Axillary Lymph Node Biopsy Research Articles

Randomised controlled study of seroma rates after mastectomy with and without quilting the skin flap to pectoralis muscle.

The aim of this study was to determine whether seroma formation was affected by reduction of the potential dead space with the flap fixation method and obliteration of the axillary region in patients with breast cancer who underwent either mastectomy and axillary lymph node dissection or sentinel lymph node biopsy. A total of 105 patients with breast cancer were divided into two groups according to wound closure patterns. The operating time, postoperative pain and complications, time to drain removal, seroma formation, amount of fluid aspirated and number of aspirations were recorded prospectively. No significant difference was found between groups in the rates of seroma development (P = 0.7), complication rates (P = 0.6), time to drain removal (P = 0.5), length of hospital stay (P = 0.3) or numbers of aspiration (P = 0.7). The operating time for fixation was determined to be longer than that of the classic procedure (P = 0.02). Reducing potential dead space with flap fixation and obliteration of the axillary region may be useful in decreasing the development of seroma in patients who have undergone mastectomy because of breast cancer. However, surgical technique must be careful, and appropriate patient follow-up must be conducted.

Adenomyoepithelioma of the breast: A rare case from the Mankweng Hospital breast oncology clinic, Limpopo Province, South Africa

Adenomyoepithelioma of the breast is a rare benign breast neoplasm. It is characterised by the proliferation of both epithelial and myoepithelial cells. Although it is benign, adenomyoepithelioma has a potential for recurrences and malignant transformations. Here, we report a case of a 69-year-old woman with a breast adenomyoepithelioma that had been resected twice before her admission to Mankweng Hospital. It was a fast-growing tumour involving the retro-areolar area and left inner quadrant of the breast. Applied treatment included wide-simple mastectomy with sentinel axillary lymph nodes biopsy.

Venetoclax and hypomethylating agents in older/unfit patients with blastic plasmacytoid dendritic cell neoplasm

Venetoclax and hypomethylating agents in older/unfit patients with blastic plasmacytoid dendritic cell neoplasm

Disseminated lymph node tuberculosis after splenectomy: an unusual case report in an adolescent

BackgroundSplenectomized patients are at an increased risk for overwhelming post-splenectomy infections typically with encapsulated bacteria. The clinical association between splenectomy and lymph-node tuberculosis is unclear.Case presentationWe describe a rare case of disseminated tuberculous lymphadenitis in an 18-year-old woman with history of splenectomy because of hereditary sherocytosis. She was admitted with enlargement of bilateral-cervical and left-axillary lymph nodes and fever. A diagnosis of probable tuberculosis was made based on the findings of fine-needle aspiration. Histology showed granulomas and extensive caseous necrosis, with the site of puncture located at an enlarged lymph node on the right side. The diagnosis was confirmed via nucleic-acid amplification tests following excisional biopsy of the left axillary lymph node. Disseminated tuberculous lymphadenitis was localized in the bilateral neck, right lung hilum, left sub-axillary region, and mediastinum, as detected from contrast-enhanced computed tomography of the neck.ConclusionsMycobacterium tuberculosis infection should be considered in children and adolescents with extensive enlargement of lymph nodes after splenectomy.

Prevention of Breast Cancer-Related Lymphedema Using the Lymphatic Microsurgical Preventive Healing Approach: A Case Report

Breast cancer-related lymphedema is a major complication of breast cancer surgery. The lymphatic microsurgical preventive healing approach, a surgical technique that can prevent breast cancer-related lymphedema, creates a lymphovenous bypass between the damaged axillary lymphatics during axillary lymph node dissection and the axillary vein. We report a case using the unilateral lymphatic microsurgical preventive healing approach in a patient with bilateral breast cancer. A 58-year-old woman diagnosed with bilateral invasive ductal carcinoma underwent a bilateral nipple-sparing mastectomy. The lymphatic microsurgical preventive healing approach was performed on the left side after axillary lymph node dissection; the lymphatic microsurgical preventive healing approach was not performed after axillary sentinel lymph node biopsy on the right side. Six months after the surgery, MD Anderson Cancer Center stage 2 lymphedema was observed in the lymphography images of the right arm, where the lymphatic microsurgical preventive healing approach had not been performed.

