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In craniotomy surgery, it is important to maintain hemodynamics and prevent the increase of intracranial pressure. Using semi-invasive methods such as LiDCO monitoring is a good option in this situation. This study aimed to evaluate the effectiveness of mannitol and hypertonic sodium on hemodynamic parameters in patients undergoing elective craniotomy. This randomized clinical trial was done on 40 patients of both genders. Patients whose ages were between 18-65 years, who had American Society of Anesthesiologists (ASA) score I and II, and who underwent craniotomy surgery were eligible for this study. Participants were divided into two groups receiving hypertonic sodium and mannitol. Hemodynamic parameters were evaluated before surgery, 20 minutes, and 60 minutes after surgery in both groups, under Lithium dilution cardiac output (LiDCO) monitoring. The results showed that there was no difference between groups in terms of the average fluid intake, the duration of the operation, the amount of urinary output, and the primary hemodynamic characteristics. Significant differences were recorded in the evaluation of hemodynamic parameters. The results demonstrated a reduction in systolic, diastolic, and mean arterial blood pressure during 20 to 60 minutes after mannitol injection compared to hypertonic sodium injection. Additionally, the effectiveness of both therapies on maintaining cardiac function was similar, but the use of mannitol led to a greater decrease in arterial and peripheral vascular resistance. It can be concluded that mannitol may be more effective than hypertonic sodium during craniotomy procedures in terms of reducing blood pressure monitored with LiDCO.

Abstract Background CD44 encoded by a single gene is a cell surface transmembrane glycoprotein. Exon 2 is one of the important exons to bind CD44 protein to hyaluronan. Experimental evidences show that hyaluronan–CD44 interaction intensifies the proliferation, migration, and invasion of breast cancer cells. Therefore, the current study aimed at investigating the association between specific polymorphisms in exon 2 and its flanking region of CD44 with predisposition to breast cancer. Methods In the current study, 175 Iranian female patients with breast cancer and 175 age-matched healthy controls were recruited in biobank, Breast Cancer Research Center, Tehran, Iran. Single nucleotide polymorphisms of CD44 exon 2 and its flanking were analyzed via polymerase chain reaction and gene sequencing techniques. Association between the observed variation with breast cancer risk and clinico-pathological characteristics were studied. Subsequently, bioinformatics analysis was conducted to predict potential exonic splicing enhancer (ESE) motifs changed as the result of a mutation. Results A unique polymorphism of the gene encoding CD44 was identified at position 14 nucleotide upstream of exon 2 (A37692→G) by the sequencing method. The A > G polymorphism exhibited a significant association with higher-grades of breast cancer, although no significant relation was found between this polymorphism and breast cancer risk. Finally, computational analysis revealed that the intronic mutation generated a new consensus-binding motif for the splicing factor, SC35, within intron 1. Conclusions The current study results indicated that A > G polymorphism was associated with breast cancer development; in addition, in silico analysis with ESE finder prediction software showed that the change created a new SC35 binding site.

Background: Seroma formation is a common complication after surgery for breast cancer. It may originate from dissected lymphatic ducts in axillary area. Two important predictive factors are the surgical technique, and instruments used during surgery. This study was conducted to determine the impact of three axillary dissection techniques, namely, blunt dissection with hemostat, sharp dissection with Metzenbaum scissors, and dissection with harmonic scissors, on seroma formation. Methods: Patients with a tissue diagnosis of breast cancer who did not have metastasis, and were candidates for either breast conservation surgery (BCS) and sentinel lymph node biopsy (SLNB) with or without axillary lymph node dissection (ALND), or modified radical mastectomy (MRM) were included in a prospective study. Patients were randomly allocated to one of the above mentioned three groups. The incidence of seroma formation was compared among the groups. Results: Sixty patients (age: 50.25 ± 10.33 years) were enrolled for the study. At the end of the study, after four weeks of postoperative follow up, 19 patients developed seroma (31.6%), of whom 5 (26.3%) had dissection with harmonic scissors, 6 (31.5%) with Metzenbaum scissors, and 8 (42.1%) were dissected bluntly. There was no significant difference among groups regarding seroma formation (P = 0.583). Conclusion: Application of harmonic scissors for axillary dissection has no significant impact on seroma formation. However, MRM leads to significantly more seroma formation compared with BCS.

