Imaging Intensity and Survival Outcomes in High-Risk Resected Melanoma Treated by Systemic Therapy at Recurrence.

BACKGROUND: Intensive imaging in melanoma remains controversial because its survival impact is unknown. We investigated the impact of imaging intensity on the rates of asymptomatic surveillance-detected recurrence (ASDR) and subsequent treatment outcomes in patients with access to immune checkpoint inhibitors (ICIs) and targeted therapy (TT). METHODS: Patients with resected malignant melanoma undergoing imaging surveillance at a single center between 2006 and 2016 were identified. Surveillance and recurrence characteristics (imaging, symptom, treatment, and survival data) were retrospectively collected. Univariate (t test, Chi square test) and multivariate Cox regression analyses were conducted. RESULTS: Of 353 high-risk melanoma patients (stage IIB, 24%; IIC, 19%; IIIA, 27%; IIIB, 16%; IIIC, 14%), 71 (45%) had ASDR and 88 (55%) had symptomatic recurrence (SR). Shorter imaging intervals identified more ASDR (57%, 0-6 months; 34%, 6-12 months; 33%, > 12 months; p = 0.03). ASDR had better prognostic factors than SR [fewer than three metastatic sites (43 vs. 21%, p = 0.003), normal lactate dehydrogenase (LDH; 53 vs. 38%, p = 0.09), brain metastases (11 vs. 40%, p < 0.001)] and received more systemic treatment (72 vs. 49%, p = 0.003; ICIs 55 vs. 31%, p = 0.002; TT 8 vs. 13%, p = 0.41). ASDR had better survival outcomes on ICI treatment (2-year OS, 56 vs. 31%, p < 0.001). Median OS from surveillance start was 39.6 vs. 22.8 months (p < 0.001). ASDR was independently associated with survival (hazard ratio 0.47, 95% confidence interval 0.29-0.78, p = 0.003), adjusting for stage, sex, age, disease burden, LDH, era of recurrence, brain metastases, and ICI/TT treatment. CONCLUSIONS: These real-world data support further study on intensified imaging surveillance protocols for high-risk resected melanoma, as ASDR was associated with superior survival outcomes from ICI therapy.

Correction to: Imaging Intensity and Survival Outcomes in High-Risk Resected Melanoma Treated by Systemic Therapy at Recurrence.

In the original article, the survival curves are missing in Fig. 1c, d.

Going Beyond the Numerical Scoresheet: Identifying Maladaptive Narcissistic Traits in Residency Applicants.

OBJECTIVE: Certain personality traits assessed during interviews have been shown to negatively predict performance in residency. An informal needs assessment at our institution suggested that it would be particularly important to identify traits associated with maladaptive narcissism (i.e., entitlement, difficulty accepting criticism, and arrogance). The objective of this study was to evaluate an interview station designed to identify narcissistic personality traits among applicants to our general surgery residency program. DESIGN: An interview station was developed in which applicants were provided negative feedback as a simulated evaluation. Two interviewers (1 staff surgeon, 1 senior resident) interviewed 48 applicants at this station. The 48 participants were also asked to complete the Narcissism Personality Index (NPI-40), which assesses adaptive and maladaptive facets of narcissism. NPI-40 scores were compared to the interview station scoresheet, which included numerical rating scales and a subjective "red flag" system used to identify concerns related to professionalism or personality. RESULTS: Linear regression demonstrated a significant correlation between red flags on the negative feedback station and a high maladaptive proportion of narcissism on the NPI-40 (p = 0.02). The numerical interview score and the proportion of maladaptive narcissism score did not reach significance (p = 0.05). There was a high inter-rater reliability between interviewers' numerical scores (r = 0.89) and in determining red flags (σ = 0.83). CONCLUSIONS: We designed an interview station that successfully identified general surgery residency interviewees displaying high proportions of maladaptive narcissistic traits. Despite an objective scoring process, subjective opinion of interviewers was more valuable in identifying these applicants. Our findings suggest that the written comments of surgeons in interview stations designed to identify applicants with difficulty accepting negative feedback may provide valuable information that is not captured by the numerical scoring process.

Radioactive Seed Localization Versus Wire-Guided Localization for Nonpalpable Breast Cancer: A Cost and Operating Room Efficiency Analysis.

