A rare occurrence of breast, thyroid, and stomach tumors in a single patient: A case report.

INTRODUCTION AND IMPORTANCE: There are only a few case reports to date that have described patients with three or more multiple primary tumors. However, they have been reported more in the last decade, so a precise screening in patients with or without risk factors could be helpful in early diagnosis and treatment. This work has been reported in line with the SCARE criteria. CASE PRESENTATION: Here, we presented a 44-year-old female patient without any history of smoking, alcohol consumption, or cancer in her family. She had three metachronous primary tumors; breast, thyroid, and gastric cancer, which had metastasized to both her ovaries and colon. She died in January 2023 due to complex pneumonia and septic shock. To our knowledge, this article is the second case in which breast, thyroid, and stomach cancer are reported together. CLINICAL DISCUSSION: When it comes to Multiple primary malignancies (MPMs), not only screening in patients with risk factors should be considered, but patients without any other risk factors except current or past history of tumors should be screened precisely for early diagnosis and treatment. In this study, we discuss prevalence and causes of MPMs, prevalence of breast, thyroid, and stomach cancer, and also their possible relations with each other that may affect their occurrence. CONCLUSION: Reporting other cases with MPMs by physicians could lead to establish an evidence based approach to these patients.

Strategies to Promote Empowerment Status of Breast Cancer Women.

Background: As the second leading cause of death in women in the world, breast cancer has several physical and psychological effects. Nowadays, nonclinical approaches such as patient empowerment have been considered by physicians along with clinical care. Given the increasing number of breast cancer women worldwide, promoting the empowerment of these patients is one of the key factors affecting their survival and quality of life. Therefore, because of no comprehensive research on the empowerment needs and related improvement strategies, this study is aimed at determining the empowerment status of breast cancer patients referred to the Shahid Motahari Breast Cancer Clinic in Iran, Shiraz, and at providing strategies to improve their empowerment in 2021. Methods: This applied study was conducted in two phases. In the quantitative phase, 310 Cancer-Related Patient Empowerment Scale questionnaires (Persian format) were distributed among the studied patients selected through the random sampling method in the clinic, and the items with "unacceptable status" became the basis for determining the empowerment strategies through the scoping review and semistructured interviews with 22 medical staff and patients through the thematic analysis. The collected data were analyzed using the SPSS 20.0 and MAXQDA10 software. Results: The mean score of the participants' empowerment strategies was 3.58. The results showed that trust in the physician, family support, and spiritual beliefs could affect the empowerment of the studied patients. Moreover, the participants needed empowerment strategies in 11 scale items with unacceptable status, for which 46 strategies were determined in the scoping review and interview phase. Conclusion: The results of this study provided useful strategies for empowering breast cancer patients, the most important of which were classified into five categories of financial support, informational support, interaction with the physician, occupational support, and complementary therapies, the use of which by the stakeholders could help to improve the patients' quality of life while improving their empowerment.

Outcomes and complications of intraoperative radiotherapy versus external beam radiotherapy for early breast cancer.

BACKGROUND: Intraoperative radiotherapy (IORT) is an alternative for external beam radiotherapy (EBRT) for early stage breast cancer (BC). Herein, we compared outcomes, postoperative and post-radiation complications of IORT and EBRT. METHODS: We conducted a cohort study to compare complications of IORT and EBRT in patients. A checklist of the complications of IORT and EBRT, was used to assess and post-radiation complications and outcomes. RESULTS: Overall, 264 women (121 in IORT and 143 in EBRT group) with a mean (SD) age of 55 ± 8.6 years analyzed in this study. The IORT group (quadrantectomy + SLNB + IORT) had more severe post-operative pain compared to the EBRT group (quadrantectomy + SLNB) (OR = 1.929, 95% CI: 1.116-3.332). Other postoperative complications, including edema, erythema, seroma, hematoma, and wound complications were not significantly different between the IORT and EBRT groups. EBRT was associated with higher rates post-radiation complications, including erythema (95.8% vs. 21.5%), skin dryness (30.8% vs. 12.4%), pruritus (26.6% vs. 17.4%), hyperpigmentation (48.3% vs. 9.9%), and telangiectasia (1.4% vs. 0.8%). Multivariate analysis showed that erythema, skin dryness and pruritus, and hyperpigmentation were more severe in the EBRT group, while breast induration was higher in the IORT group (OR = 4.109, 95% CI: 2.242-7.531). Excellent, good, and fair cosmetic outcome was seen in 11.2%, 72%, and 16.8% of the patients in the EBRT group and 29.8%, 63.6%, and 6.6% in the IORT group, respectively, suggesting that the cosmetic outcome was significantly better in the IORT group (P < .001). There wasn't statistically significant difference in recurrence-free survival and overall survival rates between two groups of patients who received either IORT or EBRT (P = .953, P = .56). CONCLUSION: IORT is considered to have lower post-radiation complications and better cosmetic outcomes in breast cancer patients. Therefore, IORT might be used as the treatment of choice in eligible patients.

