Background:Early postoperative hypocalcemia is one of the most common complications after surgery for differentiated thyroid cancer (DTC) and may lead to prolonged hospitalization and impaired postoperative recovery. Most existing prediction tools are based on conventional regression methods and may be insufficient to capture complex interactions among clinical variables. This study aimed to develop and validate an interpretable machine learning model and a web-based calculator for early prediction of postoperative hypocalcemia in patients with DTC. Methods:This retrospective cohort study included 1,222 patients with DTC who underwent surgery at a tertiary hospital between February 2021 and October 2025. Candidate predictors were screened using a combined feature selection strategy incorporating least absolute shrinkage and selection operator (LASSO) regression and the Boruta algorithm. Eight machine learning algorithms were developed and compared. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration metrics. Model interpretability was assessed using SHapley Additive exPlanations (SHAP), and the optimal model was deployed as a web-based calculator. Results:Seven consensus variables were selected for final model construction. Among the eight algorithms, the light gradient boosting machine (LGBM) achieved the best overall performance in the testing cohort, with an AUC of 0.875 [95% confidence interval (CI): 0.838-0.912] and a Brier score of 0.132, indicating good discrimination and calibration. SHAP analysis showed that bilateral central lymph node dissection (CLND), severe preoperative vitamin D deficiency, and thyroid capsular invasion were the most influential predictors of postoperative hypocalcemia. The final model was implemented as a freely accessible web-based clinical tool. Conclusions:We developed an explainable web-based LGBM model that showed good predictive performance for early postoperative hypocalcemia in patients with DTC. By combining accurate risk estimation with transparent interpretation, this tool may help clinicians identify high-risk patients and support individualized perioperative management.
Background:Intrathyroidal hypofunctional normocalcemic parathyroid carcinoma (IHNPC) is a rare and aggressive malignancy; while only a small number of well-documented cases have been reported in the literature, multiple case series have described similar presentations of intrathyroidal parathyroid carcinomas (PCs) presenting as thyroid nodules without hypercalcemia. This entity accounts for an extremely small fraction of parathyroid neoplasms, with only sporadic case reports documented globally. Characterized by minimal secretion of parathyroid hormone (PTH) resulting in mild PTH elevation without corresponding hypercalcemia and normal serum calcium concentration, this neoplasm poses a distinct diagnostic challenge by virtue of its intrathyroidal location, where its clinical and radiological features closely mimic those of a common thyroid nodule, often resulting in substantial diagnostic delays. Case Description:A 51-year-old woman presented with a solitary thyroid nodule that had been incidentally discovered two years earlier and monitored conservatively, and an isolated mild elevation of PTH. Imaging studies revealed a solid nodule with ill-defined margins within the right thyroid lobe. Initially misdiagnosed with a benign thyroid lesion by preoperative fine-needle aspiration cytology, she underwent right thyroid lobectomy. Intraoperative suspicion and subsequent definitive histopathology confirmed the diagnosis of PC. The patient recovered uneventfully, and at six-month follow-up, serum PTH and calcium levels had normalized with no evidence of recurrence. Conclusions:Clinicians should consider IHNPC in the differential diagnosis of any thyroid nodule, especially those with ill-defined borders or abnormal PTH levels, even in the absence of hypercalcemia. Routine measurement of serum PTH and 25-hydroxyvitamin D in patients with thyroid nodules, along with multimodal imaging and intraoperative frozen section when indicated, is essential to unmask this diagnostic masquerader and guide appropriate management.
