Using a combination of superb microvascular imaging and other auxiliary ultrasound techniques to increase the accuracy of gray-scale ultrasound for breast masses

BACKGROUND

Breast ultrasound is highly sensitive, but its specificity is not as high for detecting malignant lesions. Auxiliary modalities like elastography, Color and Power Doppler ultrasound are used as adjuncts to yield both a high sensitivity and specificity. Superb microvascular imaging (SMI) is a newer modality with more accuracy for detecting breast lesions. In this study, our goal was to investigate the role of SMI as an adjunct to ultrasound and find a suitable combination model for the evaluation of breast masses.

METHODS

In this cross-sectional study, 132 women with 172 breast masses who underwent ultrasound-guided biopsy were included.. The ultrasound features of the lesion, the strain ratio in strain elastography, the number of vessels for each lesion, their morphology and distribution in Doppler and Power Doppler ultrasound and SMI were recorded for each lesion. A vascular score and a vascular ratio were defined.

RESULTS

In the histologic examination, 31 lesions (18%) were malignant and 141 lesions (82%) were benign. The vascular score was more accurate than the vascular ratio in all three modalities. The predictive ability of strain ratio was higher than Doppler and Power Doppler ultrasound and SMI. Adding SMI alone to ultrasound increased the specificity from 46.10% to 61.2% and the accuracy from 55.80% to 70.11%. In the combination of ultrasound with other modalities, the best was the combination of ultrasound, strain elastography, and SMI; which yielded a specificity and sensitivity of 100% and 74.4%, respectively.

CONCLUSION

Adding SMI and STE modalities as adjuncts to ultrasound lowers the chance of missing malignant lesions and reduces unnecessary biopsies of breast lesions. A study with a larger sample size using this combination model to evaluate the accuracy with greater precision is recommended.

A New Model Including AMH Cut-off Levels to Predict Post-treatment Ovarian Function in Early Breast Cancer: A Prospective Cohort Study

BACKGROUND

Breast cancer (BC) treatment decreases fertility capacity, but unnecessary fertility preservation procedures in women who would not be infertile after treatment would be a waste of time and resources and could cause the unwarranted exposure of cancer cells to exogenous sex hormones. It has been largely shown that post-treatment ovarian reserve is directly associated with pre-treatment anti-mullerian hormone levels (AMH0). A threshold for AMH0, or a model including AMH0 and patient characteristics that could distinguish the patients who will be infertile after treatments, still needs to be defined. Accordingly, this study was performed to specifically target this high-priority concern.

METHODS

Women≤45 years old with newly diagnosed non-metastatic BC were entered in this multicenter prospective cohort study. AMH0 and two-year post-treatment AMH (AMH2) were measured, and hormonal patient features were recorded as well. Receiver operating characteristic (ROC) curve analysis, decision tree (DT), and random forest analyses were performed to find a cut-off point for AMH0 and define a model involving related features for the prediction of AMH2.

RESULTS

The data from 84 patients were analyzed. ROC curve analysis revealed that AMH0>3 ng/mL (Area under the curve=0.69, 95% CI: 0.54‒0.84) was the best indicator for predicting AMH2≥0.7 (sensitivity=79%, specificity=60%). The best model detected by DT and random forest for predicting an AMH2>0.7 with a probability of 93% consisted of a combination of AMH0>3.3, menarche age<14, and age<31.

CONCLUSION

This combination model can be used to withhold fertility preservation procedures in BC patients. Performing larger studies is suggested to further test this model.

Imiquimod as a new treatment in refractory idiopathic granulomatous mastitis: report of two cases

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast that mimics breast cancer or infection. Immunological pathogenesis is strongly suggested for the disease.

REASON FOR THE REPORT

The treatment remains controversial, comprising a spectrum from observation or NSAIDs to immunosuppressive agents and surgery. Intractable cases are not uncommon and represent a major treatment challenge. Therefore in this study, we examine the effect of a topical immunomodulator agent, imiquimod, on refractory IGM. Patient 1 had IGM for 9 months and had not responded to the existing treatments. She responded to a 7-week course of imiquimod. In patient 2, the disease had begun 4 months sooner and had been resistant to all treatments; it responded to imiquimod after 4 weeks. Ulcers appeared on the skin of both patients but resolved safely.

OUTCOME

Both patients were very satisfied with the results. Imiquimod can be an appropriate local treatment with limited adverse effects in refractory IGM. We propose similar studies to assess the efficacy of imiquimod in IGM further, paying attention to the possibility of developing skin wounds.

Feasibility of measuring comorbidity indices based on clinical breast cancer records

Background

Comorbidities have a significant impact on the treatment and outcome of breast cancer. However, data on such comorbidities from low-income countries are limited.

Aim

To evaluate the feasibility and accuracy of comorbidity data extracted from medical records for estimating the prevalence of comorbidities among patients registered in the clinical breast cancer registry of the Islamic Republic of Iran.

Methods

We collected data from the medical records of 400 patients on 30 comorbidities included in the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). The sensitivity and specificity of comorbidity data extracted from medical records were calculated using data from interviews with 97 randomly selected patients. We studied the prevalence of comorbidities using the CCI and ECI. Data were analysed using SPSS version 24.

Results

The mean age of patients was 51.69 SD 12.28 years. The sensitivity and specificity of medical records for detecting any comorbidity data contained in CCI versus non-comorbidity were 93.2% and 69.8%, respectively. However, for the comorbidity data included in ECI, both sensitivity (86.9%) and specificity (44.4%) were lower than in CCI. Hypertension (n = 144, 36.0%) and diabetes without chronic complications (n = 77, 19.3%) were the most prevalent comorbidities. A higher proportion of patients had no comorbidity with CCI (72.2%) than with ECI (44.8%).

Conclusion

It is feasible to construct a comorbidity index using medical records with high accuracy, especially when we extract comorbidities using the CCI. Further studies are needed to understand the association between comorbidity index and breast cancer survival among Iranian patients.

