Clinical breast exam contribution to breast cancer diagnosis in BRCA mutation carriers vs. average to intermediate risk women.

PURPOSE: The contribution of clinical breast exam (CBE) to breast cancer diagnosis in average risk women undergoing regular screening mammography is minimal. To evaluate the role of CBE in high-risk women, we compared BC diagnosis by CBE in BRCA mutation carriers undergoing regular BC surveillance to average to intermediate risk women undergoing regular breast cancer screening. METHODS: A retrospective chart review of all consecutive screening visits of BRCA mutation carriers (January 2012-October 2022) and average to intermediate risk women (November 2016-December 2022) was completed. Women with histologically confirmed BC diagnosis were included. Additional CBE yield for BC diagnosis, defined as the percentage of all BC cases detected by CBE alone, was assessed in both groups. RESULTS: Overall, 12,997 CBEs were performed in 1,328 BRCA mutation carriers in whom 134 BCs were diagnosed. In 7,949 average to intermediate risk women who underwent 15,518 CBEs, 87 BCs were diagnosed. CBE contributed to BC diagnosis in 3 (2%) BRCA mutation carriers and 3 (4%) non-carriers. In both groups, over 4,000 CBEs were needed in order to diagnose one cancer. In all 3 BRCA mutation carriers BC was palpated during the surveillance round that did not include MRI. In the average to intermediate risk group, 2 of 3 cancers diagnosed following CBE findings were in a different location from the palpable finding. CONCLUSIONS: The contribution of CBE to BC diagnosis is marginal for all women including BRCA mutation carriers. In BRCA mutation carriers, CBE appears redundant during the MRI surveillance round.

Totally Laparoscopic Ileocolic Resection with Intracorporeal Anastomosis for Crohn's Disease: A Comparative Study.

BACKGROUND: Although minimally invasive surgery for Crohn's disease has been validated in previous studies, most of those reports have referred to laparoscopic-assisted procedures with an extra-corporeal anastomosis. OBJECTIVES: To evaluate the short- and long-term outcomes of total laparoscopic ileocolic resection with an intracorporeal anastomosis for Crohn's disease patients. METHODS: We conducted a single-center retrospective review of all patients who underwent primary ileocolic resection for Crohn's disease between 2010 and 2021. Group A included 34 patients who underwent total laparoscopic ileocolic resection with intracorporeal anastomosis. Group B comprised 144 patients who underwent an open or laparoscopic-assisted procedure. RESULTS: No differences were noted in operative time (mean 167 minutes vs. 152 minutes, P = 0.122), length of stay (median 6.4 days vs. 7.5 days, P = 0.135), readmission rates (11.8% vs. 13.2%, P = 1), and microscopic involvement of surgical margins (7.7% vs. 18.5%, P = 0.249). Group A had significantly fewer postoperative surgical site infections (2.9% vs. 22.2% respectively, P = 0.013), with no differences in other complications prevalence. After a median follow-up of 46 months, there were similar rates of endoscopic recurrence (47.1% vs. 51.4%, P = 0.72), clinical recurrence (35.3% vs. 47.9%, P = 0.253), and surgical recurrence (2.9% vs. 4.9%, P = 0.722). CONCLUSIONS: Total laparoscopic ileocolic resection with intracorporeal anastomosis for Crohn's disease is safe and resulted in favorable outcomes in terms of postoperative wound healing. The long-term disease recurrence rates were like those of laparoscopic-assisted and open ileocolic resection.

Resection of Recurrent Pelvic Soft Tissue Sarcoma: Is the Risk Worth the Reward?

INTRODUCTION: Soft tissue sarcomas (STS) of the pelvis present a surgical and oncological challenge. We investigated the outcomes of patients undergoing resection of pelvic sarcomas. METHODS: A retrospective analysis of all patients who underwent surgical resection for STS between 2014 and 2021 at a tertiary academic referral center (n = 172). Included all patients with primary or recurrent STS which originated or extended to the pelvic cavity (n = 29). RESULTS: The cohort was divided into primary pelvic sarcomas (n = 18) and recurrent pelvic sarcomas (rPS, n = 11). Complete R0/R1 resection was achieved in 26 patients (89.6%). The postoperative complication rate was 48.3%. The rate of major complications was 27.5%. The median time of follow-up from surgery was 12.3 months (range, 0.6-60.3 months). Disease-free survival was superior in the primary pelvic sarcomas group compared to the rPS group (P = 0.002). However, there was no significant difference in overall survival, (P = 0.52). Univariant and multivariant analyses identified rPS group (Hazard Ratio 8.68, P = 0.006) and resection margins (Hazard Ratio 6.29, P = 0.004) to be independently associated with disease-free survival. CONCLUSIONS: We have demonstrated that achieving R0/R1 resection is feasible. Oncological outcomes are favorable for primary tumors, whereas recurrent tumors exhibit early recurrences. Consideration of resection of recurrent pelvic STS should involve a careful multidisciplinary evaluation.

Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy.

BACKGROUND: Small-bowel obstruction (SBO) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a common complication associated with re-admission that may alter patients' outcomes. Our aim was to characterize and investigate the impact of bowel obstruction on patients' prognosis. METHODS: This was a retrospective analysis of patients with SBO after CRS/HIPEC (n = 392). We analyzed patients' demographics, operative and perioperative details, SBO re-admission data, and long-term oncological outcomes. RESULTS: Out of 366 patients, 73 (19.9%) were re-admitted with SBO. The cause was adhesive in 42 (57.5%) and malignant (MBO) in 31 (42.5%). The median time to obstruction was 7.7 months (range, 0.5-60.9). Surgical intervention was required in 21/73 (28.7%) patients. Obstruction eventually resolved (spontaneous or by surgical intervention) in 56/73 (76.7%) patients. Univariant analysis identified intraperitoneal chemotherapy agents: mitomycin C (MMC) (HR 3.2, p = 0.003), cisplatin (HR 0.3, p = 0.03), and doxorubicin (HR 0.25, p = 0.018) to be associated with obstruction-free survival (OFS). Postoperative complications such as surgical site infection (SSI), (HR 2.2, p = 0.001) and collection (HR 2.07, p = 0.015) were associated with worse OFS. Multivariate analysis maintained MMC (HR 2.9, p = 0.006), SSI (HR 1.19, p = 0.001), and intra-abdominal collection (HR 2.19, p = 0.009) as independently associated with OFS. While disease-free survival was similar between the groups, overall survival (OS) was better in the non-obstruction group compared with the obstruction group (p = 0.03). CONCLUSIONS: SBO after CRS/HIPEC is common and complex in management. Although conservative management was successful in most patients, surgery was required more frequently in patients with MBO. Patients with SBO demonstrate decreased survival.

Improving pre-bariatric surgery diagnosis of hiatal hernia using machine learning models.

BACKGROUND: Bariatric patients have a high prevalence of hiatal hernia (HH). HH imposes various difficulties in performing laparoscopic bariatric surgery. Preoperative evaluation is generally inaccurate, establishing the need for better preoperative assessment. OBJECTIVE: To utilize machine learning ability to improve preoperative diagnosis of HH. METHODS: Machine learning (ML) prediction models were utilized to predict preoperative HH diagnosis using data from a prospectively maintained database of bariatric procedures performed in a high-volume bariatric surgical center between 2012 and 2015. We utilized three optional ML models to improve preoperative contrast swallow study (SS) prediction, automatic feature selection was performed using patients' features. The prediction efficacy of the models was compared to SS. RESULTS: During the study period, 2482 patients underwent bariatric surgery. All underwent preoperative SS, considered the baseline diagnostic modality, which identified 236 (9.5%) patients with presumed HH. Achieving 38.5% sensitivity and 92.9% specificity. ML models increased sensitivity up to 60.2%, creating three optional models utilizing data and patient selection process for this purpose. CONCLUSION: Implementing machine learning derived prediction models enabled an increase of up to 1.5 times of the baseline diagnostic sensitivity. By harnessing this ability, we can improve traditional medical diagnosis, increasing the sensitivity of preoperative diagnostic workout.

Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series.

INTRODUCTION: Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. METHODS: This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. RESULTS: The cohort included 25 patients with an average age of 60.4 (range: 40-86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien-Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205-510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. CONCLUSION: This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.

Comprehensive single institute experience with melanoma TIL: Long term clinical results, toxicity profile, and prognostic factors of response.

