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Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system–related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Background Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions. Materials and Methods Cross-sectional retrospective analysis included all patients with non-metastatic T4 BCa treated from 2010 to 2016 at Memorial Sloan Kettering Cancer Center (New York, New York) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated. Results Three hundred and eight patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. Fifty-six out of ninety-three (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt. Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative versus 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five-year survival was significantly shorter in Nigeria versus the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5-year survival (67% vs. 72%) and 5-year recurrence-free survival (48% vs. 61%) did not significantly differ between countries. Conclusion Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria. Implications for Practice This cross-sectional retrospective analysis of patients with T4 breast cancer in Nigeria and the U.S. found a significant difference in pathologic complete response to neoadjuvant chemotherapy (5% Nigeria vs. 27% U.S.). Five-year survival was shorter in Nigeria, but in patients receiving multimodality treatment, including neoadjuvant chemotherapy and surgery with curative intent, 5-year overall and recurrence-free survival did not differ between countries. Capacity-building efforts in Nigeria should focus on access to pathology services to direct systemic therapy and promoting receipt of complete chemotherapy to improve outcomes.

High-quality data are needed to guide interventions aimed at improving breast cancer outcomes in sub-Saharan Africa. We present data from an institutional breast cancer database to create a framework for cancer policy and development in Nigeria. An institutional database was queried for consecutive patients diagnosed with breast cancer between January 2010 and December 2018. Sociodemographic, diagnostic, histopathologic, treatment and outcome variables were analyzed. Of 607 patients, there were 597 females with a mean age of 49.8 ± 12.2 years. Most patients presented with a palpable mass (97%) and advanced disease (80.2% ≥ Stage III). Immunohistochemistry was performed on 21.6% (131/607) of specimens. Forty percent were estrogen receptor positive, 32.8% were positive for HER-2 and 43.5% were triple negative. Surgery was performed on 49.9% (303/607) of patients, while 72% received chemotherapy and 7.9% had radiotherapy. At a median follow-up period of 20.5 months, the overall survival was 43.6% (95% CI -37.7 to 49.5). Among patients with resectable disease, 18.8% (57/303) experienced a recurrence. Survival was significantly better for early-stage disease (I and II) compared to late-stage disease (III or IV) (78.6% vs 33.3%, P

Background The majority of women in Nigeria present with advanced-stage breast cancer. To address the role of geospatial access, we constructed a geographic information-system-based model to evaluate the relationship between modeled travel time, stage at presentation, and overall survival among patients with breast cancer in Nigeria. Methods Consecutive patients were identified from a single-institution, prospective breast cancer database (May 2009-January 2019). Patients were geographically located, and travel time to the hospital was generated using a cost-distance model that utilized open-source data. The relationships between travel time, stage at presentation, and overall survival were evaluated with logistic regression and survival analyses. Models were adjusted for age, level of education, and socioeconomic status. Results From 635 patients, 609 were successfully geographically located. The median age of the cohort was 49 years (interquartile range [IQR], 40-58 years); 84% presented with ≥stage III disease. Overall, 46.5% underwent surgery; 70.8% received systemic chemotherapy. The median estimated travel time for the cohort was 45 minutes (IQR, 7.9-79.3 minutes). Patients in the highest travel-time quintile had a 2.8-fold increase in the odds of presenting with stage III or IV disease relative to patients in the lowest travel-time quintile (P = .006). Travel time ≥30 minutes was associated with an increased risk of death (HR, 1.65; P = .004). Conclusions Geospatial access to a tertiary care facility is independently associated with stage at presentation and overall survival among patients with breast cancer in Nigeria. Addressing disparities in access will be essential to ensure the development of an equitable health policy.