S2395 A Series of Unfortunate Events: A Unique Case of Multiple Small Bowel Malignancies in the Setting of Inflammatory Bowel Disease

Introduction: Crohn’s disease (CD) is known to increase malignancy risk. Both large and small bowel adenocarcinoma and intestinal carcinoid tumors have been reported at increased rates in patients with CD but rarely concurrently. Additionally, there is an association between Non-Hodgkin Lymphoma and CD, however this is attributed to the use of immunosuppressive medications. We present a patient with a history of follicular lymphoma and ileal CD who later developed two separate small bowel malignancies. Case description/methods: The patient is a 63-year-old male with hypertension, chronic kidney disease, pulmonary embolism, and follicular lymphoma. His follicular lymphoma was diagnosed in 2009 by axillary lymph node biopsy after presenting with lower extremity swelling, night sweats, and weight loss. Staging CT scans prior to treatment demonstrated thickening of the ileum. He was treated with chemotherapy for two years and then remained on maintenance therapy. Five years after diagnosis, the patient was evaluated for 20 years of intermittent diarrhea. Endoscopic evaluation revealed CD of his ileum as well as a duodenal nodule. Elevated serum gastrin and chromogranin A levels, a positive octreotide scan, and EUS fine needle aspiration confirmed the nodule as a stage 1 duodenal carcinoid tumor which was subsequently resected. The following year, he developed fatigue and was noted to have iron deficiency anemia. Repeat EGD and colonoscopy was unrevealing thus he had a video capsule study which demonstrated narrowing of his ileum. CT enteroclysis revealed inflammation in his ileum. He underwent a small bowel resection and surgical pathology confirmed intestinal-type moderately differentiated adenocarcinoma of the ileum. Discussion: This case describes a unique course of a patient with follicular lymphoma and CD developing two small bowel malignancies related to underlying CD. While there are reports of CD developing as a treatment related complication of NHL and NHL developing as a treatment related complication of CD, our patient likely had untreated CD at time of his lymphoma diagnosis. This untreated CD likely led to the development of adenocarcinoma and his carcinoid is also likely associated with his CD. While it is rare to develop multiple small bowel malignancies, this case highlights the importance of maintaining a high index of suspicion of symptom changes in CD patients as they may be indicative of treatment specific and/or CD complications which may ultimately change management.

Quality assurance review: Intra-operative evaluation of sentinel lymph nodes in breast cancer.

BackgroundIntraoperative consultation (IOC) of axillary sentinel lymph node (SLN) biopsy continues to play a role in selected breast cancer patients. The reported sensitivity rates for intraoperative SLN evaluation in breast cancer range from 47% to 80%. We study a center where the majority of SLN IOC is performed by imprint cytology, and a protocol was established to limit microscopic examination to three slides for a reporting TAT goal of 30 min.MethodsApproval to conduct this study was obtained from the REB. A retrospective review was performed on all consecutive SLN cases sent for IOC. Reported IOC assessments of all cases were compared with the final pathology.ResultsOf 164 patients, there were 22 (13%) false negative IOC events, including 15 missed macro‐metastasis and 7 missed micro‐metastasis. The overall sensitivity for touch imprint in detecting SLNs macro‐metastasis was 70.9%. Reporting total turnaround time was on average 3 min longer, whereas sensitivity and specificity were not significantly different in the two protocol periods.ConclusionImplementation of an IOC policy for a maximum of three slides for imprint cytology did not result in a significant impact on the sensitivity, specificity, or total turnaround time for SLN in breast cancer patients. False negative IOC events were mainly due to sampling error. Quality review was made difficult by limited documentation related to the gross handling of the specimens at IOC. System factors identified include insufficient space for the IOC report on the pathology requisition, and the lack of clearly communicated expectations for documentation.

