Aims and Scope Gland Surgery (Gland Surg; GS, Print ISSN 2227-684X; Online ISSN 2227-8575), launched in May 2012, is an open access, peer-reviewed journal. Published quarterly from May 2012 to Dec. 2014 and bimonthly from Jan. 2015 to Dec. 2020, GS now follows a monthly publication model. GS has been indexed by PubMed/PubMed Central (PMC) and Web of Science [Science Citation Indexed Expanded (SCIE)]. Its latest impact factor (2025 citation year) is 1.9. As a monthly published journal, it aims at providing cutting-edge findings and practical information on diagnosis, prevention, and treatment of gland diseases, such as breast, thyroid, adrenal, pancreas surgery and other related fields. Dedicated to the understanding and treatment of gland diseases, this multidisciplinary periodical publishes articles that describe basic, translational and clinical research of gland disease from a range of fields as biomarkers, imaging, pathology, biology and interventional radiology etc. Readers can expect to gain new insights into diagnosis, therapeutic approaches and prognosis of gland diseases. The journal is proud of the quality and content, which is further enhanced by a hands-on approach by its editorial team. Its international readership is reflected in the prestigious Editorial Board supported by numerous experts worldwide. It aims to advance and improve education in surgery and to diffuse knowledge on new and improved methods of teaching and practising surgery in all its branches. The journal features original articles, case reports, cutting-edge reviews, surgical techniques and visualized surgery, thus representing a source of valuable, novel information for clinical and basic researchers alike. The entire submission and review process are managed through OJS, an electronic system to increase efficiency and ensure that submitted papers can be published within a short turnaround period. GS is published by AME Publishing Company, with support from Wolters Kluwer (the journal content will be made available on Wolters Kluwer Health’s Lippincott and Ovid platforms). Indexing Gland Surgery is indexed and covered by Web of Science [Science Citation Index Expanded (SCIE)] PubMed PubMed Central (PMC) Google Scholar Scopus Ovid Information for Authors GS is a member of Committee on Publication Ethics (COPE) and it follows the Committee on Publication Ethics (COPE)'s guidelines and the ICMJE recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journal. GS is a member of the Surgery Journal Editors Group (SJEG, https://www.facs.org/member-services/sjeg), striving for diversity in the peer review process and among the editorial boards and editorial leaders. Manuscripts submitted must be the original work of the author(s) and must not be published previously or under consideration for publication elsewhere. Manuscripts Turnaround Time In-house review: 1-3 weeks. External peer review: 1-3 months. Publication Ahead of Print: within 1 month after being accepted (with APC payment received). Formal publication: within 1-3 months after being accepted (with APC payment received). Original Articles are listed as priority. GS is the Official Publication of: The Society for Translational Medicine (STM), Hong Kong Publication Schedule Published quarterly from May 2012 to Dec. 2014 and bimonthly from Jan. 2015 to Dec. 2020, GS now follows a monthly publication model. Open Access Statement This journal is a peer reviewed, open access journal. All content of the journal is published under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). All articles published open access will be immediately and permanently free for all to read, download, copy and distribute as defined by the applied license. Free access and usage Permitted third party reuse is defined by the CC BY-NC-ND 4.0 license. This license allows users to copy and distribute the article, provided: this is not done for commercial purposes and further does not permit distribution of the Article if it is changed or edited in any way. the user gives appropriate credit (with a link to the formal publication through the relevant DOI) and provides a link to the license but not in an any way implying that the licensor is endorsing the user or the use of the work. no derivatives including remix, transform, or build upon the material was allowed for distribution. The full details of the license are available at https://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright For open access publishing, this journal uses an exclusive licensing agreement. Authors will transfer copyright to AME Publishing Company, but will have the right to share their article in the same way permitted to third parties under the relevant user license, as well as certain scholarly usage rights. For any inquiry/special circumstance on the copyright, commercial usage or adaptation of GS articles, please contact: permissions@amegroups.com For reprint order, please contact: sales@amegroups.com Support for Authors to Comply with Funding Body Mandates We work with authors of research articles supported by funding bodies with open access mandates to ensure that authors can meet their funders’ requirements for public access to research results. In addition, we offer further support for authors who are required to comply with funding body mandates, including but not limited to: All articles published open access will be immediately and permanently free for everyone to read, download, copy and distribute. If a specific open access license is needed, please contact the editorial office for confirmation before submission. Example of statements in a published article: https://jgo.amegroups.org/article/view/76355/html. No copyright is claimed for any work of the U.S. government. Example of statements in published articles: https://actr.amegroups.org/article/view/8875; https://med.amegroups.org/article/view/8358/html. Contact with Editorial Office Suki Tang, Corresponding Editor, Gland Surgery Email: editor@glandsurgery.org Publisher Information GS is published by AME Publishing Company. Addresses: Hong Kong branch office: Flat/RM C 16F, Kings Wing Plaza 1, NO. 3 on Kwan Street, Shatin, NT, Hong Kong, China. Updated on June 18, 2026
Repeat quadratus lumborum blocks in pancreatectomy: needed or not?
Leveraging the perioperative window in pancreatic cancer: lessons from the PROSPER trial
Mesenteric approach or conventional approach for pancreatoduodenectomy?
Comparing the analgesic effect of the erector spinae plane block to the paravertebral block in breast cancer surgery
Comparison of neoadjuvant TCbHP versus THP in HER2-positive breast cancer: a retrospective cohort study
Background: Although the Chinese Society of Clinical Oncology (CSCO) guidelines list both the TCbHP regimen (taxane + carboplatin + trastuzumab + pertuzumab) and the carboplatin-sparing THP regimen (taxane + trastuzumab + pertuzumab) as category I neoadjuvant recommendations for human epidermal growth factor receptor 2 (HER2)-positive breast cancer, TCbHP carries a significantly higher toxicity burden, and current guidelines do not clearly define which patients can safely omit platinum. Accordingly, this study aims to compare the efficacy and long-term outcomes of neoadjuvant TCbHP versus THP in HER2-positive breast cancer and to preliminarily identify patients who may safely forgo carboplatin. Methods: This retrospective cohort study included patients with HER2-positive breast cancer who received neoadjuvant TCbHP or THP at Tianjin Medical University Cancer Institute and Hospital between January 2019 and December 2022. Inclusion criteria were age 18 years, clinical stage II-III disease, completion of six cycles of neoadjuvant therapy (NAT), and no prior anticancer treatment or distant metastasis at diagnosis. Baseline clinicopathological characteristics were extracted from electronic medical records. The primary endpoint was pathological complete response (pCR). Secondary endpoints were event-free survival (EFS) and disease-free survival (DFS). Follow-up was conducted via outpatient records and telephone interviews, with data censored on June 30, 2025. Results: Of 427 screened patients, 148 matched pairs were generated by 1:1 propensity score matching using age, menopausal status, clinical T stage, lymph node status, HR status, HER2 status, Ki-67 and taxane. There was no significant difference in pCR rates between TCbHP and THP (53.4% vs. 43.2%, P=0.08). Exploratory subgroup analyses showed a significant benefit for the TCbHP regimen over the THP regimen in patients aged ≤60 years [odds ratio (OR) =0.56; 95% confidence interval (CI): 0.33–0.93; P=0.03], premenopausal patients (OR =0.47; 95% CI: 0.24–0.91; P=0.03), and those with Ki-67 >30% (OR =0.48; 95% CI: 0.28–0.82; P=0.007). But formal interaction tests revealed a statistically significant interaction only between the two Ki-67 subgroups (P for interaction =0.02). The estimated 3-year EFS rates were 96.6% (95% CI: 93.8–99.6%) in the TCbHP group and 96.0% (95% CI: 92.8–99.2%) in the THP group, with no significant difference between the two regimens [hazard ratio (HR) =1.26; 95% CI: 0.47–3.40; P=0.64]. Conclusions: No significant difference in efficacy or 3-year EFS was observed between TCbHP and THP. Exploratory subgroup analyses showed that TCbHP achieved a higher pCR rate than THP in patients aged ≤60 years, premenopausal patients, and those with Ki‑67 >30%. Furthermore, interaction tests suggested that patients with Ki‑67 >30% derived a greater benefit from the TCbHP regimen compared with those with Ki‑67 ≤30%.