PURPOSE The prevalence of themes linked to delay in presentation of breast cancer (BC) and their underlying factors vary considerably throughout Africa. Regional differences and trends are largely unreported. The purpose of this research was to provide summary estimates of the prevalence and distribution of the themes and underlying factors linked to delay in the presentation of BC, regional variation, and trends in an effort to identify targets for intervention. DESIGN We screened articles found through PubMed/Medline, African Journal OnLine, Science Direct, Google/Google Scholar, and ResearchGate. We included patient-reported surveys on the reasons linked to delayed presentation under 6 previously identified themes: symptom misinterpretation, fear, preference for alternative care, social influence, hospital-related factors, and access factors. The meta-analytical procedure in MetaXL used the quality-effect model. RESULTS Twelve of the 236 identified articles were eligible for this review. The overall summary estimate of late presentation (> 90 days) was 54% (95% CI, 23 to 85) and was worst in the eastern and central regions. Symptom misinterpretation was the most common theme (50%; 95% CI, 21 to 56), followed by fear (17%; 95% CI, 3 to 27), hospital-related theme (11%; 95% CI, 1 to 21), preference for alternative care (10%; 95% CI, 0 to 21), social influence (7%; 95% CI, 0 to 14), and access-related theme (6%; 95% CI, 0 to 13). The most common factor underlying symptom misinterpretation was mischaracterizing the breast lesion as benign (60%; 95% CI, 4 to 100) which surpassed lack of awareness in the last decade. Misdiagnosis and failure to refer were the dominant hospital-related factors. CONCLUSION Modifiable factors such as mischaracterizing malignant masses as benign, fear, misdiagnosis, and failure to refer were the prevalent factors contributing to delays throughout Africa. These factors are promising targets for intervention.

Historically, more than one-third of patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) underwent additional surgery. The SSO-ASTRO guidelines advise 2 mm margins for patients with DCIS having BCS and whole-breast radiation (WBRT). Here we examine guideline impact on additional surgery and factors associated with re-excision. Patients treated with BCS for pure DCIS from August 2015 to January 2018 were identified. Guidelines were adopted on September 1, 2016, and all patients had separately submitted cavity-shave margins. Clinicopathologic characteristics, margin status, and rates of additional surgery were examined. Among 650 patients with DCIS who attempted BCS, 50 (8%) converted to mastectomy. Of 600 who had BCS as final surgery, 336 (56%) received WBRT and comprised our study group. One hundred twenty-eight (38%) were treated pre-guideline and 208 (62%) were treated post-guideline. Characteristics and margin status were similar between groups. The re-excision rate was 38% pre-guideline adoption and 29% post-guideline adoption (p = 0.09), with 91% having only one re-excision. Re-excision for ≥ 2 mm margins was uncommon (6% pre-guideline vs. 5% post-guideline). On multivariate analysis, younger age (OR 0.97, 95% CI 0.94–0.99, p = 0.02) and larger DCIS size (OR 1.43, 95% CI 1.2–1.8, p

Background/objective Breast cancer (BC) mortality is exceptionally high in Africa due to late presentation and advanced-stage diagnosis. Previous studies examining barriers to early BC presentation are markedly inconsistent, showing conflicting findings within and between African regions, making resource allocation and designing interventional campaigns challenging. Our objective was to assess the strength or magnitude of the association between determinants/risk factors and delayed presentation/advanced-stage diagnosis of BC in Africa. Methods Electronic searches in PubMed, AJOL, Google, ResearchGate, ScienceDirect, and PubMed Central found eligible articles between 2000 and 2020. The meta-analytical procedure in Meta-XL used the quality effect model. I-squared (I2) above 75% indicated high heterogeneity. The summary effect size was the odds ratio with 95% confidence intervals. Results The effect of socio-economic and demographic determinants on delay varies across African regions. Low level of education (1.63, 95% CI 1.01-2.63), and not performing breast self examination (BSE) (13.59, 95% CI 3.33-55.4) were significantly associated with delayed presentation. Younger patients had more significant delays in West Africa (WA, 1.41, 95%CI 1.08-1.85), and the reverse occurred in North Africa (0.68, 95%CI 0.48-0.97). Lack of BC knowledge (1.59, 95% CI 1.29-1.97), not performing BSE, or no history of undergoing clinical breast examination (CBE) (2.45, 95% CI 1.60-3.40), were associated with advanced-stage disease at diagnosis. Older patients had significantly more advanced disease in WA, and the reverse occurred in South Africa. Aggressive molecular BC subtypes [Triple negative (OR 1.62, 95% CI 1.27-2.06) or HER2 positive (1.56, 95% CI 1.10-2.23)] were significant determinants of advanced-stage diagnosis. Conclusion Promoting early presentation and reducing advanced-stage BC throughout Africa should focus on modifiable factors, including providing quality education, improving breast health awareness and BC knowledge, and developing strategies to increase BSE and CBE. Interventions targeting socio-demographic determinants should be context-specific.

