains invasive and technically difficult. Therefore, certain patients may benefit from advancing straight to surgery. Objective: To determine whether clinical and biochemical resolution varied for patients with primary aldosteronism with unilateral adenomas who underwent adrenal venous sampling vs those who proceeded to surgery based on imaging alone. Design, Setting, and Participants: Retrospective, international cohort study of patients treated at 3 tertiary medical centers from 2004 to 2019, with a median follow-up of approximately 6 months. A total of 217 patients were consecutively enrolled. Exclusion criteria consisted of unknown postoperative serum aldosterone level and imaging inconsistent with unilateral adenoma with a normal contralateral gland. A total of 125 patients were included in the analysis. Data were analyzed between October 2019 and July 2020. Exposures: Adrenal venous sampling performed preoperatively. Main Outcomes and Measures: The primary outcome measurements were the clinical and biochemical success rates of surgery for the cure of hyperaldosteronism secondary to aldosterone-producing adenoma. Results: A total of 125 patients were included (45 cross-sectional imaging with adrenal venous sampling and 80 imaging only). The mean (SD) age of the study participants was 50.2 (10.6) years and the cohort was 42.4% female (n = 53). Of those patients for whom race or ethnicity were reported (n = 80), most were White (72.5%). Adrenal venous sampling failure rate was 16.7%, and the imaging concordance rate was 100%. Relevant preoperative variables were similar between groups, except ambulatory systolic blood pressure, which was higher in the imaging-only group (150 mm Hg; interquartile range [IQR], 140-172 mm Hg vs 143 mm Hg, IQR, 130-158 mm Hg; P = .03). Resolution of autonomous aldosterone secretion was attained in 98.8% of imaging-only patients and 95.6% of adrenal venous sampling patients (P = .26). There was no difference in complete clinical success (43.6% [n = 34] vs 42.2% [n = 19]) or partial clinical success (47.4% [n = 37] vs 51.1% [n = 23]; P = .87) between groups. Complete biochemical resolution was similar as well (75.9% [n = 41] vs 84.4% [n = 27]; P = .35). There was no difference in clinical or biochemical cure rates when stratified by age, although complete clinical success rates downtrended in the older cohorts, and sample sizes were small. Conclusions and Relevance: Given the improved sensitivity of cross-sectional imaging in detection of adrenal tumors, adrenal venous sampling may be selectively performed in appropriate patients with clearly visualized unilateral adenomas without affecting outcomes. This may facilitate increased access to surgical cure for aldosterone-producing adenomas and will decrease the incidence of morbidities associated with the procedure.

Evaluation of the central pedicled, modified Wise-pattern technique as a standard level II oncoplastic breast-conserving surgery: A retrospective clinicopathological study of 190 breast cancer patients.

Involving 207 breast cancer patients a retrospective study was performed to facilitate the acceptance of the central pedicled, modified Wise-pattern therapeutic mammoplasty technique as a standard volume-displacement level II oncoplastic breast-conserving surgery (OBCS). The overall local recurrence rate was 5.8% with an average follow-up of 43.9 months. The median time to the initiation of the adjuvant treatment was 4.9 weeks. Due to positive surgical margins, 13 (6.84%) completional surgeries were performed. In total, 45 complications (12.9%) were recorded. The median values of the esthetic outcomes represented improved cosmetic results. The modified Wise-pattern technique could be a standard, safe and repeatable level II volume-displacement OBCS.

Evaluation of a Retroglandular Oncoplastic Technique as a Standard Level I Oncoplastic Breast-Conserving Surgery: A Retrospective Clinicopathologic Study of 102 Patients With Breast Cancer.

BACKGROUND: This study presents a novel Level I oncoplastic breast-conserving surgery technique for performing tumorectomy by retroglandular exploration through a skin incision made in the inferior mammary fold. PATIENTS AND METHODS: A retrospective single-center cohort study involving patients with early-stage breast cancer (n = 102) was performed. The patient characteristics were recorded, as well as the quality of life rated by BREAST-Q. Postoperative complications were assessed using the Clavien-Dindo classification system. Esthetic outcomes were evaluated with Breast Cancer Conservative Treatment-cosmetic results (BCCT.core) software and a 5-point Likert scale. RESULTS: The median follow-up time was 11 months (range, 7-25 months). The median specimen weight and operative time were 49.8 g (range, 13.4-117.9 g) and 40 minutes (range, 20-80 minutes), respectively. The mean pathologic tumor size was 15 mm (SD, ±7). Owing to positive surgical margins, re-excisions and mastectomies were performed in 13.7% and 2.9% of patients, respectively. The overall complication rate was 24.5% (n = 25), with the most common being seroma formation (13.7%; n = 14). The median Likert scale score was 4.3 (range, 2.1-5), and the median overall esthetic outcome assessed by BCCT.core was 2.1 points (range, 1-4 points). In BREAST-Q domains, the median scores of the "adverse effects of radiation," "physical well-being," the "satisfaction with breasts," and the "psychosocial well-being" were 27, 35, 90, and 93, respectively. CONCLUSION: Retroglandular oncoplastic breast-conserving surgery is a novel, effective Level I oncoplastic technique for radical resection of breast tumors ≤ 3 cm in size. Additional advantages include the preservation of natural breast shape, the safety of the technique, and the lack of a need for contralateral symmetrization.

Comparison of clinicopathologic, cosmetic and quality of life outcomes in 700 oncoplastic and conventional breast-conserving surgery cases: A single-centre retrospective study.

INTRODUCTION: Limited data is available from studies that directly compare oncoplastic breast surgery and conventional breast-conserving surgery (CBCS) procedures. The aim of this study was to compare three volume displacement oncoplastic breast-conserving surgery (OBCS) techniques to CBCS procedures, providing more evidence and facilitating the standardization of OBCS techniques. PATIENTS AND METHODS: A retrospective single-centre comparative study was performed between January 2010 and January 2017 involving 758 breast cancer patients. The endpoints for comparison were oncological safety, frequency of complications, initiation time of adjuvant therapy, aesthetic outcome, quality of life and operation time. To compare data, statistical analyses were performed. RESULTS: The mean follow-up time was 51 months for the OBCS group and 52 months for the CBCS group. The excised weight of the specimens was significantly larger in the OBCS group than in the CBCS group (90 g vs. 63 g). The overall complication rate (5.7% vs. 6.6%), the initiation time of adjuvant therapy (4.2 weeks vs. 4.1 weeks) and the local recurrence rate (2.0% vs. 3.7%) did not differ significantly. Scores for the aesthetic outcome were significantly higher in the OBCS group; however, required longer operation time. CONCLUSION: The investigated OBCS procedures allowed the removal of large volumes of breast tissue with improved cosmetic outcomes without delay in adjuvant therapies, maintaining the oncological safety. However, OBCS required longer operation time. Furthermore, the extended radicality of the OBCS could reduce the rate of re-excision and completion mastectomy, although it may result in the overtreatment of some breast cancer patients.