Upper Quadrant Research Articles

Routine upper gastro-intestinal tract endoscopy before elective cholecystectomy for symptomatic gallstones-justified

Gallstones are common in Western countries and increasing in developing countries through adoption of western lifestyle. Gallstones may cause life-threatening complications, including acute cholecystitis, acute cholangitis, and acute pancreatitis. Cholecystectomy is the treatment of choice for symptomatic gallstones. Presentation of symptomatic gallstones may be indistinguishable from that of other upper gastro-intestinal tract (UGI) pathologies. Some surgeons routinely perform preoperative UGI endoscopy to diagnose and treat concomitant UGI pathology. A prospective cross-sectional observational study was undertaken at University of Pretoria teaching hospitals to evaluate this practice. Patients aged 18 years and older, with symptomatic gallstones but did not satisfy Tokyo guidelines for acute cholecystitis were recruited. UGI endoscopy was performed before cholecystectomy. There were 124 patients, 110 (88.7%) females and 14 (11.3%) males, mean age 44.0 (13.2) (range: 22–78) years. Most common symptoms were right upper quadrant (RUQ) pain (87%), epigastric pain (59.7%), nausea (58.1%) and vomiting (47.9%). Clinically, 80% had RUQ tenderness and 52.4% epigastric tenderness. UGI endoscopy found 35.4% pathology, 28.2% were active, and comprised acute gastritis (27.4%), peptic ulcers (4.8%), duodenitis (3.2%) and oesophagitis (2.4%). Twelve patients had more than one pathology. This warranted treatment before elective cholecystectomy and justifies the practice of routine preoperative UGI endoscopy.

Sonographic Evaluation of Cholelithiasis in Diabetic Patients at District Swabi

Background: Cholelithiasis, the formation of gallstones in the gallbladder, is prevalent among individuals experiencing abdominal discomfort such as epigastric pain, nausea, and loss of appetite. The relationship between diabetes and the increased risk of developing gallstones has been noted, highlighting the importance of understanding this association for better disease management. Objective: The aim of this study was to evaluate the prevalence and characteristics of gallstones in diabetic patients in the district of Swabi using ultrasonography to enhance early diagnosis and treatment approaches. Methods: This cross-sectional study was conducted at the Department of Radiology, District Head Quarters Hospital, Swabi, Pakistan. Participants included individuals presenting with upper right quadrant pain or with a history of diabetes. Ultrasonographic examinations were performed using a Toshiba Xeiro convex probe with a frequency range of 3-5 MHz. Data was collected through clinical histories and radiographic examinations, and analyzed using SPSS version 25. Ethics approval was obtained in accordance with the Declaration of Helsinki, and all participants provided informed consent. Results: A total of 112 patients were enrolled with ages ranging from 8 to 80 years (mean ± SD = 39.37 ± 16.72 years). Females constituted 56.4% (n=62) and males 43.6% (n=48) of the study population. The majority, 88.2% (n=97), reported right hypochondriac pain. Among the patients, 60% (n=66) had multiple gallstones; of these, 36.4% (n=24) were diabetic. Conversely, 40% (n=44) had a single stone, with 38.6% (n=17) being diabetic. Conclusion: The study indicates a significant association between diabetes and the presence of multiple gallstones, underscoring the need for routine ultrasonographic screening in diabetic patients experiencing right hypochondriac pain. Early detection could lead to better management and potentially reduce complications associated with cholelithiasis.

Incidental finding of an arteriovenous malformation originating from the diaphragm: Case report and literature review

