Southern Medical Journal最新文献

Objectives: Invasive breast cancer (IBC) is a heterogeneous disease, with molecular subtypes guiding treatment and prognosis. Radiotherapy, a key component of breast cancer therapy, may vary in efficacy across subtypes. This study assessed the distribution of molecular subtypes and the use of radiotherapy, as well as their associations with clinicopathological features, overall survival (OS), and disease-free survival (DFS) in a single-center cohort.

Methods: We retrospectively analyzed 178 IBC patients diagnosed between 2018 and 2021. Associations between molecular subtypes (luminal A, luminal B, human epidermal growth factor receptor 2 enriched, triple-negative breast cancer [TNBC]) and clinical features were assessed via χ² tests. Kaplan-Meier and Cox regression analyses were performed on 158 patients with follow-up, after propensity score matching.

Results: Tumor size (P = 0.012), American Joint Committee on Cancer stage (P = 0.004), histological grade (P < 0.001), and chemotherapy (P = 0.016) differed significantly among the four molecular subtypes. OS and DFS varied by subtype (P = 0.024 and P = 0.042), with TNBC showing poorer outcomes than luminal B (OS P = 0.006, DFS P = 0.007) and luminal A (OS P = 0.035). Radiotherapy was associated with improved OS and DFS (P = 0.04 and P = 0.03). Multivariate Cox analysis confirmed radiotherapy as an independent factor for improved OS (hazard ratio 0.112; 95% confidence interval 0.022-0.566) and DFS (hazard ratio 0.129; 95% confidence interval 0.026-0.632).

Conclusions: IBC displays molecular subtype-specific differences in tumor behavior and prognosis, with TNBC linked to the worst clinical outcomes. Radiotherapy independently improved OS and DFS across all subtypes, supporting its continued role regardless of molecular profile.

There are similarities between neuroendocrine tumors (NET) and primary breast cancers. A misdiagnosis can significantly affect prognosis and patient treatment plans, leading to potential catastrophic effects on patient care. In this study, we look at two cases in which NET was misdiagnosed as a primary breast cancer, in the breast in one case, and as metastatic breast cancer in the liver in the other case. The goals of this study were to highlight the pathological overlap between primary breast cancer with NET features and neuroendocrine tumors and the differences between their radiological appearances and to suggest steps to prevent this misdiagnosis from occurring, highlighting both the utility of informed clinical suspicion and timed imaging and pathology reviews.

Objectives: Axillary lymph node (ALN) metastases are difficult to diagnose in invasive lobular carcinoma (ILC). This study evaluated the use of axillary ultrasound (AUS) and magnetic resonance imaging (MRI) in predicting ALN metastases in patients with ILC tumors >5 cm, who are at high risk of axillary metastases.

Methods: This is a single-institution, institutional review board-approved, retrospective review of patients with pT3 ILC between 2014 and 2023. Clinicopathologic features, preoperative axillary imaging, surgical pathology, and locoregional or distant recurrence were collected. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. The Kruskal-Wallis (numerical covariables) and χ² or Fisher exact (categorical covariates) tests were used with significance set at P < 0.05.

Results: In total, 139 patients with a mean age of 61 years (range 36-89) were included; all patients underwent AUS and 110 (79.1%) received preoperative MRI. After either AUS or MRI, 93 (66.9%) were classified as having clinical N0 (cN0) disease and 43 (30.9%) as cN1 disease. In total, 49.5% (46/93) cN0 patients converted to pathologic N1-3 (pN1-3) disease after surgery. A total of 43 patients had ALN fine-needle aspiration. Nine patients with negative fine-needle aspiration converted to pN1-3 disease (false negative rate of 25.7%).

Conclusions: Despite preoperative AUS and/or MRI, nearly half of the patients with T3 ILC diagnosed as having cN0 disease converted to pN1-3. Both AUS and MRI had low sensitivity and negative predictive value. Our data suggest that current imaging has poor accuracy for axillary metastases in ILC. Surgeons should have a high index of suspicion for axillary disease, despite a negative preoperative evaluation.

Objectives: Pathogenic germline CDH1 variants result in increased risk of gastric (GC) and invasive lobular (ILC) carcinomas with high penetrance. Limited data suggest a higher incidence of colorectal neoplasia in carriers of CDH1 mutations, but data remain limited on the risk of colorectal adenoma formation and the role of colonoscopy in this population.

Methods: Adult patients who underwent germline testing revealing a pathogenic mutation (PM) or variant of uncertain significance (VUS) in CDH1 were identified and seen in consultation were identified. Clinical and treatment characteristics were analyzed.