Omission of intraoperative frozen section in sentinel lymph node biopsy for early breast cancer: impact on survival outcomes
Background: The implementation of sentinel lymph node biopsy (SLNB) with permanent section (PS) analysis alone in patients who satisfied the ACOSOG Z0011 criteria did not alter the standard of care offered by the additional frozen section (FS) analysis. This study reports the patient survival outcomes of early-stage breast cancer based on SLNB techniques. Methods: Our previous investigation examined 453 SLNB cases at King Chulalongkorn Memorial Hospital, with follow-up concluding on April 15, 2025. The retrospective cohort study included patients diagnosed with clinically node-negative primary invasive breast cancer, who underwent breast-conserving surgery. The primary endpoint was 5-year disease-free survival (DFS), while secondary outcomes encompassed the overall cumulative incidence of local, distant, and axillary recurrence, as well as overall survival (OS). Results: Of the 453 patients undergoing SLNB, 239 underwent SLNB with PS alone, while 214 received additional FS. Kaplan-Meier analysis demonstrated a statistically significant difference in DFS between groups (log-rank P=0.008). In multivariable Cox regression analysis, with the FS group as the reference, the PS group showed a lower estimated risk of recurrence [hazard ratio (HR): 0.34; 95% confidence interval (CI): 0.15–0.79]. The 5-year DFS rates were 95.8% in the PS group and 93.5% in the FS group; however, this difference was not statistically significant when compared using crude event rates (P=0.26). OS was similar between groups (P=0.60). In the PS group, local and distant recurrence rates were 1.3% and 2.5%, respectively, with no regional recurrences observed. Conclusions: Based on the DFS and OS outcomes from our 5-year follow-up data, SLNB with PS analysis alone in patients meeting the ACOSOG Z0011 criteria was found to be comparable to SLNB with FS analysis.
Development and validation of an Automated computed tomography segmentation model for thyroid nodules using a channel attention high-resolution network
Background: Thyroid nodules are highly prevalent. Accurate segmentation of thyroid nodules is a prerequisite for computed tomography (CT)-based radiomics and computer-aided diagnosis, but manual region-of-interest delineation is time-consuming, subjective, and difficult to standardize. Although ultrasound remains the first-line imaging modality for thyroid nodule assessment, contrast-enhanced CT is frequently used in selected patients who have complex anatomy, suspected local extension, or require preoperative evaluation. Current deep learning models suffer from insufficient boundary capture for irregular nodules and high computational complexity, which has led to a lack of clinically practical tools. This study aimed to develop and internally validate an efficient automated CT segmentation model for thyroid nodules. Methods: This single-center retrospective study included CT images from 500 patients with pathologically confirmed thyroid nodules (250 benign and 250 malignant). Patients were divided at the patient level into training, validation, and internal test sets comprising 350, 50, and 100 patients, respectively. Eligible patients had thyroid CT and histopathological confirmation, and manual lesion contours served as the ground truth for segmentation. We propose Channel Attention High-Resolution Network (CA-HRNet), which enhances High-Resolution Network (HRNet) with a Channel Feature Selection Module (CFSM) that dynamically fuses multi-scale features by retaining discriminative channels and pruning redundant features, balancing representational capacity and computational efficiency. The model was trained using Dice loss with the RAdam optimizer and data augmentation. Segmentation performance was evaluated using the Dice coefficient (DC) and intersection over union (IoU), and CA-HRNet was compared with U-Net, SegFormer, Transformer U-Net​ (TransUNet), DAC-Net, and HRNet. Test-time augmentation (TTA) was applied during inference. Results: The cohort had a median age of 48 years, 373 female patients (74.6%), and a median nodule diameter of 1.60 cm. On the internal test set, CA-HRNet + TTA achieved the best overall segmentation performance, with a DC of 78.6% and an IoU of 70.0%. Performance was higher for benign nodules (Dice, 85.5%) than for malignant nodules (Dice, 66.2%), reflecting the more irregular morphology and less distinct boundaries of malignant lesions. Ablation experiments showed that the combination of CFSM and Channel Attention Convolution Module (CACM) achieved the best accuracy-efficiency balance and reduced computational complexity by 73%, from 93.764 to 25.376 giga multiply-accumulate operations (Giga MACs). Qualitative assessment showed that CA-HRNet produced masks with improved boundary adherence and detail preservation compared with competing models. Conclusions: CA-HRNet achieved accurate and computationally efficient automated segmentation of thyroid nodules on a single-center internal CT test set. The model may support reproducible region of interest (ROI) generation for CT-based radiomics and computer-aided diagnosis; however, multicenter external validation and downstream diagnostic or prognostic testing are required before routine clinical implementation.
Development and validation of an ultrasound-based predictive model for central lymph node metastasis in papillary thyroid carcinoma with peripheral calcification
Background: Patients with peripherally calcified papillary thyroid carcinoma (PTC) represent a unique subtype with potentially distinct metastatic behavior. However, a specific tool for predicting central lymph node metastasis (CLNM) in this subgroup is lacking, creating a knowledge gap in personalized preoperative assessment. This study aimed to develop and validate a preoperative prediction model for this patient population, addressing the absence of a specific risk assessment tool. Methods: We retrospectively enrolled 210 consecutive patients with pathology-confirmed, solitary PTC exhibiting peripheral calcification on preoperative ultrasound, who underwent initial surgery (lobectomy or total thyroidectomy) with central lymph node dissection (CLND) between January 2017 and July 2025. Patients with incomplete data, prior neck treatment, or distant metastases were excluded. The primary outcome, CLNM, was definitively diagnosed by postoperative pathology. The data were subsequently divided into training and validation datasets at a 7:3 ratio using 1,000 bootstrap resamples. In addition to a therapeutic or preventive CLND, each patient underwent an ultrasonography examination and either a thyroid lobectomy or a total thyroidectomy. The most significant risk factors were identified using the least absolute shrinkage and selection operator (LASSO) regression approach, and a Clinical-ultrasound (Clin-US) nomogram was created. The area under the receiver operating characteristic (ROC) curve was used to evaluate the model’s performance. Accuracy and clinical utility were evaluated using calibration and decision curve analysis (DCA) curves. Results: The study cohort comprised 210 patients, with 131 (62.4%) females and 79 (37.6%) males. The median age was 39.0 years in the training set and 36.0 years in the validation set. Postoperative pathology confirmed CLNM in 120 cases (57%). Age, abutment-to-lesion perimeter ratio (A/P), tumor location, US-reported central lymph node (CLN) status, halo sign, extrusion beyond calcification, and type of peripheral calcification were identified as independent risk factors. The developed Clin-US model demonstrated high discriminative performance, yielding an area under the ROC curve (AUC) of 0.942 [95% confidence interval (CI): 0.904–0.980] in the training cohort and 0.870 (95% CI: 0.777–0.962) in the validation cohort. Corresponding sensitivities and specificities were 91.9% and 89.1% for the training set, and 73.5% and 84.6% for the validation set, respectively. Calibration curve indicated good agreement between predicted and observed probabilities, and DCA curve suggested clinical utility across a wide probability threshold range (0.12–0.89). Conclusions: In this study, we developed and preliminarily validated a nomogram for predicting CLNM in patients with peripherally calcified PTC. The model showed promising performance in our cohort and may serve as a reference tool to aid in individualized preoperative decision-making for this specific subtype.
