The Utility of ACR TI-RADS in Predicting False-Negative Fine Needle Aspiration for Thyroid Cancer.

BACKGROUND: Thyroid nodule fine needle aspiration (FNA) biopsies are associated with a low false-negative rate. There is limited data regarding the predictive value of American College of Radiology Thyroid Imaging Reporting and Data System for false-negative FNA. METHODS: This single-center retrospective study evaluated 119 patients who underwent thyroidectomy. The association of TR category, along with other clinical variables, with false-negative FNA was evaluated. RESULTS: The overall false-negative rate of FNA was 10.8% (n = 9). False-negative FNAs were associated with younger age (mean 42 years vs 50.6 years, P = .04), larger nodule size (mean 4.4 cm vs 3.2 cm, P = .03), and a lower TR category (median 3 v 4, P = .01). DISCUSSION: Lower TR category, younger age, and larger nodule size were associated with false-negative FNA of thyroid nodules. These findings should be taken into context when counseling patients with thyroid nodules who have a benign FNA.

Preserving and Enhancing Resident Autonomy-Strategies for Surgical Educators.

This Viewpoint suggests measures to improve surgical resident autonomy and thereby produce capable and resilient surgeons.

Creating an Optimal Learning Environment in the Operating Room: Lessons From the Soccer Field.

For trainees, the operating room (OR) often represents an educational sanctuary, where for a few hours they can focus on their craft, rather than on phone calls, pages, and the never-ending task of electronic health record documentation. The OR provides a unique opportunity for unfettered one-on-one time with an attending surgeon at their side, where they can learn the art of surgery without interruption. It is vitally important to maximize learning in the OR, yet evidence suggests that it is not always an ideal educational environment. Considering the recent excitement over the World Cup soccer tournament (full disclosure: the senior author is an Argentine immigrant and soccer fan), in this article, we provide evidence-based ideas and suggestions on how to optimize learning in the OR using some analogies from the soccer field.

Clinical Features and Outcomes of Patients with Pancreaticobiliary Malignancies in Los Angeles County and Their Association with CA 19-9 Levels.

Although CA 19-9 is a commonly used tumor marker in the management of PBMs, the literature describing outcomes in patients with PBMs who have undetectable or low (hereinafter "low") CA 19-9 levels remains scarce. In this study, we sought to compare clinical features and outcomes in patients with PBMs and low CA 19-9 levels to those with normal and elevated CA 19-9 levels. METHODS: We retrospectively collected data on patients with biopsy-confirmed PBMs and stratified patients into categories based on their CA 19-9 level at diagnosis. Survival curves were estimated for patients in each of the three aforementioned CA 19-9 groups using the Kaplan-Meier method and compared using a Cox proportional hazards regression model. RESULTS: Of the 283 patients identified, 23 (8.1%) had low, 70 (24.7%) had normal, and 190 (67.1%) had elevated CA 19-9 levels. After controlling for sex, age, BMI, the presence of metastases at the time of diagnosis, and treatment with curative intent, the hazard ratio for death in the elevated CA 19-9 group compared to the low CA 19-9 group was 1.993 (95% CI 1.089-3.648; p = 0.025). CONCLUSION: The elevated CA 19-9 level compared to the low CA 19-9 level and the presence of metastases were associated with an increased hazard of death, while treatment with curative intent was associated with a decreased hazard of death.

Routine pre-operative Covid testing in elective surgeries: Is it worth it?

BACKGROUND: Pre-procedural COVID-19 testing in patients scheduled for elective cases have become routine to reduce the risk of COVID-19 exposure and pulmonary complications related to perioperative COVID-19 infection, and to reduce the use of specific hospital resources among other reasons. This study evaluates the efficacy of universal COVID-19 testing for elective procedures. METHODS: Single institution retrospective observational study from July 2020 through August 2021. RESULTS: There were a total of 499 unique patients who were scheduled for 581 surgeries or procedures. A total of 569 anterior nares reverse transcriptase polymerase chain reaction (RT-PCR) tests were completed before scheduled procedure. There were 2 (0.35%) positive COVID tests, both of whom were asymptomatic and unvaccinated at time of testing, and 13 (2.2%) cancelled cases overall. The total cost for labor and materials during this period was $19,738, with each RT-PCR test costing $34.69 and each true positive test costing $9,869. CONCLUSIONS: Given the low COVID-19 positivity in the elective procedural patient population, testing protocols for elective procedures should be re-evaluated as the pandemic evolves.

The impact of waste reduction in general surgery operating rooms.

