Accreditation Council for Graduate Medical Education Milestone Training Ratings and Surgeons' Early Outcomes.

Importance: National data on the development of competence during training have been reported using the Accreditation Council for Graduate Medical Education (ACGME) Milestones system. It is now possible to consider longitudinal analyses that link Milestone ratings during training to patient outcomes data of recent graduates. Objective: To evaluate the association of in-training ACGME Milestone ratings in a surgical specialty with subsequent complication rates following a commonly performed operation, endovascular aortic aneurysm repair (EVAR). Design, Setting, and Participants: This study of patient outcomes followed EVAR in the Vascular Quality Initiative (VQI) registry (4213 admissions from 208 hospitals treated by 327 surgeons). All surgeons included in this study graduated from ACGME-accredited training programs from 2015 through 2019 and had Milestone ratings 6 months prior to graduation. Data were analyzed from December 1, 2021, through September 15, 2023. Because Milestone ratings can vary with program, they were corrected for program effect using a deviation score from the program mean. Exposure: Milestone ratings assigned to individual trainees 6 months prior to graduation, based on judgments of surgical competence. Main Outcomes and Measures: Surgical complications following EVAR for patients treated by recent graduates during the index hospitalization, obtained using the nationwide Society for Vascular Surgery Patient Safety Organization's VQI registry, which includes 929 participating centers in 49 US states. Results: The study included outcomes for 4213 patients (mean [SD] age, 73.25 [8.74] years; 3379 male participants [80.2%]). Postoperative complications included 9.5% major (400 of 4213 cases) and 30.2% minor (1274 of 4213 cases) complications. After adjusting for patient risk factors and site of training, a significant association was identified between individual Milestone ratings of surgical trainees and major complications in early surgical practice in programs with lower mean Milestone ratings (odds ratio, 0.50; 95% CI; 0.27-0.95). Conclusions and Relevance: In this study, Milestone assessments of surgical trainees were associated with subsequent clinical outcomes in their early career. Although these findings represent one surgical specialty, they suggest Milestone ratings can be used in any specialty to identify trainees at risk for future adverse patient outcomes when applying the same theory and methodology. Milestones data should inform data-driven educational interventions and trainee remediation to optimize future patient outcomes.

Role of the San1 ubiquitin ligase in the heat stress-induced degradation of nonnative Nup1 in the nuclear pore complex.

The nuclear pore complex (NPC) mediates the selective exchange of macromolecules between the nucleus and the cytoplasm. Neurodegenerative diseases such as amyotrophic lateral sclerosis are characterized by mislocalization of nucleoporins (Nups), transport receptors, and Ras-related nuclear proteins into nucleoplasmic or cytosolic aggregates, underscoring the importance of precise assembly of the NPC. The assembly state of large protein complexes is strictly monitored by the protein quality control system. The ubiquitin-proteasome system may eliminate aberrant, misfolded, and/or orphan components; however, the involvement of the ubiquitin-proteasome system in the degradation of nonnative Nups in the NPC remains unclear. Here, we show that in Saccharomyces cerevisiae, although Nup1 (the FG-Nup component of the central core of the NPC) was stable, C-terminally green fluorescent protein-tagged Nup1, which had been incorporated into the NPC, was degraded by the proteasome especially under heat stress conditions. The degradation was dependent on the San1 ubiquitin ligase and Cdc48/p97, as well as its cofactor Doa1. We also demonstrate that San1 weakly but certainly contributes to the degradation of nontagged endogenous Nup1 in cells defective in NPC biogenesis by the deletion of NUP120. In addition, the overexpression of SAN1 exacerbated the growth defect phenotype of nup120Δ cells, which may be caused by excess degradation of defective Nups due to the deletion of NUP120. These biochemical and genetic data suggest that San1 is involved in the degradation of nonnative Nups generated by genetic mutation or when NPC biogenesis is impaired.

Supersaturation dependent nucleation of methane + propane mixed-gas hydrate.