Clinical factors of prolonged treatment duration in patients with non-puerperal mastitis
Background: Non-puerperal mastitis (NPM) is a benign inflammatory breast disease characterized by a prolonged clinical course and substantial impairment in quality of life. This study aimed to identify clinical factors associated with prolonged treatment duration to support more individualized management strategies. Methods: This retrospective cohort study included female patients aged 18–60 years with histopathologically confirmed NPM who achieved clinical recovery at a single center between January 2017 and September 2022. Eligible cases were identified through electronic medical records. Exclusion criteria included pregnancy, lactation, malignancy, severe organ dysfunction, and participation in other clinical trials. The primary outcome was treatment duration, measured in months from treatment initiation to documented clinical recovery. Patients were categorized into short-duration (≤6 months) and prolonged-duration (>6 months) groups. Logistic regression and multiple linear regression analyses were performed to evaluate factors associated with prolonged treatment duration. Results: A total of 121 patients were included in the analysis, with a mean age of 36.5±8.1 years. Among these patients, 74 (61.2%) required more than 6 months to achieve recovery. The median treatment duration was 4.7 months, and 59.5% of patients achieved recovery within 6 months. Multivariate logistic regression identified a maximum breast mass area >50 cm2 as an independent factor associated with prolonged treatment duration [odds ratio (OR) =2.70, 95% confidence interval (CI): 1.07–6.78, P=0.04]. Multiple linear regression analysis further demonstrated that larger breast mass area (>50 cm2, B=1.98, P=0.02), severe breast pain [numeric rating scale (NRS) ≥5, B=2.00, P=0.02], and abscess formation (B=1.95, P=0.03) were significantly associated with prolonged treatment duration, whereas absence of nipple inversion was associated with shorter recovery duration (B=−1.64, P=0.04). Conclusions: Larger breast mass area, greater pain severity, nipple inversion, and abscess formation during the lesion stage were identified as potential factors associated with prolonged treatment duration in patients with NPM. Early intervention targeting nipple inversion during the mass stage may reduce the risk of abscess formation and contribute to improved clinical outcomes.
Explainable machine learning based on habitat analysis of axillary lymph node ultrasound images for preoperatively noninvasive evaluation of axillary lymph node metastasis in breast cancer: a bi-center study
Background: Accurate evaluation of axillary lymph node (ALN) is crucial for guiding staging and treatment strategies in breast cancer (BC) patients. This study aimed to develop an optimal machine learning model for predicting ALN status by utilizing both conventional radiomics and habitat analysis based on axillary B-mode ultrasound (BMUS) images, offering a powerful, non-invasive means to quantify and map ALN heterogeneity, providing deeper insights into biological behavior of ALN metastasis. Methods: This study retrospectively analyzed the preoperative BMUS images of ALNs in 297 patients with BC from Hunan Cancer Hospital and Yueyang Central Hospital. Patients were divided into training (n=172), test (n=45), and external validation (n=80) sets. Habitat features were segmented into sub-regions using K-means clustering. Both habitat and conventional radiomics models were developed using twelve widely adopted machine learning algorithms respectively, including least absolute shrinkage and selection operator (LASSO), the support vector machine (SVM), K-nearest neighbors (KNN), random forest (RF), ExtraTrees, extreme gradient boosting (XGBoost), light gradient boosting machine (LightGBM), naive Bayes (NB), adaptive boosting (AdaBoost), gradient boosting (GB), logistic regression (LR) and multilayer perceptron (MLP). Model performance was assessed using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). SHapley Additive exPlanations (SHAP) values were used to identify key features and enhance model transparency and interpretability. Results: Most habitat models exhibited better performance with higher area under the curve (AUC) values in external validation sets compared to conventional radiomics models. A comparative analysis of the diagnostic efficacy of these models demonstrated that the habitat-based MLP model exhibited superior efficacy, achieving the highest AUC value of 0.913 [95% confidence interval (CI): 0.842–0.967], an accuracy of 87.62% (95% CI: 79.97–93.75%), and an F1 score of 0.84 (95% CI: 0.73–0.93) in the external validation set. SHAP provided further insight into the contributions of each feature to the model's outcomes. Conclusions: We developed and validated machine learning models utilizing habitat-based ALN ultrasound images, demonstrating outstanding predictive performance for ALN metastasis in BC compared to conventional radiomics models. Among all machine learning models, the habitat-based MLP model showed the best predictive efficacy. The prediction process was visualized using SHAP, holding promise as a non-invasive tool for preoperative assessment of ALN status and potentially supporting surgeons in developing evidence-based, risk-stratified surgical strategies.
Research status and frontier trends of near-infrared autofluorescence for parathyroid identification and protection: a bibliometric analysis from 2006 to 2026
Background: Accurate identification and protection of parathyroid glands are crucial in both thyroid and parathyroid surgery. Near-infrared autofluorescence (NIRAF) imaging has emerged as a key technique to achieve this goal. Despite growing research interest in recent years, the rapidly expanding body of literature in this field lacks a systematic bibliometric analysis. This study aims to map the research landscape, identify hotspots, and trace emerging trends in NIRAF-based parathyroid identification and protection, thereby providing guidance for future investigations. Methods: Publications related to NIRAF for parathyroid applications from 2006 to January 2026 were retrieved from the Web of Science Core Collection. Bibliometric analyses were conducted using VOSviewer and CiteSpace. Results: A total of 371 articles were included in this review. The annual publication count remained relatively stable at a low level until a sharp increase beginning in 2019. The United States and China were the top two countries in terms of publication output. The Cleveland Clinic and Vanderbilt University emerged as leading research institutions. Eren Berber was the most productive author, whereas Anita Mahadevan-Jansen was the most cited. Surgery was the most influential journal in this field. Keyword and co-citation network analyses identified parathyroid function preservation as the core research theme, with NIRAF as the mainstream technique and indocyanine green (ICG) fluorescence acting as a complementary adjunct. Three main research directions were identified: clinical application scenarios, technical evolution, and biological mechanisms. The 2018 U.S. Food and Drug Administration (FDA) approval of NIRAF systems represented a pivotal milestone in the field. Over time, the research focus has evolved from initial clinical problems and conventional localization techniques toward deeper investigations into NIRAF mechanisms, clinical applications, and fluorescence-guided surgery. Conclusions: NIRAF research on parathyroid identification and protection is advancing rapidly and is currently focused on clinical translation and technological refinement. Future efforts should integrate artificial intelligence and advanced label-free imaging modalities.