Fatty acid profiles and Delta9 desaturase (stearoyl-CoA desaturase; SCD 1) expression in adipose tissue surrounding benign and malignant breast tumors

The progression of tumors occurs through interactions between the tumor and the stroma. Understanding the role of adipose tissue (AT), as the main component of the breast tumor microenvironment (TME) in the development of cancer, is crucial for the early detection of breast cancer (BC). This study compared the FA profiles, desaturase index (DI), and stearoyl CoA desaturase 1 (SCD1) mRNA levels in the AT that surrounds tumors in women with BC and benign breast disease (BBD). Specimens were collected from 40 Iranian women who had undergone breast surgery. These women were age- and BMI-matched and were divided into two groups: BC (n = 20) and BBD (n = 20). Gas chromatography and quantitative real-time PCR were used to analyze the FA profiles and SCD1 mRNA levels, respectively. The DI was calculated by dividing the amounts of monounsaturated FAs by the amount of saturated FA. There were no significant differences in age and BMI between women with BC and BBD. The FA profiles and DI were also similar in both groups. However, mRNA levels of SCD1 were found to be 5 times higher in the breast AT of BC than in the breast AT of BBD (p < 0.0001). We showed that SCD1 was significantly upregulated in the AT surrounding BC tumors, even though the DI and FA profiles were unchanged compared to those in the AT of BBD patients. It is important to note that the breast AT of women with BBD has previously been overlooked and warrants further studies.

Breast Cancer Sentinel Lymph Node Detection Rate: First Large Scale Multi-Centric Data for Technetium Phytate

BACKGROUND

Sentinel lymph node biopsy (SLNB) with injection of radiopharmaceuticals is now the standard of care for staging the axilla in patients with breast cancer. Sulfur or antimony colloids labeled with 99mTechnetium (Tc) are used globally for the procedure, with a detection rate of 94%. However, in Iran, Tc phytate has been used because it is more easily producible in the country. The detection rate with Tc phytate has not been well determined in large-scale studies. Objective: We performed this study to report the detection rate of SLNB with Tc phytate, its advantages and disadvantages using large multicentric data.

METHODS

This is a retrospective cross-sectional multicenter study. Participants were breast cancer patients without previous history of axillary surgery, who underwent sentinel node biopsy using Tc phytate on the morning of surgery or the day before. The detection rate was calculated as the number of patients with histologically positive sentinel nodes to all patients with histologically positive lymph nodes; we compared those injected on the day of surgery and those injected on the day before.

RESULTS

Overall, 2663 women aged 50.2±11.6 years were included. The detection rate was 91.8% (806 out of 878). The false negative rate was 8.2% overall, and statistically similar for injections on the day or the day before surgery (2.9 vs 2.1; P=0.32).

CONCLUSION

Tc phytate has a good detection rate for breast radio-guided SLNB with similar result for injections on the surgery day or the day before it.

Evaluation of HER2 Positivity Based on Clinicopathological Findings in HER2 Borderline Tumors in Iranian Patients with Breast Cancer

Background & Objective

Human epidermal growth receptor-2 (HER2) gene amplification is an important predictive and prognostic factor in breast cancer treatment. However, the expression of HER2 determined by immunohistochemistry (IHC) is considered as borderline in some cases, and confirmation of the HER2 status by either fluorescent in situ hybridization (FISH) or chromogenic in situ hybridization (CISH) is necessary for correct treatment decision-making. Considering the high cost of FISH and CISH, we aimed to investigate whether clinicopathological findings of the tumor could predict the HER2 status.

Methods

A retrospective study was performed using the data from 584 patients with breast cancer with HER2-borderline disease, confirmed by IHC. Final HER2 status, pathologic tumor size and type, nodal involvement, Ki67 index, presence of estrogen and progesterone receptors (ER, PR), lymphovascular invasion (LVI), and stage were retrieved from the clinical records.

Results

One hundred twenty-one (20.7%) patients were HER2-positive according to the FISH or CISH results. Logistic regression analysis showed that the pathologic size was positively associated with HER2 positivity with an odds ratio (OR) of 1.02 (95% CI: 1.01-1.04). In addition, the adjusted OR illustrated a statistically significant association between HER2 positivity and PR negativity (OR= 2.22, 95% CI: 1.29-3.83).

Conclusion

In HER2 borderline breast cancer, HER2 positivity significantly increases with tumor size and PR negativity. Further studies are recommended that may find an applicable model to predict the actual status of HER2 in borderline cases.

Clinical characteristics of breast cancer patients admitted to academic surgical wards in Tehran, Iran: an analytical cross-sectional study

BACKGROUND

Breast cancer (BC) is the most commonly diagnosed cancer and the leading cause of cancer death among women. Knowledge of the clinical characteristics of BC in a population may be informative for disease prediction or diagnosis and for developing screening and diagnostic guidelines. This study aimed to evaluate the clinical characteristics of female patients with BC who were admitted to academic surgical wards in Tehran, Iran.

METHODS

In this cross-sectional study, demographic information and clinical characteristics of Iranian females with BC who had undergone breast surgery from 2017-2021 in four academic Breast Surgery Units were extracted from medical files and recorded via a pre-designed checklist.

RESULTS

A total of 1476 patients with a mean age of 48.03 (± 11.46) years were enrolled. Among them, 10.4% were aged less than 35. In younger patients, Triple-negative and Her2-enriched subtypes of BC were significantly higher compared to older ones. Overall, 85.7% of tumors were invasive ductal carcinoma, 43.3% were grade 2, 41.4% were located in the UOQ, and 65.2% had presented with mass palpation. The mean pathologic tumor size was 28.94 mm, and the most common subtype was luminal B.

CONCLUSIONS

Many characteristics of breast cancer in this study were similar to other countries and previous studies in Iran. However, a higher proportion of young BC compared with Western countries, and even with older studies in Iran, suggest a trend toward lower age for BC in recent years. These results indicate the need for preventive measures and screening in Iranian women at a younger age.

A pilot study of the use of human amniotic membrane as subcutaneous implants in a mouse model: a potential for temporary substitutes in two-stage breast reconstructions

INTRODUCTION

Breast reconstruction by prosthesis is frequently performed in breast cancer treatments, and a temporary substitute is used in the first step of two-stage operations.