Results: Thirty-eight patients with CDH1 PM or VUS were identified at a single high-volume cancer center. Median age of CDH1 mutational analysis was 42 years (interquartile range 35-58). The majority of patients had deletion (N = 15, 39.5%) or nonsense (N = 6, 15.8%) mutations or VUS (N = 7, 18.4%). Twenty-six (68%), 20 (53%), and 11 (29%) had a family history of ILC, GC, and colon cancer, respectively. Eighteen (47%) patients underwent screening colonoscopy in addition to screening for GC and ILC; the median age at screening colonoscopy was 51.5 years (interquartile range 46-58) and 4 patients (22%) patients were younger than 45 years of age at the time of colonoscopy. Among patients younger than 45 years of age, the rate of adenoma detection was 50% (n = 2/4). Adenomas were identified in 8 (44.4%) patients, and of these patients, 6 (75%) had right-sided, 4 (50%) had left-sided, and 2 (25%) had both right- and left-sided adenomas. No patients were identified on colonoscopy to have colorectal cancers. When examining only patients with CDH1 PM (N = 31), 16 (51.6%) patients underwent screening colonoscopy, and 8 (50%) patients had adenomas detected. Conversely, of the two of the seven CDH1 VUS patients who underwent screening colonoscopy, neither patient had adenomas detected.

Conclusions: The association between inherited CDH1 variants and colorectal neoplasia remains undefined, but the rate of colorectal adenoma detection in this population of patients is significantly higher than that of the general population. Since these individuals already undergo upper endoscopy for their care, consideration of earlier colonoscopy and insurance approval may be warranted.

Objective: Multiple factors are associated with re-excision after breast-conserving surgery (BCS), however there is minimal literature discussing factors associated with re-excision after oncoplastic BCS (OBCS). This retrospective study aimed to identify factors associated with positive margins requiring re-excision after OBCS.

Methods: A retrospective review was performed on patients who underwent OBCS between October 2021 and May 2024. Subjects were divided into those who required re-excision and those who did not. Factors were evaluated including patient age, body mass index, smoking status, presence of hypertension and diabetes mellitus, tumor multifocality, microcalcifications, tumor size, human epidermal growth factor receptor 2⁺ (HER2⁺) status, triple negative (estrogen receptor^-/progesterone receptor^-/HER2^-) status, and tumor pathologies including ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma.

Results: The need for re-excision was significantly associated with a DCIS pathology (50% of patients, P = 0.021), and the lack of need for re-excision was associated with an IDC pathology (12.5% of patients, P = 0.005). There was no significant correlation in the need for margin re-excision based on age, body mass index, smoking status, the presence of hypertension or diabetes mellitus, tumor size, the presence of invasive lobular carcinoma, triple negative status, presence of HER2 or triple negative status, microcalcifications, or tumor multifocality.

Conclusions: Most factors associated with re-excision after BCS were not associated with re-excision after OBCS in our study. Similar to data published for BCS, however, our results show that DCIS pathology was significantly associated with re-excision in patients who undergo OBCS. In addition, the presence of IDC seemed to be negatively associated with re-excision after OBCS.

Objective: Black women in Louisiana have an increased breast cancer incidence. In addition, mortality and incidence of breast cancer in younger patients are on the rise, regardless of race or germline mutations. Most available germline mutation data in breast cancer are based primarily on White patient populations. We sought to evaluate the relationship between race, pathogenic germline mutations, and breast cancer subtypes among young women (younger than 40 years old) diagnosed as having breast cancer in Louisiana.

Methods: We collected and reviewed a 10-year retrospective database from 2012 to 2022 of 773 women younger than age 40 years diagnosed as having breast cancer in a Louisiana-based regional health system. Associations between subtypes and germline mutations were assessed using the χ² test.

Results: In total, 632 patients had available genetics data: 38% of patients with pathogenic germline mutations were Black or African American and 62% were White, 53% of Black or African American patients had a variant of uncertain significance (VUS) vs 47% of White patients. The association between pathogenic germline mutations and triple-negative breast cancer (estrogen receptor [ER]^-/human epidermal growth factor receptor 2 [HER2]^-) was noted with P = 0.0122. The presence of VUS was not statistically significant when compared with no mutation in the triple-negative cohort (odds ratio [OR] 1.13; 95% confidence interval [CI] 0.70-1.83; P = 0.6224). No statistically significant difference was noted in the prevalence of germline mutations among ER⁺/HER2^- and ER^-/HER2⁺ cancers. Evaluation of the germline mutations demonstrated an association between germline mutation and race (P = 0.0045). VUS was twofold in Black or African American patients compared with no mutation (OR 2.12; 95% CI 1.35-3.34; P = 0.0012). The presence of a pathogenic germline mutation was 1.19 times as common in Black or African American patients compared with no mutation (OR 1.19; 95% CI 0.79-1.79; P = 0.4018].

