Evaluation of traditional targeted axillary dissection eligibility criteria for node-positive breast cancer after neoadjuvant chemotherapy in a prospective multicenter registry.

INTRODUCTION: Targeted axillary dissection (TAD) is performed after neoadjuvant systemic therapy (NST) to decrease the rate of non-therapeutic axillary dissection (ALND) for patients with node-positive breast cancer. In order to ensure the oncologic safety of TAD, eligibility criteria resulting in a low false negative rate (FNR) have been proposed. The purpose of this study was to evaluate the utility of the traditional criteria. METHODS: Data was collected from a prospective multicenter registry. In order to ascertain FNRs, pathologic findings in the sentinel lymph nodes (LN)s, malignant clipped LN, and axillary contents were determined. The FNRs within TAD eligibility criterion groups were compared. RESULTS: A total of 110 patients underwent TAD and ALND, and were therefore eligible for analysis. TAD retained a low FNR in advanced clinical T-N stage compared with earlier disease (T stage: 95% CI 0.00-11.93, p = 0.42; N stage: 95% CI 0.00-8.76, p = 0.31). Presentation with ≥4 abnormal LNs on axillary ultrasound did not predict a high TAD FNR (95% CI 0.00-5.37, p = 0.16). No significant differences were noted in TAD FNR when single was compared with dual tracer (blue dye vs dual tracer 95% CI 0.72-52.49, p = 0.13; radiotracer vs dual tracer 0.04-20.11, p = 0.51). Excision of the clipped LN and only one SLN was as accurate as excision of the clipped LN and ≥2 SLNs (95% CI 0.00-10.61, p = 0.38). CONCLUSIONS: TAD retained a low FNR among patients traditionally considered ineligible for this technique. However, excision of the clipped LN and at least one SLN remained essential to a low FNR.

Malignant Phyllodes Tumor in an Adolescent Female: A Rare Case Report and Review of the Literature.

Primary breast neoplasms are rare in adolescent females, most of which are benign. Phyllodes tumors constitute a remarkably small subset of breast neoplasms (0.3-0.9%) with malignant phyllodes tumors being even more uncommon. Malignant phyllodes tumors tend to progress rapidly though only 1.5% metastasize. They are also associated with a higher rate of recurrence than their benign counterparts, underlying the importance of adequate surgical margins. It is therefore imperative to be able to identify these tumors early allowing for prompt resection and close follow-up. Here, we present the rare case of a 17-year-old female presenting with a rapidly enlarging breast mass, which was ultimately found to be a malignant phyllodes tumor. We further performed a review of the literature to highlight only 22 other cases reported in adolescent females.

Association between socioeconomic factors and outcomes in breast cancer.

BACKGROUND: Persistent socioeconomic disparities are evident in the delivery of health care. Despite previous research into health disparities, the extent of the effect of economic inequalities in the management of breast cancer is not well understood. The purpose of our study is to perform a national assessment of the impact of economic factors on key aspects of breast cancer management. METHODS: This is a retrospective study using data from the National Cancer Database. The population consisted of female patients with primary breast cancer diagnosed between 2011 and 2015. Patients were categorized based on household income and insurance status. Outcomes investigated were stage at diagnosis, rate of breast conservation therapy, use of immediate reconstruction following mastectomy, and administration of systemic therapy for stage 3 and 4 disease. Multivariable logistic regression analyses were performed to determine significant associations between economic factors and clinical outcomes. Survival analysis was performed to evaluate the influence of income and insurance on survival. RESULTS: In total, 666 487 women were evaluated. Multivariable regression analyses revealed that patients with lower income (OR, 1.23) and no insurance (OR, 1.64) were more often diagnosed with later stage disease. Patients with lower income (OR, 1.08) and no insurance (OR, 1.05) had a higher likelihood of undergoing mastectomy instead of breast conserving therapy. Patients with lower income (OR, 0.51) and no insurance (OR, 0.27) were less likely to receive immediate breast reconstruction. Administration of systemic therapy was less frequent in patients with lower income (OR, 0.90) and no insurance (OR, 0.52). A survival benefit was demonstrated in patients with high income and insurance. CONCLUSION: Our findings demonstrate prevailing disparities in the delivery of care among patients with limited economic resources, which pertains to some of the most important aspects of breast cancer care. The full etiology of the observed disparities is complex and multifactorial, and a better understanding of these issues offers the potential to close the existing gap in quality of care.

Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management.

BACKGROUND: Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population. METHODS: A retrospective cohort study was performed. Patients ≥65 years sustaining blunt head injuries from January 2010 to July 2017 were identified using our level 1 trauma center database. AT-patients presenting with ICH who underwent D-CTH were included. Patients with worsened ICH were compared to those with stable to improved ICH on D-CTH. AT-patients were compared to a cohort of non-AT patients. Fisher's Exact and Mann-Whitney U tests were utilized and a power analysis conducted. RESULTS: 137 A T and 34 non-AT patients were identified. There was no difference in hemorrhage progression or appearance of new ICH. No patient had a change in management from D-CTH in either cohort. AT-patients were slightly older (p < 0.001), but cohorts were otherwise similar. 50 AT-patients with worsened ICH were compared to 87 with stable ICH. There was no difference in cohort demographics. Hemorrhage progression did not vary with type of AT used but did increase if multiple types of synchronous ICH were present (p < 0.001). CONCLUSIONS: Our data supports abstaining from routine D-CTH of elderly ICH patients with an intact neurologic examination who are utilizing aspirin, clopidogrel or warfarin. Conclusions cannot be drawn regarding new oral anticoagulants (NOACs) given low enrollment. Further multicenter study is required to provide adequate power and detect small levels of management change.

Oncotype DX® Recurrence Score as a Predictor of Response to Neoadjuvant Chemotherapy.

BACKGROUND: The Oncotype DX® assay has been validated in predicting response to adjuvant chemotherapy in breast cancer. Its role in neoadjuvant chemotherapy (NCT) has not been established. METHODS: The National Cancer Database was used to identify all patients with T1-T3, ER-positive, HER2-negative primary invasive breast cancer diagnosed from 2010 to 2015 who had Oncotype DX recurrence scores (RS) and received NCT. RS were classified as low, intermediate, or high. Unadjusted and adjusted regression analyses were performed to determine the association between pathologic complete response (pCR) and RS. RESULTS: A total of 989 patients (mean age, 54.6 years) with available RS who underwent NCT were identified. RS were low in 227 (23.0%) patients, intermediate in 450 (45.5%) patients, and high in 312 (31.5%) patients. Most patients had a T1 (431 [43.6%]) or T2 tumor (451 [45.6%]). Most had N0 disease (757 [76.5%]). Tumor grades were 1 (123 [12.4%]), 2 (517 [52.3%]), or 3 (349 [35.3%]). pCR was achieved by 42 (4.3%) patients. Adjusted multivariable analysis showed a significant association between pCR and high RS (odds ratio 4.87; 95% confidence interval 2.01-11.82). CONCLUSIONS: High Oncotype DX RS was associated with pCR after NCT in this national cohort of ER-positive, HER2-negative patients. Oncotype DX testing could help to identify patients most suited for NCT and should be considered for incorporation into the multidisciplinary decision-making process.

Surgical Risk Factors for the Delayed Initiation of Adjuvant Chemotherapy in Breast Cancer.

