Assessing trends in breast care surveillance metrics after implementing surgeon-specific tracking and performance reporting in a large, integrated cancer network.

BACKGROUND: There are few quality metrics and benchmarks specific to surgical oncology. Development of a surgeon-level performance metrics system based on peer comparisons is hypothesized to positively influence surgical decision-making. This study established a tracking and reporting system comprised of evidence and consensus-based metrics to assess breast care delivered by individual surgeons. METHODS: Surgeons' performance is assessed by a surveillance tracking system of metrics pertaining to referrals and surgical elements. This retrospective analysis of prospectively collected breast care data reports on recurring 6-month and cumulative data from nine care locations from 2015 to 2021. RESULTS: Breast care was provided to 6659 patients by 41 surgeons. A total of 27 breast care metrics were evaluated over 7 years. Metrics with consistent, proficient results were retired after 18 months, including the rate of core biopsy, specimen orientation, and referrals to medical oncology, genetics, and fertility, among others. In clinically node-negative, hormone receptor-positive patients 70 years of age or older, the cumulative rate of sentinel lymph node (SLN) biopsy significantly decreased by 40% over 5.5 years (p < .001). The overall breast conservation rate for T0-T2 cancer increased 10% over 7 years. At the surgeon level, improvements were made in the median number of SLNs removed and in operative note documentation. CONCLUSIONS: Implementation of a surgeon-specific, peer comparison-based metric and tracking system has yielded substantive changes in breast care management. This process and governance structure can serve as a model for quantification of breast care at other institutions and for other disease sites.

Does Neoadjuvant Chemotherapy for Breast Cancer Affect Lymph Node Harvest Rates?

Some authors report that patients receiving neoadjuvant chemotherapy have fewer lymph nodes harvested during axillary dissection and more dissections with < 10 nodes compared with patients who undergo surgery initially. We sought to determine whether there was a difference between these patient groups in terms of number of nodes harvested and number of dissections with < 10 nodes. Retrospective review of 258 patients diagnosed with breast cancer who underwent an axillary lymph node dissection between July 1, 2015, and December 31, 2017 was performed. Chi-squared test was used to assess differences between patient groups. Of 258 patients undergoing dissection, 48 per cent received neoadjuvant chemotherapy; 52 per cent underwent surgery as first therapeutic intervention. Mean number of nodes resected; 14.3 + 6.3 for patients with no prior chemotherapy versus 14.9 + 6.6 for patients with neoadjuvant chemotherapy (P = 0.48). For patients undergoing surgery as first intervention, 21 per cent had < 10 nodes harvested. For patients receiving neoadjuvant chemotherapy, 20 per cent had < 10 nodes harvested. Patients who received neoadjuvant chemotherapy showed no statistically significant difference in the number of lymph nodes harvested during axillary dissection compared with patients undergoing surgery as first intervention. Neoadjuvant chemotherapy does not reduce the node harvest at the time of axillary dissection.

Ductal Carcinoma In Situ with Microinvasion on Core Biopsy: Evaluating Tumor Upstaging Rate, Lymph Node Metastasis Rate, and Associated Predictive Variables.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) when ductal carcinoma in situ with microinvasion (DCISM) is identified on core biopsy is unclear. OBJECTIVE: Our aim was to assess the upstage rate to invasive cancer and axillary lymph node metastasis in patients diagnosed with DCISM, and whether predictive variables could be identified that may help inform who would most likely benefit from a surgical axillary evaluation. METHODS: We performed a retrospective review of 70 patients diagnosed with DCISM on core biopsy. Patients with concomitant or prior invasive cancer were excluded. Demographic, clinical, radiographic, histologic, and treatment data were collected. Fisher's exact test and univariable and multivariable logistic regression were performed to identify variables that may be associated with tumor upstaging and nodal metastasis. Time-to-event distributions were summarized using the Kaplan-Meier method. RESULTS: On final surgical pathology, 49 patients (70%) had a final diagnosis of DCISM or T1mi cancer, whereas 21 patients (30%) were upstaged to measurable invasive cancer (> 1 mm). One of 49 patients (2%) with DCISM on final pathology and 4 of 21 patients (19%) with measurable invasive cancer showed sentinel lymph node metastases. CONCLUSION: Although the upstage rate to measurable invasive cancer in our cohort of patients with DCISM on core biopsy was 30%, findings of a positive SLNB remain low at 7%. No predictive variables were identified to inform whether the routine practice of SLNB may be omitted in some patients with DCISM.