A nomogram-based risk stratification strategy to optimize central lymph node dissection in cN1a papillary thyroid cancer with Hashimoto’s thyroiditis
Background: XXXXXXXXXXXX. This study aimed to investigate the risk factors for true central lymph node metastasis (CLNM) in patients with cN1a stage papillary thyroid carcinoma (PTC) complicated by Hashimoto’s thyroiditis (HT) and to explore management strategies for low-risk patients. Methods: We retrospectively analyzed patients diagnosed with cN1a stage PTC at our hospital from 2015 to 2025. General information and ultrasound characteristics were collected, and patients were categorized based on their HT status and CLNM status. Logistic regression analysis was performed, and a predictive nomogram for CLNM was developed and validated. Results: HT significantly increased the false-positive rate of CLNM (24.7% vs. 33.3%, P<0.05) and total number of lymph nodes dissected {7 [interquartile range (IQR), 4–11] vs. 6 (IQR, 3–10), P=0.04} in cN1a PTC patients, but did not increase the number [1 (IQR, 0–3.75) vs. 2 (IQR, 1–5), P=0.28] or proportion [0.2 (IQR, 0–0.6) vs. 0.5 (IQR, 0.08–0.83), P=0.02] of metastatic lymph nodes. Gender, age, tumor size, thyroid lobe lesions, lymph node round shape, cystic change, and microcalcification were identified as independent risk factors for CLNM in cN1a PTC patients with HT. In patients with a risk stratification of very low risk, the risk of developing true CLNM is less than 0.05. Conclusions: Preoperative cN1a staging is frequently confounded by HT-related inflammatory lymphadenopathy, necessitating a more nuanced diagnostic approach. Our nomogram effectively stratifies the risk of true CLNM in this population, and serves as an auxiliary tool to provide decision-making advice for central lymph node dissection (CLND).
Use of lateral intercostal artery perforator flaps in breast-conserving surgery for breast cancer: a single-center experience
Background: Breast-conserving surgery (BCS) combined with radiotherapy has become a standard treatment for early-stage breast cancer, providing oncologic outcomes comparable to mastectomy while preserving breast aesthetics. However, large-volume resections may result in contour deformities and poor cosmetic outcomes. Perforator flaps such as the lateral intercostal artery perforator (LICAP) and anterior intercostal artery perforator (AICAP) flaps have emerged as valuable oncoplastic techniques for immediate volume replacement. This study aimed to report a single-center experience using LICAP and AICAP flaps following BCS. Methods: A retrospective observational single-center study was performed between April 2024 and April 2025. Consecutive patients undergoing BCS with immediate reconstruction using LICAP or AICAP flaps were included. Demographic data, tumor characteristics, surgical outcomes, complications, aesthetic results, and timing of adjuvant therapy were analyzed. Descriptive statistics were used. Results: Fifteen patients underwent reconstruction, predominantly using LICAP flaps (93.3%), with a single case of AICAP reconstruction (6.7%). Invasive carcinoma was identified in 73.3% of cases, with a mean tumor size of 41.7 mm. All flaps remained viable, with no cases of partial or total necrosis. All patients initiated adjuvant therapy within 12 weeks postoperatively. After a mean follow-up of 20 months, no local recurrences were observed. Conclusions: LICAP flap reconstruction may represent a feasible and effective option for immediate volume replacement following BCS in selected patients. However, these findings must be interpreted within the context of the study’s limitations, due to the small sample size, lack of a control group, and limited follow-up. Further studies with larger cohorts and longer follow-up are required to confirm these preliminary results.
Validation of a protocol for pre-operative flap thickness assessment on dual-view digital mammography for the decision-making process in implant-based breast reconstruction
Background: Pre-operative breast imaging is a critical component of the decision-making process for both oncological and reconstructive surgeons. The thickness of the non-glandular breast tissue coverage (BTC), including the skin and the subcutaneous fat layer overlying the anterior lamella of the capsula mammae, varies according to the single patient’s breast anatomy. This layer correlates with an anatomical and properly performed mastectomy to optimize mastectomy flap thickness. The aim of this study is to validate a BTC assessment modality that uses digital mammography (DM) imaging in both the cranio-caudal (CC) and the medio-lateral oblique (MLO) views. Methods: We designed a retrospective, multi-reader study on a dataset of 40 unilateral DM cases obtained in the two standard views (CC and MLO). The study set was extracted from all consecutive cases recorded from January 2022 to March 2022 in two Breast Imaging Academic Centers involved in the project (the Breast Unit of the University of Naples Federico II and the Breast Unit of the University of Turin). The robustness of the proposed pre-operative assessments has been determined by deriving the metrics associated with the inter- and intra-observer agreement (P values of the matched measurements, measurement error, repeatability, limits of agreement, correlation) for each testing site and for their possible aggregations. Results: We found a highly satisfactory inter-observer agreement with good correlation among the four senior radiologists’ measurements in all positions and on breasts of different density. The intra-observer agreement was also good: no significant differences and good correlation for either one. The method performed well also when used by less expert radiologists, satisfying the requirements for accuracy and repeatability set by the senior team. The analysis of the measured thickness consistently indicated a larger measurement error for the non-dense breast data than for the dense ones. Conclusions: The proposed approach seems to be well-standardized and reproducible, allowing good performance at different levels of experience. It is our hope that this methodological study will assist with preoperative surgical planning by providing a clinical validation tool to estimate mastectomy flap thickness and its impact on preoperative decision-making for optimizing surgical-reconstructive outcomes, both from the oncological and the aesthetic point of view.
Point of care ultrasonography (POCUS) for assessment and intervention of thyroid nodules in an office setting
Background: Traditionally, thyroid ultrasounds and fine-needle biopsy have been performed by trained radiologist or sonographer. More recently, portable office-based point of care ultrasound (POCUS) have been used in management of thyroid nodules. This study aims to compare the diagnostic accuracy and interventional performance of POCUS with conventional hospital-based console ultrasound in management of thyroid nodules. Methods: This is a retrospective case study set in a large community-based Otolaryngology practice with a dedicated thyroid ultrasound clinic. All patients referred to the thyroid clinic between January 2023 and December 2024 for ultrasound-guided fine-needle biopsy were assigned American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) category in a prospective manner by the operator immediately prior to biopsy. Studies and procedures were performed utilizing a GE (General Electric Company) Healthcare Versana Active portable ultrasound with a 12 Hz linear probe (12L-RS). Hospital assigned TI-RADS categories were subsequently obtained through a retrospective chart review of the radiologist report. The performance of both the TI-RADS categories was compared. The Bethesda system for Reporting Thyroid Cytopathology (BSRTC Categories) was utilized for all cytology reports. Results: A total of 339 nodules underwent biopsy, of which 293 had available data for both the in-office and radiologist-assigned TI-RADS. Only the nodules with cytological categories of BSRTC categories of 2 through 6 were included in the study. The POCUS TI-RADS categories yielded a sensitivity of 1.00, specificity of 0.00, positive predictive value (PPV) of 0.10, and negative predictive value (NPV) of 1.00. The hospital-based radiologist TI-RADS categories yielded a sensitivity of 0.80, specificity of 0.35, PPV of 0.12, and NPV of 0.94. Sensitivity was significantly higher with the POCUS TI-RADS categories (P=0.01), while specificity was significantly higher with the hospital-based radiologist TI-RADS categories (P<0.001). Conclusions: In-office POCUS is a reliable diagnostic tool that offers high sensitivity in identifying malignant thyroid nodules in an in-office setting.