Desmoid fibromatosis of the breast; a rare case report.

IntroductionDesmoid tumor is an uncommon tumor with variable spectrum ranged from being a locally lesion to an aggressive and destructive one. The current case aims to report a rare condition of desmoid type fibromatosis of the breast.Presentation of caseA 59-year-old female presented with a right breast mass for 9-months. Mammography showed a small speculated iso-hyper dense mass, just anterior to the pectoralis muscle measuring about 15 mm (M5) in longest axis. Ultrasound examination revealed an irregular mass with internal vascularity and posterior shadowing in the right breast with a single borderline lymph node (25 ∗ 14 mm of 4 mm cortex). Wide local excision with sentinel axillary lymph nodes biopsy was performed. Histopathological examination of the specimen confirmed the diagnosis of desmoid type fibromatosis of the breast.DiscussionThe etiology of this tumor is unknown, however, physical, hormonal and genetic factors have a significant role in the development of desmoid tumor.ConclusionDesmid type fibromatosis of the breast is an uncommon, benign, locally aggressive fibroblastic tumor with lack of metastatic potential, it may present with features of malignancy.

ABCL-365: Non-Hodgkin Lymphoma Developed in the Clinical Course of a Child with Wiskott-Aldrich Syndrome

Context Wiskott-Aldrich syndrome (WAS) is a rare X-linked disorder characterized by thrombocytopenia, dermatitis, recurrent infections, and malignancies. Hematological malignancies are common in WAS patients; unfortunately, they usually have a poor prognosis. Objective Evaluation of a clinical case of hematologic malignancy in a child diagnosed with primary immunodeficiency WAS. Methods We analyzed clinical records, lymph node biopsy, thrombocyte count, serum immunoglobulins, and genetics. Results A three-year-old male child, born to non-consanguineous parents, with a neonatal history of respiratory infections, eczema, and thrombocytopenia, was admitted to our department. Clinical examination revealed bilateral pneumonia, cervical lymphadenopathy (2×2 cm) with 4-month duration, eczematous lesions over the face, and multiple ecchymotic patches over the upper and lower limbs. With a clinical suspicion of Wiskott-Aldrich syndrome (WAS), he was investigated further. His platelet counts were variable, with a minimum of 18–20x109/L, with a mean platelet volume of 11 fL. Clinical symptoms correlated with leukocytosis, with values over 24x109/L, a left shift (non-segmented neutrophils 10%–36%), and relative lymphopenia 12%–22%. Because immunodeficiency was suspected, immunological investigations were performed, and evaluation of serum immunoglobulins showed increased concentrations of total immunoglobulin E, ranging from 85 µE/mL to 2000 µE/mL (age norm is G in intron 2 of the WAS gene. Computed tomography revealed multiple, large, coalescent nodes in the cervical, axillary, mediastinal, and perihilar regions. The patient subsequently underwent a right axillary lymph node biopsy, which was reported as diffuse large B-cell lymphoma patients (DLBCL). According to his immunological and hematological diagnosis, he was admitted to the hematological department for the preparation and initiation of a bone marrow transplant. Conclusions Variable clinical forms can be present in WAS. Due to poor immunological response, patients frequently develop malignancy, with NHL being the most common. Prognosis of NHL in WAS remains poor, and transplant remains the only curative therapy presently for WAS.

Is image-guided core needle biopsy of borderline axillary lymph nodes in breast cancer patients clinically helpful?

