Purpose: Medical schools have faced various challenges in preparing their clinical students for the frontlines of a pandemic. This study investigated medical students’ satisfaction with their institutions during the coronavirus disease 2019 (COVID-19) pandemic with the intention of guiding educators in future public health crises. Methods: In this cross-sectional study surveying students in clinical rotations, the primary outcome was overall satisfaction regarding medical schools’ responses to the pandemic, and the four secondary outcomes were school communication, exposure to COVID-19, availability of personal protective equipment, and access to COVID-19 testing. Results: The survey was distributed to ten medical schools, of which 430 students responded for a response rate of 13.0%. While most students were satisfied (61.9%, n=266) with their schools’ response, more than one in five (21.9%, n=94) were dissatisfied. Among the four secondary outcomes, communication with students was most predictive of overall satisfaction. Conclusion In future crises, schools can best improve student satisfaction by prioritizing timely communication.

Purpose: The management of intraductal papilloma (IDP) without atypia remains controversial. This study evaluated the manifestations and incidence of malignancy during observation without surgery in patients diagnosed with IDP by core needle biopsy (CNB), to confirm whether close follow-up instead of surgical treatment is the preferred treatment option in selected patients. Methods: We retrospectively reviewed the data of 589 patients diagnosed with IDP by CNB between January 2009 to December 2018. The data of the 102 IDP lesions from 90 women who did not undergo immediate excision were analyzed. Of these, 84 patients received imaging follow-up without excision, while 18 patients underwent delayed excision during follow-up. Results: During the median follow-up period of 18.6 months, the mean change in tumor size and mean percent change in tumor size were −0.06 cm and −0.22%, respectively. Delayed excision was performed in 18 patients (17.6%). In the delayed excision group, three (16.7%) patients and one (5.6%) patient were diagnosed with atypical papilloma and intraductal papillary carcinoma, respectively, based on the final pathological findings. The upstaged group (atypia and malignancy; four patients) showed a 62.0% increase in the tumor size, which is higher than the benign group that showed a 10.4% increase in tumor size. However, the difference was not statistically significant (p=0.185). Conclusion Observation without excision is possible for small IDP without atypia, because of the minimal changes in tumor size and low incidence of malignancy after excision. However, to avoid a missed diagnosis of malignancy, excision should be considered if the lesion increases in size during follow-up.

PURPOSE: Many patients with cytology proven node-positive breast cancer receive a neoadjuvant chemotherapy (NAC) treatment. We developed a nomogram to predict the breast and axillary pathologic complete responses (pCR) in patients with a cytologically proven axillary node positive breast cancer with NAC. METHODS: We selected 995 patients who were diagnosed with an invasive breast cancer and axillary lymph nodes metastasis, and who were treated with NAC followed by a curative surgery at the Samsung Medical Center between January 2007 and December 2014. The baseline patient and tumor characteristics, chemotherapy regimen, and tumor and nodal responses were thoroughly analyzed and reviewed. A nomogram was developed using a binary logistic regression model with a cross validation. RESULTS: Axillary pCR was achieved in 47.3% and breast pCR was achieved in 24.3% of the patients after NAC. In this case, the both pCR was associated with an initial clinical tumor stage, negative progesterone receptor status, positive human epidermal growth factor receptor 2 status, and clinical radiologic nodal responses. A nomogram was developed based on the clinical and statistically significant predictors. It had good discrimination performance (area under the curve [AUC], 0.868; 95% confidence interval, 0.84–0.89) and calibration fit as noted in that case. The cross validation had an average AUC 0.853 (0.837–0.869). CONCLUSION: Our nomogram might help to predict breast and axillary pCRs after NAC in patients with an initially node-positive breast cancer. Minimal surgery might be acceptable in patients for whom the nomogram indicates a high probability of achieving pCRs.
Area Under Curve ; Breast Neoplasms ; Breast ; Calibration ; Discrimination (Psychology) ; Drug Therapy ; Humans ; Logistic Models ; Lymph Nodes ; Neoadjuvant Therapy ; Neoplasm Metastasis ; Nomograms ; Polymerase Chain Reaction ; Receptor, Epidermal Growth Factor ; Receptors, Progesterone