AIM

Due to the advantageous biological features of the human amniotic membrane, we aimed to evaluate its use for temporary implants.

METHOD

We prepared small spherical implants from human amniotic membranes and inserted them into BALB/c mice's subcutaneous flanks. Then, we compared the bulging they produced, the durability, and the host reaction with implants made from the chorionic membrane, folded membrane patches, and sterile plastic beads.

RESULTS

All amionitic cases were healthy throughout the study and only mild inflammation occurred in them. Furthermore, the bulging of the implants was acceptable and faded gradually. However, moderate inflammation was observed in chorionic implant mice, and the bulging disappeared very soon. Finally, the control group had severe inflammation and the beads implant was rejected.

CONCLUSION

Our study showed that the human amniotic membrane could represent a safe and valid tool for breast reconstruction, however, further studies on larger animals and more implants are suggested.

Need assessment for the content of educational programs about breast cancer from the viewpoint of unaffected women

BACKGROUND

Breast cancer is the most common cancer among females, and early diagnosis is possible in case the patients seek medical attention on time. For this to come true, they must know about the existence and risks of the disease and be aware of the appropriate attitude and actions toward prevention or early diagnosis. However, we see that women have unanswered questions about these issues. In this study, we sought to investigate healthy women's information needs about breast cancer from their own perspective.

METHODS

This prospective study was carried out by using the maximum variation sampling, and theoretical saturation to reach sample saturation. Women who came to different clinics of Arash Women's Hospital (except the Breast Clinic) during two months were entered in the study. Participants were asked to write down all the questions and subjects they would like to be explained in a breast cancer educational program. The questions were reviewed and categorized after every fifteen consecutive forms were filled until there was not even one new question. Afterwards, all the questions were reviewed and matched based on their similarity and repeated items were eliminated. Finally, questions were organized according to their common topics and the range of details they comprised.

RESULTS

Sixty patients were included in the study, and 194 questions were gathered and categorized according to common scientific terms, resulting in 63 questions in 5 categories.

CONCLUSIONS

Many studies have been conducted on breast cancer education, but none have addressed healthy women's personal queries. This study outlines the questions of unaffected women about breast cancer that need to be addressed in educational programs. The results can be used for development of educational material at community level.

TRIAL REGISTRATION

This study was conducted as the preliminary phase of a study approved in Tehran University of Medical Sciences (Approval Code 99-1-101-46,455) and by the Ethics Committee of the University (Ethical Code IR.TUMS.MEDICINE.REC.1399.105).

Prevalence of Malnutrition among Hospitalized Elderly Patients in Hospitals Affiliated to Tehran University of Medical Sciences, Tehran, Iran

Background: Following the improvement in health status and life expectancy in developing countries, the elderly population is increasing. Elderly malnutrition is common across healthcare services and is associated with high costs and adverse outcomes. This study assesses the prevalence of malnutrition among elderly patients in the selected hospitals affiliated to Tehran University of Medical Sciences. Methods: This cross-sectional study was conducted on elderly patients aged 65 years or older in 6 selected hospitals between June and September 2015. Using convenience sampling method, a total of 451 patients were included. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) tool. Results: The mean age of the patients was 71.49 ± 6.60 year and 55.5% were female. The prevalence of malnutrition was 27.3%. A total of 30.8% were at risk of malnutrition, and 41.9% had a normal nutritional status. There were significant associations between nutritional status and chronic diseases, body mass index (BMI), mobility, psychological condition, mid-arm circumference (MAC), calf circumference, and more than three prescription drugs per day (P < 0.001). Conclusion: A satisfactory nutritional status was found among most hospitalized elderly. Future studies with follow-up during and after hospitalization are required.

Infertility Does Not Increase the Rate of Breast Fibroadenoma

Background

Fibroadenoma (FA) and infertility can share common risk factors and probably common underlying pathophysiology, but yet there is no study evaluating the prevalence of FA in infertile women. Therefore, the aim of in the present study, the purpose was evaluating the association of FA and infertility for the first time.

Methods

This short communication is a secondary analysis of a primary study that was performed in Arash Women's Hospital, Tehran, Iran. Participants were selected among reproductive-aged women with a history of infertility as the case and women without infertility as the control group. The criteria for diagnosis of FA were histopathologic assessment for lumps 1 cm in size or larger, and a typical ultrasound image for smaller lumps. Assisted reproductive technology (ART) was defined as any previous history of undergoing ovulation stimulation, intrauterine insemination, intracytoplasmic sperm injection, or in vitro fertilization.

Results

Overall, 155 cases with a mean age of 39.2±6.9, and 167 controls with a mean age of 43.08±8.3 were included (p=0.0001). Interestingly, the incidence of FA was lower in the case group (18.7% vs. 25.7%), however, the difference was not statistically significant (p=0.13). Also, logistic regression analysis showed that the chance for an infertile woman who undergoes ART to get FA is 1.7 times higher in comparison to non-ART group, although the difference was not significant (p=0.21).

Conclusion

Infertility and ART were not associated with increased risk of FA; however, larger prospective studies should be conducted in the future in order to achieve conclusive results.

The association of metformin and aspirin intake with mammographic breast density: A cross-sectional study

Background

Our purpose was to investigate the association between Mammographic breast density (MBD), a known strong marker for breast cancer and metformin and aspirin use and duration of use alone or simultaneously, in a sample of Iranian women considering other confounding factors.

Methods

In a cross-sectional study, 712 individuals were selected out of women referred to two university hospitals for screening mammography. Participants' information was collected with a questionnaire. Four-category density scale (a = almost entirely fatty, b = scattered fibroglandular densities, c= heterogeneously dense, and d = extremely dense) was categorized as low (a&b) and high (c&d) density.

Results

The mean age of the participants was 49.80 ± 7.26 years. Sixty-five percent of women belonged to the high and 35% to the low MBD category. Both aspirin and metformin had a significantly negative association with MBD, however, when confounding factors were entered into the models, only aspirin after adjustment for age and BMI had an inverse association with MBD (OR = 0.53, 95% CI: 0.35-0.94). Simultaneous use of metformin and aspirin (OR = 0.44, 95 %CI: 0.17-1.12) was associated with lower MBD. Furthermore, in women who used metformin (OR = 0.23, 95% CI: 0.09-0.62) and aspirin (OR= 0.35, 95% CI: 0.17-0.72) for 2 to 5 years, MBD was significantly lower. However, after the adjustment of confounding factors, these associations were not statistically significant.