Background and Objective:Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal solid malignancies. Neoadjuvant therapy (NAT) has been routinely used in borderline resectable and locally advanced cases, now it is also gradually expanding to some resectable cases. Post-NAT assessment on computed tomography (CT) is intrinsically challenging, as therapy-induced stromal remodeling, fibrosis, and inflammation may obscure viable tumor, while size-based criteria correlate poorly with pathological response and survival. This narrative review aims to synthesize CT-based quantitative imaging features for PDAC after NAT and to clarify how these imaging biomarkers may support clinically relevant multidisciplinary decision-making. Methods:A narrative review was conducted using a three-layer literature identification strategy. A primary search of PubMed and Web of Science Core Collection was performed on 7 April 2026 to identify English-language articles published from 2013 to 2026. The search focused on PDAC, NAT, CT, and CT-derived quantitative approaches, including radiomics, perfusion CT, dual-energy/spectral CT, and photon-counting CT (PCCT), together with clinically relevant endpoints such as response, resectability, margin status, survival, recurrence, and prognosis. Targeted supplementary retrieval and manual anchor retrieval were additionally used for key reviews, foundational pathology and tumor microenvironment (TME) references, complementary magnetic resonance imaging (MRI) and positron emission tomography (PET) literature, and methodological framework papers. Key Content and Findings:Quantitative CT features after NAT can be organized around four multidisciplinary team (MDT) decisions: assessment of tumor-vessel interface resectability and the probability of margin-negative (R0) resection, NAT stewardship, surgical-window timing, and early recurrence risk stratification. The most informative measurement layers include interpretable morphologic and enhancement-based metrics, longitudinal delta features, perfusion-derived functional parameters, iodine- and material-sensitive metrics from energy-resolved CT, and multi-compartment radiomics or habitat analysis. Conclusions:Building on this evidence, we outline a pragmatic, CT-centric measurement ladder that progresses from interpretable enhancement and iodine metrics to interface focused features and habitat-level heterogeneity, aiming to reduce inter-reader variability and improve multicenter reproducibility, with MRI and PET positioned as complementary modalities for future multimodal validation.
Background:Accurate preoperative assessment of cervical lymph node metastasis (LNM) is crucial for surgical planning in thyroid cancer (TC), yet conventional ultrasound and computed tomography have limited sensitivity. This study aimed to develop and internally validate a magnetic resonance imaging (MRI)-based radiomics prediction model for preoperative LNM status in patients with TC. Methods:We prospectively enrolled 97 consecutive patients with pathologically confirmed TC who underwent preoperative MRI and cervical lymph node dissection at The First Affiliated Hospital of Guangxi Medical University from April 2017 to January 2019. The reference standard was histopathology. Patients were randomly divided into training and validation sets at a 7:3 ratio. A total of 1,691 radiomics features were extracted from T2-weighted imaging (T2WI) and T1-weighted heterogeneous contrast-enhanced imaging (T1C+), respectively. Using the Boruta algorithm, we selected a subset of optimized features for the radiomics signature, and a random forest algorithm was used to construct the radiomics model. Subsequently, the ability of this model to predict the status of lymph nodes of patients with TC was evaluated through receiver operating characteristic (ROC) curve analysis. Results:The combined model had better diagnostic performance than did models based on T2WI and T1C+ alone. Of the 97 patients, 61 (62.9%) were LNM-positive. In the training set, the area under the curve (AUC) values for the T2WI, T1C+, and combined models were 0.914, 0.959, and 0.963, respectively; the corresponding AUC values in the validation set were 0.853, 0.881, and 0.900, respectively. In the validation set, the combined model achieved an AUC of 0.900, with a sensitivity of 0.944 and specificity of 0.500. Conclusions:The MRI based radiomics model shows promising discriminative ability for preoperative LNM prediction in TC, but its low specificity (0.500) limits standalone clinical utility. External validation in larger cohorts is required before clinical implementation.