As in other domains, artificial intelligence is becoming increasingly important in medicine. In particular, deep learning-based pattern recognition methods can advance the field of pathology by incorporating clinical, radiologic, and genomic data to accurately diagnose diseases and predict patient prognoses. In this review, we present an overview of artificial intelligence, the brief history of artificial intelligence in the medical domain, recent advances in artificial intelligence applied to pathology, and future prospects of pathology driven by artificial intelligence.
Artificial Intelligence ; Humans ; Pathology ; Prognosis

A recent study conducted at the University of Tennessee Medical Center using a large dataset from the National Cancer Database (NCDB) reported the use of nomograms for predicting Oncotype DX™ (ODX) scores with clinicopathologic data. We reviewed the data of 218 patients who underwent the ODX test at a single institution in Korea to confirm that nomograms can accurately predict ODX score groups using our data, which differ from those of the NCDB in terms of ethnicity. The concordance index (c-index) of nomograms was much lower than that of the University of Tennessee Medical Center for high- and low-risk groups of commercial ODX and Trial Assigning Individualized Options for Treatment values. Although the nomogram for predicting ODX scores was based on a large dataset, it could not be generalized to patients in Asia. Further studies using large datasets of patients from different ethnicities should be performed to develop a nomogram applicable to patients worldwide.
Asia ; Breast Neoplasms* ; Breast* ; Dataset ; Ethnic Groups ; Humans ; Korea ; Nomograms* ; Recurrence* ; Tennessee

PURPOSE: The American Joint Committee on Cancer (AJCC) recently released the breast cancer staging system, 8th edition, which included additional four biologic factors. However, there has been no external validation of the prognostic value of the new stages with different population-based databases. METHODS: To validate the prognostic value of the new staging system in the Asian population, with a focus on Korean patients with breast cancer, we performed a retrospective study with data from the Korean Breast Cancer Society that included 24,014 patients with invasive ductal or lobular carcinoma who underwent surgery between January 2009 and January 2012 in Korea. The proportional differences were evaluated between the anatomic staging system (AJCC 7th edition) and the prognostic staging system (AJCC 8th edition, December 2017 published version). Comparisons of overall survival (OS) and disease-free survival (DFS) with Kaplan-Meier graphs and hazard ratios were also performed. RESULTS: Our analysis included 24,014 patients (median age, 50 years; range, 20–91 years). Stage I, II, and III disease accounted for 47.6%, 43.5%, and 8.9%, respectively, of anatomic stages and 61.8%, 27.6%, and 10.8%, respectively, of clinical prognostic stages. A total of 6,272 cases (26.1%) were upstaged, 4,656 (19.4%) were downstaged, and 13,086 (54.5%) remained unchanged. OS and DFS decreased in the order from prognostic stages IA to IIIC but did not change among the anatomic stage groups. CONCLUSION: Our data suggests that the prognostic staging system provides superior prognostic value to the anatomic staging system in Korean patients with breast cancer.
Asian Continental Ancestry Group ; Biological Factors ; Breast Neoplasms* ; Breast* ; Carcinoma, Lobular ; Disease-Free Survival ; Humans ; Joints* ; Korea ; Neoplasm Staging ; Prognosis ; Retrospective Studies

PURPOSE: Accurate human epidermal growth factor receptor 2 (HER2) status is important in predicting prognosis and providing treatment for HER2-positive breast cancer patients. However, performing in situ hybridization (ISH) can be an economic burden on developing countries. This study aimed to find an alternative to the ISH test by predicting the HER2 status in patients with equivocal immunohistochemistry (IHC) results. METHODS: We retrospectively reviewed the clinical data of 15,535 patients who underwent curative surgery for invasive breast cancer between February 2005 and April 2015 at the Samsung Medical Center. Equivocal HER2 IHC results were obtained for 461 patients. Logistic regression analysis using stepwise selection was performed to identify the clinicopathological factors related to silver in situ hybridization (SISH) status. We analyzed the data by dividing the estrogen receptor and progesterone receptor (PR) into three groups according to Allred score. RESULTS: Multivariable analysis identified poorly differentiated histological grade, lower PR score, higher expression of Ki-67 and p53, and lower expression of cytokeratin 5/6 and epidermal growth factor receptor as predictors of SISH-positive results. The area under the curve for the receiver-operating characteristic curve was 0.74. CONCLUSION: We identified factors related to a positive HER2 status by SISH. However, there was insufficient power in the prediction model for diagnosis and evaluation. Therefore, the SISH test is essential in determining the HER2 status of breast cancer patients when the IHC result is equivocal.
Breast Neoplasms* ; Breast* ; Developing Countries ; Diagnosis ; Epidermal Growth Factor* ; Estrogens ; Humans* ; Immunohistochemistry* ; In Situ Hybridization* ; Keratins ; Logistic Models ; Prognosis ; Receptor, Epidermal Growth Factor* ; Receptors, Progesterone ; Retrospective Studies ; Silver