Rate of radial scars by core biopsy and upgrading to malignancy or high-risk lesions before and after introduction of digital breast tomosynthesis.

PURPOSE: Radial scars (RS) commonly present mammographically as architectural distortions, but these lesions may be associated with non-invasive and invasive breast cancer. Digital breast tomosynthesis (DBT) has resulted in higher detection rates of architectural distortion particularly in patients with dense breast tissue. We hypothesized that rates of clinically relevant lesions confirmed surgically would be lower in patients who received DBT imaging compared with those who received standard digital breast imaging. METHODS: We performed a retrospective review of 223 patients diagnosed with pure RS by core biopsy and surgical excision before and after DBT was introduced. The rate of upgrading to malignancy or high-risk lesion was evaluated. Demographics, biopsy type, and histologic data were analyzed. Univariable logistic regression analysis was used to identify variables that may be associated with upgrading. RESULTS: The rate of identifying RS increased from 0.04-.13% (P < 0.0001) with DBT imaging. The upgrade rate on surgical specimen to invasive or non-invasive cancer was similar before and after DBT; 6% versus 3%, as were findings of a high-risk lesion; 12% versus 22%. No predictive factors were identified for patients upgraded to malignant neoplasms or high-risk lesions. CONCLUSIONS: The likelihood of identifying RS has increased with DBT imaging, but rates of upgrading to a malignant neoplasm or high-risk lesion were similar to those before DBT. Although the rate of upgrading to malignancy after DBT was low, an excisional biopsy should be considered as 22% of patients were upgraded to high-risk lesions. These patients are candidates for chemoprevention and/or high-risk surveillance.

Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ.

BACKGROUND: Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided. RESULTS: One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%). CONCLUSIONS: We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.

Lobular breast cancer series: imaging.

The limitations of mammography in the detection and evaluation of invasive lobular carcinoma (ILC) have long been recognized, presenting real clinical challenges in treatment planning for these tumors. However, advances in mammography, ultrasound, and magnetic resonance imaging present opportunities to improve the diagnosis and preoperative assessment of ILC. The evidence supporting the performance of each imaging modality will be reviewed, specifically as it relates to the pathology of ILC and its subtypes. Further, we will discuss emerging technologies that may be employed to enhance the detection rate and ultimately result in more effective screening and staging of ILC.

Indurated vascular plaques on the legs of an 85-year-old woman.

This is a case of classic type Kaposi sarcoma occurring in an 85-year-old woman who presented with indurated vascular plaques on both legs below the knee that has been present for two years. A brief review of the literature on Kaposi sarcoma is included.

Photoletter to the editor: An erythematous folliculocentric papular lesion on the chest of a 60-year-old man: What is your diagnosis?

Folliculitis has many etiologies including bacterial, fungal, viral and parasitic. Therefore, an accurate determination of the cause is necessary to direct treatment. This is a case of a 60-year-old man who presented with an erythematous papule on his chest. Biopsy showed granulomatous inflammation, abscess formation, and the causative agent was Demodex.

Biopsy of a 5 mm cystic lesion on the right heel of a 48-year-old woman.