Before hydrates can be widely used in industry, we should better understand the problematic issues of hydrate nucleation, particularly its stochastic nature. Here, we report on measurements of the nucleation probability of mixed-gas hydrates in which the guest molecules are a mixture of methane and propane. For the pure cases, at a supersaturation near 1.0, we had previously measured an induction time for the methane hydrate of about 1 h, whereas for the propane hydrate, it was over one day. Using the same experimental setup, we examine here the nucleation probability for a mixture of 90% methane and 10% propane as the guest gas for a range of supersaturations. For the experiments, the temperature was 274 ± 0.5 K and the stirring rate was about 300 rpm. The experiments were repeated at least ten times under the same condition, exchanging the sample water every time. We define the nucleation probability at a given time as the fraction of trials that nucleated by that time and then determine the nucleation probability distribution. The resulting nucleation frequency is found to have a power-law relation to supersaturation. Then, we examine how the nucleation frequency is affected by the existence of ultrafine bubbles in the initial water. We find that the ultrafine bubbles increase the nucleation frequency but much less than that of typical changes in supersaturation.

Detailed tracking of antigen and antibody levels during coronavirus disease 2019 treatment in an immunosuppressed patient with anti-neutrophil cytoplasmic autoantibody-associated vasculitis.

A 67-year-old woman with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis was not vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was on multiple immunosuppressive drugs. She was hospitalized because of interstitial shadowing in the lungs and diagnosed with persistent coronavirus disease 2019 (COVID-19). Despite treatment with a recombinant monoclonal antibody and antivirals, her symptoms persisted and she lacked a specific antibody response. She tested negative for SARS-CoV-2 antigen after the second antiviral treatment, and a subsequent chest radiograph showed improvement. However, the antibody levels did not change. This case highlights the importance of careful monitoring of the SARS-CoV-2 antigen and antibody levels during COVID-19 treatment in patients with immunosuppression.

Systems-Based Practice 20 Years On: Navigating the System for Better Care.

ABSTRACT: Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

The Association of ACGME Milestones With Performance on American Board of Surgery Assessments: A National Investigation of Surgical Trainees.

OBJECTIVE: To determine the relationship between, and predictive utility of, milestone ratings and subsequent American Board of Surgery (ABS) vascular surgery in-training examination (VSITE), vascular qualifying examination (VQE), and vascular certifying examination (VCE) performance in a national cohort of vascular surgery trainees. BACKGROUND: Specialty board certification is an important indicator of physician competence. However, predicting future board certification examination performance during training continues to be challenging. METHODS: This is a national longitudinal cohort study examining relational and predictive associations between Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings and performance on VSITE, VQE, and VCE for all vascular surgery trainees from 2015 to 2021. Predictive associations between milestone ratings and VSITE were conducted using cross-classified random-effects regression. Cross-classified random-effects logistic regression was used to identify predictive associations between milestone ratings and VQE and VCE. RESULTS: Milestone ratings were obtained for all residents and fellows(n=1,118) from 164 programs during the study period (from July 2015 to June 2021), including 145,959 total trainee assessments. Medical knowledge (MK) and patient care (PC) milestone ratings were strongly predictive of VSITE performance across all postgraduate years (PGYs) of training, with MK ratings demonstrating a slightly stronger predictive association overall (MK coefficient 17.26 to 35.76, ß = 0.15 to 0.23). All core competency ratings were predictive of VSITE performance in PGYs 4 and 5. PGY 5 MK was highly predictive of VQE performance [OR 4.73, (95% CI, 3.87-5.78), P <0.001]. PC subcompetencies were also highly predictive of VQE performance in the final year of training [OR 4.14, (95% CI, 3.17-5.41), P <0.001]. All other competencies were also significantly predictive of first-attempt VQE pass with ORs of 1.53 and higher. PGY 4 ICS ratings [OR 4.0, (95% CI, 3.06-5.21), P <0.001] emerged as the strongest predictor of VCE first-attempt pass. Again, all subcompetency ratings remained significant predictors of first-attempt pass on CE with ORs of 1.48 and higher. CONCLUSIONS: ACGME Milestone ratings are highly predictive of future VSITE performance, and first-attempt pass achievement on VQE and VCE in a national cohort of surgical trainees.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training.