The triple-plane technique offers complete autologous prosthesis coverage in subpectoral breast reconstruction without requiring mesh. Its integration with endoscopic assistance allows for precise dissection through a concealed incision. Achieving complete implant coverage without mesh in subpectoral reconstruction remains a technical challenge. This study evaluates the feasibility and early outcomes of this novel endoscopic-assisted triple-plane technique. In this prospective case series, we describe and evaluate an integrated approach utilizing a single axillary incision under endoscopic visualization to dissect three anatomical planes: the subpectoral plane (pectoralis major, A-plane), the serratus anterior fascia (B-plane), and the deep superficial fascia (C-plane). These layers are combined to create a mesh-free pocket ensuring complete autologous prosthesis coverage. In our preliminary series, the procedure was successfully performed in 89 patients. The mean operative time was 90.28±14.95 minutes, with an average blood loss of 44.21±13.40 mL. The mean incision length was 5.47±0.52 cm, and the average hospital stay was 7.56±1.78 days. Postoperative breast appearance was rated as excellent in 86 patients (96.63%) and good in 3 patients (3.37%). All patients reported high satisfaction, with BREAST-Q (a validated patient-reported outcome measure for breast surgery) scores ranging from 80 to 100 and a mean score of 87.28. No major perioperative complications, such as prosthesis loss or total flap necrosis, were recorded. The endoscopic-assisted triple-plane technique is a safe and reproducible mesh-free method that combines the benefits of complete autologous coverage with the advantages of minimally invasive surgery. This integrated approach appears to be a promising refinement for subpectoral breast reconstruction, supported by favorable early aesthetic outcomes and high patient satisfaction. These preliminary findings warrant further validation in comparative studies with larger sample sizes and longer follow-up.
Background and Objective:Minimally invasive surgery (MIS) has been increasingly adopted in breast cancer management. Endoscopic breast surgery (EBS) and Da Vinci robotic-assisted breast surgery have emerged as the two principal MIS modalities, with the potential to combine adequate oncological safety with improved aesthetic outcomes. This review summarises the technical evolution, surgical and oncological outcomes, and learning curves of EBS and Da Vinci robotic-assisted breast surgery, and discusses cost considerations and future perspectives. Methods:We performed a structured search on PubMed, Web of Science, Scopus, and the Cochrane Library from database inception to 31 March 2026, with a supplementary literature update conducted to include relevant studies published through 1 May 2026. We included studies comparing endoscopic or robotic-assisted techniques with conventional approaches for breast-conserving surgery (BCS), nipple-sparing mastectomy (NSM), axillary lymph-node dissection (ALND), and breast reconstruction. Randomised controlled trials, prospective and retrospective cohort studies, case series, systematic reviews, and meta-analyses were eligible. Key Content and Findings:EBS, first developed in East Asian centres, can provide superior cosmetic outcomes in patients with early-stage breast cancer compared with conventional open surgery while maintaining acceptable short-term oncological results. Robotic-assisted NSM (RNSM) with the Da Vinci system provides three-dimensional high-definition visualisation, articulated EndoWrist instruments, and tremor filtering. Pooled data indicate that RNSM is associated with lower rates of skin-flap and nipple-areola complex (NAC) necrosis than conventional open NSM, with comparable short-term oncological outcomes; operative time and procedural costs remain higher. The learning curve for RNSM stabilises after approximately 20-50 cases. The latest development is the Da Vinci single-port (SP) system, which achieves a true single-incision mastectomy via a concealed axillary approach. Conclusions:Endoscopic and Da Vinci robotic-assisted surgery may be considered as minimally-invasive treatments for breast cancer surgery. Available data suggest short- to medium-term oncological equivalence with conventional surgery and favourable patient-reported outcomes, but long-term follow-up beyond 5 years remains scarce. Prospective randomised controlled trials with prolonged follow-up, formal cost-effectiveness analyses, and standardised training programmes are required before these techniques can be recommended for routine clinical use.
