WellSpan York Hospital

Background Metaplastic breast cancer (MtBC) is a rare type of aggressive breast cancer. MtBChas multiple pathological subtypes, including squamous,sarcomatoid, spindle,adenosquamous, and mixed metaplastic. Given the rare nature of the disease, there is limited information available on the behaviour of this cancer and no well-defined recommendations for treatment. We aim to investigate the clinicopathological characteristics ofMtBC,including overall survival and patterns of recurrence. Methods We conducted asingle-institutionretrospective review of 91 patients with MtBC who presented from 2009 to 2024. We collected patient-specific, clinicopathological, and survival data. Recurrence-free interval, medical and surgical treatment, follow-up, and time to death were also collected.Dataisdescribed with frequency counts and percentages. Product-limit survival estimates were calculated from the time from diagnosis to last follow-up or death. Results Our population consisted of 91 patients; the mean age at diagnosis was 60 years. All patients were female; the majority were Caucasian (59, 67.1%), followed by African American (24, 27.3%). Sixty-six patients (72.5%)hada BMI >25,and 69 (78.4%) were postmenopausal. MtBCwasestrogen, progesterone, and humanepidermal growth factor(Her2)negative in 82 (90.1%), 88 (96.7%), and 80 (88.9%) of the patients, respectively. Forty-five patients(49.5%) underwent alumpectomy, 41 (45.1%) amastectomy, and one (1.1%) nosurgery. Sixty-four patients (73.6%) had undergone sentinel lymph node biopsy (SLNB), 16 (18.4%) hadaxillarylymph nodedissection (ALND), three (3.4%) had targeted axillarysurgery, and four (4.6%) had no axillary surgery. Sixty-six patients(76.7%) underwent chemotherapy,of which 27 (40.9%) were in theneoadjuvant chemotherapy (NACT) setting. Of the patients who underwent NACT, seven had a completepathological response. Twoof thepathologic complete response (pCR) groupreceived Keynote-522. In ourpopulation, 29 (36.3%)patients hada recurrence, of which 12 (41.4%) haddistant recurrence,with amedian time to recurrenceof12 months. The 12-month, 36-month, and 60-month overall survival rates were 93.9% (Standard Error (SE): 2.7%), 81.3% (SE: 4.8%), and79.2% (SE: 5.1%), respectively.There wasno significant difference inthe survivalrates (p= 0.88)or recurrencerates (p=0.19)for NACT versus adjuvantcases.Subgroupanalysis comparing patients with and without recurrence who received NACT revealed no statistically significant differences in clinicopathologic featuressuch as grade, ER, PR,HER2 status,or metaplastic subtype.Moreover, 20 patientsinthis study received both chemotherapy and immunotherapy,and six (33.3%) experienced recurrences, withno significant differences in recurrence rates,recurrence pattern (p=0.40),or timing (p=0.32) between NACT and adjuvant groups. Conclusion We demonstratedthatMtBCexhibits aggressive oncologic behaviour, often with triple-negative receptor status and high Ki-67. The most common pattern ofrecurrenceis distant, mainly involving the lungs; hence, a chest tomography was essential during the one-year follow-up to detect these lesions. Seven patients (25.9%) whoreceivedNACT achieveda pCR,indicatingthatNACT can be highly beneficial for a subset of patients.Further studies investigating the effects ofNACT, especially keynote-522, in a larger population are necessary tocreate standardized treatment.