Adoptive cell transfer (ACT) of tumor-infiltrating lymphocytes (TIL) mediates objective responses in 30% to 50% of patients with metastatic melanoma according to multiple, small phase 2 trials. Here we report the long-term clinical results, intent-to-treat analysis, predictors of response and toxicity profile in a large patient cohort. A total of 179 refractory melanoma patients were enrolled in the ACT trial. TIL were administered in combination with high-dose bolus interleukin-2 following preconditioning with cyclophosphamide and fludarabine. Patients were followed-up for a median of 7.2 years. A total of 107 (60%) of 179 enrolled patients were treated. The main reason for the drop out of the study was clinical deterioration. Of 103 evaluated patients, 29 patients (28%) achieved an objective response (OR), including complete remission (8%) or partial response (20%). Sixteen pateints exhibited stable disease. Predictors of response were performance status, time of TIL in culture and CD8 frequency in the infusion product. The absolute lymphocyte count 1 and 2 weeks after TIL infusion was the most predictive parameter of response. With a medium follow-up time of 7.2 years, OR patients reached a median overall survival (OS) of 58.45 months and a median progression-free survival (PFS) of 15.43 months, as compared with nonresponders, with 6.73 months OS and 2.60 months PFS. By 6 years, 50% of OR patients were alive and 43% had no documented progression. TIL ACT can yield durable objective responses, even as salvage therapy in highly advanced metastatic melanoma patients.

Local recurrence of breast cancer: Salvage lumpectomy as an option for local treatment.

INTRODUCTION: The best local management for breast cancer recurrence following conservative treatment for breast cancer (BC) continues to be an open question. In this study, we compared patients' outcome after salvage lumpectomy (SL) vs mastectomy for ipsilateral breast tumor recurrence (IBTR). MATERIALS AND METHODS: Between 1987 and 2014 we identified 121 patients with pT0-2, N0-3, M0 BC who had BCT as their primary treatment, and subsequently had IBTR (unifocal). 47 patients underwent SL and 74 salvage mastectomy (SM) as the local treatment for their 1st recurrence. RESULTS: Median follow-up was 14 years (1-30) from first BC diagnosis. For the SL and SM cohorts, 8 and 10 patients (17%, 13.5%, P = 0.22), respectively, developed subsequent local recurrence as a 3rd event. Although in MVA, woman who underwent SL had higher chances of having a 2nd recurrence (3rd event), P = 0.020, at a median follow-up of 14 years, 95.8% of SL patients are alive, NED, 85% are mastectomy free. 87% of patients who opted for SM are alive, NED. Having re-irradiation following SL did not protect against 2nd breast cancer recurrence (3rd event, P = 0.42). CONCLUSION: Salvage lumpectomy following IBTR, while associated with higher second LR rate than SM is not associated with inferior outcome. With survival >95% at 14 years in the SL cohort, salvage lumpectomy with or without re-radiation, in a selected population (unifocal T), represents an acceptable treatment option for patients in order to delay time to mastectomy without reducing BC survival. Both options should be discussed prior to any surgical decision.

The Intact® breast lesion excision system as a therapeutic device for selected benign breast lesions.

The aim of this paper is to evaluate our Unit's initial experience using the Intact breast lesion excision system as a therapeutic excision option for benign or borderline breast lesions, which otherwise would entail open operative excision. The study includes the first 111 patients who underwent therapeutic excision with the intact radiofrequency system between December 2012 and May 2016 performed at the Meirav Center for Breast Health, at the Chaim Sheba Medical Center, Ramat Gan Israel. The indications for the procedure included those patients who have benign, or atypical high risk lesions following a previous core needle biospy (CNB) who would have normally undergone conventional excision biopsy. After reviewing each case separately, we found that the use of the BLES system as a treatment device permitted the avoidance of operations that would have been otherwise indicated, in 98 cases of the total 111 in the cohort (88.3%). Thirteen cases eventually had to undergo surgical excision. In eight cases pathology was upgraded from the initial CNB to invasive or noninvasive carcinoma. Although the INTACT sysytem is most commonly used as an alternative biopsy technique for its diagnostic capabilities, this study assessed its clinical role as a definitive therapeutic excisional modality in selected cases of benign breast disease. It proved valuable in the majority of cases with avoidance of surgery where it was traditionally indicated, (98/111, 88.3%) and as definitive fibroadenoma management in a further 28 patients.

Mammographic breast density in recent and longer-standing ethiopian immigrants to israel.