INTRODUCTION: Operating rooms are responsible for a significant burden of waste and negative environmental impact. This study aimed to reduce OR waste and improve both environmental impact and hospital cost savings. METHODS: The unused items in two standard single-use surgical packs were tracked for general surgery cases. A new pack was created excluding the most frequently unused items. The feasibility of the new pack was then tested, and a projected cost savings analysis was performed. RESULTS: A total of 35 general surgery operations were tracked using two standard packs ($89.51 or $93.68 per case, each 23.2 lbs). The new pack ($46.88 per case, 20.8 lbs) was then successfully used in nine cases. The projected cost-savings of substituting the new pack was $45,719 annually with a 2437 pounds annual waste reduction. CONCLUSIONS: Simple and feasible adjustments to standard single-use surgical packs can have a significant impact on waste reduction and cost-savings.

Racial Disparities in Colorectal Cancer Care for Black Patients: Barriers and Solutions.

Racial disparities in colorectal cancer for Black patients have led to a significant mortality difference when compared to White patients, a gap which has remained to this day. These differences have been linked to poorer quality insurance and socioeconomic status in addition to lower access to high-quality health care resources, which are emblematic of systemic racial inequities. Disparities impact nearly every point along the colorectal cancer care continuum and include barriers to screening, surgical care, oncologic care, and surveillance. These critical faults are the driving forces behind the mortality difference Black patients face. Health care systems should strive to correct these disparities through both cultural competency at the provider level and public policy change at the national level.

The Impact of Primary Care Physicians on the Surgical Presentation and Outcomes of Colorectal Cancer in Vulnerable Populations.

BACKGROUND: Multiple socioeconomic and clinical factors have been implicated in the health disparities that exist amongst vulnerable populations with colorectal cancer. Efforts have been directed toward addressing these factors to improve outcomes. We evaluate the impact of primary care physicians (PCP) on the surgical presentation and outcomes of colorectal cancer at a safety-net hospital. METHODS: A retrospective chart review of 331 patients diagnosed with colorectal adenocarcinoma between 2014 and 2020 at a single-institution urban county medical center. RESULTS: The cohort was predominantly male (59%) and Hispanic (52.1%). Thirty-two percent of patients had a PCP at time of diagnosis. Patients with PCPs compared to those without PCPs had significantly lower rates of acute presentation (perforation or obstruction) (17.0 vs 38.1%, P < .001), higher rates of surgical resection (83.0 vs 70.7%, P = .016), and were less likely to have metastatic disease at presentation (20.4 vs 33.5%, P = .02). Overall, having a PCP also improved probability of survival (HR 1.36, P < .04). CONCLUSION: Having a PCP at the time of colorectal cancer diagnosis is associated with improved outcomes in a safety-net population, with significant differences in surgical presentation and resection.

Patterns of gastric cancer metastasis in the United States.

BACKGROUND: Literature on the epidemiology of gastric cancer metastasis is limited, although outcomes are known to be poor. We describe patterns of gastric cancer metastasis and treatment in the United States. METHODS: Patients with metastatic gastric adenocarcinoma were identified in the NCDB from 2004 to 2016. We describe univariate associations between sites of metastasis and clinicopathologic characteristics and treatment modalities, using chi-square and Kruskal-Wallis tests. Overall survival was calculated using Kaplan-Meier estimation. RESULTS: 43% (n = 2028) of patients presented with peritoneal metastases, 26% (n = 1228) with liver metastases, 20% (n = 941) with distant nodes, and 11% (n = 552) with bone, brain or lung metastases. Compared to liver metastases, peritoneal metastases were more likely from an antral primary site (28% v. 16%); associated with signet ring histology (34% v. 6%); tumor grade of III/IV (85% vs. 60%) (p < 0.0001 for all). Isolated metastasis to distant lymph nodes had the longest median overall survival (7.6 months, p < 0.0001). CONCLUSIONS: Most patients with metastatic gastric cancer in the USA present with peritoneal disease. Predictors for peritoneal metastases include primary antral site, signet ring histology and higher tumor grades.

Determinants of Psychosocial Distress in Breast Cancer Patients at a Safety Net Hospital.