Margin status impact on recurrence of phyllodes tumors in high-risk groups: a retrospective observational study.

BACKGROUND: Phyllodes tumor (PT) is an fibroepithelial tumor with potential for local recurrence. The optimal margin for surgical resection of PT is still debated, particularly in cases of positive margins. This study aimed to identify the risk factors for phyllodes tumor recurrence and the effect of a free margin on tumor recurrence by considering these risk factors. MATERIALS AND METHODS: This is a retrospective observational study of patients diagnosed with PT who had undergone surgical management. The data were collected from medical records from 2001 to 2020 in the breast clinic of Shahid Motahhari Clinic of Shiraz. Patients were followed up for at least 3 years after the operation to be checked for local recurrence or distant metastasis at regular intervals. RESULTS: This retrospective study included 319 patients with PT who underwent surgical management. Of these patients, 83.9% (n = 267), 7.6% (n = 24), and 8.5% (n = 27) were classified as benign, borderline, and malignant, respectively. 8.8% of all patients and 7.6% of non-malignant cases experienced local recurrence, and risk factors for recurrence included oral contraceptive use, smoking, size > 4 cm, stromal overgrowth, and stromal cell atypia. A negative surgical margin decreased the prevalence of recurrence in tumors > 4 cm and with stromal overgrowth significantly. CONCLUSION: The study found that a negative margin in all patients did not reduce the recurrence rate in benign and borderline phyllodes tumors, suggesting close follow up as a reasonable alternative. However, a negative margin may be effective in reducing recurrence in certain high-risk groups.

Factors affecting the economic burden of breast cancer in southern Iran.

BACKGROUND: Breast cancer (BC) is the most common cancer in the world, and is associated with significant economic costs for patients and communities. Therefore, the information on the costs of the disease and the identification of its underlying factors will provide insights into designing effective interventions and reducing the costs. Thus, the present study aimed to identify the factors affecting the economic burden of breast cancer from all medical centers providing diagnostic and treatment services in southern Iran. METHODS: A list of factors affecting the economic burden of breast cancer was obtained based on the effective factors searched in the databases, including PubMed, ProQuest, Scopus, ISI Web of Science, SID, and Magiran, and the opinions of BC cancer specialists. Then, the data on 460 breast cancer patients was collected from March 2020 to March 2022. The relationship between the factors affecting Breast Cancer costs was analyzed using SPSS 13.0 software by the use of multiple regression analysis. RESULTS: The results of the multiple regression analysis showed that stages (P-value < 0.001), being an extreme user (p = 0.025), type of treatment center (P-value < 0.001), income (P-value < 0.001), chemotherapy side effects (P-value < 0.001), and distance to the nearest health center (P-value < 0.001) were important factors affecting the costs of breast cancer patients. CONCLUSIONS: According to the results, encouraging people to undergo annual screenings, increasing insurance coverage, assuring the patients about the desirability and adequacy of the provided medical services, deploying specialists in chemotherapy centers (especially nutritionists) to recommend special diets, and establishing cancer diagnostic and treatment centers in high-population cities could help reduce the costs of breast cancer patients.

Breast Cancer Survivors and COVID-19: Prevalence and Risk of Severe Disease in a Screening Study.