BackgroundWhen borderline axillary lymph nodes (bALN) are identified on ultrasound (US) for breast cancer (BC) patients, preoperative management is unclear. We aimed to evaluate if core needle biopsy (CNB) for bALN is clinically helpful or disruptive. MethodsRetrospective review of BC patients with bALN from 2014 to 2019 was performed. Clinicopathologic data were compared for those who did and did not have CNB. ResultsCNB (n = 34) and no CNB (n = 31) were similar with respect to clinicopathologic factors. Surgical LN-positive rate was the same between cohorts (p = 0.26). CNB was disruptive in 58.8 %; all had CNB for pN0 disease. CNB was helpful in 34.2 %: 14.7 % proceeded directly to axillary dissection; 17.6 % had positive LN localized after neoadjuvant chemotherapy. ConclusionsCNB for bALN is more likely clinically disruptive and did not impact surgical LN positive rate. BC patients with bALN should undergo CNB only if it will change clinical management.

Is ultrasound-guided fine needle aspiration biopsy of axillary lymph nodes a viable alternative to sentinel lymph node biopsy?

Axillary lymph node (ALN) ultrasound-guided fine needle aspiration biopsy (US-FNAB), a minimally invasive procedure, may be used for the preoperative evaluation of ALN status of breast cancer patients. Despite the relative ease of use and low cost, paucity of comparative studies and variation in the reported sensitivity of FNAB preclude its clinical utility in evaluation of ALNs. This study aims to determine the accuracy of US-FNAB in detecting metastasis in ALN pre-operatively and to assess US-FNAB as a viable alternative to sentinel lymph node (SLN) excision. The 228 consecutive ALN US-FNABs with subsequent histologic follow up performed from 2005 to 2020 in patients with breast carcinoma were retrospectively evaluated. FNAB results were correlated with histologic diagnosis. Sensitivity, specificity, accuracy, and risk of malignancy of FNAB were calculated. 157/228 (69%) FNABs were concordant with histology, 37/228 (16%) discordant. Positive FNAB findings correlated with primary tumor size, grade, number of metastatic lymph nodes and size of metastases. FNAB with negative diagnosis carried a 22% risk of malignancy, atypical 43%, suspicious 80%, and positive a 100% risk of malignancy (100% positive predictive value [PPV]). The sensitivity and specificity were 78% and 95% respectively; accuracy was 77%. SLN biopsy was avoided in all 82 (36%) cases with positive FNAB results. Negative FNAB result does not exclude metastatic carcinoma. With 100% PPV, full ALN dissection and/or neoadjuvant chemotherapy can be safely planned after a positive FNAB result, avoiding SLN biopsy, reducing management costs and shortening time interval to definitive therapy.

Diffuse Large B-Cell Lymphoma With a Background of Extensive Granulomatous Inflammation: A Potential Pitfall for Misdiagnosis

Granulomatous inflammation has been reported to be associated with Hodgkin and non-Hodgkin lymphomas. Here, we report a case of recurrent diffuse large B-cell lymphoma (DLBCL) with extensive granulomatous inflammation that was initially misdiagnosed as granulomatous lymphadenitis. In 2019, a 75-year-old Caucasian male presented to our hospital with an enlarged right supraclavicular lymph node. He had a medical history of prostate cancer (in 2004), DLBCL (initially diagnosed in 2009), and rectal adenocarcinoma (in 2017), all of which responded well to treatment. In 2018, the patient had experienced right axillary adenopathy, weight loss, and intermittent night sweats. An excisional biopsy of a right axillary lymph node, performed at another institution, was diagnosed as granulomatous lymphadenitis. In 2019, at our hospital, an excisional biopsy of a right supraclavicular lymph node showed DLBCL in a background of granulomatous inflammation. A review of the prior right axillary lymph node biopsy also showed DLBCL with a background of extensive granulomatous inflammation. Chemotherapy was initiated and the patient’s follow-up showed a good response. We report this case to raise awareness that granulomatous inflammation may obscure the diagnosis of some neoplasms, such as DLBCL, which are less commonly known to have granulomatous inflammation. This may result in delayed treatment and may ultimately affect outcomes.

