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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.

Consequences of varicella zoster infection reflect a wide range of minor to serious complications involving the central nervous system. This is a case series with challenging presentations, imaging features and favorable outcome. For example, the cases presented with clinical features that resemble Brown Sequard Syndrome, transverse myelitis manner and multiple sclerosis and cognitive decline. We recommend adequate history taking, clinical examination and use of available investigation. Early treatment is likely to prevent any disabling neurological damage.

Since the initial emergence of coronavirus disease 2019 (COVID-19) in Wuhan, Hubei province, China, a rapid spread of the disease occurred around the world, rising to become an international global health concern at pandemic level. In the face of this medical challenge threatening humans, the development of rapid and accurate methods for early screening and diagnosis of COVID-19 became crucial to containing the emerging public health threat, and prevent further spread within the population. Despite the large number of COVID-19 confirmed cases in China, some problematic cases with inconsistent laboratory testing results, were reported. Specifically, a high false-negative rate of 41% on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection by real-time reverse transcription-polymerase chain reaction (qRT-PCR) assays was observed in China. Although serological testing has been applied worldwide as a complementary method to help identify SARS-CoV-2, several limitations on its use have been reported in China. Therefore, the use of both qRT-PCR and serological testing in the diagnosis of COVID-19 in China and elsewhere, presented considerable challenges, but when used in combination, can be valuable tools in the fight against COVID-19. In this review, we give an overview of the advantages and disadvantages of different molecular techniques for SARS-CoV-2 detection that are currently used in several labs, including qRT-PCR, gene sequencing, loop-mediated isothermal amplification (LAMP), nucleic acid mass spectrometry (MS), and gene editing technique based on clustered regularly interspaced short palindromic repeats (CRISPR/Cas13) system. Then we mainly review and analyze some causes of false-negative qRT-PCR results, and how to resolve some of the diagnostic dilemma.

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.

By Rebecca Heist Massachusetts General Hospital Cancer Center Rebecca Heist Despite successful surgery in this otherwise healthy middle-aged woman, recurrent lung cancer remains her highest risk for death. Five-year survival for stage IB (pT2aN0) lung cancer is 58% [1]. Barely more than half of patients who undergo a successful surgery, as this patient did, will be alive at 5 years. That is a sobering statistic, and anything that can improve this patient's chance for survival should be considered. So, what about adjuvant chemotherapy? This patient with significant risk of recurrent lung cancer should not be denied adjuvant chemotherapy simply because her tumor measures 1 mm less than what is widely considered the cutoff for offering treatment. It is true that patients with higher stage of disease see more benefit with adjuvant chemotherapy; this has been borne out in all three of the large clinical trials that have shown a benefit with cisplatin-based adjuvant chemotherapy (International Adjuvant Lung Cancer Trial, or IALT [2]; JBR.10 [3]; Adjuvant Navelbine International Trialist Association [ANITA] [4]) and in a pooled meta-analysis of cisplatin-based studies [5]. Benefit is also seen with adjuvant chemotherapy in node-negative patients who have a large tumor. Although visceral pleural involvement itself would not be a trigger for adjuvant chemotherapy, the large size of her primary tumor would be. Multiple analyses have shown improvement in overall survival with adjuvant chemotherapy if tumor size is greater than or equal to 4 cm (Cancer and Leukemia Group B [6] and JBR.10 [7]). Notably, 5-year survival for patients with tumors 4 cm or larger was 59% in the observation arm and 79% with chemotherapy in JBR.10 [7]. A 3.9-cm tumor is, in my mind, close enough to 4 cm to fall within the rubric of deriving benefit from chemotherapy. The choice of chemotherapy warrants some discussion. Although the most common regimen that has been studied is cisplatin combined with vinorelbine, as used in JBR.10 and ANITA, IALT allowed multiple other agents in combination with platinum, including vindesine, vinblastine, and etoposide, and the most common regimen in that trial was actually what we think of as an “old” regimen, cisplatin-etoposide. Ongoing clinical trials such as ECOG-1505 (ClinicalTrials.gov identifier {"type":"clinical-trial","attrs":{"text":"NCT00324805","term_id":"NCT00324805"}}NCT00324805) allow multiple different adjuvant chemotherapy backbones, including cisplatin-vinorelbine, cisplatin-docetaxel, cisplatin-gemcitabine, and cisplatin-pemetrexed. With the efficacy of pemetrexed in the nonsquamous setting in metastatic disease [8], earlier use of this agent in the adjuvant setting in patients with nonsquamous histology would be warranted. I would treat with cisplatin-pemetrexed in this case, given the efficacy of pemetrexed in the nonsquamous setting in advanced disease and the tolerability of this regimen. Notably, the patient is a never-smoker and molecular testing for driver mutations such as EGFR and ALK would be of high interest. Whether adjuvant erlotinib in the setting of an EGFR mutation or adjuvant crizotinib in the setting of ALK translocation should be recommended is an unanswered question; randomized trials specifically targeting these populations have not yet been done, although several are planned. Interestingly, a phase II study of surgically resected patients with EGFR mutations who received adjuvant erlotinib for 2 years reported 2-year disease-free survival of 94% [9]. Enthusiasm for adjuvant tyrosine kinase inhibitors in this setting must be tempered by the results of several large trials that showed no benefit and perhaps a suggestion of harm. In a molecularly unselected population, Southwest Oncology Group's SWOG 0023 trial showed a detriment to maintenance gefitinib in stage III disease after chemotherapy and radiation [10]. BR.19 was a phase III study randomly assigning molecularly unselected patients to either adjuvant gefitinib or placebo in stage IB–IIIA disease instead of or following adjuvant chemotherapy. This trial was closed after the results of SWOG 0023 were reported. Preliminary results of BR.19 showed no benefit to gefitinib and, in fact, a trend toward worse disease-free survival and overall survival; somewhat surprisingly, in the subset of EGFR-mutation-positive patients, overall survival was inferior with adjuvant gefitinib as well [11]. Although these studies have their flaws (e.g. nonmolecularly selected, premature closure, subset analyses of small numbers for EGFR mutation), their results lend credence to the position that adjuvant tyrosine kinase inhibitors should be given only in the setting of an appropriately targeted clinical trial. Enrollment in clinical trials attempting to definitively answer this question would be ideal if such driver mutations were found.