Conclusions: These data demonstrate that triple-negative breast cancer continues to have a significant association with germline mutations in a young patient population. Pathogenic germline mutations and VUS may be more common in younger Black or African American patients as demonstrated by our research, however.

Objectives: The purpose of this study was to evaluate the financial literacy of medical trainees and assess knowledge gaps in loan repayment, credit management, investment strategies, and financial planning.

Methods: A cross-sectional survey study was conducted at a single institution between July 25, 2023 and January 10, 2024. A 52-question financial literacy survey was distributed to 97 residents and 101 first- and second-year medical students. The survey assessed knowledge across financial domains, including student loans, credit cards, mortgages, investing, and business ownership. Statistical analysis included independent samples t tests and analysis of variance to compare financial literacy scores across trainee levels.

Results: Residents demonstrated significantly higher financial literacy scores than medical students (mean 18.80 vs 9.40 out of 35; P < 0.05). Despite this, substantial knowledge gaps persisted across multiple financial concepts. Of all respondents, 84.5% reported student loan debt exceeding $50,000, yet 64.6% were not enrolled in income-driven repayment plans, and 57.3% could not differentiate between Pay As You Earn and Revised Pay As You Earn. In addition, although 74.2% contributed to retirement accounts, 60.8% lacked knowledge about investment strategies. Despite limited financial literacy, 82.5% expressed interest in receiving structured financial education.

Conclusions: Medical trainees, including both medical students and residents, exhibit significant financial literacy deficits despite their progression through medical education. These findings underscore the need for structured financial education early in training to improve financial decision making, debt management, and long-term financial stability among future healthcare professionals.

Objectives: An opioid-sparing, multimodal pain (MMP) protocol was initiated at our institution in August 2016 in the Division of Trauma and Acute Care Surgery (TACS). During the next year, the practice was codified into a protocol. This study aims to evaluate the dissemination and impact of MMP.

Methods: We conducted a single-center retrospective cohort study of all patients admitted to a surgical service from May 2015 to July 2020 to evaluate opioid and nonopioid prescribing for analgesia. The analysis consisted of three populations: patients admitted to the TACS service, the General Surgery subspecialty (GSS) services (excluding TACS), and other surgical department (OSD) services.

Results: Of the 12,010 patients who met the inclusion criteria, 1979 (16.5%) were admitted to the TACS service, 1106 (9.2%) to GSS services, and 8925 (74.3%) to OSD services. Opioid morphine milligram equivalents averaged 38.6 ± 33.3 daily but decreased in all groups over time. Nonopioid adjunctive medications were used in 5932 (49.4%) and increased in all groups after implementation of the protocol (all P < 0.001). After MMP introduction, nonopioid analgesic use increased most rapidly in TACS and the slowest in OSD. Conversely, the average daily morphine milligram equivalents decreased most quickly in TACS (24.4%, P < 0.001), while GSS and OSD services saw a subsequent decrease in opioid use (P = 0.004 and P < 0.001, respectively) as MMP increased.

Conclusions: Implementation of an MMP protocol by a single division can facilitate the spread of nonopioid adjunctive pain medication use and decrease opioid utilization throughout surgical specialties in a hospital.

Objective: The case-based morning report (MR) is a widespread tradition in Internal Medicine training. Because MR content was originally geared toward second- and third-year residents, however, there are limited data regarding any specific learning considerations when having an intern-only MR. We aimed to elicit attitudes surrounding the intern report (IR) as an educational exercise from interns, residents, and facilitators.

Methods: We constructed a cross-sectional online anonymous survey using a de novo item-specific 5-point Likert scales and free-text responses. We analyzed nonparametric data via Mann-Whitney U tests and content analysis for free responses.

Results: A total of 44/133 (33%) trainees and 12/14 (86%) facilitators completed the survey. Nearly all responses were concordant between trainees and facilitators. During IR, interns were often distracted and interrupted. Valued cases were interesting or applicable to clinical practice or included faculty-specific techniques such as take-home points. All groups were neutral regarding IR as an educational exercise and called for more structural and learner-specific changes.

Conclusions: One static IR format may not be sufficient to support an intern's changing clinical and diagnostic stages of development. Nuanced approaches are needed to optimize faculty training, foster engagement, align with learner progression, and ensure intern fulfillment.