Background: Determining the risk of severe course coronavirus disease 2019 (COVID-19) and its related factors in survivors of common cancers such as breast cancer is important. This study has been designed to evaluate the prevalence of COVID-19 infection in breast cancer survivors and also estimate the risk of severe disease in this population. Methods: Out of 6134 patients in the Shiraz Breast Cancer Registry (SBCR), A total of 292 patients who elapsed less than a year from their breast cancer diagnosis were excluded. We called 5842 patients. Finally, 4135 breast cancer survivors who agreed to cooperate were screened for COVID-19 symptoms by a symptom-based questionnaire in November 2020. COVID-19 in symptomatic participants was confirmed by a polymerase chain reaction (PCR) test. The clinical and paraclinical data of the COVID-19 course were collected for patients with a positive PCR test. Results: A total of 247 (5.9%) participants had at least reported one of the COVID-19 symptoms. Also, 17% of symptomatic participants had a positive PCR test; 83.7% had mild disease, 9.5% moderate, and 16.7% had severe conditions. Chronic cardiovascular disease, hypertension, and diabetes were related to an increased risk of severe illness ( P = 0.018, P = 0.018, P = 0.002). Conclusion: This study suggests that breast cancer intermediate and longtime survivors without other underlying diseases are considered at low risk for developing severe/critical COVID-19.

Benign or premalignant? Idiopathic granulomatous mastitis later diagnosed as ductal carcinoma breast cancer: Case report and review of literature.

Idiopathic granulomatous mastitis (IGM) is a rare benign infectious disease of the breast, commonly presenting with a unilateral breast mass. Since GM's clinical presentation and imaging can be very similar to breast cancer, diagnosing GM can be challenging. So far, various reports have demonstrated the probable correlation and co-occurrence of granulomatous mastitis and breast cancer. This report presents a 38-year-old female with invasive ductal carcinoma, previously diagnosed as IGM.

Pseudoangiomatous stromal hyperplasia of the breast: A case report.

Pseudoangiomatous stromal hyperplasia (PASH) is a rare benign breast entity scarcely reported in the medical literature. Its pathogenesis, etiology, and optimal treatment are still unknown. PASH tumors have a broad spectrum of clinical presentations and might be mistaken for malignancies. The authors present six patients diagnosed with PASH.

Cost-Effectiveness Analysis of Intraoperative Frozen Section in Women with Breast Cancer: Evidence from South of Iran.

Background: Breast cancer is one of the most prevalent malignancies in women worldwide, and the rate of breast cancer is increasing among Iranian women. The purpose of this study is to determine the cost-effectiveness of intraoperative frozen section analysis in women with breast cancer. Methods: This study was a cost-effectiveness analysis, which was implemented as a cross-sectional study from a societal perspective. In this case, total direct and indirect costs were calculated, and the study outcome was involved in preventing reoperation. A data collection form has been used to collect the cost and effectiveness data. The sample size was comprised of all the patients referred to the hospitals of Shiraz University of Medical Sciences for breast cancer surgery in 2019. The patients were studied in two different groups, including individuals who received frozen counseling during surgery, and individuals who did not receive it. A one-way sensitivity analysis was performed for this case. Moreover, the Tree Age and Microsoft Excel Software were employed for analyzing processes. Results: The results demonstrated that the mean costs of frozen and non-frozen patients were 4168$ and 3843$ purchasing power parity (PPP), respectively. In addition, the effectivenesses were 0.996 for the former and 0.8 for the latter. Furthermore, the incremental cost-effectiveness ratio (ICER) was 1658.2 PPP$. This issue revealed that the frozen section procedure during surgery was more cost-effective than the other case. Because, the cost-effectiveness of this option was below the threshold. Besides, the one-way sensitivity analysis confirmed the robustness of the study results. Conclusion: The results showed that performing frozen sections during surgery in women with breast cancer was more cost-effective than ignoring them. Indeed, the frozen section can prevent the costs of subsequent reoperations.

Intraoperative radiation therapy for early stage breast cancer.