Background:The incidence of coexisting Hashimoto's thyroiditis (HT) and papillary thyroid carcinoma (PTC) is rising. The risk of cervical lymph node metastasis (CLNM) in HT-PTC patients remains controversial, and overlapping ultrasonographic features of lymph nodes complicate accurate diagnosis. Therefore, this study aimed to construct a risk assessment model for CLNM in patients with concurrent HT and PTC, and to evaluate its clinical application value. Methods:A total of 261 patients with postoperative pathologically confirmed PTC coexisting with HT who underwent thyroid surgery at the Affiliated Hospital of Guizhou Medical University from January 2018 to December 2023 were retrospectively enrolled. Univariate and multivariate logistic regression analyses were first performed to identify independent predictors of CLNM. Variables with P<0.05 in the multivariate analysis were incorporated into model development. Four models were constructed: based on tumor nodule ultrasound features (TN-US), lymph node ultrasound features (LN-US), their combination (TN-LN-US), and a full-feature model integrating clinical, laboratory, and ultrasound parameters (Clin-US). Receiver operating characteristic (ROC) curves were plotted to evaluate diagnostic performance, and the DeLong test was used to compare the area under the ROC curve (AUC) among the models. Internal validation was conducted using the bootstrap method, and model performance was further assessed using calibration curves, decision curve analysis (DCA), and clinical impact curve (CIC). Results:Among the 261 patients with PTC coexisting with HT, univariate and multivariate logistic regression analyses identified age, alkaline phosphatase, primary tumor microcalcifications, primary tumor vascularity, lymph node morphology, intranodal cortical echogenicity, and lymph node microcalcifications as independent risk factors for CLNM (P<0.05). The Clin-US model demonstrated the best diagnostic performance (AUC =0.842, bootstrap 95% confidence interval: 0.792-0.885). Bootstrap internal validation indicated stable model parameters. Calibration curves showed good model fit, with predicted probabilities closely matching actual incidence. DCA and CIC further confirmed favorable clinical applicability of the model. Conclusions:We developed a Clin-US model that combines clinical data and ultrasound for predicting lymph node metastasis in PTC patients with concurrent HT. The model demonstrated promising diagnostic performance and may assist clinicians in preoperative risk stratification, facilitating individualized treatment decisions for this population.
Background:Implant-based breast reconstruction after mastectomy in breast cancer patients has been increasingly performed over the past decade, improving cosmetic outcomes. The use of supportive matrices has increased in recent years. This study aimed to compare the outcomes of implant-based breast reconstruction between acellular dermal matrix (ADM), non-ADM, and TiLOOP® bra mesh in breast cancer patients. Methods:A retrospective descriptive study, a case series from consecutive patients with breast cancer who underwent mastectomy with implant-based breast reconstruction using ADM, non-ADM, or TiLOOP® by one senior surgeon (V.L., M.D.) at a single center at Siriraj Hospital between 2018 and 2022. Fisher's exact test was used for the analysis. Demographic data and the history of radiotherapy in each patient were collected. The primary outcomes focus on the significant complications of explantation, implant loss, capsular contracture, skin necrosis, and infection. The secondary outcomes focus on the local recurrence rate and metastasis. Additional surgical interventions to correct the complications were reported. Results:A total of 36 breast cancer patients (ages between 22 and 64 years old) who underwent unilateral or bilateral mastectomy with implant-based breast reconstruction were organized into three categories of ADM, non-ADM, and TiLOOP®. The mean follow-up was 2 years and 3 months, with a range of 1 year and 2 months to 4 years. There were 10 patients in the ADM group, 19 in the non-ADM group, and 7 in the TiLOOP® group. In the ADM group, there were 2 infections (20.0%), 1 necrosis (10.0%), and 2 capsular contractures (20.0%). In the non-ADM group, there were 2 explantations (10.5%), 2 capsular contractures (10.5%), 2 local recurrences (10.5%), and 1 metastasis (5.3%). In the TiLOOP® group, there were 2 capsular contractures (28.6%). In the TiLOOP® group, two patients who received adjuvant radiotherapy developed capsular contracture: one developed grade III and the other developed grade IV. There was 1 patient in the non-ADM group who had previous chest wall radiation before reconstruction and developed capsular contracture grade IV without postoperative radiotherapy. All capsular contracture grade III or IV cases required additional revision breast surgery. Conclusions:No significant difference in complication between ADM, non-ADM and TiLOOP® implant-based breast reconstruction (P>0.05). The limitations of this study were a low number of cases and short-term follow-up.