Conclusion

It seems metformin and aspirin intakes are associated with MBD. However, further studies with more sample size are needed.

Idiopathic granulomatous mastitis and history of hypothyroidism: Intervening data of a prospective multicenter trial and meta-analysis of the existing literature

Background: Idiopathic granulomatous mastitis (IGM) is a rare benign breast disease that mostly occurs in reproductive ages in parous women. Hormonal, autoimmune, and microbial causes have been implicated as causes. We carried out this prospective study to investigate the reproductive factors and underlying disease states in IGM. Methods: This study was conducted in two phases. In the first phase, we evaluated the reproductive factors, anthropometric parameters and past medical histories of participants of an ongoing multicentric clinical trial. In the second phase, we performed an extensive review of the literature for studies that had considered patients with a histologic-proven diagnosis of IGM without date limitations, and extracted the data about parity, breastfeeding, oral contraceptive pill use and past medical histories. We then carried out a meta-analysis. Results:  Data of 123 patients were included. The mean age was 35.11±7.07 years, and the mean body mass index was 27.41±4.74. Overall, %93.8, 90.27% and 28.7% of patients were parous, had breastfed, and had used OCP, respectively. Hypothyroidism represented the most common (18.94%) previous medical disease. We included 89 studies in our search. Considering these studies and ours, the pooled prevalence of rates of parity, breastfeeding and oral contraceptive pill consumption were 96%, 89%, and 29%; and the pooled prevalence of hypothyroidism, diabetes and hypertension were 9%, 5% and 5%, respectively. Although not exactly comparable, these rates of hypothyroidism were higher than those reported in women in the general population (4.2% in one large study in Iran). Conclusion: Our study suggests a possible relation between a past history of hypothyroidism and IGM. We propose a study that investigates the occurrence of IGM in some large cohorts of healthy women, and the retrospective assessment of thyroid tests in the primary serum samples.

Evaluation of the quality and accuracy of breast cancer knowledge among persian language websites

INTRODUCTION

The internet has become a powerful worldwide information source that revolutionized access to knowledge, especially in the fields of health and medicine (health knowledge). Therefore, providing high-quality, accurate, reliable, and relevant information on dependable websites is a possible way of providing the patient with needed information and, thus, achieving the benefits of informed patients regarding outcomes. This study aimed to evaluate the quality and accuracy of breast cancer knowledge among Persian language websites.

METHODS

Two search engines were searched in the Persian language about breast cancer. The first 30 websites were selected for further evaluation based on the completeness, correctness, transparency, and accessibility of health knowledge. The DISCERN instrument was used to assess the quality of the Persian language websites on this issue.

RESULTS

Among the 30 websites, about 23% of websites provide completely correct information and about 30% provide mostly correct information. Sixty percent of the websites provided author information, and 46% of them had a healthcare professional or expert as the author. Sixty percent of the websites stated the creation date on the pages, while 40% of them did not provide any health knowledge. Scores on accessibility were always easy for most of the websites. Based on the quality rating system of DISCERN, about 60% of the websites were presented as very poor.

CONCLUSION

Website rankings enable healthcare professionals to identify and signpost patients to reliable up-to-date websites to ensure that patients receive high-quality knowledge. This review has provided evidence of inadequate and inaccurate health knowledge about breast cancer on the Persian language websites. This issue requires further investigation to understand the barriers and solutions available to provide reliable information about breast cancer and how this information affects the patient's outcomes.

TRIAL REGISTRATION

The project was found to be in accordance with the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and date of IR.TUMS.IKHC.REC.1399.379 and 2021-01-01 respectively, and is registered with research project number 49890 in the Vice Chancellor for Research and Technology Development of Tehran University of Medical Sciences, Tehran, Iran. URL: https://ethics.

RESEARCH

ac.ir/EthicsProposalViewEn.php?id=170978 .

Facile preparation of covalently functionalized graphene with 2,4-dinitrophenylhydrazine and investigation of its characteristics

This article reports a fast and easy method for simultaneously in situ reducing and functionalizing graphene oxide. 2,4-Dinitrophenylhydrazine hydrate salt molecules are reduced by graphene oxide by reacting with oxide groups on the surface and removing these groups, and 2,4-dinitrophenylhydrazone groups are replaced with oxide groups. The synthesized materials have been investigated using Fourier transform infrared spectroscopy (FTIR), Raman spectroscopy, X-ray diffraction (XRD), thermogravimetric analysis (TGA), X-ray photoelectron spectroscopy (XPS), and UV absorption. Also, the morphology has been examined with a scanning electron microscope (SEM) and Brunauer-Emmett-Teller (BET) analysis. The result of the photocurrent response and electrochemical behavior of the samples through cyclic voltammetry, galvanostatic charge/discharge, and electrochemical impedance spectroscopy (EIS) have been analyzed to investigate the effect of physical and chemical changes compared to graphene.

Innovative targets of the lncRNA-miR-mRNA network in response to low-dose aspirin in breast cancer patients

This study aimed to investigate innovative targets in breast cancer patients by considering the interaction of the lncRNA-miR-mRNA network in response to low-dose aspirin. The candidate miRs were first taken from the GEO and TCGA databases. Then, the candidate network was constructed using the high-throughput sequencing data. The expression levels of candidate targets were finally measured using Real-Time PCR in luminal A breast cancer patients undergoing aspirin (80 mg daily for three months) and non-aspirin groups during chemotherapy after surgery. The expression levels of TGFβ, IL-17, IFNγ, and IL-β proteins were measured using the ELISA technique. 5 lncRNAs, 12 miRs, and 10 genes were obtained in the bioinformatic phase. A significant expression increase of the candidate tumor suppressor lncRNAs, miRs, and genes and a substantial expression decrease of the candidate onco-lncRNAs, oncomiRs, and oncogenes were achieved after the aspirin consumption. Unlike the non-aspirin group, the expression levels of TGFβ, IL-17, IFNγ, and IL-β proteins were significantly decreased following aspirin consumption. The Kaplan-Meier analysis indicated a longer overall survival rate in the patients after aspirin consumption. Our results showed that the lncRNA-miR-mRNA network might be a significant target for aspirin; their expression changes may be a new strategy with potential efficacy for cancer therapy or prevention.