BACKGROUND AND OBJECTIVE: We report our experiences with Intraoperative radiation therapy (IORT) among breast cancer (BC) patients in our region. METHODS: All patients who received radical IORT from April 2014 on to March 2020 were included in the study. Patient selection criteria included: Age equal or older than 45 years old; All cases of invasive carcinomas (in cases of lobular carcinomas only with MRI and confirmation); Patients who were 45-50 years old with a tumor size of 0-2 cm, 50-55 years old with a tumor size of < 2.5 cm, and those who were ≥ 55 years old with a tumor size of < 3 cm; Invasive tumors only with a negative margin; Negative nodal status (exception in patients with micrometastasis); A positive estrogen receptor status. Primary endpoints included death and recurrence which were assessed using the Kaplan-Meier method. RESULTS: Overall, 252 patients entered the study. Mean (SD) age of patients was 56.43 ± 7.79 years. In total, 32.9% of patients had a family history of BC. Mean (SD) tumor size was 1.56 ± 0.55 cm. Mean (IQR) follow-up of patients was 36.3 ± 18.7 months. Overall, 8 patients (3.1%) experienced recurrence in follow-up visits (disease-free-survival of 96.1%), among which four (1.5%) were local recurrence, two (0.8%) were regional recurrence and two patients (0.8%) had metastasis. Median (IQR) time to recurrence was 46 (22, 53.7) months among the eight patient who had recurrence. Overall, one patient died due to metastasis in our series. Eleven patients (4.3%) with DCIS in our study received IORT. All these patients had free margins in histopathology examination and none experienced recurrence. CONCLUSION: Inhere we reported our experience with the use of IORT in a region where facilities for IORT are limited using our modified criteria for patient selection.

Determination of Oncologic Outcomes, Satisfaction, and Psychosocial Well-being in Patients with Breast Cancer after Oncoplastic and Conventional Breast Conserving Surgery.

Background: Breast cancer is the most common cancer in women and surgery is necessary for its treatment. We aimed to determine the oncologic outcomes, satisfaction with breasts, and psychosocial well-being in the patients with breast cancer, after oncoplastic and conventional breast conserving surgery (BCS). Method: The patients with breast cancer from Shahid Motahari Clinic affiliated to Shiraz University of Medical Sciences, Shiraz, Iran from December 2020 to December 2021 were allocated to two groups, one who had undergone BCS alone and the patients who had undergone oncoplastic BCS. For all the patients, demographic data, data about surgery, oncologic outcomes, wound complications, and BREAST-Q© questionnaire score were collected and compared between two groups. Result: The mean age of the patients in the oncoplastic BCS and BCS group was 48.13±9.73 (median=48), and 50.01±8.47 (median=50) years, respectively. The mean score of psychosocial well-being was higher in the oncoplastic BCS group in comparison with BCS alone. (P-value< 0.0001). Also, the mean score of satisfaction with breast was higher among the oncoplastic BCS group in comparison with the BCS group (P-value< 0.0001). Conclusion: Replacing traditional BCS with oncoplastic BCS does not adversely affect the oncologic results of surgery but improves the consequent psychosocial well-being and satisfaction in the patients.

How accurate is frozen section pathology compared to permanent pathology in detecting involved margins and lymph nodes in breast cancer?

BACKGROUND: Frozen section (FS) pathology has multiple limitations, and different institutions report variable experiences with the use of FS for diagnosis of tumor involvement. We aimed to compare the FS accuracy with that of permanent pathology (gold standard) regarding marginal involvement and lymph node status using data from the largest breast cancer registry in Iran. METHODS: In this retrospective study, women who had both FS and permanent pathology reports were included. The two pathology reports were cross compared with regard to the involvement of tumor margins and sentinel lymph nodes. RESULTS: Overall, 2786 patients entered the study. Mean age of patients was 48.96±11.44 years. A total of 1742 margins were analyzed. Accordingly, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FS pathology for detection of involvement of involved margins were 78.49%, 97.63%, 65.1%, and 98.7%, respectively. The accuracy and area under the curve (AUC) for FS pathology were 96.61% and 0.73 (95% CI: 0.64-0.831), respectively. A total of 1702 sentinel lymph node biopsies were assessed. Sensitivity, specificity, PPV, and NPV, of FS pathology for detection of lymph node involvement, were 87.1%, 98%, 95.5%, and 93.3%, respectively. Accuracy and AUC of FS for diagnosis of involved lymph nodes were 94.1% and 0.926 (95% CI: 0.909-0.942), respectively. CONCLUSION: Frozen pathology is a suitable method for identifying involved sentinel lymph nodes in patients with breast cancer, but this method has a less than optimum efficacy for detecting and confirming marginal involvement.