Background:Severe hypocalcemia affects 25-50% of patients with secondary hyperparathyroidism (sHPT) after total parathyroidectomy. It results from acute postoperative hypoparathyroidism and rapid skeletal mineral uptake. Severe hypocalcaemia leads to significant morbidity, prolonged hospital stays, and increased healthcare costs. Few risk assessment prediction tools exist; they lack external validation and exhibit methodological shortcomings. To enable evidence-based risk stratification and personalised perioperative management, we developed and internally validated a nomogram for predicting severe post-parathyroidectomy hypocalcaemia (SPPH) in patients with sHPT who underwent total parathyroidectomy with autotransplantation. Methods:This retrospective cohort study included 227 patients from two tertiary care institutions with sHPT who underwent total parathyroidectomy with autotransplantation between 2019 and 2024. All subjects had sHPT [parathyroid hormone (PTH) >3× upper limit of normal] in the context of stage 4-5 chronic kidney disease (CKD) or dialysis dependent. Patients with autonomous parathyroid function (calcium-independent PTH elevation) were excluded. Intensive calcium supplementation protocols were administered to all patients. SPPH was defined by: (I) serum calcium <1.9 mmol/L; (II) intravenous calcium requirement beyond postoperative day 3; (III) symptomatic hypocalcemia (tetany, seizures, arrhythmias, or laryngospasm) requiring intravenous calcium and/or urgent cardiac monitoring; or (IV) hospitalization ≥7 days primarily for calcium management. We employed the least absolute shrinkage and selection operator (LASSO) regression for variable selection, followed by multivariable logistic regression. Internal validation utilized 200 bootstrap resamples to derive the optimism-corrected performance estimates. Results:The incidence of SPPH was 49.8% (113/227). Among 157 patients with complete predictor data, LASSO identified four optimal predictors: [adjusted odds ratio (OR) 0.87 per year, 95% confidence interval (CI): 0.76-0.99], preoperative phosphate at one month (adjusted OR 1.29 per mmol/L, 95% CI: 0.96-1.71), preoperative alkaline phosphatase (ALP) at one month (adjusted OR 4.11 per 100 U/L, 95% CI: 1.89-8.92), and preoperative PTH at three months (adjusted OR 0.87 per 10 pmol/L, 95% CI: 0.68-1.13). The model demonstrated good discrimination with an apparent c-statistic of 0.751 (optimism-corrected 0.739), good calibration (Hosmer-Lemeshow P=0.657), and positive net benefit across clinically relevant threshold probabilities of 0.1-0.8. Risk stratification yielded three clinically meaningful groups: low-risk (<30% predicted probability, n=25, 8.0% observed SPPH rate), intermediate-risk (30-70%, n=92, 58.7% rate), and high-risk (>70%, n=40, 72.5% rate). Conclusions:We developed and internally validated a nomogram for preoperative risk stratification of SPPH in patients receiving intensive calcium supplementation protocols using readily available preoperative variables, identifying ALP as the predominant risk factor. The prognostic significance of ALP offers a new perspective beyond the conventional emphasis on PTH levels and insight into the underlying mechanisms of post-operative hypocalcemia. The substantial gradient across risk groups (8.0-72.5%) supports personalized perioperative management. However, multicenter external validation is essential before clinical implementation. Once validated, this tool could enhance patient outcomes and streamline healthcare resources for thousands of patients undergoing parathyroidectomy annually.