BACKGROUND: Timely administration of adjuvant chemotherapy for breast cancer is associated with a survival benefit. Specific elements of surgical management may lead to delays initiating chemotherapy, resulting in unfavorable outcomes. The purpose of this study was to determine the correlation between surgical factors and delayed chemotherapy in breast cancer patients. METHODS: A retrospective analysis of the National Cancer Database was performed. The study cohort consisted of female patients with stage 1-3 breast cancer diagnosed between 2010 and 2014. Initiation of chemotherapy beyond 90 days after surgery was defined as delayed. Multivariable logistic regression modeling was performed to establish associations between delayed chemotherapy and clinical and demographic factors of interest. Survival analysis was performed using the Kaplan-Meier estimation and Cox proportional hazards regression to evaluate potential 5-year overall survival disadvantage of delayed initiation of chemotherapy. RESULTS: Of 166,681 women assessed, 4.3% had a delay in the initiation of chemotherapy. Surgery-specific risk factors included unplanned readmission in the postoperative period, lower surgical volume, mastectomy with immediate autologous reconstruction, and positive surgical margins. Adjusted survival analysis showed a survival disadvantage of delayed initiation of chemotherapy (hazard ratio [HR] 1.46; p < 0.01). CONCLUSIONS: Risk factors for delayed initiation of chemotherapy specific to the surgical process were identified. Delayed initiation of adjuvant chemotherapy was associated with a survival detriment. Efforts should be made to address these surgical management issues and optimize the perioperative process to ensure timely patient treatment.

Minimally invasive surgery adoption into an established surgical practice: impact of a fellowship-trained colleague.

BACKGROUND: Practicing general surgeons adopt minimally invasive techniques using training opportunities such as weekend courses, videos, hands-on conferences, and traveling proctors with varying success. By integrating a fellowship-trained surgeon into an established practice, we show that minimally invasive techniques can be readily adopted. METHODS: A retrospective review of operative reports from July 2004 through June 2008 obtained the number of laparoscopic and open appendectomies, colectomies, ventral/incisional hernias, and inguinal hernias performed by five practicing surgeons. Three time intervals were formed: 18 months before arrival of the MIS-trained surgeon, a 12-month transition period, and the 18 months following. Only cases performed by the five surgeons, and not by the MIS-trained surgeon, were included. A survey elicited the opinions of the five surgeons on various aspects of the transition, including barriers and effectiveness of different methods for learning MIS techniques. RESULTS: A total of 4,016 cases were reviewed. The percentage of total cases performed laparoscopically increased from 12.1 to 48.3 %. Laparoscopic appendectomies significantly increased across time periods from 19 to 80 % (p < 0.0001). Adoption of laparoscopic ventral/incisional hernia repairs increased from 4.8 to 20.1 % (p = 0.0322). Laparoscopic inguinal hernias increased from 0.6 to 31.1 % (p < 0.0001). Finally, laparoscopic colectomies significantly increased from 25 to 52 % (p < 0.0001). Survey responses indicated that "mentoring by a colleague with MIS training" was superior to other methods for learning MIS procedures (p = 0.0327-0.0516). CONCLUSIONS: The integration of a fellowship-trained MIS colleague into a general surgery practice resulted in a 300 % increase in the proportion of appendectomies, ventral hernias, inguinal hernias, and colectomies performed laparoscopically by the other members of the practice. When surveyed, the surgeons felt that mentoring by a colleague with MIS training was the most effective method for adopting MIS procedures into their practice.

Prolonged continuous in vitro human platelet production using three-dimensional scaffolds.

OBJECTIVE: Methods producing human platelets using growth on plastic, on feeder layers, or in suspension have been described. We hypothesized that growth of hematopoietic progenitors in a three-dimensional (3D) scaffold would enhance platelet production sans feeder layer. MATERIALS AND METHODS: We grew CD34 positively selected human cord blood cells in surgical-grade woven polyester fabric or purpose-built hydrogel scaffolds using a cocktail of cytokines. RESULTS: We found production of functional platelets over 10 days with two-dimensional (2D), 24 days with 3D scaffolds in wells, and more than 32 days in a single-pass 3D perfusion bioreactor system. Platelet numbers produced daily were higher in 3D than 2D, and much higher in the 3D perfusion bioreactor system. Platelet output increased in hydrogel scaffolds coated with thrombopoietin and/or fibronectin, although this effect was largely obviated with markedly increased production caused by changes in added cytokines. In response to thrombin, the platelets produced aggregated and displayed increased surface CD62 and CD63. CONCLUSION: Use of 3D scaffolds, especially in a bioreactor-maintained milieu, may allow construction of devices for clinical platelet production without cellular feeder layers.