PURPOSE: The recent trend in breast cancer treatment is to minimize axillary dissection. However, no pattern of axillary metastasis has been precisely established. The purpose of this study was to evaluate the metastatic lymphatic pattern using near-infrared fluorescence imaging with indocyanine green (ICG) in breast cancer with cytologically proven axillary metastasis. METHODS: This was a prospective single-center study. We evaluated 147 patients with breast cancer involving cytologically proven axillary metastasis, and compared physiological and nonphysiological lymphatic metastasis. RESULTS: We performed lymphatic mapping for 64 patients who exhibited level II lymphatic flow on near-infrared fluorescence imaging with ICG, and found that all had axillary metastasis: 51 patients who did not receive neoadjuvant chemotherapy (NAC) and 13 patients post-NAC. Of patients who did not receive NAC, 32 had physiological lymphatic metastasis and 19 had nonphysiological lymphatic metastasis. The risk factors for nonphysiological lymphatic metastasis were age ≥55 years, high Ki-67 index (>20%), and perinodal extension in both univariate and multivariate analysis (p < 0.05). CONCLUSION: Patients with identified risk factors in cytologically-proven axillary metastasis who did not receive NAC may have nonphysiological lymphatic metastasis.
Axilla ; Breast Neoplasms* ; Breast* ; Drug Therapy ; Humans ; Indocyanine Green ; Lymph Nodes* ; Lymphatic Metastasis ; Multivariate Analysis ; Neoplasm Metastasis* ; Optical Imaging ; Prospective Studies* ; Risk Factors

PURPOSE: This study aimed to evaluate the effects of sentinel lymph node biopsy (SLNB) on recurrence and survival after neoadjuvant chemotherapy (NAC) in breast cancer patients with cytology-proven axillary node metastasis. METHODS: We selected patients who were diagnosed with invasive breast cancer and axillary lymph node metastasis and were treated with NAC followed by curative surgery between January 2007 and December 2014. We classified patients into three groups: group A, negative sentinel lymph node (SLN) status and no further dissection; group B, negative SLN status with backup axillary lymph node dissection (ALND); and group C, no residual axillary metastasis on pathology with standard ALND. RESULTS: The median follow-up time was 51 months (range, 3–122 months) and the median number of retrieved SLNs was 5 (range, 2–9). The SLN identification rate was 98.3% (234/238 patients), and the false negative rate of SLNB after NAC was 7.5%. There was no significant difference in axillary recurrence-free survival (p=0.118), disease-free survival (DFS; p=0.578) or overall survival (OS; p=0.149) among groups A, B, and C. In the subgroup analysis of breast pathologic complete response (pCR) status, there was no significant difference in DFS (p=0.271, p=0.892) or OS (p=0.207, p=0.300) in the breast pCR and non-pCR patients. CONCLUSION: These results suggest that SLNB can be feasible and oncologically safe after NAC for cytology-determined axillary node metastasis patients and could help reduce arm morbidity and lymphedema by avoiding ALND in SLN-negative patients.
Arm ; Breast Neoplasms* ; Breast* ; Diagnosis* ; Disease-Free Survival ; Drug Therapy* ; Follow-Up Studies ; Humans ; Lymph Node Excision ; Lymph Nodes ; Lymphedema ; Neoadjuvant Therapy ; Neoplasm Metastasis ; Pathology ; Polymerase Chain Reaction ; Recurrence ; Sentinel Lymph Node Biopsy*