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Background and Objectives: Venous thromboembolism (VTE) can be the first manifestation of an underlying cancer. This study aimed to develop a predictive model to assess the risk of occult cancer between 30 days and 24 months after a venous thrombotic event using machine learning (ML). Materials and Methods: We designed a case–control study nested in a cohort of patients with VTE included in a prospective registry from two Spanish hospitals between 2005 and 2021. Both clinically and ML-driven feature selection were performed to identify predictors for occult cancer. XGBoost, LightGBM, and CatBoost algorithms were used to train different prediction models, which were subsequently validated in a hold-out dataset. Results: A total of 815 patients with VTE were included (51.5% male and median age of 59). During follow-up, 56 patients (6.9%) were diagnosed with cancer. One hundred and twenty-one variables were explored for the predictive analysis. CatBoost obtained better performance metrics among the ML models analyzed. The final CatBoost model included, among the top 15 variables to predict hidden malignancy, age, gender, systolic blood pressure, heart rate, weight, chronic lung disease, D-dimer, alanine aminotransferase, hemoglobin, serum creatinine, cholesterol, platelets, triglycerides, leukocyte count and previous VTE. The model had an ROC-AUC of 0.86 (95% CI, 0.83–0.87) in the test set. Sensitivity, specificity, and negative and positive predictive values were 62%, 94%, 93% and 75%, respectively. Conclusions: This is the first risk score developed for identifying patients with VTE who are at increased risk of occult cancer using ML tools, obtaining a remarkably high diagnostic accuracy. This study's limitations include potential information bias from electronic health records and a small cancer sample size. In addition, variability in detection protocols and evolving clinical practices may affect model accuracy. Our score needs external validation. [ABSTRACT FROM AUTHOR]

Background and Objectives: Venous thromboembolism (VTE) can be the first manifestation of an underlying cancer. This study aimed to develop a predictive model to assess the risk of occult cancer between 30 days and 24 months after a venous thrombotic event using machine learning (ML). Materials and Methods: We designed a case–control study nested in a cohort of patients with VTE included in a prospective registry from two Spanish hospitals between 2005 and 2021. Both clinically and ML-driven feature selection were performed to identify predictors for occult cancer. XGBoost, LightGBM, and CatBoost algorithms were used to train different prediction models, which were subsequently validated in a hold-out dataset. Results: A total of 815 patients with VTE were included (51.5% male and median age of 59). During follow-up, 56 patients (6.9%) were diagnosed with cancer. One hundred and twenty-one variables were explored for the predictive analysis. CatBoost obtained better performance metrics among the ML models analyzed. The final CatBoost model included, among the top 15 variables to predict hidden malignancy, age, gender, systolic blood pressure, heart rate, weight, chronic lung disease, D-dimer, alanine aminotransferase, hemoglobin, serum creatinine, cholesterol, platelets, triglycerides, leukocyte count and previous VTE. The model had an ROC-AUC of 0.86 (95% CI, 0.83–0.87) in the test set. Sensitivity, specificity, and negative and positive predictive values were 62%, 94%, 93% and 75%, respectively. Conclusions: This is the first risk score developed for identifying patients with VTE who are at increased risk of occult cancer using ML tools, obtaining a remarkably high diagnostic accuracy. This study’s limitations include potential information bias from electronic health records and a small cancer sample size. In addition, variability in detection protocols and evolving clinical practices may affect model accuracy. Our score needs external validation.

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Introduction: Patients with cancer are known to have an increased risk of ischemic stroke (IS) around the time of their diagnosis. However, there is a paucity of data in Asian populations, and as such, we aimed to determine cancer incidence rates and patterns in Asian IS patients as well as investigate the differences in vascular risk profile of IS patients with and without concomitant cancer. Methods: We conducted a retrospective cross-sectional study using data from the Singapore Stroke and Cancer registries. We defined cases as patients with IS and a cancer diagnosis 2 years before or after the index IS. Cancer incidence was determined using the same direct age-standardization method performed for the Singapore general population in the 2015 Singapore cancer report. Multivariable logistic regression was used to analyze differences in vascular risk factors. Results: Among 21,068 IS patients (mean age, 67.9 ± 13.3 years), 6.3% (1,330) were found to have concomitant cancer; 4.4% (935) had prior cancer while 1.8% (395) had cancer diagnoses within 2 years following IS. The cancer incidence among IS patients was 3,393 (95% confidence interval [CI], 1,937–4,849) per 100,000 person-years compared to 219–231 per 100,000 person-years in the general population. Older age (odds ratio [OR], 1.02 [95% CI, 1.01–1.02] per year), males (OR, 1.25 [95% CI, 1.11–1.41), Chinese ethnicity (OR, 1.61 [95% CI, 1.37–1.89]) and a lower prevalence of hypertension (OR, 0.84 [95% CI, 0.73–0.97)]), and hyperlipidemia (OR, 0.53 [95% CI, 0.45–0.62]) were independently associated with cancer-related IS. Conclusions: The age-standardized cancer incidence was 15 times higher in IS patients than the general population. IS patients with concomitant cancer were older and had a lower prevalence of vascular risk factors.