High breast density is associated with an increased risk of breast cancer development. Little is known concerning ethnic variations in breast density and its relevant contributing factors. We aimed to study breast density among Ethiopian immigrants to Israel in comparison with Israeli-born women and to determine any effect on breast density of the length of residency in the immigrant population. Mammographic breast density using the BI-RADS system was estimated and compared between 77 women of Ethiopian origin who live in Israel and 177 Israeli-born controls. Logistic regression analysis was performed to estimate the odds ratios (OR) for high density (BI-RADS score ≥ 3) vs low density (BI-RADS score < 3) cases, comparing the 2 origin groups. Ethiopian-born women had a crude OR of 0.15 (95% CI: 0.08-0.26) for high breast density compared with Israeli-born women. Adjustments for various cofounders did not affect the results. Time since immigration to Israel seemed to modify the relationship, with a stronger association for women who immigrated within 2 years prior to mammography (OR:0.07, 95% CI: 0.03-0.17) as opposed to women with a longer residency stay in Israel (OR:0.23, 95% CI:0.10-0.50). Adjustments of various confounders did not alter these findings. Breast density in Ethiopian immigrants to Israel is significantly lower than that of Israeli-born controls. Our study suggests a positive association between time since immigration and breast density. Future studies are required to define the possible effects of dietary change on mammographic density following immigration.

Perioperative BRAF inhibitors in locally advanced stage III melanoma.

BACKGROUND AND OBJECTIVES: Stage III malignant melanoma is a heterogeneous disease where those cases deemed marginally resectable or irresecatble are frequently incurable by surgery alone. Targeted therapy takes advantage of the high incidence of BRAF mutations in melanomas, most notably the V600E mutation. These agents have rarely been used in a neoadjuvant setting prior to surgery. METHODS: Thirteen consecutive patients with confirmed BRAFV600E regionally advanced melanoma deemed marginally resectable or irrresectable, were treated with BRAF inhibiting agents, prior to undergoing surgery. The primary outcome measures were a successful resection and pathological response. Disease-free survival was a secondary outcome measure. RESULTS: Overall, 12/13 patients showed a marked clinical responsiveness to medical treatment, enabling a macroscopically successful resection in all cases. Four patients had a complete pathological response with no viable tumor evident in the resected specimens and eight patients showed evidence of minimally residual tumor with extensive tumoral necrosis and fibrosis. One patient progressed and died before surgery. At a median follow up of 20 months, 10 patients remain free of disease. CONCLUSIONS: Perioperative treatment with BRAF inhibiting agents in BRAFV600E mutated Stage III melanoma patients facilitates surgical resection and affords satisfactory disease free survival.

Bariatric Surgery Improves Sexual Function in Obese Patients.

BACKGROUND: Obesity causes specific sexual problems, including diminished sexual desire, poor performance and avoidance of sexual encounters. OBJECTIVES: To systematically evaluate the effect of bariatric surgery on patients' sexual function as compared to their preoperative status. METHODS: Bariatric surgery candidates were given a validated sexual function questionnaire the day before surgery and again 6 months after surgery. Females were polled with the Female Sexual Function Index (FSFI) and males with the Brief Sexual Function Inventory (BSFI). Statistical analysis was performed to elucidate differences in response to the questionnaires. RESULTS: The study population included 34 females and 14 males. Mean age and body mass index (BMI) were 40.2 ± 10.2 years and 43.4 ± 5.3 kg/m2, respectively. Postoperative BMI was 31.4 ± 4.9 kg/m2 (P < 0.001). Laparoscopic sleeve gastrectomy was performed in 36 patients and laparoscopic Roux-Y gastric bypass in 12. In females, the FSFI index rose significantly from 24 to 30 (P = 0.006), indicating increased sexual performance and satisfaction. In males the BSFI increased from 40.2 to 43.9 but did not reach statistical significance (P = 0.08). However, general satisfaction, desire and erection were each significantly improved within the BSFI. CONCLUSIONS: In addition to the well-documented medical and quality-of-life benefits of bariatric surgery, there is also clear improvement in patients' sexual function, both physical and psychosexual.

Freehand elastography for determination of breast cancer size: comparison with B-mode sonography and histopathologic measurement.