Development and validation of a nomogram to assess recurrence risk in young patients with breast cancer based on preoperative serum tumor markers
Background: Postoperative recurrence is a primary risk following breast cancer surgery. Compared to older patients, younger breast cancer patients typically experience a poorer prognosis. This study aimed to develop a predictive model based on preoperative serological markers—carbohydrate antigen 125 (CA125) and carbohydrate antigen 153 (CA153) and postoperative treatment modalities to evaluate the 3- and 5-year recurrence-free survival (RFS) in young breast cancer patients aged under 40 years. Methods: This retrospective study enrolled 521 patients who underwent breast cancer surgery at Fengxian District Central Hospital between June 2015 and April 2020. Based on the inclusion and exclusion criteria, 411 patients aged under 40 were ultimately included and divided into a training cohort and a validation cohort. Clinical characteristics were evaluated, including age, surgical procedure, tumor histological type, history of radiotherapy and chemotherapy, lymphovascular invasion (LVI), neural invasion (NI), tumor-node-metastasis (TNM) stage, molecular subtype, and preoperative serum tumor markers such as CA125 and CA153. Univariate analysis and Cox proportional hazards regression were used to select variables and develop a nomogram based on the training cohort. Survival analysis and plotting were performed using Kaplan-Meier curves and the log-rank test. The reliability of the nomogram was assessed using the concordance index (C-index), calibration plots, and clinical decision curve analysis (DCA). Results: Using the random grouping function in SPSS, the patients were divided into a training cohort (282/411) and a validation cohort (129/411) at a 7:3 ratio. The nomogram prediction model incorporated four risk factors: high expression of CA125 or CA153, receipt of radiotherapy, and LVI. In the training and validation cohorts, the area under the curve (AUC) of the nomogram for predicting 3-year RFS was 0.854 and 0.793, respectively, while the AUC for 5-year RFS was 0.85 and 0.801, respectively. Calibration curves demonstrated that the predicted probabilities of the model were in good agreement with the actual observations. Furthermore, DCA indicated that the nomogram model provided a superior net clinical benefit within the threshold probability range of 10–75%. Conclusions: We developed a survival prognostic model for young breast cancer patients based on preoperative serum tumor markers and postoperative treatment. The results confirmed that the combination of CA125 and CA153 is of great significance in predicting RFS in young women with breast cancer.
The association of Hashimoto’s thyroiditis with central lymph node metastasis in papillary thyroid cancer: a retrospective cross-sectional study
Background: Multiple studies have found that Hashimoto’s thyroiditis (HT) is associated with the occurrence of papillary thyroid cancer (PTC). The relationship between HT and central lymph node metastasis (CLNM) in PTC remains controversial in these studies. To further explore this issue, we conducted a retrospective study and attempted to investigate it from alternative perspectives by employing a variety of statistical methods, including multivariable regression and sensitivity analyses such as propensity score matching (PSM). Methods: This retrospective cross-sectional study consecutively enrolled 1,123 patients (aged 16–84 years) who underwent initial thyroidectomy with central lymph node dissection at a single center [2015–2024]. HT was histologically confirmed by the presence of extensive lymphocytic infiltration with germinal center formation. CLNM was defined as histologically confirmed metastasis to at least one central lymph node (Level VI, including prelaryngeal, pretracheal, and paratracheal nodes). The primary analysis employed multivariable logistic regression on the full cohort. PSM, inverse probability of treatment weighting (IPTW) and standardized mortality ratio weighting (SMRW) were used as sensitivity analyses. Subgroup analyses were conducted to examine potential effect modification. Results: A total of 1,123 patients with PTC were involved and 243 (21.6%) patients had HT. In the primary multivariable analysis adjusting for 13 confounders, HT was independently associated with a significantly lower odds of CLNM [adjusted odds ratio (OR) =0.68; 95% confidence interval (CI): 0.49–0.94; P=0.02]. This inverse association remained robust across multiple sensitivity analyses, including PSM (OR =0.67; 95% CI: 0.47–0.96; P=0.03), IPTW (OR =0.74; 95% CI: 0.56–0.98; P=0.04), and SMRW (OR =0.70; 95% CI: 0.53–0.94; P=0.02). Subgroup analysis revealed that it was more statistically significant in female, <55 years old, multifocal tumors, without concurrent follicular adenoma. Conclusions: This study demonstrates that HT is associated with a lower risk of CLNM in patients with PTC. Therefore, for PTC patients with HT, alternative surgical modalities such as sentinel lymph node biopsy should be explored, rather than relying solely on prophylactic central lymph node dissection.
Comprehensive analysis of cuproptosis-related lncRNAs in immunotherapy response and prognosis in papillary thyroid cancer
Background: Cuproptosis is a copper-induced mechanism of programmed cell death (PCD) that may influence the progression of papillary thyroid cancer (PTC). However, research linking this route to long non-coding RNAs (lncRNAs) in PTC is limited. This study assesses the correlation between cuproptosis-associated lncRNAs and immunotherapy sensitivity as well as clinical outcomes in PTC. Methods: PTC transcriptomic profiles, tumor mutational burden (TMB), and clinical annotations were obtained from The Cancer Genome Atlas (TCGA). Cuproptosis-associated lncRNAs were identified via co-expression analysis with known cuproptosis genes. We employed least absolute shrinkage and selection operator (LASSO)-penalized Cox modeling to develop a lncRNA signature for predicting progression-free survival (PFS) and calculated a patient-level risk index. Subsequently, we evaluated the associations among this index, immune infiltration, predicted immunotherapy response, and clinical outcomes. Results: Ten lncRNAs associated with cuproptosis-related risk were identified. Using the median value of risk score, we stratified individuals into higher- and lower-risk strata. Individuals in the higher-risk category exhibited poorer PFS, disease-specific survival (DSS), and overall survival (OS) rates. In multivariable Cox models, the lncRNA-derived score independently predicted PFS and outperformed traditional clinicopathologic factors as demonstrated by receiver operating characteristic (ROC) and C-index comparisons. A nomogram that incorporates the risk score alongside essential covariates exhibited well-calibrated estimates for PFS at 1, 3, and 5 years. The heightened risk was positively correlated with increased immune-cell infiltration, augmented immunological effector actions, and elevated expression of immune checkpoints. Model-based inference indicated that high-risk patients are more likely to get benefits from immune-checkpoint blocking, with enhanced results expected from anti-programmed cell death protein 1 (PD-1) or anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) monotherapy. The reverse transcription quantitative polymerase chain reaction (RT-qPCR) results demonstrated that LINC01545 overexpressed in PTC tissues while DLG3-AS1 downregulated in PTC tissues compared with the normal tissues, which is in consistent with the bioinformatic results. Conclusions: A lncRNA signature associated with cuproptosis serves as an independent predictor of clinical outcomes and immunotherapy response in PTC, supporting the use of these transcripts as biomarkers for risk stratification and treatment selection guidance.