INTRODUCTION: Psychosocial distress screening of cancer patients is an American College of Surgeons Commission on Cancer mandate for accredited cancer programs. We evaluated psychosocial distress in breast cancer patients to characterize risk factors for high distress scores at a safety net hospital. MATERIALS AND METHODS: The psychosocial distress screening form includes a list of potential issues and a distress score scaled from 1 through 10. Psychosocial distress screening results were retrospectively analyzed, along with patient demographics and clinical data. Cochran-Mantel-Haenszel test was applied to identify predictors for high distress scores, which were defined as a score of 5 and greater. RESULTS: 775 distress screens were completed by 171 breast cancer patients. High distress scores were reported in 21.3%. Patients who had no evidence of disease at time of screening were less likely to report a high distress score compared to those who were newly diagnosed or in active treatment (odds ratio 0.51, 95% CI, 0.38-0.68, P< .0001). Patients with high distress scores were more likely to report concerns with insurance (29.1% vs. 7.6%, P< .0001), transportation (16.4% vs. 4.6%, P< .0001), housing (15.2% vs 2.1%, P< .0001), sadness/depression (63.6% vs. 14.1, P< .0001), and physical issues (89.1% vs. 52.8%, P< .0001). CONCLUSION: Status of cancer at time of screening, particularly newly diagnosed cancer and active treatment of cancer were associated with high distress scores in this patient group. While there should be an emphasis to ensure patients with these risk factors receive psychosocial distress screening, routine periodic screening for all patients should continue to be implemented to ensure quality cancer care.

Surgical referral for cholecystectomy in patients with atypical symptoms.

BACKGROUND: Cholelithiasis referrals often present with concomitant or isolated atypical symptoms such as reflux, bloating, or epigastric pain. We sought to identify the impact of preoperative symptomatology of atypical or dyspepsia-type biliary colic on operative and non-operative clinical outcomes. METHODS: A retrospective review of patients referred for gallstone disease from 2014 to 2018 at a single institution in Los Angeles County was performed. RESULTS: Of 746 patients evaluated for gallstone disease, 87.4% (n = 652) underwent cholecystectomy - 90.8% (n = 592) had symptom resolution postoperatively whereas 9.2% (n = 60) did not. Over half presented with concomitant atypical and/or dyspepsia symptoms (n = 411). Heartburn/reflux was significantly associated with unresolved symptoms postoperatively (OR 2.1,1.0-4.4, p = 0.04). Overall, 11.1% (n = 83) of all 746 patients and 20.2% of patients with atypical and/or dyspepsia symptoms improved with medical management of gastritis or Helicobacter pylori triple therapy pre/post-operatively. CONCLUSION: Atypical biliary colic and/or dyspepsia is associated with unresolved symptoms following cholecystectomy. Such patients may benefit from H. pylori testing or PPI trial prior to cholecystectomy.

Pancreatic Adenocarcinoma Invasiveness and the Tumor Microenvironment: From Biology to Clinical Trials.

Pancreatic adenocarcinoma (PDAC) originates in the glandular compartment of the exocrine pancreas. Histologically, PDAC tumors are characterized by a parenchyma that is embedded in a particularly prominent stromal component or desmoplastic stroma. The unique characteristics of the desmoplastic stroma shape the microenvironment of PDAC and modulate the reciprocal interactions between cancer and stromal cells in ways that have profound effects in the pathophysiology and treatment of this disease. Here, we review some of the most recent findings regarding the regulation of PDAC cell invasion by the unique microenvironment of this tumor, and how new knowledge is being translated into novel therapeutic approaches.

N-myristoyltransferase-1 is necessary for lysosomal degradation and mTORC1 activation in cancer cells.

N-myristoyltransferase-1 (NMT1) catalyzes protein myristoylation, a lipid modification that is elevated in cancer cells. NMT1 sustains proliferation and/or survival of cancer cells through mechanisms that are not completely understood. We used genetic and pharmacological inhibition of NMT1 to further dissect the role of this enzyme in cancer, and found an unexpected essential role for NMT1 at promoting lysosomal metabolic functions. Lysosomes mediate enzymatic degradation of vesicle cargo, and also serve as functional platforms for mTORC1 activation. We show that NMT1 is required for both lysosomal functions in cancer cells. Inhibition of NMT1 impaired lysosomal degradation leading to autophagy flux blockade, and simultaneously caused the dissociation of mTOR from the surface of lysosomes leading to decreased mTORC1 activation. The regulation of lysosomal metabolic functions by NMT1 was largely mediated through the lysosomal adaptor LAMTOR1. Accordingly, genetic targeting of LAMTOR1 recapitulated most of the lysosomal defects of targeting NMT1, including defective lysosomal degradation. Pharmacological inhibition of NMT1 reduced tumor growth, and tumors from treated animals had increased apoptosis and displayed markers of lysosomal dysfunction. Our findings suggest that compounds targeting NMT1 may have therapeutic benefit in cancer by preventing mTORC1 activation and simultaneously blocking lysosomal degradation, leading to cancer cell death.