An excisional biopsy of an asymptomatic cystic lesion that had been present for several years on the right heel of a 48-year-old woman revealed a subcutaneous cyst lined by ciliated columnar epithelium. On immunostaining, the epithelial cells were positive for Pan-cytokeratin (CK AE 1/3), estrogen receptor (ER) and progesterone receptor (PR), but negative for carcinoembryonic antigen (CEA), suggesting Mullerian type of epithelium. Cutaneous ciliated cyst of Mullerian type occurs almost exclusively on the lower extremity of premenopausal women. The lesion is benign and excision is curative.

Clear cell Basal cell carcinoma.

Introduction. Clear cell basal cell carcinoma (BCC) is an uncommon and unusual variant of BCC, which is characterized by a variable component of clear cells. The pathogenesis of this histological variant and its clinical significance has not been clarified. Differentiation of this uncommon variant of BCC from other clear cell tumors is important for the treatment. Case Presentation. A 65-year-old male presented with a 0.9 cm dome-shaped lesion on his upper chest. A shave biopsy revealed a dermal basaloid tumor that comprised nests with a peripheral palisading pattern, retraction artifacts, and striking clear cell changes. Histopathologic examination, along with findings from immunohistochemical studies and special staining of the clear cells, supports the diagnosis of clear cell basal cell carcinoma. Conclusion. Clear cell BCC is a rare and unusual variant of BCC. The underlying pathogenesis of this subtype is unclear; however, accurate identification may affect treatment and prognosis.

A woman with a lower lip nodule: what is your diagnosis?

Angiolymphoid hyperplasia with eosinophilia (ALHE), also known as epitheliod hemangioma is an uncommon benign vascular tumor of the skin. It usually presents as nodules and erythema over the ears, forehead, or scalp. Histologically, the lesion is composed of a combination of immature blood vessels, endothelial cells with distinct epitheliod appearance and chronic inflammatory cell infiltration with numerous eosinophils. Such a case occurring on the lower lip of a 55-year-old woman is presented. The lesion was completely excised with clear margins. Surgical resection is the preferred mode of treatment and is curative.

Rapidly growing hemorrhagic papule on the cheek of a 54-year-old man.

A 54-year-old man sought medical attention for a growth on his right cheek that had been present for three months. The growth began as a small, brown "pimple" that gradually increased in size over time. Physical examination revealed a 9 mm well-circumscribed erythematous nodule with a hemorrhagic crust. On dermoscopy, the lesion was completely vascular appearing, with no pigment visualized. A clinical diagnosis of pyogenic granuloma was made. The lesion was biopsied and histopathologic examination revealed a 2.8 mm thick, Clark level IV, ulcerated, amelanotic nodular melanoma. Because the literature contains reports of nodular melanoma mimicking the presentation of a pyogenic granuloma, all such lesions should be biopsied for histopathologic diagnosis.

Pink pigtail in a skin biopsy: What is your diagnosis?

Sarcoptes scabiei is an obligate ectoparasite, which burrows into the stratum granulosum of the epidermis and lays its eggs. The resultant host inflammatory response leads to intensely pruritic papules. CASE SYNOPSIS: A 63-year-old man undergoing treatment for immunoproliferative disease was suspected of having a pruritic drug eruption. Subsequent skin biopsy revealed an intracorneal burrow containing three pink, refractile pigtail-like structures, believed to be empty eggshells of S. scabiei. CONCLUSION: Traditionally, the presence of adult mites or eggs in skin scrapings or a skin biopsy is required for a definitive diagnosis of scabies. However, our case and similar cases suggest that the diagnosis of scabies can also be made on the basis of pink pigtail-like structures, remnants of eggshells, within the intracorneal burrow.

Erythema ab igne: a case report and review of the literature.

Erythema ab igne (EAI) is a rare condition since the advent of central heating. Its incidence has been rising as heating sources are being used to treat chronic pain. Multiple activities that chronically expose patients to heating sources also have been documented with this condition. We present a case of EAI induced by the use of an electric blanket.

A man with an umbilicated papule of the hand: what is your diagnosis?