Air pollution exposure and mammographic breast density in Tehran, Iran: a cross-sectional study

BACKGROUND

Air pollution is one of the major public health challenges in many parts of the world possibly has an association with breast cancer. However, the mechanism is still unclear. This study aimed to find an association between exposure to six criteria ambient air pollutants (PM_2.5, PM₁₀, SO₂, NO₂, O₃, and CO) and mammographic breast density (MBD), as one of the strongest predictors for developing breast cancer, in women living in Tehran, Iran.

METHODS

Participants were selected from women attending two university hospitals for screening mammography from 2019 to 2021. Breast density was rated by two expert radiologists. Individual exposures to 3-year ambient air pollution levels at the residence were estimated.

RESULTS

The final analysis in 791 eligible women showed that low and high breast density was detected in 34.8 and 62.2 of participants, respectively. Logistic regression analysis after considering all possible confounding factors represented that an increase in each unit of NO₂ (ppb) exposure was associated with an increased risk of breast density with an OR equal to 1.04 (95CI: 1.01 to 1.07). Furthermore, CO level was associated with a decreasing breast density (OR = 0.40, 95CI = 0.19 to 0.86). None of the other pollutants were associated with breast density.

CONCLUSION

Higher MBD was associated with an increased level of NO₂, as a marker of traffic-related air pollution. Furthermore, CO concentration was associated with a lower MBD, while other criteria air pollutants were not related to MBD. Further studies are needed to evaluate the association between ambient air pollutants with MBD.

Development, validation, and implementation of a Short Breast Health Perception Questionnaire

BACKGROUND

Health status and perception can be assessed by general or disease-specific questionnaires, and disease specific questionnaires are more specific than general questionnaires. Considering the importance of breast health perception (BHP) in women's lives and the lack of any pertinent questionnaires, we performed this study to develop a valid and reliable short BHP questionnaire (BHPQ); and then used it to assess the participants' BHP.

METHODS

We first designed and developed the instrument and then measured its inter-rater agreement (IRA), content validity including content validity index (I-CVI) and scale content validity index (S-CVI), and reliability (through internal consistency and test-retest). We then evaluated the BHP of eligible women with normal breasts and benign breast disorders who attended our breast clinic.

RESULTS

The IRA index (78.6%) showed the optimal relevance and clarity of the questionnaire. The content validity was acceptable; with S-CVIs of 87.35 and 84.42 for clarity and relevance, respectively. The internal reliability was high (Cronbach's alpha = 0.93). Three questions were eliminated for internal consistency (intraclass correlation coefficient < 0.7) but the rest of the questions showed good and excellent reliability. In the next step, BHP in the 350 eligible participants showed an overall score of 43.89 ± 9.09.

CONCLUSION

This study introduces a valid and reliable 11-item BHPQ. We propose its use in various circumstances throughout breast cancer screening, diagnosis, and treatment; and in the assessment of BHP in various physiologic and reproductive situations.

Use of Inguinal Hernia Mesh (DynaMesh-ENDOLAP) in Immediate Implant-based Breast Reconstruction

INTRODUCTION

The rate of immediate implant-based breast reconstruction after mastectomy is increasing, and providing enough coverage for the implant is mandatory; however the choice of appropriate mesh for implant coverage is controversial. Considering the high cost and the limited availability of breast-dedicated meshes in our country, we conducted this study to investigate the consequences of using a polyvinylidene fluoride (PVDF) mesh designed for endoscopic and laparoscopic hernia repair (ENDOLAP) as a coverage for breast prostheses in breast reconstruction.

MATERIALS AND METHODS

A retrospective cross-sectional study was performed on data of patients who had underwent immediate implant-based breast reconstruction between 2012 and 2019. After skin sparing mastectomy and subpectoral implant insertion, the exposed lower and lateral parts were covered with the mesh.

RESULTS

Seventy-nine reconstructions were performed on 62 patients. The average follow-up was 31.9 months (ranges 6-102 months). Postoperative complications including small flap necrosis (3.8%), seroma (8.9%), infection (5.1%), hematoma (3.8%), malposition (1.3%), rippling (1.3%), grade two and three capsular contracture (2.5%), and chronic pain (1.3%) occurred in 19% of the operated breasts. The complication rate requiring intervention was 5.3%, and no implant loss was observed. None of the patients who received radiation developed complications.

CONCLUSION

ENDOLAP mesh is a cost-effective and safe option for implant coverage in immediate implant-based breast reconstruction, with an acceptable complication rate.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of the association of endometriosis and mammographic breast density, a cross-sectional study

Background

Endometriosis is a common benign but painful gynecologic condition. Studies suggest that the risk of some types of malignancies such as breast cancer is higher in women with endometriosis. Mammographic breast density (MBD) is known as an important predictor for breast cancer. The present study aimed to investigate the potential relationship between endometriosis and MBD.

Methods

This cross-sectional study was conducted on 370 women over 40 years of age. Laparoscopic surgery was carried out for the diagnosis of endometriosis. MBD was classified into four categories according to the ACR BI-RADS classification. Statistical analysis was performed using SPSS software to evaluate the potential association between variables.

Results

The mean age of all participants was 47.2 ± 6.4 years, and most participants (76.8%) were premenopausal. Multivariate analysis of the potential predictors of MBD, including age, body mass index, oral contraceptive consumption, progesterone consumption, family history of breast cancer and endometriosis showed that age (P value = 0.002), history of progesterone consumption (P value = 0.004) and endometriosis (P value = 0.006) were independent factors for MBD.