Follicular Lymphoma Response with CDK4/6 Inhibitor(Palbociclib) Utilized in the Setting of Metastatic Breast Cancer

INTRODUCTIONHere we report our clinical observation and first objective evidence of partial response seen in follicular lymphoma from the use of drug (palbociclib) that inhibits cyclin D-dependent kinases (CDK) CDK4 and CDK6. CASE HISTORYA 66 year old female with metastatic breast cancer in the bones and relapsing nodal follicular lymphoma (FL) was initiated on Palbocilib and fulvestrant for her breast cancer.The details of her Non-Hodgkin's lymphoma (NHL) history include her initial presentation in 2005 with large cell lymphoma. She underwent treatment with four cycles of R-CHOP and four cycles of RICE (dose of anthracycline was limited given prior exposure of doxorubicin administered for breast cancer). She achieved complete remission. The patient later relapsed with follicular lymphoma grade I/II in 2011 requiring treatment with six cycles BR(bendamustine, rituximab) followed by two years of R-maintenance. Her treatment completed in 2013. She remained in remission for the next two years and relapsed again in late 2015 with right breast mass and multiple lymph nodes above and below the diaphragm. Biopsy of breast mass and right axillary lymph nodes showed FL Grade IIIa.CD10+, Bcl-2+, Bcl-6+ and Cyclin D1 negative.The details of breast cancer include the initial diagnosis in 2003 stage T2N1 ER/PR positive (estrogen, progesterone), Her-2 was negative. She underwent treatment with lumpectomy, sentinel lymph node biopsy and axillary lymph node dissection. She also received Cyclophosphamide and doxorubicin (AC) for four cycles followed by paclitaxel for four cycles and five years of anastrazole. Later in 2013 as patient completed R-maintenance for the follicular lymphoma she presented with pathological fracture of T8 vertebral body. Biopsy confirmed metastatic breast cancer. CAT-scans showed extensive sclerotic bony metastasis consistent with metastatic breast cancer. The patient received hormonal therapy letrozole and zoledronic acid. The patient responded very well with decrease in breast tumor marker (CA 15-3) and improvement of skeletal pain.The patient progressed two years later in late 2015 with CAT-scan showing progression of sclerotic bone lesions with multiple new foci noted. The imaging also showed multiple areas of lymph nodes above and below diaphragm. Patient also developed palpable right breast mass 3cm and PET-scan showed multiple FDG-avid lymph nodes including bony sclerotic PET-avid lesion. The biopsy of breast mass and axillary lymph nodes showed FL. The radiological progression was also seen in the previously biopsy proven bony sclerotic lesion showing breast cancer. The plan was made to pursue treatment with breast cancer as patient had significant skeletal pain along with once again rise in tumor marker CA 15-3.Patient was initiated treatment on palbocilib and fulvestrant in early 2016. Three months later right breast nodal mass and axillary lymph node was not palpable. PET-scan showed decrease in the size and metabolic activity. Most of the lymph nodes showed shrinkage in size as well as SUV consistent with partial response. With respect to metastatic breast cancer tumor markers normalized and sclerotic foci in the bones also showed radiological improvement.To date patient continues to do well with respect to both malignancies. She has not required any treatment for the FL and does appear to maintain partial response from CDK4/6 inhibition. CONCLUSIONFL is a common and incurable form of NHL characterized by the translocation t (14;18) that results in increased expression of the anti-apoptotic BCL2 protein. Exactly what drives expansion of the malignant B-cells in FL is not clear. However recurrent genetic lesions targeting cell cycle control in FL have been reported including mutation in CYCLIN D3 gene, chromosomal gains of CDK4, losses of CDKN2a/b and RB1.We have seen clinical and radiological evidence of response with regard to FL while patient was on treatment with CDK4/6 inhibitor for the indication of metastatic breast cancer. Given that now we already have Bcl-2 inhibitor drug venetoclax which is approved for CLL, this early clinical observation leads us to hypothesize that it would be worth exploring the combination of CDK4/6 inhibition with BCl-2 inhibitor in FL for further exploration. DisclosuresNo relevant conflicts of interest to declare.