BACKGROUND: Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM). OBJECTIVE: To compare patterns of industry payments among IM graduates. DESIGN: Retrospective, observational cohort study. SUBJECTS: IM graduates from residency or fellowship programs between January 2015 and December 2019. MAIN MEASURES: We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion. KEY RESULTS: There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001). CONCLUSION: Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

Industry Payments Received by Residents During Training.

Importance: Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest. Objective: To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies. Design, Setting, and Participants: Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023. Exposures: Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted. Main outcomes and measures: Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database. Results: In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01). Conclusions and relevance: In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

Gender Bias and Ophthalmology Accreditation Council for Graduate Medical Education Milestones Evaluations.

Importance: Women remain underrepresented in ophthalmology and gender-based disparities exist in salary, grant receipt, publication rates, and surgical volume throughout training and in practice. Although studies in emergency medicine and general surgery showed mixed findings regarding gender differences in Accreditation Council for Graduate Medical Education (ACGME) Milestones ratings, limited data exist examining such differences within ophthalmology. Objective: To examine gender differences in ophthalmology ACGME Milestones. Design, Setting, and Participants: This was a retrospective cross-sectional study of postgraduate year 4 (PGY-4) residents from 120 ophthalmology programs graduating in 2019. Main Outcomes and Measures: PGY-4 midyear and year-end medical knowledge (MK) and patient care (PC) ratings and Written Qualifying Examination (WQE) scaled scores for residents graduating in 2019 were included. Differential prediction techniques using Generalized Estimating Equations models were performed to identify differences by gender. Results: Of 452 residents (median [IQR] age, 30.0 [29.0-32.0] years), 275 (61%) identified as men and 177 (39%) as women. There were no differences in PC domain average between women and men for both midyear (-0.07; 95% CI, -0.11 to 0; P =.06) and year-end (-0.04; 95% CI, -0.07 to 0.03; P =.51) assessment periods. For the MK domain average in the midyear assessment period, women (mean [SD], 3.76 [0.50]) were rated lower than men (mean [SD], 3.88 [0.47]; P = .006) with a difference in mean of -0.12 (95% CI, -0.18 to -0.03). For the year-end assessment, however, the average MK ratings were not different for women (mean [SD], 4.10 [0.47]) compared with men (mean [SD], 4.18 [0.47]; P = .20) with a difference in mean of -0.08 (95% CI, -0.13 to 0.03). Conclusions and Relevance: Results suggest that ACGME ophthalmology Milestones in 2 general competencies did not demonstrate major gender bias on a national level at the time of graduation. There were, however, differences in MK ratings at the midyear mark, and as low ratings on evaluations and examinations may adversely affect career opportunities for trainees, it is important to continue further work examining other competencies or performance measures for potential biases.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice.

Importance: Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. Objective: To investigate the association between resident Milestone ratings and posttraining patient complaints. Design, Setting, and Participants: This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Exposures: Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. Main Outcomes and Measures: PARS year 1 index scores, based on recency and severity of complaints. Results: The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

Giant Coronary Aneurysm with Coronary-Pulmonary Artery Fistula in a Jehovah's Witness.

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Association of Surgical Resident Competency Ratings With Patient Outcomes.