Background: Investigating patients with unprovoked venous thromboembolism (uVTE) for occult malignancy can prove a diagnostic dilemma and imaging is often used extensively in this patient group. Aims: The primary objective of this study was to determine the incidence of malignancy on CT and other imaging over a 10-year period. A secondary objective was to evaluate the role of laboratory and other non-imaging tests performed. Methods: A retrospective key word search of our hospital's imaging system was performed to identify patients with unprovoked DVT/PE over the last 10 years. All imaging, histology, endoscopy, laboratory tests, and clinical follow-up over 2 years were analysed. Patients with provoked VTE were excluded. Results: 150 patients had uVTE. 9 patients were diagnosed with occult malignancy by different investigations on index hospital admission (3 patients) or subsequently on clinical follow-up (6 patients). Mean age of patients was 62 years. 116 patients had CT body imaging. The incidence of malignancy diagnosed by initial CT imaging was 1.7% with a sensitivity of 22%, specificity 87%, and PPV 12.5%. Overall incidence of malignancy identified by imaging alone during the index hospital admission was 2%. Total incidence of malignancy including index admission and follow-up was 6%. Median time to cancer diagnosis was 12 months. Conclusion: CT imaging had a low yield for diagnosing malignancy. Extensive imaging strategies increase cost and radiation exposure without improving mortality. Clinical follow-up, history taking, and physical examination guiding appropriate investigations remain the best tool for unmasking occult malignancy in patients with uVTE. [ABSTRACT FROM AUTHOR]

Abstract Background Tonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected. Methods We sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics. Results 95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations. Conclusion Eliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice. Graphical Abstract

Colorectal carcinoma (CRC) is a common malignancy with steadily declining incidence rates and mortality, secondary to improved screening and lifestyle changes (eg, decreased smoking rates). The association between pelvic inflammatory disease (PID) and CRC has been unclear in the past. However, multiple studies showed a positive association between PID and underlying malignancy (gynecologic and pelvic primarily). Several studies evaluated the relation between PID and CRC, but the results were conflicting. We describe a case of a 33-year-old female patient, with a history of PID and recurrent pelvic abscesses, who was found to have CRC. Of note, the patient's diagnosis was based on abnormal computed tomography findings, which were further investigated (by colonoscopy and biopsy), rather than on symptoms suggestive of CRC, such as rectal bleeding, constipation, symptomatic anemia, or abdominal pain. [ABSTRACT FROM AUTHOR]

Tonsillar malignancy typically presents with asymmetrical tonsillar enlargement, lesion on the tonsils, sore throat or a neck mass. We report a case of unsuspected tonsillar malignancy in a 56-year-old gentleman who presented with symptoms of obstructive sleep apnoea. His tonsils were grade III bilaterally with normal mucosa. Tonsillectomy was performed to improve patient's compliance with Continuous Positive Airway Pressure (CPAP) therapy. These tonsillar specimens were reported to be Mantle Cell Lymphoma (MCL) based on the histology and ancillary studies. This case highlights that benign-looking symmetrical tonsillar enlargement can harbour occult malignancy. It is important to note that OSA symptoms may be the presentation for haematological malignancies. Tonsillar specimens should be sent for histopathological examination regardless of the indication to avoid misdiagnosis and delay in treatment. [ABSTRACT FROM AUTHOR]