MYCOBACTERIUM AVIUM COMPLEX ASSOCIATED IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME IN HIV- INFECTED PATIENT

The incidence of Mycobacterium avium Complex (MAC) Disease in HIV-infected individuals has significantly decreased in recent years due to the introduction of Highly Active Antiretroviral Therapy (HAART) and the initiation of Clarithromycin prophylaxis. We present the case of a patient with advanced AIDS, with generalized lymphadenopathy and digestive symptoms, diagnosed with disseminated MAC, a diagnosis which was based on the results obtained from axillary lymph node and intestinal biopsies. Considering the time of the MAC diagnosis in relation to the recent introduction of antiretroviral (ARV) therapy, we considered immune reconstitution inflammatory syndrome (IRIS) with good evolution under azithromycin, ethambutol and moxifloxacin treatment.

P06. First do no harm: Reducing morbidity from excision biopsy of axillary lymph nodes

Background: Often no guidelines exist within a hospital for the appropriate pathway for unexplained axillary lymphadenopathy. Excision biopsy of axillary lymph nodes is a morbid procedure. It is frequently done on the emergency list by the on call surgical registrar or at the end of a busy breast list. We should think again.

P05. Is precautionary Axillary lymph node (ALN) Fine needle aspiration (FNA) or biopsy needed in patients with T2 lesions and above

Introduction/Aim: Bigger breast tumours have a higher tendency of ALN involvement in most cases. Our study aims to find out the relation between tumour size and axillary involvement, to establish whether precautionary ALN biopsy is needed in T2 lesions and above (≥) which will avoid a second axillary surgery.

Near-infrared laparoscopy with indocyanine green for axillary sentinel lymph node biopsy in early breast cancer: preliminary experience of a single unit.

A sentinel lymph node biopsy (SLNB) is a routine procedure for axillary staging in cN0 breast cancer (BC) patients. Indocyanine green (ICG) fluorescence can detect sentinel lymph nodes with higher sensitivity than carbon nanoparticle suspension (CNS). The present study investigated the availability and benefits of a near-infrared (NIR) laparoscopy-assisted SLNB using ICG and carbon nanoparticle suspension as tracers. Forty patients with invasive BC, who had clinically negative axillary lymph nodes, participated in this observational study. ICG and CNS tracers were injected into the periareolar region simultaneously or sequentially. In the endoscopy-assisted group (n=20), the patients were given NIR laparoscopic SLNB based on ICG fluorescence and CNS staining. In the open-surgery group, the patients were given traditional SLNB using an open incision, and CNS tracers were injected into the same region as that in the endoscopy-assisted group. In the endoscopy-assisted group, lymphatic vessels and sentinel lymph nodes (SLNs) were successfully identified using ICG fluorescence imaging in most patients (19/20). The average number of SLNs removed was 2.85 (range, 1-4) in the endoscopy-assisted group, and 3.40 (range, 1-7) in the open-surgery group. There was no significant difference between the number of detected nodes (P=0.30). The patients who underwent endoscopy-assisted SLNBs had similar operating times, blood loss and hospital-stay lengths, but lower postoperative drainage volumes and higher satisfaction scores, as they did not have axillary incisions. The NIR laparoscopy-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLNB with good efficacy and acceptable safety. When combined with CNS, more SLNs can be detected and dissected.

Kikuchi Fujimoto as an Initial Presentation of Systemic Lupus Erythromatosis


 
 
 
 Kikuchi-Fujimoto Disease (KFD) is a rare benign, condition of necrotising histiocytic lymphadenitis. In this case report, we discuss a case of 10 year old male patient who presented with a fever, rash and generalised lymphadenopathy that was not attributable to the more common causes. Axillary lymph node biopsy confirmed the diagnosis of KFD. Treatment with prednisolone improved his symptoms but after six months he had recurrence of his symptoms. He was investigated again and finally met diagnostic criteria for SLE. This case report highlights importance of close follow up in a child with KFD.
 