Background: In an attempt to reduce the risk of developing lymphedema following breast cancer surgery, some researchers suggested that by identifying and preserving the lymphatic plexus which drains ipsilateral arm we can minimize the risk of lymphedema. The procedure is known as axillary reverse mapping (ARM). In the current study, we investigated the oncological safety of this technique. Methods: A total of 60 patients who were undergoing axillary lymph node dissection were involved. The indications for axillary dissection were whether clinically node-positive axilla or positive sentinel lymph node biopsy. ARM was performed by injecting 2 ml of methylene blue subcutaneously in the upper and medial part of ipsilateral patients’ arm along the intermuscular groove. Results: ARM nodes were identified by means of methylene blue injection in 51(85%) patients (identification rate = 85%). For the subgroup of clinically positive axillary lymph nodes, identification rate was 93.1%, and the corresponding figure was 77.4% for positive SLNB group (P = 0.148). Pathological evaluation of harvested ARM nodes demonstrated metastatic involvement in 8(27.5%) and 1(3.2%) patients in clinically positive and SLNB positive groups respectively (P = 0.026). Conclusions: Based on the findings of this study it seems that ARM could be considered as a safe procedure in patients who are a candidate for ALND when SLNB is positive. In contrast, in patients with clinically positive axillary nodes, there is a considerable risk of tumoral metastasis in ARM nodes.

Background: It has been suggested that the autonomic system function and the metabolic syndrome can significantly affect patients' survival. The aim of the current study was to investigate the impact of the cardiac rehabilitation program on the autonomic system balance in patients with coronary artery disease. Methods: Patients with a previous diagnosis of coronary artery disease who were referred to the Cardiovascular Rehabilitation Center of Afshar Hospital (Yazd, Iran) between March and November 2011 were enrolled. All the patients participated in rehabilitation sessions 3 times a week for 12 weeks. Heart rate recovery (HRR) was measured as an indicator of the autonomic system balance. In order to calculate HRR, the maximum heart rate during the exercise test was recorded. At the end of the exercise test, the patients were asked to sit down without having a cooldown period and their heart rate was recorded again after 1 minute. The difference between these 2 measurements was considered as HRR. Results: A total of 108 patients, including 86 (79.6%) men and 22 (20.4%) women, completed the rehabilitation course. The mean age of the study participants was 58.25 ± 9.83 years. A statistically significant improvement was observed in HRR (p value = 0.040). Significant declines were also observed in the patients' waist circumference (p value < 0.001) and systolic and diastolic blood pressures (p value = 0.018 and 0.003, respectively). A decreasing trend was observed in the patients' body mass index, but it failed to reach statistical significance (p value = 0.063). No statistically meaningful changes were noted in fasting blood glucose (p value = 0.171), high-density lipoprotein (p value = 0.070), or triglyceride concentrations (p value = 0.149). Conclusion: The cardiac rehabilitation program may help to improve HRR and several components of the metabolic syndrome in patients with coronary heart disease.