Development and external validation of a machine learning model for predicting overall survival in head and neck adenoid cystic carcinoma based on the SEER database and a Chinese clinical cohort
Background: Adenoid cystic carcinoma (ACC) of the head and neck is a rare malignancy with high rates of perineural invasion (PNI) and distant metastasis. Although the tumor-node-metastasis (TNM) staging system provides a crucial anatomical foundation, it may not fully capture the biological heterogeneity of ACC. Existing predictive models often lack robust external validation or contain too many variables for routine clinical use. This study aimed to develop and validate a simplified prognostic model using a multi-algorithm machine learning (ML) consensus approach. Methods: This retrospective study included patients with pathologically confirmed primary head and neck ACC and complete follow-up data from two cohorts: a training cohort from the Surveillance, Epidemiology, and End Results (SEER) database (n=2,870) and an external validation cohort from Sichuan Cancer Hospital (n=172). The primary endpoint was overall survival (OS), defined as a binary outcome (all-cause mortality vs. survival). Clinical variables were extracted from SEER via database queries and from the external cohort via medical records and telephone interviews. The SEER cohort was divided into training and internal testing sets at a 7:3 ratio. Traditional Cox regression was first applied to establish a prognostic baseline and construct a clinical nomogram. Subsequently, four ML algorithms—logistic regression (LR), classification and regression tree (CART), random forest (RF), and support vector machine (SVM)—were used to build prognostic models. A SHapley Additive exPlanations (SHAP)-based consensus strategy was then applied across the four algorithms specifically for objective feature selection to identify a minimal set of core prognostic features. Results: A total of 3,042 patients were analyzed. In the external cohort, the median follow-up was 86.0 months, with 49 mortality events (28.5%) observed. Six core prognostic features were identified: M stage, age, brain metastasis, T stage, surgery, and N stage. The simplified LR model achieved the best performance among all tested algorithms, with an area under the curve (AUC) of 0.825 in the internal testing set. In the external validation cohort, it achieved an AUC of 0.817, outperforming the other three algorithms, with good calibration observed. Conclusions: This study developed a simplified prognostic model for head and neck ACC based on six core features. The model showed promising discrimination in both the internal testing set (AUC =0.825) and the external validation cohort (AUC =0.817). However, the external cohort was relatively small (n=172), which limits our ability to fully assess the model’s generalizability. These findings should therefore be interpreted with caution. Future prospective studies with larger, multi-center cohorts are needed to confirm these results before the model can be recommended for routine clinical use.
Our experience with retro-glandular breast implants: a 14-year review and analysis of 1,043 consecutive cases
Background: The consistent demand for breast augmentation has led to the development of numerous techniques for implant placement over the past 20 years. Our study, based on a 14-year clinical and radiological follow-up of patients and 1,043 implanted cases, aims to investigate a breast implant positioning technique and standardize its application in various clinical cases. Methods: All patients undergoing breast augmentation were studied using pre-surgical breast ultrasound, which served to rule out new growths and establish essential intervention feasibility parameters, including glandular and skin thickness. Results: After 1,043 implants, we observed a 94% patient satisfaction rate (980 patients, measured by a follow-up questionnaire). Additionally, two external surgeons were asked to assess pre- and post-op pictures using a scoring scale from 0 to 5, with an average rating of 4 out of 5. Post-surgical complications included instances of capsular contracture 0.2%, implant rotation 0.8%, post-operative hematomas 0.2%, and wrinkling 0.4%. Conclusions: Standardizing the retro-glandular breast augmentation procedure, along with careful preoperative studies, can yield excellent results in terms of patient and practitioner satisfaction by fully respecting the anatomy, avoiding pectoralis major muscle impairment, achieving faster recovery, and ensuring a safer, quicker procedure.
Integrating intratumoral and peritumoral ultrasound radiomics with clinicopathological features to predict axillary lymph node metastasis in early breast cancer
Background: XXX. This study aimed to develop and validate a predictive model for axillary lymph node metastasis (ALNM) in early breast cancer (EBC) based on preoperative ultrasound-derived intratumoral and peritumoral radiomics features integrated with clinicopathological features. Methods: In this retrospective study, 327 patients with EBC were enrolled. Clinicopathological variables and preoperative ultrasound images were collected, and patients were randomly assigned to a training cohort (n=228) and a validation cohort (n=99) at a 7:3 ratio. Intratumoral, 4-mm peritumoral, and combined intratumoral-peritumoral regions of interest were delineated using ITK-SNAP software. Logistic regression (LR), support vector machine, and random forest machine learning (ML) algorithms were applied to construct radiomics models based on intratumoral, peritumoral, and combined regions, respectively. A clinical-radiomics combined model was subsequently developed by integrating independent clinical predictors. Model performance was evaluated using receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and Shapley additive explanations (SHAP). Results: Multivariable LR analysis identified maximal diameter and lymphovascular invasion as independent predictors of ALNM. Among the evaluated ML algorithms, the LR-based combined intratumoral and peritumoral radiomics model demonstrated the best performance, achieving an area under the curve (AUC) of 0.868 [95% confidence interval (CI): 0.795–0.933] in the validation cohort. Incorporation of independent clinical predictors further improved model performance, with the clinical-radiomics combined model yielding a validation AUC of 0.909 (95% CI: 0.851–0.960). Calibration curves and DCA indicated good agreement between predicted and observed outcomes and demonstrated favorable clinical utility. SHAP analysis revealed that radiomics features contributed predominantly to model predictions. Conclusions: A predictive model integrating intratumoral and peritumoral ultrasound radiomics features with clinicopathological variables enables accurate preoperative identification of ALNM in patients with EBC. This model may serve as a reliable and non-invasive tool to guide individualized axillary management strategies.
The prognostic value of tumor quadrant in breast cancer patients achieving pathologic complete response: a retrospective cohort study from the Sir Run Run Shaw Hospital database
Background: A clinically significant proportion of patients who achieve pathologic complete response (pCR) still experience unfavorable long-term outcomes. Traditional clinical trials often oversimplify the binary assessment of pCR, whereas real-world observational data are needed to capture the heterogeneity of post-pCR outcomes and to refine risk stratification. This retrospective cohort study utilizes real-world data from the Sir Run Run Shaw Hospital database to analyze factors associated with adverse outcomes in pCR patients. Methods: This retrospective study included 293 patients from Sir Run Run Shaw Hospital (2005–2024) who achieved pCR (ypT0/is ypN0) after neoadjuvant therapy (NAT). This study included patients with a diagnosis of unilateral breast cancer, female sex, and without histopathological evidence of malignant cells in both the breast and axillary lymph nodes post-surgery. Baseline characteristics were compared between patients with and without subsequent disease progression. Univariable Cox proportional hazards regression was performed to identify factors associated with event-free survival (EFS). Kaplan-Meier curves with log-rank tests were used to visualize EFS differences among tumor quadrants, the only variable with statistical significance in univariable analysis. Five-year and 10-year EFS rates were estimated by the Kaplan-Meier method. Analyses were conducted using R software. Results: This study included 1,773 patients who had received NAT and overall pCR rate was 16.5% (n=293), with subtype-specific rates of 33.5% human epidermal growth factor receptor 2 (HER2)-positive breast cancer, 13.3% triple-negative breast cancer (TNBC), and 6.1% (luminal). Among pCR patients, 16 patients (5.4%) experienced disease progression (5 recurrences, 10 metastases, and 8 deaths). With a median follow-up of 41 months, progression-free survival was shorter in patients with progression events compared to those without progression events (24 vs. 41 months, P<0.001). In baseline characteristic comparisons between pCR patients with and without subsequent disease progression, Ki-67 was the only variable that differed significantly between the two groups (P<0.05), which did not reach statistical significance in univariate Cox analysis. Tumor quadrant was the only variable that demonstrated a statistically significant association with EFS in univariable Cox analysis (overall P=0.01 by likelihood ratio test; log-rank P=0.06). Patients with tumors in the outer upper quadrant had zero progression events, whereas those in the outer lower and inner upper quadrants exhibited the lowest survival rates (5-year EFS: 83.1% and 88.6%; 10-year EFS: 83.1% and 70.9%, respectively). Conclusions: In this cohort of breast cancer patients achieving pCR after NAT, tumor quadrant was significantly associated with EFS, with the outer upper quadrant showing the most favorable outcomes. Although Ki-67 differed between progression groups at baseline, it did not retain prognostic significance in time-to-event analysis. These findings suggest that tumor location may be associated with post-pCR outcomes, warranting validation in larger cohorts.