PURPOSE: Accurate assessment of clinical performance is essential to ensure graduating residents are competent for unsupervised practice. The Accreditation Council for Graduate Medical Education milestones framework is the most widely used competency-based framework in the United States. However, the relationship between residents' milestones competency ratings and their subsequent early career clinical outcomes has not been established. It is important to examine the association between milestones competency ratings of U.S. general surgical residents and those surgeons' patient outcomes in early career practice. METHOD: A retrospective, cross-sectional study was conducted using a sample of national Medicare claims for 23 common, high-risk inpatient general surgical procedures performed between July 1, 2015, and November 30, 2018 (n = 12,400 cases) by nonfellowship-trained U.S. general surgeons. Milestone ratings collected during those surgeons' last year of residency (n = 701 residents) were compared with their risk-adjusted rates of mortality, any complication, or severe complication within 30 days of index operation during their first 2 years of practice. RESULTS: There were no associations between mean milestone competency ratings of graduating general surgery residents and their subsequent early career patient outcomes, including any complication (23% proficient vs 22% not yet proficient; relative risk [RR], 0.97, [95% CI, 0.88-1.08]); severe complication (9% vs 9%, respectively; RR, 1.01, [95% CI, 0.86-1.19]); and mortality (5% vs 5%; RR, 1.07, [95% CI, 0.88-1.30]). Secondary analyses yielded no associations between patient outcomes and milestone ratings specific to technical performance, or between patient outcomes and composites of operative performance, professionalism, or leadership milestones ratings ( P ranged .32-.97). CONCLUSIONS: Milestone ratings of graduating general surgery residents were not associated with the patient outcomes of those surgeons when they performed common, higher-risk procedures in a Medicare population. Efforts to improve how milestones ratings are generated might strengthen their association with early career outcomes.

The Use of Learning Analytics to Enable Detection of Underperforming Trainees: An Analysis of National Vascular Surgery Trainee ACGME Milestones Assessment Data.

OBJECTIVE: This study aims to investigate at-risk scores of semiannual Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings for vascular surgical trainees' final achievement of competency targets. SUMMARY BACKGROUND DATA: ACGME Milestones assessments have been collected since 2015 for Vascular Surgery. It is unclear whether milestone ratings throughout training predict achievement of recommended performance targets upon graduation. METHODS: National ACGME Milestones data were utilized for analyses. All trainees completing 2-year vascular surgery fellowships in June 2018 and 5-year integrated vascular surgery residencies in June 2019 were included. A generalized estimating equations model was used to obtain at-risk scores for each of the 31 subcompetencies by semiannual review periods, to estimate the probability of trainees achieving the recommended graduation target based on their previous ratings. RESULTS: A total of 122 vascular surgery fellows (VSFs) (95.3%) and 52 integrated vascular surgery residents (IVSRs) (100%) were included. VSFs and IVSRs did not achieve level 4.0 competency targets at a rate of 1.6% to 25.4% across subcompetencies, which was not significantly different between the 2 groups for any of the subcompetencies ( P = 0.161-0.999). Trainees were found to be at greater risk of not achieving competency targets when lower milestone ratings were assigned, and at later time-points in training. At a milestone rating of 2.5, with 1 year remaining before graduation, the at-risk score for not achieving the target level 4.0 milestone ranged from 2.9% to 77.9% for VSFs and 33.3% to 75.0% for IVSRs. CONCLUSION: The ACGME Milestones provide early diagnostic and predictive information for vascular surgery trainees' achievement of competence at completion of training.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery.

OBJECTIVE: Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories. DESIGN: This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings. SETTING: All ACGME-accredited vascular surgery training programs within the United States. PARTICIPANTS: All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses. RESULTS: The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%). CONCLUSIONS: As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

[A Case of pagetoid Carcinoma of the Breast with Pathological Complete Response by Neoadjuvant Chemotherapy].

We herein report a 63-year-old woman who presented with about 20 mm-sized mass in the right breast and the right nipple with erosion. Preoperative examinations revealed a diagnosis of HER2-type pagetoid carcinoma with axillary lymph node metastasis. After neoadjuvant chemotherapy(pertuzumab, trastuzumab, and docetaxel, followed by adriamycin and cyclophosphamide), a pathological complete response was achieved. The patient was treated with anti-HER2 therapy without recurrence.