Arteriovenous malformations (AVMs) are defined as aberrant linkages between arteries and veins in the absence of a capillary network. This case report will discuss the incidental finding of an AVM likely originating from the diaphragm. A 65-year-old female presents for an umbilical hernia repair. Her past medical history is significant for HTN, type 2 diabetes mellitus, gastroesophageal reflux disease, and class 1 obesity. She has a past surgical history of hysteroscopy in 2020 and laparoscopy in 1996. She has no history of tobacco use, alcohol use, or recreational drug use. She is allergic to contrast. A computed tomography (CT) scan was ordered and incidentally showed a soft tissue mass in the left upper quadrant adjacent to the stomach and diaphragm, possibly a gastrointestinal stromal tumor (GIST) or splenule, in addition to diastasis of the abdominal wall. Biopsies of the esophagus, stomach, and duodenum from the esophagogastroduodenoscopy (EGD) were all benign. A nuclear medicine scan of the liver and spleen found an estimated 2.3 cm soft tissue nodule located between the fundus of the stomach and the left hemidiaphragm that does not demonstrate sulfa colloid uptake and is therefore not consistent with a splenule. This is the only incidence cited of an AVM originating from the diaphragm. We suspect that the origin of this AVM is the inferior phrenic artery. The decision for management for this case was to get a CT scan of the abdomen and chest to trace the path of the AVM and manage with surveillance.

Marked gallbladder wall thickening caused by Epstein–Barr virus‐induced infectious mononucleosis

Key Clinical MessageIn patients with symptoms of viral infection and marked thickening of the gallbladder wall, it is important to suspect acalculous cholecystitis due to Epstein–Barr virus‐induced infectious mononucleosis.AbstractA 35‐year‐old Japanese man presented with fever, abdominal right upper quadrant pain, and liver dysfunction. Positive immunoglobulin M and ‐G antibodies and negative nuclear antigen for Epstein–Barr virus were observed. Abdominal ultrasonography revealed a markedly thickened gallbladder wall. Acalculous cholecystitis due to Epstein–Barr virus‐induced infectious mononucleosis was diagnosed.

Cholelithiasis Diagnosis and Management in Thalassemia

Background: Cholelithiasis, while infrequently found in children, carries a significant risk for those with underlying conditions like thalassemia compared to the general population. This study aimed to described the manifestations of cholelithiasis in thalassemic children. Case: A 12-year-old girl with beta-thalassemia major presented with recurrent right upper quadrant abdominal pain and vomiting. Imaging revealed cholelithiasis and choledocholithiasis. Due to complications related to her thalassemia, she underwent endoscopic retrograde cholangiopancreatography (ERCP) for gallstone removal followed by laparoscopic cholecystectomy. Post-operative management addressed post-ERCP pancreatitis and bleeding concerns. The patient recovered well and is scheduled for follow-up. Discussion: Increased bilirubin production, iron overload, and altered bile properties in beta-thalassemia contribute to cholelithiasis risk. The patient presented with typical symptoms and underwent successful laparoscopic cholecystectomy after initial management with ERCP, which led to post-ERCP pancreatitis. Conclusion: This case underscores the elevated risk of cholelithiasis in thalassemic children and the importance of early diagnosis and intervention for optimal outcomes.

Incomplete microvascular reperfusion in a swine model of recanalized acute ischemic stroke