An integrated multiomics-based risk model for predicting the prognosis and immune microenvironment status in patients with papillary thyroid carcinoma
Background: Papillary thyroid carcinoma (PTC) is the most common type of primary endocrine malignancy. The tumor immune microenvironment (TIME) and genetic alterations play crucial roles in the progression of PTC. With the advance in research, there has been a heightened focus on re-evaluating molecular targeted therapies and identifying novel targets through molecular biology-based approaches. This study aimed to identify robust prognostic biomarkers and to construct a reliable risk model for patients with PTC by integrating multiomics data. Methods: RNA-sequencing (RNA-seq) data from six Gene Expression Omnibus (GEO) datasets and genome-wide association study (GWAS) data were integrated to identify differentially expressed genes (DEGs) and facilitate Mendelian randomization (MR) analysis for causal inference. The CIBERSORT algorithm was employed to evaluate immune cell infiltration. A prognostic risk model was constructed via least absolute shrinkage and selection operator (LASSO) Cox regression and validated in The Cancer Genome Atlas (TCGA) and GEO cohorts. Functional experiments, including Cell Counting Kit-8 (CCK-8), transwell, and wound-healing assays, were conducted to investigate the role of the key gene ALOX15B in PTC cells. Results: We identified seven PTC-associated genes (ALOX15B, TIAM1, TMC6, GPX3, RAP1GAP, JUN, and PAPSS2) through expression quantitative trait loci and MR analysis. A robust three-gene risk model (ALOX15B, RAP1GAP, and JUN) was established. Patients in the high-risk group exhibited significantly poorer progression-free survival (PFS), which was confirmed to be an independent prognostic factor by multivariate analysis [hazard ratio =1.355, 95% confidence interval (CI): 1.052–1.746; P=0.02]. The high-risk group was characterized by an immunosuppressive TIME—including decreased CD8+ T-cell and increased regulatory T-cell abundance—higher tumor mutational burden, and a higher frequency of BRAF mutations. Conversely, the low-risk group showed a higher prevalence of NRAS mutations. In addition, functional assays in vitro revealed that ALOX15B markedly enhanced the proliferative, migratory, and invasive capacities of PTC cells. Conclusions: A novel three-gene signature was developed and was demonstrated to be an independent prognostic indicator for patients with PTC. This model effectively reflects the intrinsic characteristics of the TIME and genomic instability and can inform risk stratification and therapeutic targeting. Due to its oncogenic activity, ALOX15B may represent a viable therapeutic target in PTC.
Prophylactic nipple-sparing mastectomy and immediate breast reconstruction in Chinese BRCA1/2 carriers: a case series with 45-month follow-up and zero breast cancer incidence
Background: Nipple-sparing prophylactic bilateral mastectomy (NSM) dramatically decreases the risk of breast cancer in healthy women with germline BRCA1/2 pathogenic variants (PVs). Unlike Western BRCA1/2 carriers, data regarding this procedure for Chinese healthy women with BRCA1/2 PVs are currently lacking. This may be attributed to many factors, including the incomplete nationwide availability of BRCA1/2 gene testing and lack of precise risk estimate, Chinese culture, and limited reconstruction accessibility. Here, we report nine highly selected Chinese BRCA1/2 carriers with a strong desire and family cancer history who underwent this procedure. Case Description: Nine healthy Chinese BRCA1/2 carriers (6 BRCA1 and 3 BRCA2 carriers) underwent NSM and immediate breast reconstruction at Peking University International Hospital from January 2018 to August 2022. All nine women carried germline BRCA1/2 PVs identified by two independent agencies. The median age at surgery in this series was 36 years (range 34 to 57), with eight of them aged at 40 years or younger. Eight had a family history of breast and/or ovarian cancer; two BRCA1 carriers had a prior history of triple-negative breast cancer in their left breast and had received breast-conserving therapy, adjuvant chemotherapy and radiotherapy. No imaging abnormalities were found in the nine carriers before operation through ultrasound, mammography, or breast MRI. All nine women were anxious about breast cancer risk and had a strong desire to receive this procedure. Therefore, the nine women received NSM and immediate breast reconstruction; both sides of the breast were removed entirely while nipples and breast skin were retained, and the implants were primarily positioned in a subpectoral plane. Ductal carcinoma in situ was found in one side of the breast sample in two women through pathological diagnosis. After a median follow-up of 45.0 months, no breast cancer occurred in any patient, and all women reported satisfaction with the aesthetic outcome and breast symmetry. Anxiety about breast cancer risk was remarkably reduced. Conclusions: Prophylactic NSM and immediate breast reconstruction may be a viable option for highly selected healthy Chinese women with germline BRCA1/2 PVs to reduce breast cancer risk, especially for BRCA1/2 carriers with a family history of breast cancer.
Balance-shaped sternal elevation-assisted uniportal subxiphoid video-assisted thoracoscopic surgery for thymoma with persistent left superior vena cava
The subxiphoid approach for video-assisted thoracoscopic surgery (VATS) thymectomy offers a midline view but is constrained by the limited retrosternal space. This limitation is accentuated in cases with complex vascular anatomy, such as a persistent left superior vena cava (PLSVC). We describe and evaluate a novel balance-shaped sternal elevation technique designed to overcome this spatial challenge. A 52-year-old male with a 6.3 cm anterior mediastinal mass and a concomitant PLSVC underwent uniportal subxiphoid VATS thymectomy. A percutaneous suspension system utilizing a balance-shaped retractor was employed to indirectly elevate the sternum via subcutaneous tunnels, thereby expanding the anterior mediastinal operating domain without direct bone contact. The procedure’s safety profile, including preventive measures against skin injury, is discussed. The sternal elevation technique increased the retrosternal space from a preoperative computed tomography (CT)-measured average of 3.5 to 8.2 cm intraoperatively (135% increase). This provided simultaneous and clear visualization of both the right superior vena cava and the PLSVC. The thymoma, located 0.8 cm from the PLSVC, was successfully dissected free. The procedure was completed in 58 minutes with 5 mL blood loss. No chest tube was required. The patient reported minimal pain [Visual Analog Scale (VAS) score 1 on postoperative day 1] and was discharged on day 3. Final pathology confirmed a type AB thymoma. No skin or soft tissue complications occurred at the suspension sites. The balance-shaped sternal elevation technique is a safe and effective adjunct to uniportal subxiphoid VATS in selected cases with complex anterior mediastinal anatomy, such as those with major venous anomalies. While its applicability may be limited to VATS and requires dedicated equipment, it significantly improves exposure in anatomically challenging scenarios and may serve as a valuable rescue technique when conventional methods prove inadequate.