Background: Tonsillectomy is a commonly performed procedure in Canada. The rate of occult malignancy is rare in adult and pediatric populations. At present, no guidelines exist surrounding the need for routine histopathological evaluation of tonsil specimens when no malignancy is suspected. Methods: We sent a confidential online survey to active members of the Canadian Society of Otolaryngology – Head and Neck Surgery (CSO-HNS) about their current tonsillectomy practice and beliefs surrounding the need for routine histopathological evaluation of tonsillectomy specimens when no malignancy is suspected. We used Opinio survey software for data collection and descriptive statistics. Results: 95 participants completed our survey (response rate 19.3%). Most participants reported performing both adult and pediatric tonsillectomies. When no malignancy is suspected, participant responses were split between whether they send tonsil specimens in pediatrics only (4.2%), in adults only (31.6%), or not sending specimens (29.5%). Half of the participants reported that routinely sending specimens to rule out occult malignancy is an institutional policy. Approximately 75% of participants were in favour of removing this practice in both the pediatric and adult populations. Conclusion: Eliminating the practice of automatically sending tonsil specimens for histopathological evaluation when no malignancy is suspected was supported by the majority of study participants. This is in keeping with Choosing Wisely, a campaign designed to facilitate conversations about unnecessary medical tests and procedures. Institutional change is likely required in order to alter this practice. [ABSTRACT FROM AUTHOR]

Anna Louise Russell,1 Ben Haagsma,2 Thumuluru Kavitha Madhuri3,4 1Department of Gynae-Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK; 2Department of Histopathology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK; 3Department of Gynaecological Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK; 4Department of Experimental Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK Abstract: The presentation of a new vaginal lesion could represent a variety of diagnoses from benign warts to more sinister primary malignancies. Rarely, a new lesion could represent a metastatic deposit from a malignancy elsewhere in the body. Colonic carcinomas are the third most common malignancy, frequently metastasising to the liver and lung. There have been a small number of cases in the literature reporting vaginal metastases from colonic carcinoma and this is usually indicative of advanced disseminated disease. We present an interesting case of a 65-year-old female with a strong family history of bowel cancer who originally presented with a vaginal skin tag that was biopsied and found to be a moderately differentiated adenocarcinoma. The immunohistochemistry profile was cytokeratin (CK) 20 positive/CK 7 negative, highly suggestive of a bowel cancer primary. However, subsequent extensive radiological and endoscopic investigations failed to identify a colonic primary tumor. The vaginal lesion was successfully excised, and no systemic treatments were warranted. To date, no primary cancer has been identified; the patient remains asymptomatic with no clinical signs of disease recurrence 5 years following her initial diagnosis. This case represents a diagnostic dilemma between two very rare diagnoses of either a vaginal metastasis from an occult colonic primary tumor or a primary vaginal adenocarcinoma of endometrioid morphology demonstrating intestinal immunophenotype. Organizing colonic screening is recommended in view of the high risk of colonic adenocarcinoma. Keywords: skin tag, vaginal cancer, metastases, occult malignancy, colon cancer, villiform, intestinal villiform, endometrioid

Objective: National pathology guidelines recommend full pathologic analysis for all adult tonsillectomy specimens. We evaluated the available data on occult malignancy in adult tonsillectomy for benign indication, and created a screening system to reduce the risk of missed malignancies if routine histopathologic examination were to be discontinued. Study design: Retrospective chart review and systematic review of the literature. Setting: Tertiary care academic hospital and multi-hospital private healthcare system. Subjects and methods: A systematic literature review identified case series of adult tonsillectomy. Retrospective chart review at our institutions from 2000 to 2016 produced an additional case series. The pooled rate of occult malignancy was determined, and re-analyzed using criteria based on preoperative risk factors designed to identify patients requiring full pathologic analysis. The predicted effects of prospective application of the proposed criteria were calculated. Pooled occult malignancy prevalence was estimated. Results: Literature review and our own case series yielded 12,094 total cases. Occult malignancy prevalence in the combined data was 0.033%, representing four occult malignancies. Three out of the four would have been selected for full pathology preoperatively with use of the proposed criteria. Statistical analysis indicates that the predicted frequency of occult malignancy incidence in cases negative for the criteria is 0.01%, or 1/10,000. Conclusion: Application of the proposed criteria to adults undergoing tonsillectomy for benign indication identifies a subset of patients with an estimated incidence of occult malignancy similar to that reported for pediatric tonsillectomy, and potentially may permit safe elimination of pathologic analysis of their tonsil specimens. Level of Evidence: Pooled analysis of case series from the literature and a single institution, level 4. [ABSTRACT FROM AUTHOR]