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CONTRAST CONSORTIUM (CVON, Dutch Heart Foundation) Background Incomplete microvascular reperfusion (IMR) could be a detrimental factor impairing regained functionality in stroke patients despite early recanalization. However, the presence of this phenomenon remains to be ascertained. Gyrencephalic large-animal models of acute ischemic stroke (AIS) such as swine are gaining attention as a next step in translation of preclinical to clinical stroke research, with brain anatomy and hemostasis more similar to humans. However, the occurrence and relevance of IMR in swine models of AIS is not well described yet, since most models do not include recanalization. Purpose We aimed to study the presence of IMR after brain ischemia in a translational swine model of AIS. Methods Anesthetized female Yorkshire-Landrace pigs (n=23) underwent craniotomy to occlude the right-sided middle cerebral arteries with aneurysm clips. Clips were released after 1 (n=5), 2 (n=5), and 4 (n=5) hours of occlusion to allow recanalization for 4 hours (recanalized AIS, n=15) or left in place for 8 hours (non-recanalized AIS, n=5). Three animals underwent the craniotomy without vessel clipping (Sham, n=3). 3D angiography was used to confirm occlusion and recanalization. Brains were collected after sacrifice, stained with TTC and then processed for histologic analysis. Infarct size was determined by TTC staining and expressed as percentage of the infarcted hemisphere. Histologic sections of the upper quadrant of the left and right hemispheres were immuno-stained with CD61 to visualize platelet aggregates in the microvasculature. Intravascular platelet aggregates (Figure 2A) were quantified using automated software analysis (Orbit) (CD61+ aggregates/mm2). Results All animals survived until the end of the procedure. Figure 1 shows differences in infarct size depending on the duration of occlusion (p=0.006). Figure 2 depicts an overall higher presence of platelet (CD61+) aggregates in the right hemisphere (infarct) compared to the left hemisphere (intact) (Figure 2B). There was a significant difference in platelet aggregates between left and right hemisphere but groupwise comparison showed only a trend (p=0.075) for more aggregates in the right hemisphere, compared to left, after 4 hours occlusion. Linear regression model could not identify whether infarct size and duration of occlusion were independent predictors of the number of platelet aggregates in the right hemisphere (p=0.191). Conclusions IMR occurs after brain ischemia in a swine model of AIS as a result of microvascular platelet aggregates. Further analysis and experiments are needed to elucidate which predictors can explain intravascular platelet aggregation.Infarct SizePlatelet aggregates

Adrenal Pseudocyst, Case Report

Pseudocyst type of adrenal cysts is most common; however, this type of ectopic cyst is quite rare in excessively large adrenal cysts. A35-year-old woman was admitted to our institution with distension of her right flank and the upper quadrant of her abdomen. Abdominal ultrasonography revealed a cystic lesion with a homogenous anechoic texture, and measuring 28 cm in diameter. Computed tomography imaging displayed a giant cystic lesion adjacent to the liver, pancreas, kidney. The origin of the cyst was not identified. We were not able to make a preoperative diagnosis; therefore, the patient underwent resection of the mass by open laparotomy for therapeutic diagnosis. Intraoperatively, the mass was identified to be cystic and adhered to the right adrenal gland. It was filled with more than 2500 mL of serous brown fluid. The content of the cyst contained no atypical cells on cytological examination, and the cyst was pathologically classified as a pseudocyst cyst. We describe a case of a patient with a giant pseudocyst of the adrenal gland. The present data suggest that surgeons should decide treatment strategy for large adrenal cysts in consideration of hormonal function, degree of size, and possibility of malignancy.

Impact of Intraoperative Nefopam on Postoperative Pain, Opioid Use, and Recovery Quality with Parietal Pain Block in Single-Port Robotic Cholecystectomy: A Prospective Randomized Controlled Trial.

Background and Objectives: This study explored how nefopam, a non-opioid analgesic in a multimodal regimen, impacts postoperative pain, opioid use, and recovery quality in single-port robot-assisted laparoscopic cholecystectomy (RALC) patients with a parietal pain block, addressing challenges in postoperative pain management. Materials and Methods: Forty patients scheduled for elective single-port RALC were enrolled and randomized to receive either nefopam or normal saline intravenously. Parietal pain relief was provided through a rectus sheath block (RSB). Postoperative pain was assessed using a numeric rating scale (NRS) in the right upper quadrant (RUQ) of the abdomen, at the umbilicus, and at the shoulder. Opioid consumption and recovery quality, measured using the QoR-15K questionnaire, were also recorded. Results: The 40 patients had a mean age of 48.3 years and an average body mass index (BMI) of 26.2 kg/m2. There were no significant differences in the pre- or intraoperative variables between groups. Patients receiving nefopam reported significantly lower RUQ pain scores compared to the controls, while the umbilicus and shoulder pain scores were similar. Rescue fentanyl requirements were lower in the nefopam group in both the PACU and ward. The QoR-15K questionnaire scores for nausea and vomiting were better in the nefopam group, but the overall recovery quality scores were comparable between the groups. Conclusions: Nefopam reduces RUQ pain and opioid use post-single-port RALC with a parietal pain block without markedly boosting RSB's effect on umbilicus or shoulder pain. It may also better manage postoperative nausea and vomiting, underscoring its role in analgesia strategies for this surgery.