Background: Breast cancer arising in young patients (? 40 years) is being considered as a distinct clinical entity with more aggressive tumor features and poorer survival. Our aim was to assess the impact of age on survival among a large group of Iranian women diagnosed with breast cancer. Methods: In a cross-sectional study, demographic and clinicopathological characteristics of patients with breast cancer who were treated in two referral centers in Tehran, Iran during the past 13 years were reviewed and extracted from an electronic database. Patients were divided into two groups based on the age at the time of diagnosis (?40 and >40 years). The association of age with different clinicopathological features and its impact on disease-free survival were assessed. Results: Study population comprised of 353(26.1%) patients who were 40 years old or younger and 1000(73.9%) who were older. Compared to older patients, younger participants had more commonly tumor size larger than 5 cm (P = 0.034), higher chance of lymph node metastasis (P = 0.036), and overexpression of HER-2 (P = 0.004). No significant differences were observed between the two groups regarding ER, PR, and LNR (lymph node ratio). Age was the only factor affecting patients' disease-free survival and younger patients had higher chance of local or distant metastases compared to older subjects (HR: 1.49, 95%CI: 1.02-2.17, P = 0.038). Conclusions: Based on the results of current study, it can be suggested that younger patients who are diagnosed with breast cancer tend to have larger tumor size, higher chance of lymph node metastasis and overexpression of HER-2 compared to patients older than 40 years. Age was the only significant factor that was associated with shorter disease-free survival.

Background: Embarrassment and shame of visiting a doctor for a breast disease are among psychosocial factors that potentially contribute to delay in seeking medical advice. The purpose of this study is to review the published literature to determine if embarrassment regarding breast examination, diagnosis and treatment is associated with patient delay. Methods: We searched PubMed with the following key terms: patient acceptance of health care (MeSH), breast neoplasms/psychology (MeSH), shame (MeSH), embarrassment, delayed diagnosis, to find relevant literature published before August 2015. Results: The studies that explicitly assessed the association between embarrassment and delay for seeking medical advice for breast cancer were very limited. Among these studies, only 2 were quantitative studies, 4 were based on qualitative research and 4 were reviews. Other studies assessed attitudes in population-based surveys or included patients (females and males) suffering from different types of cancer. Conclusions: Women should be educated that diseases of the breast need to be cared for as health issues in other parts of the body. They should be informed that embarrassment in this regard is not related to grace and integrity but can be potentially life-threatening. Further research is necessary to quantify the association of embarrassment or shame with delay in seeking diagnosis and treatment of breast cancer. More research can elucidate the ways that the negative impact of shame/embarrassment can be minimized in different ethnic groups.

Background: Quality of life (QOL) is becoming an important indicator of treatment efficacy in patients with breast cancer. Most previous studies have compared patients' QOL following breast conserving surgery (BCS) and mastectomy with or without reconstruction. Our aim was to assess the impact of BCS versus oncoplastic breast surgery (OBS). Methods: Selection of patients for BCS or OBS was performed according to standard criteria e.g the breast and tumor size. The QOL was assessed by employing EORTC QLQ-C3 and QLQ-BR23 questionnaires concurrently and one year after the surgery. The QOL scores one year after the surgery were compared between two groups using analysis of covariance, after adjusting for the baseline values. Results: A total of 120 patients with a mean age of 46.16±1.4 years were enrolled in the study. BCS and OBS were the main surgical treatment techniques in 57(47.5%) and 63(52.5%) patients, respectively. At the time of the last follow-up visit, there were no differences between the two groups regarding functional scales such as physical (P = 0.761), role (P = 0.356), emotional (P = 0.107), cognitive (P = 0.051), and social functioning (P = 0.659). No differences were observed between the two groups regarding nine symptom scales. Based on the results of breast cancer specific module of the questionnaire, no differences were observed in functional scales and symptoms with the exception of arm symptoms which were less common in OBS group (P = 0.023) Conclusions: Based on the results of the current study, it could be suggested that there are no significant differences in the in scores of QOL components between patients who received BCS or OBS.