Introduction: Heavy metal pollution, which contaminates water, soil, and food, particularly from arsenic, cadmium, lead, copper, and mercury, is a concerning cardiovascular risk factor and a major public health concern. These metals are linked to chronic conditions through inflammation, oxidative stress, and endothelial dysfunction. Whereas traditional cardiovascular disease (CVD) risk factors are well established, environmental exposures are less recognized despite their growing significance. Objective: To find the association between heavy metal exposure and risk of CVD, coronary heart disease (CHD), and stroke through epidemiological studies Methods: Adhering to PROSPERO and PRISMA guidelines, search was conducted across PubMed, Cochrane CENTRAL, and Google Scholar till April 2025 for studies involving heart disease patients or stroke patients exposed to heavy metals. Primary outcomes were the events of CVD, CHD, and stroke. Proportions of events within populations with 95% confidence intervals were pooled. Analysis was conducted by R software and p < 0.05 was considered statistically significant. Results: We included 17 studies involving 324,331 populations. Six studies assessed stroke proportions in cadmium- and arsenic-exposed populations. The cadmium subgroup showed a pooled proportion of 0.09 (95% CI: 0.01–0.17), with individual values ranging from 0.01 to 0.22; the arsenic subgroup showed a pooled proportion of 0.04 (95% CI: 0.04–0.04). The overall pooled proportion was 0.08 (95% CI: 0.01–0.15). Six studies found cases of CHD in groups exposed to cadmium and arsenic, with combined rates of 0.10 (95% CI: 0.00–0.22) for cadmium and 0.00 (95% CI: 0.00–0.00) for arsenic. The overall pooled proportion was 0.08 (95% CI: 0.00–0.18). Ten studies assessed CVD proportions by metal exposure. Arsenic showed a pooled proportion of 0.06 (95% CI: 0.00–0.18), cadmium 0.14 (95% CI: 0.00–0.31), lead 0.08 (95% CI: 0.01–0.14), and mercury 0.05 (95% CI: 0.04–0.06). The overall pooled proportion was 0.10 (95% CI: 0.03–0.17). All outcomes showed high heterogeneity despite sensitivity analysis. Conclusion: Our findings align with prior research showing that cadmium and arsenic exposure significantly increase cardiovascular risk, while lead and mercury are linked mainly to CVD. These results underscore environmental toxic metals' relevance in cardiovascular risk beyond behavioural risk factors.

Purpose: This study analyzes global trends in age-standardized IHD mortality from 1990 to 2021 across Socio-Demographic Index (SDI) groups to assess income-based disparities. Methods: GBD data was analysed to assess the mortality rates for IHD from 1990 to 2021 across five SDI groups. Annual Percent Change (APC) and Average Annual Percent Change (AAPC) were calculated to determine mortality rate trends over time, with p-values determining the statistical significance. Results: Global age-standardized IHD mortality declined by 30%, from 158.9 per 100,000 in 1990 to 111.5 in 2021, highlighting a significant three-decade reduction. The AAPC was -1.30% (CI: -1.34 to -1.26) with a highly significant p-value, indicating a clear decreasing trend. In low SDI regions, IHD mortality declined by 9.4% from 1990 to 2021. From 1990–2013, the decline was slow (APC = -0.20%, 95% CI: -0.30 to -0.09), but from 2014–2021, it accelerated (APC = -1.13%, 95% CI: -1.57 to -0.68). The overall trend shows no significant change (AAPC = 0.01, CI: -0.10 to 0.11). In low-middle SDI regions, mortality decreased by 13%. From 2014–2021, a moderate decline was observed (APC = -0.64%, 95% CI: -1.00 to -0.26). However, overall, there was a slight but significant increase (AAPC = 0.16, CI: 0.09 to 0.23). In middle SDI regions, mortality declined by 11%. From 2011–2021, the trend showed a steady decrease (APC = -0.78%, 95% CI: -0.99 to -0.56). Overall, a small but significant decline was observed (AAPC = -0.12, CI: -0.19 to -0.04). In high-middle SDI regions, mortality dropped by 26%. From 1990–2006, the decline was slow (APC = -0.33%, 95% CI: -0.58 to -0.07), but from 2007–2021, the decline accelerated sharply (APC = -2.41%, 95% CI: -2.77 to -2.05). The overall trend shows a significant decrease (AAPC = -1.56, CI: -1.77 to -1.36). In high SDI regions, mortality fell by 49%. Conclusions: IHD mortality has declined globally, with high-income regions achieving the earliest and steepest reductions, though progress has slowed. Low- and middle-income regions saw slower improvements initially but experienced a faster decline in the 2010s. High-middle SDI regions showed the most significant improvement after 2007, driven by economic growth and healthcare advancements. Despite progress, sustained efforts are needed for equitable cardiovascular care.

