Preoperative or NST is emerging as an important initial strategy for the management of invasive breast cancer. From the surgeon's perspective, the primary goal of NST is to increase the resectability of locally advanced breast cancer, increase the feasibility of breast-conserving surgery and sentinel node biopsy, and decrease surgical morbidity. To ensure optimal patient selection and efficient patient care, the guideline recommends: (1) baseline breast and axillary imaging; (2) minimally invasive biopsies of breast and axillary lesions; (3) determination of tumor biomarkers; (4) systemic staging; (5) care coordination, including referrals to medical oncology, radiation oncology, plastic surgery, social work, and genetic counseling, if indicated; (6) initiation of NST; (7) post-NST breast and axillary imaging; and (8) decision for surgery based on extent of disease at presentation, patient choice, clinical response to NST, and genetic testing results, if performed.

Synchronous CAS-CABG, when CABG is performed within the 2 hours of the CAS procedure, may be a viable alternative to the more generally accepted staged combination, particularly among patients for whom CABG cannot be postponed. We hope that this strategy will be further evaluated in larger prospective studies and adequately powered randomized clinical trials.

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Spontaneous aortocaval fistulas are rare and thoracoabdominal aneurysms eroding into the inferior vena cava are rarer still. We describe a patient who presented to our hospital with a fistula between a Type IV thoracoabdominal aneurysm and the inferior vena cava. Expanding endovascular capabilities of vascular surgeons enabled us to insert proximal and distal occluding balloon catheters into the vena cava which greatly minimized blood loss.

Figure 2, B and C). The patient's dyspnea has since resolved. For the past 18 months, the patient has had no evidence of disease with regular follow-ups with surveillance CT scans. DISCUSSIONRecurrent metastatic disease after nephrectomy for RCC is relatively common, occurring in 20% to 50% of patients. The prognosis of metastatic RCC is poor, demonstrating a 6-to 12-month median overall survival and a 10% to 20% 2-year overall survival. 2 The lungs are the most common location for RCC metastases, accounting for the location of 45% to 75% of all metastatic disease. 3 Pulmonary metastasectomy appears to yield favorable results in certain patients, although these individuals largely have a high performance status with generous pulmonary reserve. Moreover, the biology of the cancer is important, because patients with shorter disease-free intervals and those with large (>3 cm) metastases have poorer outcomes. 3 Pleural metastases of RCC are relatively rare. 4,5 Autopsy data have demonstrated that 12% of all patients with metastatic RCC have pleural involvement, involvement that is invariably associated with pulmonary metastasis. 4While cases of pleural RCC metastasis are generally thought to occur from direct extension of lung parenchymal RCC metastases, some cases of pleural RCC, such as that described here, occur without lung metastases. In such cases, it has been suggested that pleural metastases may occur by way of the Batson venous plexus. 5 Although pulmonary metastasectomy is considered by many to be reasonable for metastatic parenchymal RCC, a pleurectomy and decortication procedure for pleural RCC metastases has never been reported to the best of our knowledge. We present here a case study of a pleurectomy and decortication procedure for pleural metastatic RCC that provided excellent symptom relief and local control. References1. Sugarbaker DJ, Wolf AS. Surgery for malignant pleural mesothelioma. Expert Rev Respir Med. 2010;4:363-72. 2. Flanigan RC, Campbell SC, Clark JI, Picken MM. Metastatic renal cell carcinoma. Curr Treat Options Oncol. 2003;4:385-90. 3. Kim DY, Karam JA, Wood CG. Role of metastasectomy for metastatic renal cell carcinoma in the era of targeted therapy. World J Urol. 2014;32:631-42. 4. Saitoh H. Distant metastasis of renal adenocarcinoma. Cancer. 1981;48: 1487-91. 5. Ohnishi H, Abe M, Hamada H, Yokoyama A, Hirayama T, Ito R, et al. Metastatic renal cell carcinoma presenting as multiple pleural tumours. Respirology. 2005;10: 128-31.Multiple medical and interventional therapies are currently available for correcting persistent atrial fibrillation. One such procedure, hybrid ablation, aims to decrease postablative atrial fibrillation relapse by combining transvenous endocardial ablation with surgical scarring of the epicardium. 1 Recent reports suggest superior outcomes relative to stand-alone transvenous or surgical ablation and an overall complication rate of 4.1% to 11%. 1,2 Reported complications include bleeding, myocardial edema, cardiac tamponade, atrioesophageal fistula, esophage...