Study Objective: The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication.Design: Retrospective chart review.Setting: Tertiary care referral center in the United States.Patients: A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018.Interventions: All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication.Measurements and Main Results: Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001).Conclusion: In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient. [ABSTRACT FROM AUTHOR]

Abstract Background Morcellation of undiagnosed uterine sarcoma is cause of abdominal/pelvic dissemination, residual tumor and recurrence. In the preoperative evaluation of suspect uterine masses, magnetic resonance imaging (MRI) and serum lactate dehydrogenase (LDH) total activity are referred to as the most effective tools, while computed tomography scan (CT) and LDH isoenzymes are less considered in literature. Case presentation A 46 year old woman was admitted to our department with a large uterine mass. Ultrasonography, MRI and LDH total activity did not allow a diagnosis of malignancy, and the woman expressed the wish to avoid hysterectomy. In spite of this, we opted for a total abdominal hysterectomy instead of a laparoscopic myomectomy, due to an elevation of LDH5/LDH1 ratio and CT findings indicative of sarcoma. Histological examination revealed a high grade leiomyosarcoma, confirming our suspicion. Thus, we had avoided the risks linked to morcellation. Conclusions Our experience suggests that LDH isoenzymes assessment may be relevant in preoperative diagnosis of uterine sarcoma. Further studies are necessary to determine its role in a diagnostic algorithm. We think it may be useful especially for patients with clinical or ultrasonographic suspicion of uterine sarcoma not confirmed by imaging techniques. Furthermore, the role of less considered imaging techniques, such as CT, should not be underestimated in challenging cases.

Objective: To determine the prevalence of occult malignancy in Thai patients with the first episode of unprovoked deep vein thrombosis, and to identify the methods leading to the diagnosis of occult cancer. Materials and Methods: The medical records of 369 consecutive patients with symptomatic proximal DVT of the lower extremity were retrospectively reviewed. The patients' demographic data, sites of occult cancer, and the screening methods utilized for the detection of occult cancer were recorded. Results: Among the 369 acute DVT patients enrolled in this study, there were 104 (28.2%) unprovoked DVT cases, 106 (28.7%) DVT provoked by transient risk factors, and 159 (43.1%) cancer-associated DVT. Among the 104 patients with unprovoked DVT, occult malignancies were identified in 26 (25%) patients, with 13 (50.0%) of the occult cancers being in the metastatic stage. The methods leading to the diagnosis of occult cancers were limited screening by history taking and physical examination with a routine blood test and chest x-rays in 21 (80.8%) patients, by serum tumor markers screening in 3 (11.5%) patients, and by abdominal computed tomography screening in 2 (7.7%) patients. Conclusion: The prevalence of occult cancer in acute unprovoked DVT in the present study was 25%, with most of the occult cancers detected by a limited screening strategy. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups.Design: A retrospective cohort study.Setting: A tertiary referral hospital.Patients: All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016.Interventions: Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy.Measurements and Main Results: A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%).Conclusion: The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe. [ABSTRACT FROM AUTHOR]

Background: Pericardial decompression syndrome (PDS) is defined as paradoxical hemodynamic deterioration associated with left, right, or bi‐ventricular dilation and systolic dysfunction following pericardiocentesis. It is uncommon yet under‐recognized, underreported, and associated with significant morbidity and mortality. Case report: We report a unique case of PDS associated with left ventricular (LV) systolic dysfunction and massive apical thrombosis following surgical removal of 800 ml of pericardial fluid in a 72‐year‐old man with undiagnosed lung cancer. Treatment with anticoagulation and anti‐remodeling medications resulted in complete resolution of the thrombus and recovery of LV function. Conclusions: PDS, although rare, can lead to significant morbidity and mortality. Left ventricular apical thrombosis could result from PDS in the setting of hypercoagulable state. Treatment of the underlying disease may lead to successful resolution of PDS and its complications. [ABSTRACT FROM AUTHOR]

Various paraneoplastic syndromes (PNS) are reported to be associated with breast cancer and can range from mild dermatological symptoms to severe neurological complications. Neurological and dermatological manifestations tend to be the more commonly seen paraneoplastic manifestations, albeit both are relatively rare. Diagnosis of the underlying malignancy is often delayed since the presence and severity of paraneoplastic manifestations are not dependent on the tumor size or stage. Herein, we describe a unique case of unilateral arm urticaria presenting as a paraneoplastic manifestation of metachronous bilateral breast cancer. Similar reports and other PNS associated with breast cancer are described. Recognition of PNS associated with underlying malignancies and age-appropriate screening can facilitate diagnosis of the underlying occult malignancy. Resection of the underlying malignancy can lead to resolution and/or improvement of the PNS for some patients.