BACKGROUND: This study aimed to compare the cost and resource use between our first-year experience using breast-conserving surgery (BCS) with radioactive seed localization (RSL) and the previous-year standard practice of BCS with wire-guided localization (WGL) for patients with nonpalpable breast cancer at a large Canadian tertiary center. METHODS: For this retrospective cohort study, data for BCS cases with RSL was collected from 1 April 2015 to 31 March 2016 and for BCS cases with WGL from 1 April 2014 to 31 March 2015. RESULTS: The study compared 153 WGL patients with 194 RSL patients. The two groups had no significant demographic differences. The average cost per patient for RSL, including opportunity costs, was $250.90 versus $1130.41 for WGL. Dedicated allocated radiology appointments to RSL increased (9 per day), and fewer radiologists were required for these procedures per day. Patients were transported to the operating room more quickly for RSL procedures (120 vs. 254 min; p < 0.001). Fewer vasovagal reactions occurred after insertion of RSL versus WGL (p = 0.05). No significant differences were observed in terms of surgical time, specimen volume, positive margins, or margin reexcision rates. No significant differences in postoperative complication rates were observed. CONCLUSIONS: In this study, RSL had lower costs than WGL, allowed for more efficient use of radiology scheduling and resources, and had shorter wait times for patients on their day of surgery. In addition, RSL led to fewer vasovagal reactions at insertion. Therefore, RSL should be used instead of WGL given the reduced cost, decreased need of human resources, improved efficiency, and potential benefits to the patient experience.

Antitumor activity of nivolumab on hemodialysis after renal allograft rejection.

BACKGROUND: Nivolumab (Opdivo™) is a novel IgG4 subclass programmed death-1 (PD-1) inhibiting antibody that has demonstrated breakthrough-designation anti-tumor activity. To date, clinical trials of nivolumab and other checkpoint inhibitors have generally excluded patients with solid organ transplantation and patients with concurrent immunosuppression. However, organ transplant recipients are at high-risk of development of malignancy as a result of suppressed immune surveillance of cancer. CASE PRESENTATION: We illustrate the outcomes of a 63 year-old type I diabetic female patient who developed pulmonary metastatic, BRAF wild-type cutaneous melanoma 10 years after renal transplantation. After downward titration of the patient's immunosuppressive medications and extensive multidisciplinary review, she was treated with nivolumab in the first-line setting. Within 1 week of administration, the patient experienced acute renal allograft rejection, renal failure and concurrent diabetic ketoacidosis due to steroid therapy. Allograft function did not return, but patient made a full clinical recovery after being placed on hemodialysis. Subsequently, the patient had clinical disease progression off therapy and required re-challenge with nivolumab on hemodialysis, resulting in ongoing clinical and radiographic response. CONCLUSIONS: This case illustrates multiple practical challenges and dangers of administering anti-PD1 immune checkpoint inhibitors to patients with solid-organ transplantation including need for titration of immunosuppressive medications, risks of allograft rejection, and treatment during hemodialysis.

Viro-immune therapy: A new strategy for treatment of pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is an almost uniformly lethal disease with less than 5% survival at five years. This is largely due to metastatic disease, which is already present in the majority of patients when diagnosed. Even when the primary cancer can be removed by radical surgery, local recurrence occurs within one year in 50%-80% of cases. Therefore, it is imperative to develop new approaches for the treatment of advanced cancer and the prevention of recurrence after surgery. Tumour-targeted oncolytic viruses (TOVs) have become an attractive therapeutic agent as TOVs can kill cancer cells through multiple mechanisms of action, especially via virus-induced engagement of the immune response specifically against tumour cells. To attack tumour cells effectively, tumour-specific T cells need to overcome negative regulatory signals that suppress their activation or that induce tolerance programmes such as anergy or exhaustion in the tumour microenvironment. In this regard, the recent breakthrough in immunotherapy achieved with immune checkpoint blockade agents, such as anti-cytotoxic T-lymphocyte-associate protein 4, programmed death 1 (PD-1) or PD-L1 antibodies, has demonstrated the possibility of relieving immune suppression in PDAC. Therefore, the combination of oncolytic virotherapy and immune checkpoint blockade agents may synergistically function to enhance the antitumour response, lending the opportunity to be the future for treatment of pancreatic cancer.