Background:Synchronous breast cancer and thymoma are uncommon clinical scenarios and are traditionally treated with phased surgery, often requiring separate operative sessions and potentially delaying comprehensive oncologic management. Although minimally invasive surgery enables single-stage approaches, the role of surgical planning in coordinating multidisciplinary procedures remains underreported. Case Description:We report the case of a 40-year-old woman who had synchronous thymoma and HER2-positive breast cancer. After multidisciplinary evaluation, a single-stage surgical strategy was planned, combining robotic extended thymectomy, bilateral nipple-sparing mastectomy, axillary lymph node dissection and immediate reconstruction. The novelty of this report lies in the planning-driven strategy that guided procedural sequencing, access selection, and incision placement, with the explicit aim of preserving oncologic radicality while minimizing surgical footprint. Robotic thymectomy was performed first through a left-sided approach, with subxiphoid specimen extraction to avoid interference with breast incisions. Breast surgery and reconstruction were then carried out using scar-sparing approaches. Postoperative recovery was uneventful, with complete pathological response of breast cancer, R0 thymoma resection, and excellent aesthetic outcome. Conclusions:This case demonstrates that combined chest surgery should be considered primarily a planning challenge rather than only a technical challenge. Careful preoperative coordination among thoracic surgeons, breast surgeons and reconstructive teams plays a key role in defining operative priorities, minimizing surgical conflict, and achieving optimal oncologic and aesthetic outcomes. This experience supports the feasibility of a personalized single-stage approach in selected patients undergoing simultaneous treatment of thoracic and breast malignancies.
Background:Breast cancer is one of the most commonly diagnosed malignancies worldwide. For patients undergoing nipple-sparing mastectomy with immediate prosthetic reconstruction (NSM-IPR), optimizing postoperative recovery and reducing complications are critical. Prolonged postoperative drainage is a common issue that increases infection risk and prolongs hospital stay. This study aimed to evaluate the effect of an inactivated Pseudomonas aeruginosa preparation (PAP) on postoperative drainage and cosmetic outcomes in this patient population. Methods:This was a single-center, prospective, four-arm parallel-group randomized controlled trial. A total of 100 patients were randomly assigned in a 1:1:1:1 ratio to receive either low-, medium-, or high-concentration inactivated PAP immersion, or povidone-iodine alone (control). Outcome assessors were blinded. Therapeutic efficacy was assessed, including total drainage volume, drainage duration, complications, and cosmetic outcomes at 3 months postoperatively. Results:Total drainage volume was significantly lower in all PAP groups compared with the control group (low-concentration: 578.4±39.34 mL, medium-concentration: 477.8±35.53 mL, high-concentration: 444.8±34.26 mL vs. control: 733.0±99.43 mL; all P<0.001). Drainage duration was also significantly shorter (low: 13.4±1.98 d, medium: 10.76±2.17 d, high: 10.76±1.88 d vs. control: 15.92±2.58 d; all P<0.001). Conclusions:The combination of inactivated PAP and povidone-iodine reduces postoperative drainage volume, shortens drainage time, and may improve cosmetic outcomes in patients undergoing NSM-IPR. Trial Registration:ClinicalTrials.gov NCT07460297.
