Inflammatory Breast Cancer in Pregnancy and Lactation.

Inflammatory breast cancer (IBC) represents only 1% to 5% of all breast malignancies and is an extremely aggressive subtype. At time of diagnosis, up to 85% of patients will present with regional nodal metastases and up to 30 % will have metastasis to distant organs. There is limited medical literature describing treatment guidelines for IBC during gestation. The best diagnostic tools are core needle and full-thickness skin punch biopsies to assess presence of dermal lymphatic invasion. Breast Ultrasound is preferred to mammogram, but mammography could still be done with proper fetal shielding. Ultrasound and Magnetic resonance imaging are used for staging. Pregnant patients should be managed with special attention to the health of the fetus by a multidisciplinary team. Treatment based on current guidelines consist of a sequence of systemic chemotherapy followed by mastectomy with axillary dissection (modified radical mastectomy), and even if good clinical nodal response to neoadjuvant therapy is obtained, sentinel node biopsy is not recommended. Radiation therapy is to be given once the baby has been delivered. Chemotherapy is not recommended in the first trimester, and anti-estrogen hormonal therapy, as well as targeted Her2-neu therapies are contraindicated during the length of the pregnancy. There is no evidence that early termination improves the outcome. However, given the poor prognosis of IBC, patients should be fully counseled on the risks and benefits of continuing or terminating an early pregnancy.

The role of heparin in endovascular repair of blunt thoracic aortic injury.

OBJECTIVE: Early diagnosis and treatment are essential to improve survival of patients with blunt thoracic aortic injury (BTAI). Often, aortic surgical intervention may be delayed because of increased risk of bleeding with heparin, particularly in polytrauma victims. We believe that surgical delay may be remedied by proceeding without heparinization. This study reviewed the outcome of patients subjected to thoracic endovascular aortic repair (TEVAR) under full, low-dose, and no intraoperative systemic heparinization. METHODS: There were 77 cases of confirmed BTAI identified and retrospectively analyzed at a high-volume urban trauma center during a period of 15 years (March 2003-September 2017). Patients were stratified into three groups on the basis of the intraoperative use of heparin during TEVAR, as follows: full heparin (FH), low-dose heparin (LH), and no heparin (NH). Baseline characteristics including the patients' demographics, diagnostic laboratory data and imaging studies, operative reports, postoperative complications, embolic and bleeding outcomes, and mortality data were reviewed. RESULTS: Of the 77 total patients who underwent TEVAR for BTAI, 42 patients received full-dose heparinization, 18 received low-dose heparin, and 17 had no use of systemic heparin. There was no significant difference in age, sex, body mass index, or smoking history. The most common mechanism of injury was motor vehicle collision. Grade 3 (pseudoaneurysm) was the predominant type of BTAI (FH, 69.0%; LH, 61.1%; NH, 76.5%; P = .23). The mean interval between admission and repair was three times longer in the FH group than in the NH group (FH, 2.33 days; NH, 0.76 day; P = .091). The mean time in the intensive care unit was shorter in the NH group vs the FH group (15 days vs 26.21 days; P = .025). Thromboembolic and bleeding outcomes and mortality rates were comparable in all three groups; 57 patients continued follow-up for a mean time of 30.99 months. CONCLUSIONS: Our study shows no statistically significant difference in outcomes between the heparinized and nonheparinized groups. The primary benefit of the NH group is seen in time to repair. Although not statistically significant, the mean time to repair was three times longer in the FH group. Patients in the NH group also benefited from prompt intervention and treatment. Therefore, intraoperative heparinization in critically ill patients with BTAI undergoing TEVAR remains at the surgeon's discretion, although the lack of heparinization appears to be a safe and potentially faster alternative, particularly in the polytrauma patient.

Disparities in Overall Survival for Male Breast Cancer Patients in the State of Florida (1996-2007).

BACKGROUND: Little is known regarding population-based disparities in male breast cancer (MBC). We analyzed this for Florida using data from 1996 to 2007. MATERIALS AND METHODS: Data from the Florida Cancer Data System, the Agency for Health Care Administration, and the US Census were linked for MBC patients (n = 1589). Survival time was our primary end point, with adjustments for sociodemographic status, neighborhood-based poverty measures, clinical and hospital characteristics, and comorbidity measures based on linkage with in- and outpatient treatment records. Survival time was modeled using univariate and multivariate Cox regression models. RESULTS: Five-year overall survival was 65.7%. Overall mean survival time in years was 7.7, but shorter in black (5.9) than white (7.8) individuals, in non-Hispanic (7.7) than Hispanic (8.5) individuals, and in the lowest socioeconomic status (SES) group (5.9) than in the highest (8.2) SES group. Patients with low SES also presented at a more advanced stage with only 75/175 [42.9%] of low SES patients who presented with localized disease compared with 311/621 [50.1%] for middle-high SES and 162/334 [48.5%] for the highest SES. Univariate hazard regressions found only the highest (hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.46-0.85) and middle-high (HR, 0.71; 95% CI, 0.54-0.94) SES were at improved survival compared with lowest SES but this advantage did not remain significant in the fully adjusted model. Marital status, age, smoking status, stage, treatments, and comorbidities were also predictors of survival. CONCLUSION: Survival disparities among SES groups were most apparent in our study. Improved access to screening and health care utilization might attenuate these differences. Understanding other survival disparities can aid in public health and clinical care choices.

The desire to utilize postmastectomy breast reconstruction in Saudi Arabian women. Predictors and barriers.

OBJECTIVES: To study factors that influence the desire to utilize breast reconstruction after mastectomy, and to investigate the barriers to reconstruction among women in Saudi Arabia. METHODS: We conducted a cross-sectional study at 2 surgical centers in Jeddah, Saudi Arabia. A self-administered questionnaire was distributed to all breast cancer patients attending the surgery clinics for follow-up after mastectomy between January and March 2013. Ninety-one patients met the study inclusion criteria. The first part of the questionnaire covered the demographic and socioeconomic information regarding factors that might influence the desire to utilize breast reconstruction including possible barriers. Multivariate logistic regression was used to determine the significant predictors of the desire to undergo reconstruction. RESULTS: Overall, 16.5% of patients underwent breast reconstruction after mastectomy. Young age and high educational attainment were significantly associated with an increased desire to undergo reconstruction. The main barriers to reconstruction were the lack of adequate information on the procedure (63%), concerns on the complications of the procedure (68%), and concerns on the reconstruction interfering with the detection of recurrence (54%). CONCLUSION: Age and educational level were significant predictors of the desire to utilize breast reconstruction. Furthermore, modifiable barriers included the lack of knowledge and misconceptions on the procedure. Addressing these issues may increase the rate of breast reconstruction in Saudi Arabia.