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.

Background: Delays to breast cancer diagnosis and treatment initiation are associated with worsened outcomes. However, population-based screening is impractical in many low-income and middle-income countries (LMICs) because of resource constraints and a lack of capacity to effectively diagnose and treat screen-detected disease. Mexico and Peru have similar mortality-to-incidence ratios for breast cancer. Unlike Peru, Mexico has attempted to implement mammography screening, although it remains opportunistic with low (20%) national coverage rates. The aim of this study was to compare delays and describe barriers to care among breast cancer patients in Mexico and Peru. Methods: This international cross-sectional study included breast cancer patients interviewed at four public cancer hospitals in Mexico City between 2009 and 2011, and a federally-funded regional cancer institute in Trujillo, Peru in 2015. A Breast Cancer Delays Questionnaire, developed and validated in Mexico and modified for Peru, was administered to breast cancer patients during routine hospital visits at each location. Patient-related, diagnostic, and treatment delays were quantified, and barriers to care identified. Findings: We included data from 597 Mexican women and 113 Peruvian women. Age at diagnosis did not differ between countries (53 years [Mexico] vs 54 years [Peru], p=0·266). Most women in both countries had breast cancer detected by symptoms (84% [Mexico] vs 93% [Peru]; p

Background Both patients with inflammatory breast cancer (IFLBC) and patients with noninflammatory T4 breast cancer (non-IFLBC) have a heavy disease burden in the breast; whether the unique biology of IFLBC conveys a higher locoregional recurrence (LRR) risk and worse outcomes in comparison with other T4 lesions is uncertain. Here the outcomes of patients with IFLBC and patients with non-IFLBC treated with modern multimodality therapy are compared. Methods Patients with nonmetastatic T4 breast cancer treated with neoadjuvant chemotherapy, mastectomy, and radiation therapy between 2006 and 2016 were identified. Recurrences and survival were compared between patients with IFLBC and patients with non-IFLBC overall and stratified by receptor subtype. Results For 199 T4 patients, the median age was 52 years, and the median clinical tumor size was 7 cm. One hundred seventeen (59%) had IFLBC. With a median follow-up of 41 months, 4 patients had isolated LRR; all cases occurred in patients with IFLBC. The 5-year isolated LRR rate for patients with IFLBC was 4.8%. Overall, 14 patients had both LRR and distant recurrence (DR); 47 had DR only. The 5-year distant recurrence-free survival (DRFS) rates were similar for patients with IFLBC and patients with non-IFLBC (63% vs 71%; log-rank P = .14). The 5-year DRFS rate was lowest among triple-negative (TN) patients (43%) and was significantly lower for patients with TN IFLBC versus patients with non-IFLBC (28% vs 62%; log-rank P = .02). The 5-year overall survival rates (71% vs 74%; log-rank P = .4) and cancer-specific survival rates (74% vs 79%; log-rank P = .23) did not differ between IFLBC and non-IFLBC. Conclusions Although IFLBC is often considered a unique biologic subtype, patients with IFLBC and patients with non-IFLBC had similar outcomes with modern multimodality therapy; isolated LRR was uncommon. The TN subtype in patients with IFLBC is associated with poor outcomes, and this indicates the need for new treatment approaches in this group.