Background: The purpose of this study was to assess Iranian surgeons' perceptions toward mastectomy and breast conserving therapy (BCT) and determine the contributing factors. Methods: In this cross-sectional study, a structured questionnaire was devised and hosted on survey.tums.ac.ir and a link to the questionnaire was emailed to surgeons registered in Iranian Medical Council, branch of Tehran. The results of the current study were compared to a similar study which was performed in 2004 on a comparable sample of surgeons in Tehran, Iran. Results: A total 166 surgeons filled out the study questionnaire. Only 24 surgeons declared that they have not performed BCT before. Variables that showed a significant association with performing BCT were attending a breast surgery or surgical oncology fellowship (P = 0.010) and breast surgery workshop (P = 0.042). No associations were observed between performance of BCT and age category (P = 0.951), gender (P = 0.416), duration of practice (P = 0.821), number of breast cancer patients per year (P = 0.083), and setting of practice categorized as teaching – nonteaching hospitals (P = 0.417). Comparing the results of the current study with the study performed in 2004 revealed a significant increase in the frequency of surgeons who performed BCT (85.5% vs 19.3%, respectively) (P < 0.001). Participants of the current study were more likely to mention "lack of experience" as the reason for not performing BCT compared to the previous study (P = 0.004). Conclusions: Our results delineated that there was a significant increase in the percentage of surgeons performing BCT compared to the previous study. Factors significantly associated with performing BCT were participating in a surgical oncology or breast surgery fellowship or short courses in breast surgery.

Background: The Gail model has been widely used for estimation of absolute risk of breast cancer development. The original model and most of the validation studies have been performed among western populations and controversial results have been reported regarding the applicability of this model in Asian populations. Our aim was to investigate the performance of this model in Iranian women. Methods: In a cross-sectional study, a total of 280 patients with breast cancer and 280 participants with normal screening results were enrolled as case and control groups, respectively. Risk factors used in the latest version of the Gail model were compared between the two study groups. Gail score was calculated by using Breast Cancer Risk Assessment Tool and based on the cut-off point of 1.67, patients were categorized in order to assess model performance. Results: In total, 560 patients with a mean age of 43.07±8.60 years were enrolled. Comparison of different risk factors between the two groups revealed significant associations of patients’ age (P < 0.001), age at first pregnancy (P = 0.022), previous history of breast biopsy (P < 0.001) and atypical hyperplasia (P = 0.002) with risk of breast cancer. No association was found between age at menarche (P = 0.115) or first-degree family history (P = 0.117) and increased risk. Considering the Gail score for 5-year risk of breast cancer development, the difference between the two groups failed to reach significance (P = 0.052). The sensitivity and specificity of the model were 13.9% and 94%, respectively. Conclusions: Based on the current findings, it can be suggested that employing the current version of the Gail model for breast cancer risk assessment will underestimate the risk of cancer development in Iranian women.

Background: Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) in early breast cancer patients as the first line surgical approach to axillary nodes. Further dissection is performed only when SLN is involved by tumor cells. However, in a significant proportion of patients, non-sentinel nodes are still not involved and axillary dissection has no additional therapeutic benefits. Selective axillary clearance has been considered to prevent unnecessary dissection. The purpose of this study was to define predictors of non-sentinel lymph node involvement in patients with positive SLNB. Methods: Patients with early stage breast cancer and positive SLNB who underwent ALNDin a referral hospital in Tehran, Iran between2010 and 2012 were recruited into the study. Relations between different clinico-pathological characteristics and involvement of non-sentinel nodes were investigated. Results: From 139 patients who had positive SLNB and underwent ALND, only in 71 cases (51%) positive non-sentinel lymph nodes (NSLNs) were detected. In univariate analysis, there was no association between tumor size, lymphovascular invasion, ER, PR and HER-2 expression and NSLN metastasis. In contrast, presence of more than one SLN (P = 0.016) and a sentinel node ratio (SNR) more than 0.5 showed a significant association (P< 0.001). Only the latter remained as the significant predictor of NSLN involvement in mutltivariate analysis (P < 0.001, OR = 3.706). Conclusions: Based on our results, patients with a SNR more than 0.5 were more commonly diagnosed with NSLN metastasis. Thus, it is recommended that surgeons think twice before skipping ALND in this subgroup of patients.