Assessment of Masses in the Right Upper Quadrant using Ultrasound Imaging: A Comprehensive Diagnostic Approach for Clinical Evaluation in Bangladesh

Ultrasound serves as a pivotal tool in identifying and assessing masses in the right upper quadrant (RUQ) of the abdomen, crucial for determining precise organ involvement, composition, characteristics, and extension into neighboring structures. This cross-sectional prospective study conducted at various medical facilities in Dhaka enrolled 130 patients, utilizing real-time ultrasound with a 3.5MHz transducer. Among the 100 patients with abnormal sonographic findings, 40% exhibited RUQ masses, predominantly affecting males (75%). Liver masses were most common (75%), including abscesses, hepatocellular carcinomas, secondary lesions, hemangiomas, and simple cysts. Gall bladder masses (10%) mostly consisted of advanced stage carcinomas and polyp-like masses. Right renal masses (15%) comprised simple cysts, severe hydrone-phrosis, renal cell carcinoma, and angiomyolipoma. Ultrasound emerges as the preferred initial imaging modality for RUQ mass detection, offering high diagnostic accuracy, non-invasiveness, affordability, and widespread availability. While supplementary investigations like serological tests, CT scans, and histopathology may be necessary for definitive diagnoses, ultrasound aids in formulating initial patient management guidelines. Despite its limitations, ultrasound remains popular and highly preferred for RUQ imaging, emphasizing its significance in clinical practice.

Robotic Splenic Flexure Takedown: Single Docking Crossed-Arm Technique.

Splenic flexure mobilization is typically required in the management of left-sided colon and rectal resections to achieve tension-free anastomosis. Although the da Vinci Xi® surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was designed for multi-quadrant operations, robotic mobilization of the splenic flexure continues to be challenging for some surgeons. Re-docking and patient repositioning may be required, which can be time-consuming, especially in centers without motion-activated operating tables. However, there are some tips and tricks to overcome these challenges. Here, we describe our single docking crossed-arm technique, which facilitates splenic flexure mobilization. We demonstrate our technique in a 61-year-old woman with sigmoid colon cancer, and informed consent was obtained. The operation starts in the medial-to-lateral approach by ligating the inferior mesenteric artery and vein. After the left colon mobilization, robotic arm one (tip-up fenestrated grasper) is positioned on the patient's left, while arms two, three, and four are on the patient's right. A tip-up fenestrated grasper, inserted through port #1, retracts the descending colon medial and inferior towards the cecum. Then, we cross the arms from the lateral aspect of arm one and takedown the flexure without the collision of robotic arms. After the lateral side dissection is completed, we change the position of the instruments to mobilize the transverse colon. This time, the tip-up grasping instrument is used to retract the colon through the left lower quadrant, which enables us to work in the medial aspect of the grasping instrument. Dissection can be performed using bipolar forceps, monopolar scissors, or vessel-sealing devices. We achieved complete mobilization of the splenic flexure. With this technique, dissection can be carried medially and cranially beyond the falciform ligament. After the splenic flexure takedown and freeing up the mesocolon above the pancreatic body, tension-free anastomosis can be performed. In this approach, re-docking is not necessary. During robotic left-sided colorectal surgery, the crossed-arm technique with single docking avoids robotic arms collision and restricted mobility of the left upper quadrant instrument (port#1). This technique facilitates robotic splenic flexure mobilization and eliminates re-docking/repositioning, leading to shorter operative time and improved intraoperative flow. See Video Vignette.