BACKGROUND. Low incidence of breast cancer in men (BCM) (65 years). Kaplan-Meier methods were used to compare overall survival (OS) and breast cancer-specific survival (BCSS). Competing-risk methods analyzed time to second primary cancers (SPCs), with any-cause death treated as a competing risk. RESULTS. The study identified 152 BCM patients with a median age of 64 years (range, 19–96 years). The median body mass index (BMI) was 28 kg/m(2). Men age 65 years or younger (n = 78, 51 %) were more overweight/obese than men older than 65 years (n = 74, 49 %) (89 % vs 74 %, respectively; P = 0.008). Both groups had similar nodal metastases rates (P = 0.4), estrogen receptor positivity (P = 1), and human epidermal growth factor receptor 2 (HER2)neu overexpression (P = 0.6). Men 65 years of age or younger were more likely to receive chemotherapy (P = 0.002). The median follow-up period was 5.8 years (range, 0.1–14.4 years). The 5-year OS was 86 % (95 % confidence interval [CI], 80–93 %), whereas the 5-year BCSS was 95 % (95 % CI, 91–99 %). The BCM patients 65 years of age and younger had better OS (P = 0.003) but not BCSS (P = 0.8). The 5-year cumulative incidence of SPC was 8.4 % (95 % CI, 3.4–13.4 %). The prior SPC rate was higher for men older than 65 years (n = 20, 31 %) than for those age 65 years or younger (n = 7, 11 %) (P = 0.008). This did not account for differences in life years at risk. No difference was observed in SPC cumulative incidence stratified by age (P = 0.3). CONCLUSIONS. Men 65 years of age or younger received more chemotherapy and had improved OS, but not BCSS compared with men older than 65 years. For all BCM, SPC is a risk, and appropriate screening may be warranted.

INTRODUCTION: Nipple-sparing mastectomy (NSM) is increasingly used for breast cancer risk reduction and treatment. Prior small studies with variable control for baseline characteristics suggest superior satisfaction with NSM. The aim of this study was to compare patient satisfaction following NSM and total mastectomy (TM) utilizing the BREAST-Q patient-reported outcome measure in a well-characterized patient population. METHODS: Patients at a single institution undergoing NSM or TM with immediate tissue expander/implant reconstruction who completed a follow-up BREAST-Q from 2007–2017 were identified by retrospective review of a prospective database. Baseline characteristics were compared, and linear mixed models were used to analyze associations with BREAST-Q scores over time. RESULTS: Of 1866 eligible patients, 219 (12%) underwent NSM, and 1647 (88%) underwent TM. Median time from baseline to BREAST-Q was 658 days. Patients having NSM were younger, more likely to be white, and had lower BMI. They more often had prophylactic surgery, bilateral mastectomies, lower-stage disease, and less often received chemotherapy/radiation than patients having TM. On multivariable analysis, after controlling for relevant clinical variables, there was no difference in satisfaction with breasts or satisfaction with outcome overall between NSM and TM patients. Psychosocial well-being and sexual well-being were significantly higher in the NSM group. After additionally controlling for pre-operative BREAST-Q score in a subset of patients (72 NSM; 443 TM), only psychosocial well-being remained significantly higher in NSM patients. CONCLUSION: Patient-reported outcomes should be discussed with women weighing the risks and benefits of NSM to provide a better understanding of expected quality of life.

The role of MRI in the workup of newly diagnosed breast cancer patients remains controversial. Breast MRI detects additional disease, but this has not translated into improved outcomes. In light of a dramatic rise in MRI use, we investigated patterns of MRI ordering for newly diagnosed breast cancer. All newly diagnosed breast cancer cases presenting for surgical management to a specialized breast center from 2011 to 2013 were reviewed. Patients who had an MRI ordered by their operating surgeon were compared with those who had an MRI completed previously. Of 1037 patients, 504 (49%) with newly diagnosed breast cancer underwent MRI as part of their pre-operative evaluation. Variables associated with MRI use included commercial insurance, increased breast density, genetic testing, mamographically occult disease, and lobular pathology. Of women who presented to our center with an MRI already completed, 63 per cent were ordered by a primary care provider. Of the 504 patients, 233 (44%) who had an MRI underwent an additional biopsy, and 166 (33%) had a resultant change in management. There was no significant difference in MRI-directed change in patient care depending on ordering provider. Further research is needed to develop evidence-based guidelines for preoperative MRI evaluation to optimize patient outcomes.