Presentation of the Case A 58-year-old woman presents with 2 months of back discomfort. Abdominal computed tomography reveals a 5-cm mass in the body of the pancreas with no obvious metastatic disease. The tumor surrounds the celiac artery, and the superior mesenteric vein is obliterated. Endoscopic ultrasound-guided fine needle aspiration shows adenocarcinoma, positive cytokeratin 7, positive carbohydrate antigen 19–9, and negative cytokeratin 20. She receives 4 months of FOLFIRINOX, with resolution of symptoms and a reduction in the size of the tumor, but the tumor continues to demonstrate superior mesenteric artery encasement and superior mesenteric vein obliteration. Should this patient continue chemotherapy or initiate chemoradiation at this juncture?

Presentation of the Case A 37-year-old woman presented at 35 weeks of gestation with her third child with failure to adequately gain weight and was noted by her obstetrician to have delay in the growth of her baby. Ultrasound of the abdomen incidentally revealed the presence of a liver lesion. After additional evaluation, she ultimately delivered her daughter at 36 weeks uneventfully. She subsequently underwent additional evaluation. Liver magnetic resonance imaging (MRI) revealed a 5-cm solitary solid mass in segment 4A of the liver, concerning for malignancy. Serum α-fetoprotein, carcinoembryonic antigen, cancer antigen (CA)19–9, CA15–3, and CA125 were all normal. Liver biopsy was positive for adenocarcinoma. The tumor cells demonstrated a phenotype suggesting a possible breast primary, although the immunohistochemistry did not support that diagnosis and the tumor was negative for mammaglobin, gross cystic disease fluid protein (GCDFP)-15, estrogen receptor (ER), and progesterone receptor (PR) (Table 1). The tumor was also CDX2 and cardiotrophin-1 negative, but cytokeratin (CK) 19 positive. Her endoscopic retrograde cholangiopancreatography, upper endoscopy, colonoscopy, breast mammogram, and breast MRI were completely normal. A positron emission tomography–computed tomography scan showed a fluorodeoxyglucose-avid 5.8-cm × 6.0-cm hypoattenuating lesion with peripheral enhancement involving segment 4 and segment 8 at the dome. In addition, central necrosis within the lesion was noted. The left main portal vein was mildly attenuated by the mass. She eventually underwent a left hepatectomy en bloc with caudate resection, portal lymphadenectomy, cholecystectomy, and omental pedicle flap. On exploration of the abdomen, no additional disease was noted. The final pathology revealed a 9.4-cm moderately to poorly differentiated adenocarcinoma of the intrahepatic bile ducts. Venous invasion was present. Perineural invasion was absent. The margins were negative. Thirteen lymph nodes were obtained, all of which were negative, consistent with a stage T2, N0, MX intrahepatic cholangiocarcinoma. The tumor was positive for CK7, CK19, and CA19–9 and negative for CK20, CDX2, CA125, ER, PR, GCDFP-15, synaptophysin, and chromogranin (Table 1). The uninvolved liver was unremarkable and a trichrome stain showed no fibrosis. Following an uneventful postoperative recovery, she was referred for consideration of adjuvant therapy.

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.)