Abstract Objective To evaluate the incidence of tonsil and adenoid malignancy in pediatric patients in Israel compared to the known literature and to revisit the common practice of routine histopathologic examination of tonsils and adenoids. Methods Analysis of the Israel National Cancer Registry data on pediatric tonsil and adenoid malignancies between the years 2005 and 2015, and a systematic literature review of all relevant articles that reported on malignancies amongst pediatric patients who underwent tonsillectomy with or without adenoidectomy. Results Only seven cases of tonsillar malignancies were documented out of 152,352 (0.0052%) surgeries in the pediatric population. All malignancies were lymphoproliferative and mainly Burkitt's lymphoma. In our medical center no malignancy was found in 2165 patients in the same age groups and time period. We found the incidence of tonsillar malignancy in Israel to be significantly lower (p = 0.013) compared to the previously described literature. Conclusion The incidence of malignancy in routine histopathological examination of tonsils and adenoids is Israel is very low when compared to the known literature. According to these results, we suggest that routine histopathological examination of all such samples is not clinically justified. [ABSTRACT FROM AUTHOR]

Hysteroscopy is the treatment of choice of benign intrauterine conditions, whenever feasible. During hysteroscopic procedures performed with the intent of resecting myomas and polyps, there is a potential risk of an unexpected diagnosis of an occult malignant lesion. Objective: To estimate the incidence of occult uterine malignancy in women undergoing hysteroscopic electroresection due to a diagnosis of benign uterine lesions: endometrial polyps and submucosal myomas, by ultrasound. Material and methods: The electronic database of patients hospitalized between January 2010 and December 2016 in the Department of Gynecology and Oncology of the Jagiellonian University was searched for women who had undergone hysteroscopic surgery due to presumed endometrial polyps and submucosal myomas. Medical records of 1,006 eligible women were analyzed. Results: Ten cases (10/1,006; 1%) of occult endometrial cancer, 2 cases (2/1,006; 0,2%) of low-grade endometrial stromal sarcoma and 3 cases (3/1,006; 0,3%) of atypical endometrial hyperplasia were found postoperatively. One case of ovarian cancer coexisting with endometrial cancer was diagnosed. Of the factors analyzed, only age, menopausal status and abnormal uterine bleeding turned out to be significant endometrial cancer risk factors. Too few sarcoma cases did not allow similar estimates. We did not observe worsening of the prognosis, and all 15 patients who underwent hysteroscopic resection of the unforeseen malignancy or precancerous lesion are still alive within 2-8 years of follow-up. Conclusions: The incidence of unlooked-for malignancy in patients with benign intracavitary lesions, i.e. endometrial polyps and submucosal myomas, is relatively high. No negative effects of hysteroscopic resection on potential further treatment and prognosis have been proven so far. High risk of malignancy in women with presumed benign intracavitary lesions may indicate that not all these women are appropriate candidates for laparoscopic procedures with power morcellation, particularly when no previous histopathological verification is ordered. [ABSTRACT FROM AUTHOR]