Hypometabolism in the Posteromedial Temporal and Medial Occipital Cortex on Preoperative 2-Deoxy-2-(18F) Fluoro-D-Glucose Positron Emission Tomography Suggests Exacerbation of Visual Field Defects After Surgery for Temporal Lobe Epilepsy: A Retrospective Long-Term Follow-Up Study

ObjectiveSurgery is a good treatment option for drug-resistant temporal lobe epilepsy (TLE). 2-deoxy-2-(18F) fluoro-D-glucose (FDG) positron emission tomography (PET) is used to detect epileptic foci as hypometabolic lesions in presurgical evaluation. Visual field defects (VFDs) in the contralateral homonymous upper quadrant are common postoperative complications in TLE. This study aimed to quantify VFDs using pattern deviation probability plots (PDPPs) and examine the effect of hypometabolism in FDG-PET on VFDs. MethodsThis study included 40 patients. Both visual fields were assessed using the Humphrey field analyzer (HFA) preoperatively and 3 months and 2 years postoperatively. PDPPs with <0.5% confidence level counted in the contralateral homonymous upper quadrant. FDG-PET results were compared between groups with (15 patients) and without (24 patients) hypometabolism in the optic radiation. ResultsAll 40 patients were evaluated by HFA at 3 months postoperatively and 39 at 2 years postoperatively. The incidence of VFDs 3 months postoperatively was 35/40 (87.5%), and 17/40 (42.5%) patients had severe VFDs. In cases of surgery on the left temporal lobe, ipsilateral eyes appeared to be more significantly affected than contralateral eyes. VFDs were more severe in patients with FDG hypometabolism than in those without hypometabolism in posteromedial temporal and medial occipital cortex (P < 0.01); however, 85% of patients with FDG hypometabolism had a reduced VFD 2 years postoperatively. ConclusionPDPP counting is useful for quantifying VFDs. Preoperative dysfunction indicated by preoperative FDG-PET in the posteromedial temporal and medial occipital cortex could enhance VFDs early after TLE surgery.

Characteristics of her2-positive breast cancer, and the current use of anti-her2 therapy and its related factors

ABSTRACT Objective: To describe the characteristics of patients with HER2-positive breast cancer and to identify the proportion of patients using anti-HER2 therapy, and treatment-making related factors. Methods: An analytical cross-sectional study was conducted on 79 patients with BC and HER2-positive diagnosed by immunohistochemistry (IHC) or with FISH at the Oncology Department of Hue University of Medicine and Pharmacy Hospital and Oncology Center of Hue Central Hospital from 1/2021 to 12/2022. Clinical and pathological features, type of drug, number of cycles using anti-Her2 therapy were recorded using medical documents. The decision-making related factors were recorded by questionnaire interviewing patients and relatives. Exclusion criteria included recurrent or previously treated tumors; having contraindications with anti-HER2 therapy; not being willing to participate in the study. SPSS 22.0 was used for the analysis. Results: Mean age was 54.14 ± 11.03. Patients with right-sided BC accounted for 53.1%. 60.8% of tumors were located in the upper right quadrant of the breast. Patient’s self-report of lumps was the most common cause of hospitalization (77.2%). By ultrasound, 60.2% of participants had a tumor size of 2 - 5cm. Abnormal lymph nodes were identified in 40.8% of patients. Histopathologically, invasive ductal carcinoma was found in the majority of tumors (75.9%). Stage II was predominant with 59.5% and 7.6% of patients with stage IV. The rate of treatment with Trastuzumab in our study was 27.8%. The main reason that patients refused anti-HER-2 therapy was financial problems (96.5%). The awareness of anti-HER2 therapy among patients and their relatives was significantly associated with the treatment decision (p = 0.007). Conclusion: Regarding the positive-HER2 BC patients, invasive ductal carcinoma was the major histopathological finding. More than half of the patients were classified as stage II of the disease. The rate of patients undergoing antiHER2 therapy was 27.8%. Financial problems were found to be the main reason for refusal of treatment. Awareness of anti-HER2 therapy is significantly associated with the patient’s decision on treatment.