 
 

The influence of preoperative biopsy on the surgical method in breast cancer patients: a single-center experience of 3,966 cases in China.

The National Surgical Adjuvant Breast and Bowel Project (NSABP) B32 trial reported that the detection rate of sentinel lymph nodes by core needle biopsy (CNB) is higher than that by segmental resection. However, there are few reports regarding the detection rate of sentinel lymph nodes by vacuum-assisted breast biopsy (VABB). Therefore, we analyzed the impact of preoperative biopsy methods on the surgical modes of 3,966 patients with breast cancer in our center. In total, 3,966 female breast cancer patients [clinical tumor node metastasis (TNM) stage I-III] were enrolled in this study. Preoperative pathological diagnosis methods included fine needle aspiration (FNA) biopsy, CNB, excision biopsy, and VABB. According to the time of diagnosis. The data were analysis by chi square test, variance analysis and the Kaplan-Meier time series in SPSS 22.0. There was a decrease in the number of patients that underwent excision biopsy (7.3% to 2.7%) and intraoperative freezing (89.4% to 28.9%) over time, while CNB exhibited an increasing trend (1.6% to 55.3%). The positive rates of VABB, CNB, excision biopsy, and FNA were 99.5%, 97.1%, 97.9%, and 82.2%, respectively, and the false negative rates were 0%, 1.8%, 0.34%, and 8.9%, respectively. The overall breast-conserving rate was 36.7%, while the breast-conserving rate for VABB was 57.1%. The axillary sentinel lymph node biopsy rate of cN0 patients was 48.3%, and the intraoperative frozen group (36.7%) and excision biopsy group (39.5%) were lower than the CNB (57.1%) and VABB (77.9%) groups. Until December 2019, there were 350 cases with tumor recurrence or metastasis. The methods of biopsy were not correlated to the cumulative survival time. Changes to the diagnosis and treatment of breast cancer has a profound impact on the method of tumor biopsy. VABB biopsy offers advantages such as accurate diagnosis, a greater volume of tissue taken at one time, minimally invasive and repeatable, and does not affect the surgical approach and prognosis of patients. It will gradually become the primary method of preoperative pathological evaluation of breast cancer.

Autoimmune hypophysitis as a cause of adrenocorticotropic hormone deficiency in pulmonary arterial hypertension: a case report

Background Severe pulmonary arterial hypertension (PAH) is generally treated with multiple PAH-specific vasodilators. If these agents are unsuccessful, additional treatment options are scarce, and the prognosis is poor due to right-sided heart failure. Some of these severe cases are also accompanied by endocrinological side effects. The most common side effect of prostacyclin is thyroid dysfunction, but in very few cases, adrenocorticotropic hormone (ACTH) deficiency may occur.Case summary A 35-year-old woman was diagnosed with hereditary PAH 2 years ago. Since her mean pulmonary arterial pressure was high, combination therapy of vasodilators, including prostacyclin, was introduced. Several months later, she was hospitalized with a persistent fever. Laboratory tests showed no findings suggestive of infection. However, hypereosinophilia and decreased secretion of ACTH and cortisol were noted, which led to the diagnosis of ACTH deficiency. A multimodal diagnostic approach, including pituitary magnetic resonance imaging and axillary lymph node biopsy, indicated that the aetiology of the ACTH deficiency was likely autoimmune hypophysitis. She was treated with hydrocortisone supplementation, which significantly relieved her condition.Discussion Endocrinological side effects in PAH patients using prostacyclin should be carefully addressed. If right-sided heart failure worsens during the administration of prostacyclin, it is essential to determine whether it is due to progression of pulmonary hypertension or endocrinological side effects. Careful diagnosis and treatment are important for managing the haemodynamics and symptoms of PAH patients given prostacyclin.