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Ophthalmic viscoelastic devices (OVDs) are currently used in cataract surgery and have significantly improved the safety and effectiveness of this surgical procedure. OVDs are classified according to the zero-shear viscosity and the cohesion-dispersion index in cohesive, dispersive, and viscoadaptives. OVDs create and maintain anterior chamber depth and visibility, protecting the corneal endothelium and other intraocular tissues during surgery. The selection of the most adequate OVD is especially relevant when performing cataract surgery in challenging cases, such as in hard, mature cataracts, flat anterior chamber, pseudoexfoliation syndrome, intraoperative floppy iris syndrome, or glaucoma surgery. In such cases, OVD is crucial for facilitating the surgical procedure and the associated minimal complication rate. The use of a combination of OVDs (soft-shell technique and modifications), the use of blue-colored OVDs, and the combination of sodium hyaluronate with lidocaine have also been described as useful tools in some of these challenging cases.

The Covid‐19 pandemia has many other undesirable consequences apart of virus infection. Less people is hospitalized due to acute coronary syndrome and the delay to seek medical attention has increased. Patients with ST segment elevation myocardial infarction arrive at the hospital too late to be timely treated and we have recently seen mechanical complications that were more frequent in the past decades before the use of reperfusion strategies. In this report we describe the presentation, evolution and detailed imaging evaluation of two patients with unusual presentations of cardiac rupture: left ventricular pseudoaneurysm and left ventricular intramyocardial dissecting hematoma.

We report the case of a healthy 35‐year‐old woman who had experienced a flu‐like syndrome during the week before childbirth and heart failure symptoms 10 days before the current hospitalization and presented to our emergency department with clinical signs of congestive heart failure, echocardiographic evidence of a severely dilated and hypokinetic heart, laboratory evidence of SARS‐CoV‐2 disease, and radiologic findings consistent with both virus‐related pneumonia and heart failure. Early cardiac magnetic resonance was crucial for the diagnosis of postpartum cardiomyopathy and for the exclusion of virus‐related myocarditis, allowing us to decide on a prudent and supportive clinical approach.

Presentation of the Case A 53-year-old postmenopausal woman was found to have a new area of microcalcification at the 10 o'clock position of her right breast during a routine screening mammogram. Ultrasound-guided core biopsy revealed a grade 2 invasive ductal carcinoma, estrogen receptor (ER)+ (90%), progesterone receptor positive (20%), and human epidermal growth factor receptor (HER)-2+ (3+ by immunohistochemistry). A right breast lumpectomy and sentinel node biopsy were performed. The invasive tumor measured 0.7 cm, no lymphovascular space invasion was identified, surgical margins were uninvolved, and the sentinel lymph nodes were negative for tumor. She was evaluated postoperatively in the medical oncology clinic to discuss an adjuvant treatment strategy. The question for our colleagues is: should she be offered adjuvant chemotherapy and trastuzumab prior to adjuvant radiation and 5 years of hormonal therapy?

Presentation of the Case A 51-year-old woman presents with an abnormal screening mammogram. Core biopsy shows an invasive ductal cancer that stains strongly for estrogen receptor (ER) and progesterone receptor (PR) and does not overexpress human epidermal growth factor receptor 2. She underwent a partial mastectomy and sentinel node biopsy. The invasive tumor measured 2.1 cm in greatest diameter and was grade 1. There was a 0.4 cm metastatic deposit in one of two sentinel lymph nodes (pT1cN1/stage IIA). There was no tumor within 0.2 cm of all margins and no lymphatic or vascular invasion noted. She was evaluated in the breast multidisciplinary clinic by a medical, surgical, and radiation oncologist. The question for our colleagues is what is the optimal adjuvant therapy for this woman and, more specifically, is chemotherapy necessary?

Presentation of the Case A 68-year-old woman with no past medical history presents with rectal bleeding. Colonoscopy reveals a mass in the midrectum at approximately 8 cm. Biopsy shows adenocarcinoma. On physical exam, the tip of the mass is barely palpable. A magnetic resonance imaging (MRI) scan of the pelvis demonstrates a tumor with invasion through the muscularis in the midrectum (Fig. 1). There is at least 2 cm between the tip of the mass and the mesorectum. A single 8-mm lymph node is seen in the perirectal space. A medical oncologist, surgical oncologist, and radiation oncologist see the patient and they recommend that the patient receive 6 weeks of infusional 5-fluorouracil (5-FU) and external beam radiation to a dose of 50.4 Gy. After chemoradiation, the oncologists expect the patient to undergo a low anterior resection and, upon recovery, 4 months of 5-FU–based adjuvant chemotherapy. The oncology fellow asks the attending physicians whether short-course radiation therapy is appropriate for this patient.

Section Editor's Note: Metastatic colorectal cancer is the second leading cause of cancer death in the United States. Since 1995, treatment regimens have included capecitabine, irinotecan, oxaliplatin, bevacizumab, cetuximab, panitumumab, aflibercept, and reforafenib. These medications have doubled the median survival of patients and improved the 5-year survival from less than 1% to 20%. Approximately 75% of patients stop first-line chemotherapy in clinical trials for reasons other than progressive disease and face the question of whether to consider “maintenance” chemotherapy or take a chemotherapy break. In this challenging case, Drs. Díaz-Rubio, Pietrantonio, and de Braud reflect on the data and offer their opinions. If each of the nearly 40,000 patients in the U.S. who face this decision chooses bevacizumab, the total cost is approximately $240 million per dose ($6,000 per infusion). The importance of this question and the cost to society are enormous.

Presentation of the Case A 68-year-old man presents for management of prostate-specific antigen (PSA)-recurrent prostate cancer. His PSA level had become undetectable after prostatectomy for a high-risk localized tumor but began to rise 8 months later. This later led to the initiation of androgen deprivation therapy (ADT), which he has received for the last 3.5 years. After initially falling in response to ADT, his PSA level again trended steadily upward and is now 13.2. Restaging with an abdominal and pelvic computed tomography scan and a bone scan reveals no evidence of metastases. Is this man likely to benefit from denosumab? Bone is the most common site of metastasis for advanced prostate cancer. Bone metastases can cause considerable morbidity in the form of pain, pathologic fractures, and even spinal cord compression. Two bone-targeted therapies (zoledronic acid and denosumab) have been shown to reduce the risk for skeletal events (SREs) among men with bone metastases and a rising PSA level despite a testosterone level The trial was positive because denosumab led to a 4.2-month significantly longer bone-metastasis-free survival time relative to placebo (median, 29.5 months versus 25.2 months; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.73–0.98; p = .028) [1]. The time to first bone metastasis and risk for symptomatic bone metastasis were also significantly better with denosumab treatment. Dror Michaelson and Philip Saylor discuss the potential implications of this trial.

Presentation of The Case A 61-year-old man undergoes a sigmoid colectomy for a T3N1 (two of 18 nodes) adenocarcinoma of the sigmoid colon. He recovers well and receives 6 months of adjuvant FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) uneventfully. At his first follow-up visit, the oncologist recommended every 3 month visits for a physical, liver function tests, and carcinoembryonic antigen (CEA) measurement; every 6 month chest, abdomen, and pelvic computed tomography (CT) scans for 3 years; and aspirin, vitamin D supplementation, and exercise. Is CT scanning appropriate in the follow-up of colon cancer patients? (This case was presented at Massachusetts General Hospital Cancer Center.)