Conclusion

This study indicated that endometriosis had an inverse association with MBD. Age and history of progesterone use were also independent influential factors for MBD. This finding shows that the positive association between breast cancer and endometriosis is not mediated through MBD.

Residency training amid the COVID-19 pandemic: exploring the impact on mental health and training, a lesson from Iran

BACKGROUND

COVID-19 has affected the training programs and the clinical schedules of surgical wards in many countries, including Iran. Also, the continuous involvement with COVID-19 patients has caused stress in health care workers; among them, residents are on the frontlines of care delivery. Therefore, we designed a study to assess the mental effects of these circumstances, and the effects on General Surgery and Obstetrics & Gynecology residency training in the busiest surgical departments of our university.

METHODS

Participants of this cross-sectional study were residents of General Surgery and Obstetrics & Gynecology of Tehran University of Medical Sciences, and the conventional sampling method was used. We used a questionnaire consisting of 47 questions (mostly using multiple choice questions and answers on the Likert scale) about personal, familial, and demographic characteristics; training activities, and mental effects of COVID-19.

RESULTS

The response rate was 63.5%. (127 filled questionnaires). Around 96% of the residents had emotional problems, 85.9% were highly stressed about contracting COVID-19, 81.3% were worried about transferring it to their families; and 78% believed that their residency training had been impaired.

CONCLUSION

Overall, our study shows the negative impact of COVID-19 on mental health and the training of residents. We propose that appropriate emotional support and suitable planning for compensation of training deficits is provided for residents.

Metformin in the management of fibrocystic breast disease: a placebo-controlled randomized clinical trial

BACKGROUND AND PURPOSE

Fibrocystic disease (FCD) of the breast as a very common health problem in women has estrogen-dependent and proliferative features. No effective management strategy has been validated for this disorder, so far. The anti-hyperglycemic agent metformin has both anti-proliferative and estrogen-suppressing effects. Thus, we investigated metformin as a management strategy for FCD.

METHODS

The study was a double-blind placebo-controlled randomized clinical trial. Premenopausal women with FCD according to history, physical exam and ultrasound, who had measurable microcyst clusters on ultrasound (US) were entered the study. Oral placebo and metformin tablets (500 mg) were used twice daily by participants in the intervention and control groups. Size and number of microcyst clusters on US and the subjective pain score were recorded before and after the intervention.

RESULTS

154 participants were randomly allocated into two groups of 77 interventions and 77 controls. The decrease in size of the largest microcyst cluster in each patient and the mean decrease in number of microcyst clusters were not statistically significant (P = 0.310 and P = 0.637, respectively). However, those microcyst clusters which were ≥ 14 mm became significantly smaller after metformin use (P = 0.006). Additionally, in the subset of participants with pain at baseline, a larger proportion in the intervention group experienced at least 50% reduction in pain score (63.8% (30/47) in the intervention vs. 44.2% (19/43) in the placebo groups, P = 0.031).

CONCLUSION

Our study showed that metformin might be effective in the management of FCD. Further studies are proposed for confirmation of this subject.

Metformin as a new option in the medical management of breast fibroadenoma; a randomized clinical trial

BACKGROUND

Fibroadenoma (FA) is the most common benign solid breast mass in women, with no definite method of management. Because fibroadenoma is dependent on female sex hormones and comprises hypertrophic changes at cellular levels, we investigated the effects of metformin (MF), a safe hypoglycemic agent with anti-estrogenic and anti-proliferative properties, in the management of fibroadenoma.

METHODS

In this randomized clinical trial study, eligible women with fibroadenomas were assigned randomly to the metformin (1000 mg daily for six months) or the placebo group. Breast physical and ultrasound exam was performed before and after the intervention, and the changes in the size of fibroadenomas were compared in the two groups.

RESULTS

Overall, 83 patients in the treatment, and 92 in the placebo group completed the study. A statistically significant difference in changing size between the two groups was observed only in the smallest mass. In the largest FAs, the rate of size reduction was higher in the treatment group (60.2 % vs. 43.5 %); while a higher rate of enlargement was observed in the placebo group (38 % vs. 20.5 %). In the smallest FAs, the rate of the masses that got smaller or remained stable was about 90 % in the treatment group and 50 % in the placebo group. We categorized size changes of FAs into < 20 % enlargement and ≥ 20 % enlargement. The odds ratio (OR) for an elargemnt less than 20% was 1.48 (95 % CI = 1.10-1.99) in the treatment group in comparison with the placebo group; the odds for an enlargement less than 20% was higher in women with multiples fibroadenomas (OR = 4.67, 95 % CI: 1.34-16.28). In our study, no serious adverse effect was recorded, and the medicine was well-tolerated by all users.

CONCLUSIONS

This is the first study that evaluates the effect of MF on the management of fibroadenoma, and the results suggest a favorable effect. Larger studies using higher doses of MF and including a separate design for patients with single or multiple FAs are suggested in order to confirm this effect.

TRIAL REGISTRATION

This trial (IRCT20100706004329N7) was retrospectively registered on 2018-10-07.

Breast fibroadenomas are less frequent in women with uterine fibroids

BACKGROUND

The etiology and incidence of Fibroadenoma (FA) as the most frequent benign breast mass and uterine fibroma (UF) as the most benign gynecological disorders are unknown.

OBJECTIVE

Considering the dependency of FA and UF to sex hormones, our objective was to investigate the association of these two neoplasms.

METHODS

Among women attending the hospital Gynecology Clinic, those with typical uterine fibroids in their pelvic ultrasound constituted cases and those with no pathology the controls. All participants underwent breast ultrasound for FA. Criteria for diagnosis of FA were a typical image for lumps <2 cm in women aged <40 and <1 cm in ages ≥ 40, and a histologic diagnosis for all other participants or larger lumps.

RESULTS

The mean age of cases and controls was 42.4 and 41.7 years, respectively. FA were detected in 140 (23%) of all participants; 19.7% of the cases, and 26.2% of the controls (p = 0.07). FA and UF had a borderline reverse association (OR = 0.69, 95% CI = 0.46-1.02, p = 0.07).

CONCLUSION

The incidence of FA is lower in patients with UF. Further studies are needed to find the selective effects of estrogen and progesterone on hormonal receptors of these two tumors.