Background:Surgical management of granulomatous lobular mastitis (GLM) requires balancing complete lesion excision with the preservation of breast aesthetics. While the chest wall perforator flap (CWPF) is a valuable volume replacement technique, its clinical adoption may be limited by the need for intraoperative handheld Doppler localization and specialized training. This study aimed to evaluate the efficacy of a simplified CWPF reconstruction approach guided by multimodal preoperative imaging and performed without intraoperative handheld Doppler. Methods:A retrospective analysis was performed on 80 patients diagnosed with GLM between January 2022 and May 2024. Patients were assigned to two groups: Group A (n=43) underwent extended mass resection followed by modified CWPF reconstruction without intraoperative handheld Doppler, while Group B (n=37) received conventional surgical therapy (simple lumpectomy, extended mass resection, or segmental mastectomy without reconstruction). Group A was managed via a multimodal imaging protocol: magnetic resonance imaging (MRI) for source vessel identification, computed tomography (CT) for skeletal landmark referencing, and ultrasound for surface marking, thereby eliminating the need for intraoperative handheld Doppler localization. Results:All CWPF flaps were harvested under preoperative imaging guidance without the use of a handheld Doppler device. Postoperative complication rate was comparable between groups, mainly involving delayed wound healing, positive bacterial culture, subcutaneous fat liquefaction, incision infection, nipple-areola ischemic necrosis, ecchymosis, or hematoma (all P>0.05). Notably, Group A achieved significantly superior cosmetic outcomes compared with Group B (P<0.001). Patients in Group A also reported improved quality of life and higher patient satisfaction (P<0.001). Conclusions:Precise preoperative planning using multimodal imaging (MRI, CT, ultrasound) enables safe and effective CWPF reconstruction without intraoperative handheld Doppler in GLM surgery. This streamlined approach maintains surgical precision and favorable aesthetic outcomes while potentially reducing dependence on additional intraoperative localization devices, and may represent a practical strategy for breast reconstruction in resource-limited settings.
Background:Occult high-volume central lymph node metastasis (CLNM) can remain undetected in clinically node-negative papillary thyroid carcinoma (cN0 PTC), yet nodal burden influences preoperative counseling and recurrence-oriented risk stratification. For clinical implementation, a preoperative radiomics-based risk estimate must remain transportable, locally calibrated, and interpretable after transfer to another center. This study evaluated the clinical transportability, calibration drift, threshold consequences, and local updating of a B-mode ultrasound radiomics-clinical prediction model for occult high-volume CLNM. Methods:This three-center retrospective model-development, validation, and updating study used the source workbook containing 957 cN0 PTC patients. The endpoint was occult high-volume CLNM, defined as more than five metastatic central lymph nodes on postoperative pathology. Candidate predictors were restricted to preoperative clinical-ultrasound variables and a prespecified B-mode radiomics score. Clinical-only, B-mode score-only, and clinical plus B-mode score models were compared in the development cohort; the clinical plus B-mode score model was treated as the locked primary implementation model because it preserved routine clinical interpretability while incorporating the quantitative image signal. The locked model was evaluated in a temporal Center 1 cohort (n=210), Center 2 (n=139), and Center 3 (n=119). Discrimination, Brier score, calibration, fixed-threshold classification, decision curve analysis, threshold consequences, and post hoc intercept-only recalibration were assessed. Results:High-volume CLNM was present in 399 of 957 patients (41.7%). Event rates were 44.8%, 45.2%, 41.0%, and 23.5% in the development, temporal validation, Center 2, and Center 3 cohorts. Development-cohort comparisons showed larger tumors, higher B-mode radiomics scores, higher Chinese Thyroid Imaging Reporting and Data System (C-TIRADS) subclass, and richer vascularity among endpoint-positive patients. The B-mode score accounted for most discrimination. Compared with the B-mode score-only model, adding clinical-ultrasound variables changed the area under the receiver operating characteristic curve (AUC) by +0.015 in development, +0.008 in temporal validation, -0.009 in Center 2, and -0.029 in Center 3. The locked clinical plus B-mode score model had AUC values of 0.823, 0.874, 0.866, and 0.870, respectively. Mean predicted risk aligned with observed risk in the development, temporal validation, and Center 2 cohorts but overestimated risk in Center 3 (36.4% predicted vs. 23.5% observed; calibration intercept, -0.902). At the locked threshold of 0.565, Center 3 retained specificity of 0.857 and negative predictive value (NPV) of 0.897, while intercept-only updating reduced the Center 3 Brier score from 0.138 to 0.121. Conclusions:The locked radiomics-clinical model provided an interpretable preoperative risk-stratification framework whose deployment value depends on local calibration and threshold consequences. External deployment should evaluate spectrum shift, positive predictive value (PPV) and NPV, calibration, decision curves, and local updating rather than relying on AUC alone.