Introduction. Ecthyma contagiosum is a zoonotic disease caused by the parapoxvirus that causes "sore mouth" in sheep and goats and orf in human. Case Presentation. A 61-year-old sheep farmer presented with a painful non-pruritic lesion on the left hand that had been present for approximately 5 weeks. Physical examination demonstrated a 1 cm pearly, umbilicated papule with raised borders. A biopsy showed an asymmetrical nodule with parakeratotic crust and acanthosis with thin epidermal strands extending deeply in the underlying dermis. Marked edema, capillary proliferation and extensive lymphocytic infiltration was also present. One red intranuclear inclusion was identified in an epidermal keratinocyte. A diagnosis of human orf (ecthyma contagiosum) was made. Conclusion. Infected sheep and freshly vaccinated sheep or goats are the reservoir for human infection. After an incubation period of 3-7 days, parapoxvirus infections produce 1-3 painful lesions measuring 1-2 cm in diameter. The natural history of the disease is complete resolution and no treatment is indicated. Prevention of echthyma contagiosum in ruminants through vaccination is thought to be the best way to control infection.

An unusual clinical presentation of merkel cell carcinoma: a case report.

Introduction. Merkel cell carcinoma is a rare, aggressive neuroendocrine cell carcinoma arising in the sun-exposed skin of elderly patients. Most of these tumors are located in the dermis. An unusual clinical presentation of such a tumor in the subcutis, if not biopsied, may be easily mistaken as a benign lesion. Case Presentation. An 83-year-old white woman presented with a several-month history of a painless 7 mm subcutaneous mass that was initially thought to be a lipoma. A conservative follow-up was planned. At the insistence of the patient, an excisional biopsy of the mass was performed revealing a subcutaneous Merkel cell carcinoma. The tumor cells stained positively for CK 20, chromogranin, and synaptophysin. No other primary or metastatic tumors found after a thorough work-up. The patient was treated with local irradiation. She remains disease free at her six-month follow-up visit. Conclusion. When a new growth is encountered in the sun-exposed skin of elderly patients, a biopsy is warranted even if the lesion clinically appears benign.

Poorly differentiated squamous cell carcinoma arising in tattooed skin.

Introduction. Tattoos have increasingly become accepted by mainstream Western society. As a result, the incidence of tattoo-associated dermatoses is on the rise. The presence of a poorly differentiated squamous cell carcinoma in an old tattooed skin is of interest as it has not been previously documented. Case Presentation. A 79-year-old white homeless man of European descent presented to the dermatology clinic with a painless raised nodule on his left forearm arising in a tattooed area. A biopsy of the lesion revealed a poorly differentiated squamous cell carcinoma infiltrating into a tattoo. The lesion was completely excised and the patient remains disease-free one year later. Conclusion. All previous reports of squamous cell carcinomas arising in tattoos have been well-differentiated low-grade type or keratoacanthoma-type and are considered to be coincidental rather than related to any carcinogenic effect of the tattoo pigments. Tattoo-associated poorly differentiated invasive carcinoma appears to be extremely rare.

'Lint ball' omphalitis, a rare cause of umbilical discharge in an adult woman: a case report.

INTRODUCTION: Umbilical discharge in adult is rare and is usually induced by foreign material, most commonly hair. Rarely, it may be due to embryonal anomalies. We are reporting an unusual case of umbilical discharge in adult secondary to an impacted lint ball. CASE PRESENTATION: A 55-year-old obese woman presented with a 4-month history of hemorrhagic discharge from the umbilicus. Deep from the base of the umbilicus, a 0.8 cm gray-tan mass was removed that on microscopic examination revealed a lint ball. CONCLUSION: An impacted lint ball may be a rare cause of umbilical discharge in adult.

Poroma of the hip and buttock.

Poroma is a benign adnexal skin tumor seen in middle aged individuals with no sex predilection. The acral sites are the most commonly affected regions. Hip or buttock as a location of origin has rarely been reported. We report two cases of poroma, one located on the hip of a 75-year-old man and the other on the buttock of a 60-year-old man.