Occurrence of residual disease in specimens of re-excision surgery in patients with positive margins of primary quadrantectomy.

Performing a re-intervention following a positive margin after primary lumpectomy in patients with breast cancer entails several disadvantages such as additional costs and postponing the follow-up treatments. In the present study, we sought to measure the incidence rate of residual disease in specimens taken from breast cancer patients who had positive margins after quadrantectomy and also compare the clinical and pathological factors between patients with and without a residual disease after the secondary surgery. All of the medical records of patients undergoing quadrantectomy from December 1994 to December 2019 were collected from Shiraz Breast Cancer Registry (SBCR). Patients were divided into two subgroups of patients with and without residual disease from the secondary surgery and also with and without positive margin from the first operation. Two groups were compared in terms of all clinicopathological factors. The records of 4843 patients undergoing quadrantectomy were reviewed, of which 132 (2.3%) had involved margins. Of these, 112 patients underwent a secondary surgery and 28 had residual disease (25%). No clinicopathological factor was correlated with presence of residual cancer. Also, bigger tumor size (p < 0.001) and the presence of in situ component (p < 0.001) were associated with positive margin and hence the need for a re-excision surgery. These results revealed that the significant rate of residual disease in the specimens of the secondary surgery indicates that a re-operation (either re-excision or simple mastectomy) cannot be omitted after obtaining a positive margin from the primary quadrantectomy.

Determinants of Prognosis in Triple-Negative Breast Cancer: Report from a Large Breast Cancer Registry.

BACKGROUND: The outcome of patients with triple-negative breast cancer (TNBC) is highly dependent on demographic factors and ethnicity. We aimed to evaluate the clinicopathological determinants of prognosis among women with TNBC using data from one of the largest breast cancer (BC) registries. METHODS: A total of 6145 patients with BC from our referral center were evaluated from 1995 to 2018, among whom 523 had TNBC. The baseline, menstrual and reproductive, treatment and pathology related characteristics were evaluated. RESULTS: Among TNBC patients, the rate of stage 3 and 4 BC (29.9% vs. 14.4% and 7.8% vs. 0% for stage 3 and 4, respectively; P<0.001), invasive ductal carcinoma (90.7% vs. 75.6%; P=0.004), nodal involvement (46.7% vs. 33.4%; P=0.026), mastectomy (57.3% vs. 37.8%; P=0.001) and axillary node dissection (76.7% vs. 59.8%; P=0.019) was significantly higher in the group that developed recurrence. Disease-free-survival was 80.6% (157.76 ± 9.48 months) and overall-survival was 90.1% (182.73 ± 3.28 months). For death, stage 3 BC (compared to stages 0 and 1 as base) showed a higher risk of earlier death (adjusted HR: 4.191, 95% CI=1.392-12.621; P=0.011). For recurrence, stage 3 BC (adjusted HR: 1.044, 95% CI=1.209-6.673; P=0.017) (compared to stages 0 and 1 as base) showed significantly higher risk for developing earlier recurrence. Moreover, those who had invasive ductal carcinoma (compared to other types of BCs) had a higher risk for developing earlier recurrence (adjusted HR: 3.307, 95% CI=1.191-0.724; P=0.012). CONCLUSION: BC stage plays a significant role in both earlier recurrence and earlier mortality among patients with TNBC.

Intraoperative radiation therapy in non-breast cancer patients: A report of 26 cases from Shiraz, south of Iran.

