Redo aortic valve replacement after partial upper sternotomy (hemisternotomy) in a patient with idiopathic thrombocytopenia: a case report

BACKGROUND: We present a case of redo aortic valve replacement in a patient with thrombocytopenia. The initial operation was performed through limited access transverse sternotomy. This is the first report of this kind in the literature. CASE PRESENTATION: A 62 year old Caucasian male farmer with thrombocytopenia had uneventful redo aortic valve replacement when the first xenograft failed after 9 years, the transverse upper hemisternotomy in the first operation appearing to facilitate the redo complete sternotomy. CONCLUSION: With this only case of redo aortic valve replacement in our practice of 90 hemisternotomies over 10 years we present for consideration the use of a tissue valve in a complex relatively young patient

Current practice and surgical outcomes of neoadjuvant chemotherapy for early breast cancer : UK NeST study

Funding Information: This work was funded by a grant from the Association of Breast SurgeryPeer reviewedPublisher PD

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Neoadjuvant Chemotherapy Induces Expression Levels of Breast Cancer Resistance Protein That Predict Disease-Free Survival in Breast Cancer

<div><p>Three main xenobiotic efflux pumps have been implicated in modulating breast cancer chemotherapy responses. These are P-glycoprotein (Pgp), Multidrug Resistance-associated Protein 1 (MRP1), and Breast Cancer Resistance Protein (BCRP). We investigated expression of these proteins in breast cancers before and after neoadjuvant chemotherapy (NAC) to determine whether their levels define response to NAC or subsequent survival. Formalin-fixed paraffin-embedded tissues were collected representing matched pairs of core biopsy (pre-NAC) and surgical specimen (post-NAC) from 45 patients with invasive ductal carcinomas. NAC regimes were anthracyclines +/− taxanes. Immunohistochemistry was performed for Pgp, MRP1 and BCRP and expression was quantified objectively using computer-aided scoring. Pgp and MRP1 were significantly up-regulated after exposure to NAC (Wilcoxon signed-rank p = 0.0024 and p<0.0001), while BCRP showed more variation in response to NAC, with frequent up- (59% of cases) and down-regulation (41%) contributing to a lack of significant difference overall. Pre-NAC expression of all markers, and post-NAC expression of Pgp and MRP1 did not correlate with NAC response or with disease-free survival (DFS). Post-NAC expression of BCRP did not correlate with NAC response, but correlated significantly with DFS (Log rank p = 0.007), with longer DFS in patients with low post-NAC BCRP expression. In multivariate Cox regression analyses, post-NAC BCRP expression levels proved to predict DFS independently of standard prognostic factors, with high expression associated with a hazard ratio of 4.04 (95% confidence interval 1.3–12.2; p = 0.013). We conclude that NAC-induced expression levels of BCRP predict survival after NAC for breast cancer, while Pgp and MRP1 expression have little predictive value.</p></div

Post-NAC expression of BCRP predicts disease-free survival.

<p>Kaplan–Meier survival analyses for disease-free survival in patient groups with tumours with high or low post-NAC expression levels of Pgp (A), MRP1 (B) or BCRP (C). Cut-off used to dichotomise expression into low and high groups (Pgp: 90; MRP1∶21; BCRP: 47) were determined by ROC curve analyses (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0062766#pone.0062766.s001" target="_blank">Fig. S1</a>).</p

Representative staining patterns for Pgp, MRP1 and BCRP in matched breast tumour tissues pre- and post-neoadjuvant chemotherapy.

<p>Individual expression scores for each tissue shown, using a semi-automated scoring system, were: Pgp pre, 10.6; Pgp post, 117.9; MRP1 pre, 3.2; MRP1 post, 55; BCRP pre, 64.5; BCRP post, 89.7. Scale bar: 40 µm.</p

Clinical and pathological features of the patients.

<p>Clinical and pathological features of the patients.</p