A Practical, Clinical User-Friendly Format for Breast Ultrasound Report

Objective

Breast ultrasound (BUS) is often performed as an adjunct to mammography in breast cancer screening or for evaluating breast lesions. Our aim was to design a practical and user-friendly format for BUS that could include the details of the Breast Imaging Reporting and Data System.

Materials and Methods

As a team of radiologists and surgeons trained in the management of breast diseases, we gathered and carried out the project in four phases-literature search and collection of present report formats, summarizing key points and preparing the first draft, seeking expert opinion and preparing the final format, and pilot testing-followed by a survey was answered by the research team's radiologists and surgeons.

Results

It produced a list of items to be stated in the BUS report, the final BUS report format, and the pilot format guide. Then, the radiologists used the format in three active ultrasound units in university-affiliated centers, and reports were referred to the surgeons. At the end of the project, the survey showed a high degree of ease of use, clarity, conciseness, comprehensiveness, and well-classified structure of the report format; but radiologists believed that the new organization took more time.

Conclusion

We propose our design as a user-friendly and practical format for BUS reports. It should be used for a longer time and by various ultrasound centers in order to ascertain its benefits.

Nonlinear spatial reshaping of pulsed beam in a step-index few-mode optical fiber

In this paper we demonstrate the spatial and spectral dynamics of pulse propagation in a step-index few-mode optical fiber, through an experimental and numerical analysis. The Kerr induced spatial self-cleaning is demonstrated by coupling a sub-nanosecond pulsed laser at 532nm into the fiber supporting above 10 modes. A bell-shaped and approximately single mode beam can be obtained for peak powers above 6kW and it remained relatively unchanged up to 25kW. But at significantly higher input peak powers, the spatial contents of spectral sidebands change dramatically, because of intermodal four wave mixing effect.

Abnormal anti-Müllerian hormone level may be a trigger for breast cancer in young women: A case-control study

Background

Anti-Müllerian hormone (AMH) is a known sensitive biomarker for fertility and ovarian reserve. The results of in vivo and human studies showed inconsistency with respect to the relation between AMH and breast cancer.

Objective

To compare the AMH level of young Iranian women with early breast cancer who have not received any treatment compared to that of healthy women.

Materials and Methods

In this case-control study, 58 breast cancer cases were recruited from the breast oncology clinic of two university hospitals. They were diagnosed with an in situ or invasive breast cancer before any anticancer treatment between August 2018 and April 2019. Healthy controls (n = 58) were selected from women referred to a gynecologic outpatient clinic without any symptoms of cancer or infertility. AMH was measured by the AMH enzyme-linked immunosorbent assay kits in one laboratory.

Results

Final analysis showed that the AMH means of case and control were not statistically significant (3.36 ± 2.95 vs 3.13 ± 1.79). However, the lower and higher AMH level categories are more prevalent in breast cancer compared to the control. Pearson's correlation test showed that the AMH level was negatively correlated with age (r = -0.44, p< 0.001). The results of logistic regression analysis considering confounding factors showed the positive association between breast cancer and lower (Odds Ratio [OR] = 5.98, p = 0.02) and higher quartile of AMH level (OR = 4.95, p = 0.01).

Conclusion

Our results suggest that abnormal AMH level is more frequent in young breast cancer patients. Further investigation considering AMH determinants is required.

A Plea for Defining a Uniform Standard Order in Reporting Details of a Whole Breast Ultrasound: The Point of View of Two Breast Surgeons?

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Significant Post-Chemotherapy Decrease of Ovarian Reserve in Iranian Women With Breast Cancer

Fertility preservation counseling has a high priority in young breast cancer (BC) patients. Cytotoxic chemicals used for chemotherapy in these patients increased the risk of premature ovarian failure. This study evaluated the anti-mullerian hormone (AMH) level at the time of diagnosis and within a month after the end of chemotherapy, while predicting the time of the return of ovarian function in BC cases (n=46) younger than 46 years for the first time in Iran. Cases were selected from those attending the breast oncology clinic of the two hospitals with a newly diagnosed in situ or invasive BC. The present study results showed AMH levels were significantly decreased in almost all women within a month after chemotherapy. It seems that the need for fertility preservation depends on patient age and baseline AMH level, but counseling should be offered by the clinician in young breast cancer patients.

COVID-19 Outbreak and Consequent Delays in Schedules of the Breast Clinic: Effects on Patients' Breast and Emotional Symptoms

Objective

The pandemic of COVID-19 has affected many aspects of life, and emotional symptoms have been reported to worsen during this time. Also, elective visits in the Breast Clinic have been cancelled or postponed based on the priorities defined in local and international guidelines. Our aim was to investigate the effect of these delays on the breast symptoms and emotional status of our patients.

Materials and Methods

We called patients whose appointments should have taken place between March and May 2020. After asking for their consent to participate in the study, we asked questions about their breast and emotional symptoms and any worsening of these due to cancellation of their schedules because of the COVID-19 outbreak. We also inquired the relation of breast symptoms with news and thoughts about COVID-19, and if the patients or their close relatives or friends had been affected by COVID-19. We compared the worsening of breast symptoms in patients with and without a positive self- or family history of COVID-19.

Results

None of the breast or emotional symptoms had significantly got worse in the patients. Also, there was no significant difference between the two groups regarding the changes in their breast symptoms or emotional health.

Conclusion

We believe that these results might be evidence in favor of the Breast Clinic triage system, which conforms to most international and specifically to our local recommended strategies.

Phyllodes Tumor of the Breast in Pregnancy and Lactation

Phyllodes tumor constitutes around 1% of all and 2.5% of fibroepithelial breast lumps. Three types including benign, borderline, and malignant tumors have been described. The benign variant is the most common, is close to fibroadenoma, but is usually larger and recurs more frequently. The rare malignant type is aggressive. Standard treatment consists of lumpectomy with appropriate margins for benign phyllodes tumor, while the borderline and malignant variants must be treated by wide resection or mastectomy. Phyllodes tumor is a rare tumor in pregnancy and lactation, and the effect of gestational alterations in hormone levels on this tumor have not been discussed in the literature, except for several case reports. In summary and alluding to our recent literature review, large size, fast growth, bilaterality, and probably malignancy are more commonly expected in gestational phyllodes tumors.