Summary Breast cancer incidence and mortality rates continue to rise in Peru, with related deaths projected to increase from 1208 in 2012, to 2054 in 2030. Despite improvements in national cancer control plans, various barriers to positive breast cancer outcomes remain. Multiorganisational stakeholder collaboration is needed for the development of functional, sustainable early diagnosis, treatment and supportive care programmes with the potential to achieve measurable outcomes. In 2011, PATH, the Peruvian Ministry of Health, the National Cancer Institute in Lima, and the Regional Cancer Institute in Trujillo collaborated to establish the Community-based Program for Breast Health, the aim of which was to improve breast health-care delivery in Peru. A four-step, resource-stratified implementation strategy was used to establish an effective community-based triage programme and a practical early diagnosis scheme within existing multilevel health-care infrastructure. The phased implementation model was initially developed by the Breast Cancer Initiative 2·5: a group of health and non-governmental organisations who collaborate to improve breast cancer outcomes. To date, the Community-based Program for Breast Health has successfully implemented steps 1, 2, and 3 of the Breast Cancer Initiative 2·5 model in Peru, with reports of increased awareness of breast cancer among women, improved capacity for early diagnosis among health workers, and the creation of stronger and more functional linkages between the primary levels (ie, local or community) and higher levels (ie, district, region, and national) of health care. The Community-based Program for Breast Health is a successful example of stakeholder and collaborator involvement—both internal and external to Peru—in the design and implementation of resource-appropriate interventions to increase breast health-care capacity in a middle-income Latin American country.

BACKGROUND: Many factors influence decisions regarding choice of breast-conserving surgery (BCS) versus mastectomy with reconstruction for early invasive breast cancer. The purpose of this study was to compare patient satisfaction following BCS and mastectomy with implant reconstruction (M-iR) utilizing the BREAST-Q patient-reported outcome measure. METHODS: Women with stage I or II breast cancer undergoing BCS or M-iR who completed a BREAST-Q from 2010 to 2016 were identified by retrospective review of a prospective database. Baseline characteristics were compared, and linear mixed models were used to analyze associations with BREAST-Q scores over time. RESULTS: Our study group was composed of 3233 women; 2026 (63%) had BCS, 123 (3.8%) had nipple-sparing mastectomy, and 1084 (34%) had skin-sparing or total mastectomy. Median time from surgery to BREAST-Q was 205 days for BCS and 639 days for M-iR (p

Importance Mammographic screening is impractical in most of the world where breast cancers are first identified based on clinical signs and symptoms. Clinical breast examination may improve early diagnosis directly by finding breast cancers at earlier stages or indirectly by heightening women’s awareness of breast health concerns. Objective To investigate factors that influence time to presentation and stage at diagnosis among patients with breast cancer to determine whether history of previous clinical breast examination is associated with earlier presentation and/or earlier cancer stage at diagnosis. Design, Setting, and Participants In this cross-sectional analysis of individual patient interviews using a validated Breast Cancer Delay Questionnaire, 113 (71.1%) of 159 women with breast cancer treated at a federally funded tertiary care referral cancer center in Trujillo, Peru, from February 1 through May 31, 2015, were studied. Main Outcomes and Measures Method of breast cancer detection and factors that influence time to and stage at diagnosis. Results Of 113 women with diagnosed cancer (mean [SD] age, 54 [10.8] years; age range, 32-82 years), 105 (92.9%) had self-detected disease. Of the 93 women for whom stage was documented, 45 (48.4%) were diagnosed with early-stage disease (American Joint Committee on Cancer [AJCC] stage 0, I, or II), and 48 (51.6%) were diagnosed with late-stage disease (AJCC stage III or IV). Mean (SD) total delay from symptom onset to initiation of treatment was 407 (665) days because of patient (mean [SD], 198 [449] days) and health care system (mean [SD], 241 [556] days) delay. Fifty-two women (46.0%) had a history of clinical breast examination, and 23 (20.4%) had undergone previous mammography. Women who underwent a previous clinical breast examination were more likely to have shorter delays from symptom development to presentation compared with women who had never undergone a previous clinical breast examination (odds ratio, 2.92; 95% CI, 1.30-6.60; P = .01). Women diagnosed with shorter patient delay were more likely to be diagnosed with early-stage disease (AJCC stage 0, I, or II) than those with longer patient delay (31 [58.5%] vs 11 [30.6%], P = .01). Women who underwent a previous clinical breast examination were more likely to be diagnosed with early-stage disease compared with women who had never undergone previous clinical breast examination; this relationship remained significant after controlling for insurance and household income (odds ratio, 2.44; 95% CI, 1.01-5.95; P = .048). Conclusions and Relevance In a population in which most breast cancers are self-detected, previous clinical breast examination was associated with shorter patient delay and earlier stage at breast cancer diagnosis. In regions of the world that lack mammographic screening, the routine use of clinical breast examination may provide a resource-appropriate strategy for improving breast cancer early diagnosis.