The application of double pedicled free deep inferior epigastric artery perforator flap breast reconstruction following mastectomy in unilateral breast cancer
This study aims to elucidate the technical points of double pedicled free deep inferior epigastric perforator (DIEP) breast reconstruction for breast cancer patients with large and ptotic breast. A retrospective analysis was conducted on patients who underwent DIEP flap breast reconstruction between January 2022 to December 2023, of which 92 immediate breast reconstructions using DIEP flap were included in this study. There were 21 cases underwent double-pedicled DIEP and 71 cases underwent unilateral pedicled DIEP. Using the internal thoracic vessels were employed for vascular anastomosis, and in the double pedicled DIEP group, 21 flaps survived while in the unilateral group 70 cases survived. The satisfaction degree of the double pedicled group was higher than that of the unilateral-pedicled group. In the double pedicled group, there was 0 case with moderate to severe radiation dermatitis, compared to 12 cases in the unilateral group. The double pedicled DIEP group tended to explore obviously higher biopsy rate (47.6%) of unexpected discovery internal mammary lymph nodes (IMLNs) than the unilateral pedicled group (16.9%). However, there was no significant difference (P=0.058) of the metastatic rate of IMLNs in the double pedicled group (50%) compared with that in the unilateral-pedicled group (25%). Clinically, for patients with large and sagging breasts, those requiring IMLN biopsy, those seeking to reduce side effects such as radiation-induced dermatitis, and those needing to ensure adequate blood supply to the flap, the double-tissue DIEP breast reconstruction surgery is an extremely effective autologous breast reconstruction method.
Adrenal angiosarcoma, a rare neoplasm: a case report and a literature review
Background: Angiosarcoma (AS) is a rare malignant tumor of vascular endothelial origin, accounting for approximately 1% of soft tissue sarcomas. Primary adrenal AS represents an exceptionally rare entity, with very limited cases reported in the literature, resulting in significant diagnostic and therapeutic challenges. Case Description: A 67-year-old male with arterial hypertension presented with an incidentally detected left adrenal mass on abdominal ultrasound. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large heterogeneous lesion measuring up to 90 mm × 82 mm × 88 mm, with hemorrhagic components and progressive enlargement, raising suspicion for an aggressive malignancy. Endocrine workup was unremarkable. The patient underwent robotic left adrenalectomy with complete (R0) resection. Histological examination showed a malignant proliferation of pleomorphic epithelioid cells; immunohistochemistry confirmed positivity for CD31, CD34, and podoplanin, with a Ki-67 index of ~80%, establishing the diagnosis of adrenal AS. No adjuvant therapy was administered. At 4-month follow-up, the patient was alive and disease-free. A systematic review of the PubMed database identified 51 additional published cases, totaling 52 patients. The disease predominantly affects males (67%), mean age 58 years. Overall survival was 41% and disease-free rate 33% at 36 months; tumor size <6 cm was associated with improved survival (P=0.04). Conclusions: Primary adrenal AS is an aggressive tumor with poor prognosis. Complete surgical resection is the cornerstone of treatment. However, since available evidence is limited, no definitive prognostic factors can be established.
Multicavity gas migration following da Vinci 5 transoral robotic thyroidectomy in a 50-year-old male: a case report of successful conservative management
Background: Transoral robotic thyroidectomy (TORT) relies on continuous carbon dioxide (CO2) insufflation to maintain the operative workspace, introducing a spectrum of gas-related complications. The newly introduced da Vinci 5 (DV5) system features an integrated, actively regulated insufflation and smoke evacuation system that differs fundamentally from prior-generation platforms. The platform-specific safety profile of the DV5 in TORT remains largely uncharacterized. Case Description: A 50-year-old male with papillary thyroid carcinoma (PTC) of the left thyroid lobe underwent transoral robotic left hemithyroidectomy with central lymph node dissection using the DV5 system. Insufflation was maintained at 8 mmHg with a flow rate of 20 L/min; the procedure was uneventful. Upon post-anesthesia care unit (PACU) admission, the patient was stable (SpO2 99%), but developed acute chest pain and oxygen desaturation (SpO2 <90%) approximately 20 minutes later. Emergency chest radiography demonstrated bilateral pneumothorax requiring immediate bilateral chest tube insertion. Subsequent computed tomography (CT) confirmed pneumoretroperitoneum and pneumoperitoneum along the perirenal spaces without visceral injury, consistent with extensive CO2 migration along cervicofascial planes. The patient recovered with conservative management and was discharged without sequelae on postoperative day four. Final pathology confirmed pT1N0M0 PTC. Conclusions: Extensive multicavitary gas migration can occur following TORT even under standard insufflation settings and without direct organ injury. The DV5’s integrated airflow regulation may alter intraoperative pressure gradients in way that differ from prior platforms. Surgeons adopting DV5 for TORT should consider reducing insufflation pressure to 6 mmHg, restricting automated smoke evacuation during deep dissection, and extending PACU monitoring for at least 60 minutes post-extubation. Multidisciplinary collaboration with system specialists is essential during platform adoption.
Breast tumor with giant phyllodes: a case report
Background: Giant phyllodes tumors are rare and are characterized by rapid growth and abundant vascularity. Intraoperative hemorrhage constitutes a major surgical challenge. This report describes a case of a 36-year-old woman with a giant phyllodes tumor of the breast, along with the corresponding treatment strategy. Case Description: A 36-year-old woman presented with a right mass for 2 years. Mammography showed a mass measuring 178 mm × 113 mm in the right breast, which was categorized as Breast Imaging Reporting and Data System (BI-RADS) 4C. Core needle biopsy suggested a possible phyllodes tumor. Following multidisciplinary team (MDT) consultation and recommendations from specialists in oncology and plastic surgery experts, preoperative embolization of the main feeding arteries was performed to minimize intraoperative hemorrhage, followed by intraoperative circumferential suture ligation of subcutaneous blood vessels. A mass weighing 4.42 kg was completely resected. Postoperative pathology showed extensive hemorrhagic degeneration and infarction of the tumor, with focal brisk stromal cellular proliferation; borderline change could not be excluded. The patient’s postoperative recovery was uneventful. Conclusions: The “two-step” hemostatic strategy combining preoperative arterial embolization and intraoperative circumferential suture ligation can effectively reduce intraoperative bleeding in patients with giant phyllodes tumors. This approach is thus both feasible and safe for similar cases.
Splenic artery preservation with splenic vein sacrifice during spleen-preserving distal pancreatectomy: safety and remaining questions
Hemodynamic adaptation after splenic vein sacrifice in spleen-preserving distal pancreatectomy