Background: Seroma formation is a common complication after breast cancer surgery. Several techniques such as tube drainage, fibrin sealant and suturing methods have been employed to prevent or reduce seroma formation. Capitonnage, a suturing method widely used following hydatid cyst removal, has been used after breast surgery in limited studies. Our aim was to compare the effectiveness of tube drainage, fibrin sealant and capitonnage to prevent early complications. Methods: Eligible patients with breast cancer who were candidate for breast conserving surgery were enrolled and randomized into three different groups (tube drainage, capitonnage, capitonnage plus fibrin sealant). Patients were visited on 5th,12th and 19th days after surgery and were assessed for any probable complications. Results: A total of 90 patients were enrolled. One patient developed seroma in tube drainage and capitonnage group, while no participant from capitonnage plus fibrin sealant group experienced the mentioned complication. Three patients developed skin necrosis, all of them were treated with capitonnage plus fibrin sealant protocol. Conclusions: Based on our observations, it seems that capitonnage alone or in combination with fibrin sealant do not lead to significant differences in frequency of complications after breast cancer surgery such as hematoma, seroma and surgical site infection.

Background: Since the introduction of silicone based medical devices in to clinical practice, several reports appeared in the medical literature regarding their adverse effects. However, there are few reports of immunologic reactions to these implants. Case presentation: A case of systemic reaction to a breast implant inserted for immediate breast reconstruction in a breast cancer patient is presented. The patient developed fever and skin rash two months after the surgery. Investigations disclosed no infectious origin for the fever and a dramatic response to steroid therapy was observed. Conclusion: Immunologic reaction should be considered in case of systemic signs and symptoms after silicone breast implant placement as a rare complication.

Background: Sonoelastography (SE) is introduced as a complementary technique for ultrasoungraohy (US) to evaluate breast lesions. This method is based on tissue strain in response to compression and decompression. The current study was designed to investigate the diagnostic performance of SE for differentiating between benign and malignant breast lesions Methods: A total of 35 women with 45 breast lesions who were referred to a university affiliated hospital in Tehran were enrolled. All patients were visited and examined by a same radiologist. A five-point scale was applied for categorizing lesions in SE as malignant or benign. The results of US and SE were compared with histopathological results to calculate sensitivity and specificity of each mentioned techniques. Results: Histopathological evaluations in 12 cases were in favor of malignancy, and the rest of cases were classified as benign. The sensitivity and specificity for US were 100% and 69.7%, respectively. On other hand, SE obtained a lower sensitivity (58.3%) and higher specificity (90.9%) in comparison with US. Conclusions: simultaneous evaluation of suspicious breast lesions with both US and SE can have high sensitivity and specificity and prevent the unnecessary invasive interventions.

Background: Sentinel lymph node biopsy has shown to be a good alternative procedure for axillary lymph node dissection and to lead to lower frequency of morbidity, though this technique has its own side effects. It needs especial equipment and may not be available in some medical centers, especially in developing countries. This study aimed to identify a subgroup of patients with higher probability of metastasis to sentinel lymph node that can be excluded from indications of this procedure. Methods: In this cross-sectional study, the clinical data of 195 patients with breast cancer who underwent sentinel lymph node biopsy in Tehran, Iran, between 2009 and 2011 were reviewed. Whenever tumor features showed significant association with sentinel node metastasis in univariate analyses, logistic regression was used to identify independent predictors. Results: Univariate analyses revealed that tumor size and lymphovascular invasion have significant association with sentinel lymph node metastasis (P = 0.009 and P < 0.001, respectively). Moreover, age had an significant association with positive sentinel lymph node biopsy (SLNB) (P = 0.004). Other factors, including tumor grade, estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2, were not associated with positive sentinel lymph node biopsy in univariate analysis. All factors that showed significant association in univariate analysis remained statistically significant predictors of positive SLB in multivariate analysis. Conclusions: It seems that young breast cancer patients, those who have tumors larger than 5 cm and those with lymphovascular invasion, are at an increased risk of sentinel lymph node metastasis.