Despite advances in multimodal therapy, pancreatic ductal adenocarcinoma (PDAC) remains a highly fatal tumor. For surgically resectable and borderline-resectable PDAC (BR-PDAC), the optimal integration of neoadjuvant chemotherapy and radiotherapy has yet to be established. Recent randomized studies (e.g., ESPAC-5F, NORPACT-1, Alliance A021501, and PREOPANC) and updated guidelines [of the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), and Japanese Society of Hepato‑Biliary‑Pancreatic Surgery (JASPAC)] now identify which patients are likely to benefit from treatment before surgery. For resectable PDAC, upfront surgery followed by adjuvant chemotherapy (typically modified FOLFIRINOX) remains the standard of care. However, new research (e.g., Prep-02/JSAP05) suggests that some high-risk patients may benefit from neoadjuvant therapy. For BR-PDAC, neoadjuvant multiagent chemotherapy (typically FOLFIRINOX) is widely accepted as the standard approach for increasing the likelihood of margin-negative resection and improving survival. Induction chemotherapy (with or without ablative radiotherapy) is commonly employed to downstage tumors in locally advanced PDAC. Debate continues as to the role of radiotherapy [either conventional chemoradiotherapy or stereotactic body radiotherapy (SBRT)]. PREOPANC reported a slight survival benefit for preoperative gemcitabine-based chemoradiotherapy in resectable PDAC and BR-PDAC, while Alliance A021501 reported no additional benefit from SBRT following FOLFIRINOX in BR-PDAC. Advanced imaging [multiphasic computed tomography/magnetic resonance imaging (CT/MRI) and positron emission tomography/computed tomography (PET/CT)] enhances the precision of staging and response evaluation. Molecular diagnostics, particularly germline/somatic BRCA and KRAS status and circulating tumor DNA (ctDNA) monitoring, are currently informing perioperative decisions and innovative therapeutics. As of 2025, personalized perioperative care guided by resectability status, tumor biology, and patient-specific characteristics has emerged as the key strategy for optimizing the selection of patients for neoadjuvant chemotherapy and/or radiotherapy. This review sought to synthesize the most recent evidence and guidelines on the treatment of resectable, BR, and locally advanced PDAC.
Background and Objective:Autologous free tissue transfer is considered to be the gold-standard for breast reconstruction. The abdomen, thighs, buttocks and other donor sites have been well described in the literature. In slender patients with larger breasts who desire autologous reconstruction, breast asymmetry or insufficient volume may compromise the aesthetic or desired outcome. In these situations, hybrid reconstruction, in which the flap is combined with an implant, can provide desirable outcomes. The aim of this study to review of the available evidence and help guide clinical decision-making and optimization of outcomes. Methods:A review of the literature using keywords was performed by query of MEDLINE (PubMed), Embase, Cochrane Library. Inclusion criteria included retrospective and prospective studies that used free flaps for breast reconstruction (abdominal and other sources), studies that categorized their data into immediate and staged placement of implant, case series, case reports and review of literature. Studies from the last 30 years were included [1995-2025]. Studies that did not analyzed the use of free flaps combined with implants for breast reconstruction were not included. Key Content and Findings:Seventeen studies were identified. Of these 13 reported on patients who had free flaps augmented with an implant for breast reconstruction. Key findings included: A total of 359 patients and 598 breasts were reviewed. The majority of the of the free flaps (590) were abdominally based. The timing for implant placement was roughly evenly split between delayed (52%, 300 breasts) and immediate (48%, 298 breasts). Tissue expanders were used with the flap prior to the silicone implant in a minority of cases-11% of cases. Silicone implants were used 92% of cases. Mesh support (acellular dermal matrix or synthetic) was used in approximately 57% of cases. Conclusions:Performing hybrid flap-implant breast reconstruction has been established as a safe and reliable approach on patients with larger breasts who desire autologous reconstruction and have paucity of autologous donor tissue.
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.
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.