OBJECTIVES: Elastography assesses the strain of soft tissues and is used to enhance diagnostic accuracy in evaluating breast tumors, but minimal data exist on its ability to accurately assess tumor size. This study was performed to assess the preoperative accuracy of measuring the size of biopsyproven breast cancer lesions with elastography and conventional B-mode sonography compared with the reference standard size measured by histopathologic examination. METHODS: Elastography and conventional B-mode sonography were performed on 69 women with histologically proven breast cancer, and tumor sizes on both modalities were recorded. These measurements were compared with the final pathologic size, which was used as the reference standard. The sizes and differences between sonographic, elastographic, and pathologic measurements were statistically tested, and an analysis of equivalence to the reference standard was performed using Bland-Altman plots. RESULTS: There was a significant difference between sizes on elastography and pathologic examination, with elastography overestimating the tumor size (P = .0187). Sonography slightly underestimated the tumor size, but this finding was not significant (P = .36). Bland-Altman plots confirmed that sonography but not elastography was an acceptable standard compared with the pathologic size. CONCLUSIONS: Breast elastography but not B-mode sonography overestimates the size of breast tumors compared with the final pathologic size.

Utility of Clinical-Pathological Parameters for Exclusion of BRCA1/2 Mutation Carriers as Candidates for Partial Breast Irradiation.

PURPOSE: Several international groups have published guidelines to identify low-risk breast cancer (BC) patients who are eligible for partial breast irradiation (PBI). These include the American Society for Radiation Oncology (ASTRO), the European Society for Radiotherapy and Oncology (ESTRO), and ESTRO subgroups such as the Intraoperative radiation (IORT) Task Force and Groupe Européen de Curiethérapie (GEC) -ESTRO. Only ASTRO guidelines recommend against the use of PBI in known carriers of germline pathogenic variants (PVs) in BRCA1/2. The aim of this study was to evaluate the proportion of BC patients, subsequently found to be BRCA1/2 PV carriers who would be eligible for PBI based on clinical-pathologic criteria of the above-mentioned international guidelines. METHODS AND MATERIALS: Data were extracted from the medical records of consecutive BC BRCA1/2 PV carriers treated at a single institution between 2006 and 2023. Data included patient demographics, tumor characteristics, treatment, and disease outcomes. RESULTS: Overall, 498 patients with 518 primary tumors were analyzed. Of these, 282 (12 of them with synchronous bilateral disease) presented with unknown genetic status at diagnosis and formed the study cohort. The median age at diagnosis was 42.7 years (range, 23.8-77.9). Based on the recent ASTRO guidelines (not including conditionally recommended criteria), 17 of 294 (5.8%) of the carriers had tumors that would be eligible for PBI, including 3 Her2-positive tumors and 5 patients diagnosed between ages 40 and 49 years. Using the ESTRO IORT and the ACROP-ESTRO PBI criteria, 9 of 294 (3%) would be eligible, whereas with the GEC-ESTRO low-risk criteria, 31 of 294 (10.5%) of the carriers would be eligible, and their intermediate risk criteria would increase eligibility for PBI by an additional 8.2% (overall 18.7%). CONCLUSIONS: Using clinical-pathologic criteria published in international guidelines, 3% to 18% of BRCA1/2 PV carriers will have tumors eligible for PBI. Therefore, especially in populations who are at high risk for being BRCA1/2 PV carriers, we recommend adhering to stricter guidelines. In our cohort, ASTRO, ESTRO-IORT, and ESTRO PBI had the lowest probability of identifying BRCA1/2 PV carriers as eligible for PBI.

Predisposing factors for high output stoma in patients with a diverting loop ileostomy after colorectal surgeries.

PURPOSE: One of the most common ileostomy-related complications is high output stoma (HOS) which causes significant fluids and electrolytes disturbances. We aimed to analyze the incidence, severity, and risk factors for readmission for HOS. METHODS: We reviewed all patients who underwent loop ileostomy closure in a single institution between 2010 and 2020. Patients that were readmitted for dehydration due to HOS during the time interval between the creation and the closure of the stoma were identified and divided into a study (HOS) group. The remaining patients constructed the control group. RESULTS: A total of 307 patients were included in this study, out of which, 41 patients were readmitted 73 times (23.7% readmission rate) for the HOS group, and the remaining 266 patients constructed the control group. Multivariate analysis identified; advanced American Society of Anesthesiologists (ASA) physical status (PS) classification, elevated baseline creatinine, and open surgery as risk factors for HOS. Renal function worsened among the entire cohort between the construction of the stoma to its closure (mean creatinine of 0.82 vs. 0.96, P<0.0001). CONCLUSION: Loop ileostomy formation is associated with a substantial readmission rate for dehydration as a result of HOS, and increasing the risk for renal impairment during the duration of the diversion. We identified advanced ASA PS classification, open surgery, and elevated baseline creatinine as predictors for HOS.