Methemoglobinemia after ingestion of ammonium nitrate can lead to significant morbidity and mortality in affected patients. Ammonium nitrate is a primary ingredient in synthetic “cold packs,” which are used in healthcare as a substitute for bags of ice. Acute or chronic ingestion can have serious consequences to patient health including isosmotic diuresis, metabolic acidosis, circulatory collapse and gastritis. Methemoglobinemia is a result of nitrite toxicity. This toxicity can be compounded by patient comorbidities, which may further complicate treatment. Rapid and accurate diagnosis is essential in the treatment of Methemoglobinemia following ammonium nitrate ingestion. We present the case of a 76 year-old woman who was admitted for small bowel obstruction (SBO) and unintentionally ingested the contents of a cold pack. The patient subsequently became tachycardic, hypotensive, and unresponsive requiring urgent resuscitation and management in the ICU setting. Methemoglobin levels were elevated. The patient was treated with methylene blue (MB) and made a full recovery.

Background. Breast pathology is a challenging field, and previous work has shown discrepancies in diagnoses, even among experts. We set out to determine whether mandatory pathology review changes the diagnosis or surgical management of breast disease. Methods. Cases were referred for pathology review after patients presented for surgical opinion to the Dubin Breast Center at Mount Sinai Medical Center over the course of 2 years. Surgical pathologists with expertise in breast disease reviewed slides submitted from the primary institution and rendered a second opinion diagnosis. Comparison of these reports was performed for evaluation of major changes in diagnosis and definitive surgical management. Results. A total of 306 patients with 430 biopsy specimens were reviewed. Change in diagnosis was documented in 72 (17 %) of 430 cases and change in surgical management in 41 (10 %). A change in diagnosis was more likely to occur in patients originally diagnosed with benign rather than malignant disease (31 vs. 7 %, p \ 0.001). Twelve (7 %) of 169 specimens initially diagnosed as benign were reclassified as malignant. A malignant diagnosis was changed to benign in 4 (2 %) of 261 cases. Change in diagnosis was less common in specimens originating from commercial laboratories than community hospitals or university hospitals (8, 19, 21 %, p = 0.023). Change in management was not dependent on initial institution. Type of biopsy specimen (surgical or core) did not influence diagnostic or management changes. Conclusions. We recommend considering breast pathology review based on the individual clinical scenario, regardless of initial pathologic diagnosis or originating institution.

Patients presenting with pathologic nipple discharge (PND) often pose a diagnostic and therapeutic challenge. We used ultrasound to identify focal ductal dilatation-hypothesized to be a radiographic manifestation of the causative lesion-in patients with PND and no relevant clinical or radiographic findings. Twenty-two excisions guided by ultrasound wire localization of focal duct dilation were performed. Surgical pathology revealed papilloma in 20 cases (91%); atypia or carcinoma was detected in 7 cases (32%). The ultrasound finding of focal duct dilatation enables excision of otherwise occult though clinically significant lesions and is worthy of further study.