Screening of Breast among Women: A Cross-Sectional Study in Nepal

Background. Breast cancer ranks as the second most prevalent malignancy among women in Nepal. This cancer has a high likelihood of cure, if detected early. Therefore, it is imperative to emphasize awareness and screening for breast cancer in Nepal. It indeed underscores the importance of clinical breast examination. The study aims to find the disease burden, association of abnormal breast condition with sociodemographic variables, and the need for change in the breast cancer screening protocol. Methods. A cross-sectional study was conducted from July to September 2023 on 100 female participants who were older than 18 years. Data were collected through face-to-face interviews using a structured questionnaire. The chi-square test was used to compare nominal variables while the independent sample t-test and the paired sample t-test were used to compare nominal and continuous variables. Results. The findings of the study showed that 19% of all participants complained about abnormal breast, out of which 31.7% reported lumps, 26.31% reported discharge , another 26.31% reported pain, and the remaining 15.7% reported soreness. The upper outer quadrant and lower inner quadrant each individually accounted for 33.33% of the abnormal findings. The complaints of the participants in our study were significantly correlated with age at marriage, number of pregnancies, and use of contraception. Conclusion. Our study revealed considerable abnormal breast findings. This warrants the need for the change in breast cancer screening protocols which lead to early diagnosis and higher curability.

Pericardial effusion and impaired diastolic cardiac function as a result of a giant colonic diverticulum

This case report describes a Giant Colonic Diverticulum (GCD) found in association with a significant pericardial effusion and impaired cardiac function. A 63-year-old man presented to the Emergency Department with bilateral leg edema, mild dyspnea, and diarrhea. An echocardiogram demonstrated a large pericardial effusion and abnormal diastolic cardiac function. Abdominal imaging studies identified a 29 cm x 18 cm x 13 cm gas filled structure in the left upper quadrant concerning for GCD causing significant compression of the left lung and heart. Following surgical resection, the pericardial effusion resolved, cardiac function normalized, and the patient’s leg swelling improved. This is the first case report to record an association between GCD and pericardial effusion with impaired diastolic cardiac function.

Breast Vascularization and Its Implication in Breast Reduction and Mastopexy Surgery: Anatomical Study.

(1) Background: Breast reduction is one of the most frequently performed plastic surgeries in women worldwide. The Wise pattern breast reduction is one of the most frequent skin designs for this surgery. One key point of the surgery is to preserve a well-vascularized NAC by using different surgical pedicles. This study aims to test and update the anatomical knowledge of breast vascularization, the topographic and anatomical basis of the different surgical vascular pedicles, and the differences between the right and left sides. (2) Methods: A descriptive observational anatomical study was carried out on 15 breasts from 10 cryopreserved body donors. A dissection was performed by quadrants to know the affected arteries' origin in the different patterns. (3) Results: The largest and most frequently dissected internal mammary perforator artery was in the second intercostal space. A total of 44.9% of the dissected perforators are located in the upper inner quadrant, compared to 53.5% in the lower quadrants. (4) Conclusions: The upper inner quadrant alone has the most arterial perforators. In contrast, the sum of the two lower quadrants represents the greatest vascularization of the breast, with a small difference between both.

Clinical Presentation and Risk Factors of Acalculous Cholecystitis in Outpatients, a Literature Review and Retrospective Study

Abstract Background Acute acalculous cholecystitis in healthy patients is relatively understudied. It is usually described in patients within the intensive care unit, where it is associated with high mortality rates reaching 30%-50% in the literature. Aims To review patients who have developed AAC in outpatient or non-ICU settings, identify risk factors and clinical presentation, and compare these data with those in the literature. Methods We first performed a literature review. We then determined the inclusion criteria: acalculous cholecystitis confirmed by either an ultrasound, or CT scan, at pathology and intraoperatively. We excluded all patients hospitalized within the ICU or who developed AAC because of multiorgan failure or patients without histopathological evidence. We performed a 5-year search in our institution’s database with the terms “cholecystitis” and “acalculous cholecystitis. Results 23 patients were included in our study based on histopathology. The most frequent co-morbidities were cardiovascular and metabolic syndrome. The most common complaint was abdominal pain, ten patients (50%) presented to the emergency department with an increase of at least two of three biological markers (CRP, bilirubine and leucocytosis). We had no mortality reported at 30 days. Conclusion Epidemiologically, our population’s characteristics correspond to those of other studies, with most patients being male. The majority of patients were ASA III suggesting that this disease concerns more polymorbid patients despite a high percentage of healthy patients. Right upper quadrant pain, whether associated with leukocytosis or not, seems to be the main factor leading to further investigation. Abdominal US is considered the diagnostic technique of choice. However, most patients in our study underwent US and CT. We found that acalculous cholecystitis in outpatients, does not have the high mortality rate that was previously attributed to it, but is more frequent in polymorbid patients with cardiovascular risk factors.