Roux-en-Y gastric bypass (RYGB) is a widely performed and well-established metabolic and bariatric surgery (MBS) procedure around the world based on its high efficacy and low complication profile when offered to appropriately selected candidates. However, it is still associated with chronic abdominal pain confounded by nonspecific symptoms and signs that many times lead to a delay in diagnosis or excessive and unnecessary testing that may put patients at risk for long-term complications and adverse events. Among the most important causes of chronic abdominal pain after RYGB are marginal ulcers, intussusception, internal hernias, bile reflux gastritis, dumping syndrome, small intestinal bacterial overgrowth (SIBO), candy cane syndrome, biliary pathology, vascular etiologies, and gastroesophageal reflux disease (GERD). A comprehensive literature review based on the highest-level available published manuscripts has been conducted with the goal of providing the readers and members from the American Society for Metabolic and Bariatric Surgery (ASMBS) with a practical algorithm to diagnose and treat chronic abdominal pain after RYGB. An organized approach that promotes early diagnosis and cause-specific management in a multidisciplinary team environment led by metabolic and bariatric surgeons is advised and encouraged. This literature review by the members of the Clinical Issues Committee (CIC) of ASMBS introduces available high-level evidence to allow our members to achieve early diagnosis of the etiologies of chronic abdominal pain and the expedited therapeutic maneuvers to address them and improve quality of life while increasing patient survival.

In patients with high-risk anatomy, transcatheter aortic valve replacement (TAVR) risks coronary obstruction which is associated with high morbidity and mortality. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is effective at preventing coronary obstruction. The authors sought to test the safety and effectiveness of TELLTALE (Transmural Electrosurgery LeafLet Traversal And Laceration Equipment), the first dedicated transcatheter electrosurgery leaflet modification system. The TELLTALE trial (NCT05666713) enrolled participants with high or prohibitive surgical risk undergoing TAVR for native aortic stenosis or bioprosthetic valve failure and in whom computed tomography core laboratory confirmed high risk of coronary obstruction. The primary efficacy endpoint was technical success in the catheterization lab and the primary safety endpoint was inpatient safety. A total of ninety participants (age 79 [75-82] years, 66% [59/90] female, 30 native aortic stenosis, 60 bioprosthetic valve failure) were enrolled at 11 centers in the United States. High risk of coronary obstruction was confirmed by computed tomography (coronary height 8.2 [6.3-10.8] mm, valve-to-coronary distance 3.4 [2.7-3.7] mm, valve-to-sinotubular-junction distance 1.2 [0.7-1.7] mm). Leaflet modification was easy and reliable with median 1 traversal and laceration attempt per participant. The primary efficacy endpoint was met in 100% (95% CI: 95%-100%) of participants. The primary safety endpoint was met in 96% (95% CI: 88%-99%) of participants, including zero mortality, 3 strokes (1 disabling, 2 nondisabling), and 1 coronary obstruction from transcatheter heart valve commissural suture pos-malalignment. At 30 days, there was zero mortality and zero delayed coronary obstruction. Electrosurgical leaflet modification using the TELLTALE system is safe and effective in patients undergoing TAVR for native aortic stenosis or bioprosthetic valve failure at high risk of coronary obstruction.

This case report presents an asymptomatic 75-year-old female with a screening mammogram revealing a left-sided breast lesion, ultimately diagnosed as glycogen-rich clear cell carcinoma (GRCC) following a comprehensive evaluation and histopathological confirmation. Initial ultrasound-guided biopsy suggested a papillary neoplasm, which was discordant, and was followed by a magnetic resonance imaging (MRI)-guided biopsy showing fibrocystic changes throughout and a complex sclerosing lesion with flat epithelial atypia. We proceeded with a lumpectomy without a sentinel lymph node biopsy. Final pathology revealed findings consistent with GRCC. A multidisciplinary discussion recommended forgoing axillary surgery and proceeding with radiation, hormonal therapy, and chemotherapy. This case highlights the challenges of diagnosing rare cancers, such as GRCC, and the importance of excisional biopsy in the diagnostic process. We also emphasize the importance of multidisciplinary tumor board discussions regarding rare lesions, such as GRCC, to help guide disease management and follow-up.