Background: Intraoperative radiation therapy (IORT) is the delivery of radiation at the time of surgery. Whereas the dose delivered by external beam radiation therapy (EBRT) is limited by the tolerance of the surrounding normal tissues, IORT allows exclusion of a part or all of the dose-limiting sensitive structures by operative mobilization and/or direct shielding of these structures. The aim of the present study was to report the non-breast cancer patients' outcomes after receiving IORT in Shiraz, Iran. Methods: In this retrospective study, all cases who had received IORT and had non-breast malignancies were selected. Diagnosis was confirmed by biopsy. Additional imaging was done by sonography, magnetic resonance imaging (MRI) and computed tomography (CT). IORT was applied by self-shielded, LIAC 6-12 MeV Sordina mobile linear accelerator. Typically, a single dose of 10-21 Gy was given for maximally resected tumors. The statistical analyses were carried out using SPSS (version 21). Results: Twenty-six patients were treated with IORT alone or combined with EBRT. Different tumors were treated, including colorectal adenocarcinoma (10 cases, 38.4 %), Soft Tissue Sarcomas (STS, 11 cases, 42.3 %), head and neck cancers (3 cases, 11.5 %), one cervix malignancy case and one paravertebral fibromatosis case. Mean ± SD overall survival was 15±14.89 (0-38) and 34.3±15.72 (14-53) months for colorectal cancer and STS, respectively. Conclusion: IORT is mostly useful for pelvic and abdominal malignancies where normal bowel limits the dose that can be delivered with EBRT. However, the dose delivered in a single fraction with IORT is rarely sufficient for tumor control; therefore, IORT is usually preceded or followed by additional EBRT which should be further evaluated preferably in prospective randomized trials.

Chronological changes and trend of breast cancer clinics and pathology among Iranian women during 22 years from the largest breast cancer registry in Iran.

BACKGROUND AND OBJECTIVE: We evaluated clinicopathological changes of breast cancer (BC) during a 22-year time period among the Iranian population. METHODS: This study is part of the largest BC registry in Iran. Patients were categorized as those diagnosed with BC during 1993-2005, 2006-2011, and 2012-2017 and compared regarding baseline characteristics and socioeconomical determinants, and obstetrical/gynecological and BC characteristics. RESULTS: Overall, 688, 1871, and 3020 patients entered the 1993-2005, 2006-2012, and 2012-2017 year groups, respectively. Mean (SD) age at first presentation of BC increased throughout the year groups (47.40 ± 10.34, 49.12 ± 11.70, and 49.43 ± 12.07 years, respectively; p < 0.001). Mean (SD) tumor size increased from 1993-2005 to 2006-2011 and decreased onto 2012-2017 (2.82 ± 1.69, 2.91 ± 1.49, and 2.66 ± 1.52 cm, respectively; p < 0.001). Number of individuals with stage 4 and grade 3 BC also showed an increasing pattern (p < 0.001). Tumor necrosis rates showed an increase onto 2011-2017 (43%, 47.3%, and 56%, respectively; p < 0.001). ER positive (62.4%, 73.4%, and 77.1%, respectively; p < 0.001) and PR positive individuals (59.5%, 64.3%, 72.6%, respectively; p < 0.001) showed an increasing trend. HER2 positive expression rates increased from 1993-2005 to 2005-2011 (24.5% and 31.5%, respectively) and decreased onto 2012-2017 (31.5% and 26.8%, respectively, p < 0.001). Number of involved lymph nodes increased (5.70 ± 6.56, 5.65 ± 6.00, and 5.95 ± 6.99, respectively; p < 0.001). Pattern of BC invasion and recurrence showed significant change (p < 0.001). CONCLUSION: Clinical and pathological characteristics may be showing a changing pattern among the Iranian population.

The Shiraz Breast Cancer Registry (SBCR): study design and primary reports.

AIM: This is a description of the largest breast cancer (BC) registry in Iran, termed the Shiraz Breast Cancer Registry (SBCR). METHODS: Data on baseline and clinical characteristics, socioeconomic status, imaging, physical examination, histopathology, treatment and prognosis have been recorded for each individual. RESULTS: Overall, 5937 were included in the report. Mean age of first presentation was 49.05 ± 11.69 years. Mean tumor size was 2.78 ± 1.76 cm. Most patients had stage 2 (46.9%) and 3 (25.5%) BCs, respectively. Most common type of BC was invasive ductal carcinoma (83.3%), followed by medullary carcinoma (3.8%). Overall, 12.9% were triple negative (HER2-, ER- and PR-). CONCLUSION: The study provides an overview on the status of BC's in Iran and a wide opportunity for future studies.