Laparoscopic resection of a right upper quadrant hemorrhagic mass causing colonic obstruction

Laparoscopic resection of a right upper quadrant hemorrhagic mass causing colonic obstruction

Axillary lymph node metastasis in pure mucinous carcinoma of breast: clinicopathologic and ultrasonographic features

BackgroundThe purpose of this research is to study the sonographic and clinicopathologic characteristics that associate with axillary lymph node metastasis (ALNM) for pure mucinous carcinoma of breast (PMBC).MethodsA total of 176 patients diagnosed as PMBC after surgery were included. According to the status of axillary lymph nodes, all patients were classified into ALNM group (n = 15) and non-ALNM group (n = 161). The clinical factors (patient age, tumor size, location), molecular biomarkers (ER, PR, HER2 and Ki-67) and sonographic features (shape, orientation, margin, echo pattern, posterior acoustic pattern and vascularity) between two groups were analyzed to unclose the clinicopathologic and ultrasonographic characteristics in PMBC with ALNM.ResultsThe incidence of axillary lymph node metastasis was 8.5% in this study. Tumors located in the outer side of the breast (upper outer quadrant and lower outer quadrant) were more likely to have lymphatic metastasis, and the difference between the two group was significantly (86.7% vs. 60.3%, P = 0.043). ALNM not associated with age (P = 0.437). Although tumor size not associated with ALNM(P = 0.418), the tumor size in ALNM group (32.3 ± 32.7 mm) was bigger than non-ALNM group (25.2 ± 12.8 mm). All the tumors expressed progesterone receptor (PR) positively, and 90% of all expressed estrogen receptor (ER) positively, human epidermal growth factor receptor 2 (HER2) were positive in two cases of non-ALNM group. Ki-67 high expression was observed in 36 tumors in our study (20.5%), and it was higher in ALNM group than non-ALNM group (33.3% vs. 19.3%), but the difference wasn’t significantly (P = 0.338).ConclusionsTumor location is a significant factor for ALNM in PMBC. Outer side location is more easily for ALNM. With the bigger size and/or Ki-67 higher expression status, the lymphatic metastasis seems more likely to present.

Clinicopathological characteristics of mucinous carcinoma of the breast.

Objective: To highlight clinicopathological differences between Pure Mucinous Carcinoma (PMC) and Mixed Mucinous Carcinoma (MMC) of the breast. Study Design: Descriptive Retrospective study. Setting: Private Lab in Faisalabad, Pakistan. Period: January 2017 to December 2022. Methods: FNAC smears diagnosed with Mucinous Carcinoma fulfilling the inclusion and exclusion criteria were carefully examined for features such as cellularity, extracellular mucin (ECM), nuclear pleomorphism, plasmacytoid cells, macrophages, and myxovascular fragments (MVFs). The diagnosis was confirmed by histopathology and were characterized in to PMC and MMC. Immunohistochemistry slides were evaluated according to established protocols. Statistical analysis was performed using SPSS (p &lt; 0.05). Results: The study analyzed 16 FNAC cytological samples with subsequent histopathological confirmation. These cases were derived from a pool of 712 female breast carcinoma cytology cases over a five-year duration. The predominant age group was 40 to 50 years, with the left breast and upper outer quadrant being the most common site. Distinct cytological characteristics, particularly the significant presence of extracellular mucin in PMC, were observed. Tumor grade and lymph node involvement emerged as crucial prognostic factors. MMC exhibited a high Ki-67 index, indicating increased cellular proliferation. Conclusion: Pure mucinous carcinomas (PMCs) are uncommon breast tumors with distinguished cytologic features. It is clinically and genetically distinct from mixed mucinous carcinoma (MMC) and other types of breast cancer. An important prognostic factor is lymph node involvement, and PMCs often have a low proliferation rate and a more favorable long-term prognosis. Therefore, the identification of PMC through FNAC holds significant diagnostic and clinical importance.