Phyllodes Tumor of the Breast during Pregnancy and Lactation; A Systematic Review

BACKGROUND

Phyllodes tumor (PT) is a rare tumor of the breast, which may occur during pregnancy or lactation. Several studies have reviewed and discussed PT occurring in pregnancy, gathering up to 14 patients. We performed a thorough systematic review of the literature in an attempt to find all reported cases, and identify their common characteristics.

METHODS

We searched Google scholar, PubMed, Ovid Medline, Scopus and ClinicalTrials.gov with several relevant combinations of keywords, looking for texts or abstracts without any date or language limitations, but using only English keywords. The existing literature only consisted of case reports and series; therefore any paper including one or several cases of PT presenting during pregnancy or breastfeeding was recognized as eligible. Articles with vague description of the tumor which made the diagnosis uncertain, and those lacking data about the tumor and management data were excluded. We contacted authors for more details in cases with incomplete information.

RESULTS

After excluding those with very deficient data, we included 37 studies, counting 43 cases. The mean age of the patients was 31 years (21-43 years). Some features were different from usual PT: bilaterality (16.2%), large size (14.2 ± 8.6 cm), rapid enlargement (79.5%), and rate of malignancy (60.5%).

CONCLUSION

Our findings show high rates of bilaterality, large size, rapid growth, and malignant pathology in the reported gestational PTs.

Inflammatory Breast Cancer in a Very Young Genetically Susceptible Woman: Case Presentation in a Tumour Board Session, Discussion and Decision-Making

Background: Inflammatory breast cancer is a very aggressive type of breast cancer which invades skin lymphatics. The standard treatment includes neoadjuvant chemotherapy followed by modified radical mastectomy and postsurgical radiation. Preserving the skin or nipple are not considered reasonable due to the involvement of the dermal lymphatics and therefore skin sparing or nipplesparing mastectomy are not usually carried out for this type of breast cancer. Case presentation: In this article, we present a case of inflammatory breast cancer in a very young woman who was positive for BRCA2 genes. Question: The possibility to perform nipple sparing or skin sparing mastectomy and immediate breast reconstruction, and the indication for prophylactic contralateral mastectomy as discussed in the tumor board are presented in this article. Conclusion: Neither of the more conservative techniques of mastectomy was appropriate for this case. Also, the prognosis of the patient mostly depends on the course of the ipsilateral tumor and prophylactic mastectomy would be wise only if the subsequent course of the disease is favourable.

Covid-19 and Cancer Patients: Delving into Burning Questions

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Phytoestrogens and Breast Diseases: A Matter of Concern for the Gynecologist

Background: This study is the last part of a quadruple series investigating the relationship between breast disorders and the consumption of exogenous sex hormones. Due to the structural similarity of phytoestrogens to estrogen and the confusion associated with their possible estrogenic activity in the breast, this part aims at reviewing of the literature on the relationship between phytoestrogens and breast disorders. Methods: We carried out a thorough search of the existing literature using appropriate keywords with the aim of finding systematic reviews, reviews, cohort studies and clinical trials regarding the effects of phytoestrogens on the breast in the general population, breast cancer survivors, women at high risk of breast cancer and those with benign breast diseases. Results: Many studies have approached the relationship between phytoestrogens and the risk of breast cancer or recurrence of the disease. Also, a few studies have considered the effects of phytoestrogens on benign breast disorders, BRCA genes, and the risk of breast cancer in high risk women. However, the variety of studies and the retrospective nature of many of them make it impossible to draw definite conclusions. Conclusion: Existing data generally supports the safety of phytoestrogen consumption regarding the risk of breast cancer in the general population, in women with benign breast disorders, in those at risk of breast cancer, and even in survivors of the cancer. However, due to insufficient evidence, prescription of high doses of phytoestrogens is still not recommended.

Biocompatibility, osseointegration, antibacterial and mechanical properties of nanocrystalline Ti-Cu alloy as a new orthopedic material

The demands for high-performance biomaterials are driving the development of new metallic alloys with improved mechanical and biological responses. In this study, a nanocrystalline Ti-Cu intermetallic alloy was prepared by a powder metallurgy route, and its application as an orthopedic material was evaluated by the microstructural, mechanical, corrosion, antibacterial, cytotoxicity and osseointegration examinations. Microstructural characterization revealed the formation of TiCu and Ti₂Cu₃ as major phases with 23 nm grain size in the structure of the alloy. The synthesized alloy exhibited ultra-high hardness of 10 GPa, acceptable toughness of 8.14 MPam^1/2, a ∼98 % anti-bacterial rate against S. aureus and E. coli, excellent cell viability to MG-63 osteosarcoma cells, and high osteoblast formation rate, which indicate a great potential of this alloy for biomedical application.

Atypical Lesions of the Breast and Lobular Carcinoma in Situ in Pregnancy - Surgeons' Practice

Objective

Approach to precancerous and high-risk breast lesions occurring in pregnancy has received little attention in the literature. We carried out a study to investigate the practice of surgeons in the management of these cases.

Materials and Methods

A short survey was sent to surgeons, including a multiple-choice questionnaire about their practice for atypical hyperplasia or lobular carcinoma in situ presenting in each trimester of pregnancy or at time of breastfeeding. Answer options included observation, immediate vacuum biopsy, immediate surgery, surgery in next trimester, surgery after delivery, and surgery after end of breastfeeding; based on the time of presentation.

Results

Out of the 671 practitioners invited, 97(14.5 %) responded to the survey. Participants were from 23 countries. Answers showed that management of gestational Atypical Ductal Hyperplasia (ADH) and Lobular Neoplasia (LN) was readily postponed by surgeons in favor of fetus safety while being cautious about risks of conservative management alone.

Conclusion

Various methods of treatment are selected by surgeons for managing high-risk breast lesions during pregnancy. In the absence of relevant literature, decision making in a multidisciplinary team would be the best approach in these cases.