Lipomatous Soft Tissue Masses: Challenging the Paradigm of Routine Preoperative Biopsy.

BACKGROUND: Lipomatous masses are the most common soft tissue tumors. While the majority are benign lipomas, it is important to identify those masses that are malignant prior to excision. Current guidelines recommend core needle biopsy (CNB) for all lipomatous masses larger than 3-5 cm. The objective of this study was to determine if routine preoperative CNB based on mass size is necessary, or if radiographic features can guide the need for CNB. MATERIALS AND METHODS: Patients who underwent excision of extremity or truncal lipomatous masses at a single institution from October 2014 to July 2017 were retrospectively reviewed. By protocol, preoperative imaging was routinely obtained for all masses larger than 5 cm. High-risk radiographic features (intramuscular location, septations, nonfat nodules, heterogeneity, and ill-defined margins) and surgical pathology were evaluated to determine patients most likely to benefit from preoperative CNB. RESULTS: Of 178 patients, 2 (1.1%) had malignant tumors on surgical pathology. All masses smaller than 5 cm were benign and, if imaging was obtained, had two or fewer high-risk radiographic features. Both of the patients with malignant tumors had masses larger than 5 cm, preoperative imaging that showed at least four high-risk radiographic features, and underwent CNB prior to excision. CONCLUSIONS: The overall rate of malignancy is very low. The results of this study suggest that lipomatous masses smaller than 5 cm without concerning clinical characteristics do not require preoperative imaging or CNB. Conversely, lipomatous masses larger than 5 cm should undergo routine MRI with subsequent CNB if multiple high-risk radiographic features are present.

Traumatic bile duct neuroma presenting with acute cholangitis: A case report and review of literature.

Traumatic neuroma of the biliary tree has been previously reported as isolated case reports. In literature, these typically present following prior liver transplant or cholecystectomy, wherein the bile ducts have been disrupted in some form. Here we report the case of a 41-year old male who initially presented with acute cholangitis ten years after an open cholecystectomy complicated by a bile leak. Endoscopic retrograde cholangiography revealed a stricture within the mid distal common hepatic duct. The patient temporarily resolved his initial episode with stent placement, and he was eventually taken to the operating room for bile duct resection and hepaticojejunostomy given a persistent stricture and concern for underlying malignancy. Final pathology demonstrated a traumatic bile duct neuroma. This unusual entity should be considered in patients with benign appearing strictures presenting years after surgery, and awareness may aid in preoperative counseling as well.

Identification of invadopodia by TKS5 staining in human cancer lines and patient tumor samples.

Invadopodia, cancer cell protrusive structures with associated proteolytic activity, provide cancer cells with the ability to remodel the extracellular matrix. Invadopodia facilitate invasive migration and their formation correlates with cancer cell invasiveness and metastatic potential. The unambiguous identification of invadopodia is an important step to undergo studies on invadopodia regulatory inputs, functional outputs, as well as the prevalence and significance of invadopodia for cancer cells and human tumors. The adaptor protein TKS5 is a known invadopodia regulatory protein, which is necessary for invadopodia formation and activity. TKS5 is highly enriched at invadopodia and, unlike other commonly used invadopodia markers, it does not accumulate significantly in other types of cellular protrusions. However, the use of TKS5 as a marker of invadopodia has not been generalized, in part due to the availability of suitable antibodies against the human protein. We have evaluated two commercial antibodies raised against human TKS5. Here, we detail protocols for the detection of invadopodia-associated TKS5 in human cells in culture and in paraffin-embedded archived tumor surgical specimens using commercial antibodies. These methods should facilitate the identification and study of human invadopodia. •TKS5 staining identifies invadopodia in human cancer cell lines and archived surgical tumor specimens.

Advances in Translational Research and Clinical Care in Pancreatic Cancer: Where Are We Headed?

While significant advances have been made in the treatment of many different solid tumors, pancreatic cancer remains a glaring exception. Overall 5-year survival rates for pancreatic cancer remain in the single digits. While newer chemotherapy regimens such as FOLFIRINOX and nab-paclitaxel/gemcitabine have demonstrated modest improvement in survival benefit for metastatic disease and have improved the resectability rates of previously borderline or locally advanced tumors, clinically significant improvements from immunotherapy and targeted therapy remain to be demonstrated. Regardless, a wealth of basic science research in pancreatic cancer has been directed at understanding its aggressive biology and its resistance to therapy. We present a brief summary of key areas of laboratory research and its translation to clinical care.