Current guidelines state that "no ink on tumor" constitutes adequate surgical margins for lumpectomy specimens. However, there remains uncertainty when tumor is close (1 mm) to multiple inked margins.All local excisions for invasive breast cancer during 3 years at one center were reviewed. Tumor characteristics, margin status, patient age, reoperations, and pathology of reexcised specimen were recorded. Chi-square analysis and regression models were used to identify factors associated with residual disease upon reoperation.In 533 lumpectomies for invasive cancer, 60 (11 %) had at least one positive margin, and 106 (20 %) had one or more close margin. Multiple margins were either close or positive in 67 cases. Reoperation was performed in 125 of 533 cases (23 %) for close or positive margins. Positive margins were significantly more likely to undergo reoperation compared with close margins (p 0.001). On reoperation, 73 of 125 (58 %) demonstrated residual cancer, including 39 of 68 (57 %) with close margins, and 34 of 57 (60 %) with positive margins (p = 0.52). When multiple margins were close or positive, residual cancer was found on reexcision in 45 of 59 (76 %) cases as opposed to 34 of 79 (43 %) cases with only one involved margin (p 0.001). When controlling for other factors, positive margins were no more associated with residual disease than close margins (p = 0.32), whereas multiple close or positive margins were associated with significantly higher risk of residual disease (odds ratio 6.1; p = 0.002; 95 % confidence interval 2.6-14.45).The only significant predictor of residual tumor was multiple close or positive margins. It may be appropriate to recommend reexcision for patients with multiple close margins.

Highlights • A patient presented with sepsis and a necrotizing infection of the abdominal wall. • Upon operative exploration he was found to have perforated appendicitis. • Maintain a high index of suspicion as diagnosis is often delayed. • Necrotizing fasciitis results in significant mortality; immediate intervention is paramount., Introduction Acute appendicitis is one of the most common surgical diseases, but perforated appendicitis resulting in necrotizing fasciitis of the abdominal wall is exceedingly rare. Presentation of case A 71-year-old male presented to the emergency department with one week of severe right-sided abdominal pain. He was hypothermic, hypotensive, and tachycardic. His abdomen was distended, with a large, tender, erythematous region over the right abdominal wall. Laboratory evaluation revealed leukocytosis, acute kidney injury, and lactic acidosis. CT scan revealed large collections of fluid and gas in the right abdominal wall as well as inflammation surrounding the right colon. The patient was resuscitated with intra-venous fluid, started on broad-spectrum antibiotics, and emergently brought to the operating room. The patient underwent an exploratory laparotomy, and was found to have appendicitis, which perforated into his abdominal wall resulting in a necrotizing soft tissue infection. Discussion The diagnosis of perforated appendicitis resulting in necrotizing fasciitis is often delayed due to the unusual presentation of this common disease. Necrotizing fasciitis is associated with significant mortality and requires immediate intervention. Conclusion It is imperative to maintain a high index of suspicion for intra-abdominal pathology in patients who present with necrotizing infections of the abdominal wall, flank, back, or groin. The importance of recognizing this complication early and proceeding immediately to the operating room cannot be overstated.

Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is an effective but morbid procedure in the treatment of peritoneal carcinomatosis. We report our outcomes at a single tertiary institution.A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between July 2007 and August 2012. The peritoneal cancer index (1-39) was used for peritoneal carcinomatosis (PC) staging. Mitomycin C (88.8%) was administered intraperitoneally at 42 °C for 90 mins. Risk factors associated with major morbidities were analyzed. The Kaplan-Meier method was used for survival analyses.The mean age was 55.1 (±11.3) years, and the majority (77.1%) of patients had complete cytoreduction (CC0-1). Tumor types included colorectal (n = 51, 30.0%), appendiceal (n = 50, 29.4 %), pseudomyxoma peritonei (n = 16, 9.4%), and other (n = 53, 31.2%). Factors associated with major complications were estimated blood loss (400 ml), length of stay (1 week), intraoperative blood transfusion, operative time (6 h), and bowel anastomosis. Intraoperative blood transfusion was the only independent prognostic factor on multivariate analysis (p = 0.031). Median follow-up was 15.7 months (±1.2). The recurrence rates for colorectal and appendiceal carcinoma at 1 and 3 years were 40%, 53.5% and 68%, 79.1%, respectively. The 1- and 3-year overall survival for colorectal and appendiceal carcinomatosis was 74.0%, 32.5% and 89.4%, 29.3%, respectively. Intraoperative peritoneal cancer index (PCI) score (16) and need for blood transfusion were factors independently associated with poor survival (p 0.05).Our single institution experience of CRS/HIPEC procedures for peritoneal carcinomatosis demonstrates acceptable perioperative outcome and long-term survival. Optimal cytoreduction was achieved in the majority of cases. Intraoperative PCI 16 was associated with poor survival. This series supports the safety of CRS-HIPEC in selected patients.

15 Background: The majority of breast cancer deaths occur in low- and middle-income countries, as a result of late stage disease presentation and inadequate access to diagnosis and treatment. Delay from development of symptomatology to initiation of treatment is associated with more advanced breast cancer, and delays greater than three months have been associated with reduced survival. We investigated method of detection, disease stage, and time to diagnosis and treatment in breast cancer patients in Peru. Methods: This investigation was conducted at the Instituto Regional de Enfermedades Neoplasicas del Norte, in Trujillo, Peru. All women with a pathologic or clinical diagnosis of breast cancer who visited a breast surgeon from February-May 2015 were eligible to participate. Trained personnel conducted individual patient interviews in Spanish, utilizing a validated breast cancer delays questionnaire. Results: Of the 159 women who qualified for inclusion, 113 (71%) agreed to participate in the study. Mean age was 54 years (range 30-85). Patients lived an average of 3 hours from the oncology institute (range 0-36). Most households earned less than minimum wage, and most (66%) were covered by Seguro Integral de Salud, the government-funded medical insurance for citizens with limited financial resources. One hundred and five (93%) participants reported initially detecting their breast cancer as a result of symptoms. One cancer (1%) was detected during screening clinical breast examination, and 7 (6%) by screening mammography. Ninety-three patients had available stage at time of diagnosis, with the following distribution: stage 0- 2%, stage 1-3%, stage 2-44%, stage 3-48%, and stage 4-3%. Based on patient report, mean patient delay (symptom development to first medical visit at any facility) was 211 days. Mean provider delay (first medical visit until treatment initiation) was 241 days. Mean total delay (symptom development to treatment initiation) was 407 days. Conclusions: Almost all study participants initially detected their breast cancer as a result of symptoms. More than half presented with stage 3 or 4 disease. Average delay from symptom onset to start of treatment was greater than one year.

CONCLUSIONS: When compared to NSQIP, Explorys demonstrates similar trends in DVT and PE cumulative incidence curves after breast reconstruction surgery. Furthermore, Explorys confirms known risk factors for thromboembolism after breast reconstruction surgery, validating its use. While data are not prospective, Explorys complements NSQIP in its ability to provide long term outcomes and complication trends at the population level while minimizing selection bias.

Dear Sir, A morbidly obese 26-year-old female at a gestational age of 21 weeks presented with progressive right lower quadrant pain, nausea, vomiting, and fevers over three weeks. She had a recent pulmonary embolism and a history of Crohn's disease (CD) treated with ciprofloxacin, metronidazole, and prednisone. On exam, she was febrile to 101 °F and tachycardic to 130 bpm. Her abdomen was gravid and tender diffusely with guarding over a palpable epigastric mass. Magnetic resonance imaging demonstrated a 15 cm complex fluid collection anterior to the uterus, a thick-walled segment of terminal ileum, and ascites (Figure 1). These findings suggested perforated Crohn's ileitis with phlegmon …