Introduction: When the Food and Drug Administration (FDA) initially reported on the parlous incidence (0.28%) of occult malignancy identified following uterine power morcellation, investigations thereafter documented their particular experience with this surgical procedure. Nevertheless, the precise risk of identifying a sarcoma following uterine morcellation remains indeterminate, primarily due to varying study patient risk factors, diagnostic criteria and operative approach.Method: We retrospectively evaluated subjects who underwent an endoscopic hysterectomy and uterine power morcellation for the treatment of a presumptive, benign indication from January 2006 until December 2015. The primary outcome was the incidence of an occult malignancy. Secondarily, we were interested in characterizing the patients' specific clinical (age, menopausal status, body mass index (BMI)) risk factors within the context of a confirmed malignant or pre-malignant pathology.Results: We identified 281 patients who underwent endoscopic surgery that incorporated uterine morcellation. During the study period, one subject was ultimately diagnosed with a uterine leiomyosarcoma; the overall incidence of occult malignancy was 0.36%. There were also 3 cases of uterine premalignant disease on final pathology (2 patients had complex hyperplasia with or without atypia and 1 subject was diagnosed with a smooth muscle tumor of uncertain malignant potential (an incidence of 1.1%)). We were unable to establish any relationship between patient age, uterine weight, menopausal status or BMI and the incidence of a malignant or pre-malignant pathology (P > 0.05).Conclusion: The rate of occult malignancy in the present investigation was similar to previously documented studies and that which has been reported by the FDA. Additional study of methods in which to enhance preoperative work-up and mitigate the surgical risk for tumor cell dissemination is warranted. [ABSTRACT FROM AUTHOR]

Risk-reducing bilateral salpingo-oophorectomy reduces mortality from high-grade serous carcinoma in patients with hereditary breast and ovarian cancer associated gene mutations. Ideal surgical management includes 5 steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists. In addition, it is recommended that pathologic examination include serial sectioning of specimens. In practice, risk-reducing salpingo-oophorectomy is performed by both gynecologic oncologists and general gynecologists. To ensure optimal detection of occult malignancy, standardized adherence to outlined guidelines is necessary. This study aimed to evaluate the adherence to optimal surgical and pathologic examination guidelines and to compare the rate of occult malignancy at the time of surgery between 2 provider types. Institutional review board exemption was obtained. A retrospective review of patients undergoing risk-reducing bilateral salpingo-oophorectomy without hysterectomy from October 1, 2015, to December 31, 2020, at 3 sites within a healthcare system was conducted. The inclusion criteria included age ≥18 years and a documented indication for surgery being a mutation in BRCA1 or BRCA2 or a strong family history of breast and/or ovarian cancer. Compliance with 5 surgical steps and pathologic specimen preparation was based on medical record documentation. Multivariable logistic regression was used to determine differences in adherence between provider groups and surgical and pathologic examination guidelines. A P value of <.025 was considered statistically significant for the 2 primary outcomes after Bonferroni correction was applied to adjust for multiple comparisons. A total of 185 patients were included. Among the 96 cases performed by gynecologic oncologists, 69 (72%) performed all 5 steps of surgery, 22 (23%) performed 4 steps, 5 (5%) performed 3 steps, and none performed 1 or 2 steps. Among the 89 cases performed by general gynecologists, 4 (5%) performed all 5 steps, 33 (37%) performed 4 steps, 38 (43%) performed 3 steps, 13 (15%) performed 2 steps, and 1 (1%) performed 1 step. Gynecologic oncologists were more likely to document adherence to all 5 recommended surgical steps in their surgical dictation (odds ratio, 54.3; 95% confidence interval, 18.1–162.7; P <.0001). Among the 96 cases documented by gynecologic oncologists, 41 (43%) had serial sectioning of all specimens performed, compared with 23 of 89 cases (26%) performed by general gynecologists. No difference in adherence to pathologic guidelines was identified between the 2 provider groups (P =.0489; note: P value of >.025). Overall, 5 patients (2.70%) had occult malignancy diagnosed at the time of risk-reducing surgery, with all surgeries performed by general gynecologists. Our results demonstrated greater compliance with surgical guidelines for risk-reducing bilateral salpingo-oophorectomy in gynecologic oncologists than in general gynecologists. No considerable difference was determined between the 2 provider types in adherence to pathologic guidelines. Our findings demonstrated a need for institution-wide protocol education and implementation of standardized nomenclature to ensure provider adherence to evidence-based guidelines. [ABSTRACT FROM AUTHOR]

Unprovoked venous thromboembolism (VTE) can be the first sign of cancer. In 5-10% of patients with unprovoked VTE, cancer is diagnosed in the twelve months following the event. After an unprovoked VTE diagnosis, patients should undergo a thorough medical history, careful physical examination, laboratory investigations (blood counts with blood smear, liver enzymes, calcium, and urinalysis) and chest X-ray. In addition, specific cancer screening (colon, cervix, breast, and prostate) should be performed according to age and sex. Any anomalies must be further investigated. So far, no study has been able to prove that extended screening could improve the rate of occult cancer detection or decrease cancer-related mortality. [ABSTRACT FROM AUTHOR]