Abstract PO5-20-10: Treatment with CDK4/6 Inhibitor in a Patient with Metastatic Breast Cancer Causing Myelophthisis

Abstract Background: Symptomatic bone marrow metastasis causing myelophthisis is a rare manifestation of metastatic breast cancer, indicating a poor prognosis due to significant cytopenias. CDK4/6 inhibitors are first-line therapies for metastatic hormone-positive breast cancer but remain an unclear choice in breast cancer patients with significant cytopenias due to associated hematological adverse effects. We present a case of biopsy-proven hormone-positive breast cancer with bone marrow infiltration causing profound pancytopenia. CDK4/6 inhibitors were safely administered despite their cytopenic effects. Case Presentation: A 59-year-old female presented after an abnormal annual mammogram and biopsy showed calcifications stromal fibrosis, cyst formation, and usual ductal hyperplasia in the right upper outer quadrant. One month later, she presented to an outside hospital with gingival bleeding, epistaxis, progressive dyspnea on exertion, and generalized weakness. Labs showed severe anemia with a hemoglobin of 4.8 g/dL (baseline 12.1 g/dL), thrombocytopenia with platelets of 5 K/mm (baseline 215 K/mm), LDH of 879, reticulocyte count of 5%, and negative direct Coombs test. Peripheral smear showed no schistocytes, but showed nucleated RBCs, severely reduced platelets, and occasional giant platelets. The patient was treated for presumed ITP, and the presence of nucleated RBCs prompted bone marrow biopsy which confirmed metastatic invasive lobular carcinoma breast cancer (ER 90-95%, PR 90-95%, HER2 1+). She was discharged on letrozole 2.5 mg daily with close outpatient oncologic follow-up. One week later, she presented to our institution with persistent symptomatic anemia and thrombocytopenia. Inpatient systemic therapy was begun using dose-reduced Palbociclib (75mg) and letrozole with close CBC monitoring while also receiving packed red blood cells (goal &amp;gt;6.5) and platelet transfusions (goal &amp;gt;10). Repeat bone marrow biopsy showed extensive marrow fibrosis, but no significant hematopoietic elements. ADAMTS13 was 134%, ruling out TTP, and she was treated again for presumed ITP with dexamethasone and IVIG, Throughout the 4-week admission, her right breast mass decreased in size and she was discharged after completing 3 weeks of Palbociclib with biweekly outpatient transfusions. During follow-up, the patient’s hemoglobin and platelets slowly started to respond allowing her to become transfusion-independent and allowing dose escalation. Restaging scans 2 months after hospitalization showed an overall improvement of disease burden. The patient continued to do well for almost 18 months, however, later redeveloped visceral crisis and is responding to chemotherapy. Discussion: There is limited data on the management of breast cancer with bone marrow infiltration at presentation. A wide range of survival data in different case reports exists, ranging from 5 to 44 months. However, chemotherapy was used in these studies rather than CDK4/6 inhibitors. By far, cytopenias are the most concerning grade 3 and 4 side effect of Palbociclib. Data from the PALOMA-1 trial suggest that hematologic toxicities, specifically neutropenia, were different from those associated with cytotoxic chemotherapies and are more transient and reversible in nature. Studies have examined the in vitro mechanism of bone marrow suppression in Palbociclib versus cytotoxic chemotherapy, and its cytostatic effect on neutrophil precursors allows for hematological toxicities to be transient. With strong supportive care measures, patients in bone marrow visceral crisis can be safely treated with cytopenic CDK4/6 inhibitors. Citation Format: Nikita Dahake, Jordan Senchak, Jalil Nasibli, Jason Incorvati. Treatment with CDK4/6 Inhibitor in a Patient with Metastatic Breast Cancer Causing Myelophthisis [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-10.