A 40-year-old African American man with recently diagnosed Human Immunodeficiency Virus (HIV) presented with isolated left abducens palsy. Initial neuro-imaging and laboratory evaluation, including cerebrospinal fluid (CSF) analysis, were unremarkable. Continued search for causative aetiology revealed systemic lymphoma diagnosed ultimately by bone marrow biopsy. Systemic lymphoma is commonly encountered in the HIV patient population, but presentation can be unusual and has been seen, albeit rarely, in the setting of isolated cranial neuropathy. This case demonstrates the often diligent investigation required in the setting of isolated cranial neuropathies in patients with HIV. [ABSTRACT FROM PUBLISHER]

Objective: The aims of this research were to quantify the incidence of malignancy in women undergoing hysterectomy for benign indications and to compare the preoperative evaluation of patients undergoing hysterectomy with and without morcellation. Materials and Methods: This retrospective cohort study identified women undergoing hysterectomies between October 2007 and June 2014. Chart abstraction included demographics; prehysterectomy evaluation, including current cervical cytology, pathologic endometrial assessment (biopsy, dilation and curettage [D&C]); and imaging (ultrasound, magnetic resonance imaging, computed tomography); intraoperative factors; and final pathology. Results: The analyzed cohort included 2309 women undergoing hysterectomy with 396 (17.1%) who had morcellation. Women undergoing hysterectomy with morcellation were, on average, younger, compared to those having hysterectomy without morcellation (33.4 ± 18.8 versus 39.7 ± 17.6; p < 0.001). The incidence of malignancy was 1.7% and was different between nonmorcellated versus morcellated specimens (2.0% versus 0.3%; p < 0.001). There was no significant difference in preoperative cervical cytology (68.9% versus 71.0%) and imaging (39.6% versus 35.2%) assessment rates between the nonmorcellated versus morcellated groups; however, patients who had morcellation were less likely to have had preoperative pathologic endometrial assessments (21.7% versus 34.1%; p < 0.001). Conclusions: The risk of occult malignancy noted during hysterectomy was low overall. Preoperative evaluation of patients undergoing hysterectomy with morcellation was similar to those without morcellation, except for lower rates of endometrial assessment by biopsy or D&C. Given the concern for possible dissemination of occult malignancy with morcellation, one may consider preoperative assessment with endometrial biopsy prior to surgery or contained morcellation. The cost-efficacy and clinical efficacy of this warrants further investigation. (J GYNECOL SURG 34:18) [ABSTRACT FROM AUTHOR]

Background The present meta-analysis aimed to evaluate the efficacy and sensitivity of an extensive screening strategy for occult malignant diseases in patients with unprovoked venous thromboembolism (VTE). Methods We conducted a systematic search of PubMed, Cochrane, EMBASE, and relevant article references. Meta-analysis was used to pool weighted relative risks (RR) for the rate of missed diagnosis, all-cause mortality, and cancer-related mortality. Heterogeneity test was performed using the inconsistency index. Furthermore, pooled analysis of the sensitivity and the proportion of false-positive findings of PET/CT were conducted. Results A total of 5 controlled studies were included with 1,115 and 1,159 unprovoked VTE patients receiving limited or extensive screening strategy, respectively. The risk of missed diagnosis (RR, 0.51; 95% CI, 0.20–1.28; P = 0.15) was not significantly different between the limited and extensive screening group. Moreover, there was no statistically significant difference in all-cause mortality (RR, 0.86; 95% CI, 0.58–1.27; P = 0.44) and cancer-related mortality (RR, 0.86; 95% CI, 0.46–1.62; P = 0.65) between the two groups. The pooled sensitivity and proportion of false-positive findings of PET/CT as a screening tool for occult malignancy in patients with unprovoked VTE was 95% (95% CI, 38%–100%) and 33% (95% CI, 20%–47%), respectively. Conclusions Extensive screening strategy did not show a clinically significant benefit over limited screening strategy. Considering the high cost and the additional physical and emotional harm, current evidence did not support extensive screening for each patient in the setting. [ABSTRACT FROM AUTHOR]

Recurrent cryptogenic embolic strokes pose a diagnostic challenge, often necessitating an extensive evaluation to determine the underlying cause. Cancer-related stroke is a frequently overlooked etiology, accounting for a substantial proportion of cryptogenic strokes. This case study underscores the importance of considering occult malignancies in patients with recurrent strokes of unknown origin and emphasizes the need for a comprehensive diagnostic workup to detect hidden malignancies. A 50-year-old male with a complex medical history presented with expressive aphasia and blurred vision resembling previous stroke episodes. Neurological examinations revealed right hemianopsia, paraphasia, and abnormal coordination. Neuroimaging studies showed multiple chronic infarctions, a large hemorrhagic infarction in the left posterior cerebral artery territory, and a small acute-to-subacute left parietal infarction. Due to the time of presentation and the presence of hemorrhagic transformation, the patient did not meet the criteria for intravenous tissue plasminogen activator administration. Given the recurrent nature of the strokes, an extensive evaluation was initiated to determine the underlying cause. Vascular imaging, including magnetic resonance angiography (MRA) of the head and neck and a CT angiogram, showed no significant stenosis. Vasculitis workup and cardiac evaluation yielded negative results. The blood workup was notable for elevated D-dimer levels. The involvement of multiple vascular territories and recurrent stroke despite adequate treatment and the absence of traditional risk factors for stroke raised a high clinical suspicion of occult malignancy. Further investigations led to the diagnosis of locally advanced squamous cell carcinoma (P16+), metastatic to the right neck lymph nodes (cTxN3M0). Although the primary source of cancer could not be identified, the P16+ status suggests the right tonsil or base of the tongue as the probable origin. Anticoagulation therapy was initiated, and the patient was scheduled for chemoradiation therapy. Although routine cancer investigation is not justified in ischemic strokes, the possibility of an occult malignancy should be considered in the presence of multifocal infarctions across different vascular territories with elevated D-dimer levels, particularly when traditional risk factors have been ruled out. A detailed physical exam can help localize the malignancy and early identification of occult malignancies can guide appropriate management strategies and help prevent future strokes. Further clinical trials are needed to establish optimal therapeutic approaches for preventing stroke recurrence in cancer-related strokes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Prabakar et al.)

Association between stroke and cancer is well-established and has led to a growing literature over the past decades. Risk of ischemic and hemorrhagic stroke is increased among patients with newly diagnosed cancer and 5-10% of stroke patients bear an active cancer. All cancers are concerned, but hematological malignancy in childhood and adenocarcinoma from lung, digestive tract and pancreas in adults are most usually identified. Unique stroke mechanisms are dominated by hypercoagulation, a condition that may lead to both arterial and venous cerebral thromboembolism. Direct tumor effects, infections and therapies may also play some active role in stroke happening. Magnetic Resonance Imaging (MRI) is helpful in: i) detecting typical patterns of ischemic stroke in cancer patients (i.e. concomitant strokes in multiple arterial territories); ii) distinguishing spontaneous intracerebral hemorrhage from tumor bleeding. Recent literature suggests that acute treatment using intravenous thrombolysis is safe in non-metastatic cancer patients. First results from endovascular procedures are reassuring, although arterial reobstruction is more frequent than in cancer-free patients. Prognosis is worse in patients with compared to those without cancer and mostly depends upon several predictors such as the initial stroke severity and the presence of metastasis. In the present review, we aim to provide some practical responses to neurologists about the stroke-cancer association, including prevalence, stroke mechanisms, biomarkers indicative for an occult cancer, influence of neoplasia on acute and long-term stroke treatments, and prognosis., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Various paraneoplastic syndromes (PNS) are reported to be associated with breast cancer and can range from mild dermatological symptoms to severe neurological complications. Neurological and dermatological manifestations tend to be the more commonly seen paraneoplastic manifestations, albeit both are relatively rare. Diagnosis of the underlying malignancy is often delayed since the presence and severity of paraneoplastic manifestations are not dependent on the tumor size or stage. Herein, we describe a unique case of unilateral arm urticaria presenting as a paraneoplastic manifestation of metachronous bilateral breast cancer. Similar reports and other PNS associated with breast cancer are described. Recognition of PNS associated with underlying malignancies and age-appropriate screening can facilitate diagnosis of the underlying occult malignancy. Resection of the underlying malignancy can lead to resolution and/or improvement of the PNS for some patients. [ABSTRACT FROM AUTHOR]