De-implementation of Axillary Dissection in Women Undergoing Mastectomy for Breast Cancer.

BACKGROUND: Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy. PATIENTS AND METHODS: Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use. RESULTS: From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables. CONCLUSIONS: There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics.

Unmeasured factors are associated with the use of completion lymph node dissection (CLND) in melanoma.

BACKGROUND: Completion lymph node dissection (CLND) was the standard treatment for patients with melanoma with positive sentinel lymph nodes (SLN) until 2017 when data from the DeCOG-SLT and MLST-2 randomized trials challenged the survival benefit of this procedure. We assessed the contribution of patient, tumor and facility factors on the use of CLND in patients with surgically resected Stage III melanoma. METHODS: Using the National Cancer Database, patients who underwent surgical excision and were found to have a positive SLN from 2012 to 2017 were included. A multivariable mixed-effects logistic regression model with a random intercept for the facility was used to determine the effect of patient, tumor, and facility variables on the risk of CLND. Reference effect measures (REMs) were used to compare the contribution of contextual effects (unknown facility variables) versus measured variables on the variation in CLND use. RESULTS: From 2012 to 2017, the overall use of CLND decreased from 59.9% to 26.5% (p < 0.0001). Overall, older patients and patients with government-based insurance were less likely to undergo CLND. Tumor factors associated with a decreased rate of CLND included primary tumor location on the lower limb, decreasing depth, and mitotic rate <1. However, the contribution of contextual effects to the variation in CLND use exceeded that of the measured facility, tumor, time, and patient variables. CONCLUSIONS: There was a decrease in CLND use during the study period. However, there is still high variability in CLND use, mainly driven by unmeasured contextual effects.

De-implementation of Axillary Dissection in Women With Breast Cancer is Largely Driven By Site-level Contextual Effects.

OBJECTIVE: To assess the contribution of unknown institutional factors (contextual effects) in the de-implementation of cALND in women with breast cancer. SUMMARY OF BACKGROUND DATA: Women included in the National Cancer Database with invasive breast carcinoma from 2012 to 2016 that underwent upfront lumpectomy and were found to have a positive sentinel node. METHODS: A multivariable mixed effects logistic regression model with a random intercept for site was used to determine the effect of patient, tumor, and institutional variables on the risk of cALND. Reference effect measureswere used to describe and compare the contribution of contextual effects to the variation in cALND use to that of measured variables. RESULTS: By 2016, cALND was still performed in at least 50% of the patients in a quarter of the institutions. Black race, younger women and those with larger or hormone negative tumors were more likely to undergo cALND. However, the width of the 90% reference effect measures range for the contextual effects exceeded that of the measured site, tumor, time, and patient demographics, suggesting institutional contextual effects were the major drivers of cALND de-implementation. For instance, a woman at an institution with low-risk of performing cALND would have 74% reduced odds of havinga cALND than if she was treated at a median-risk institution, while a patient at a high-risk institution had 3.91 times the odds. CONCLUSION: Compared to known patient, tumor, and institutional factors, contextual effects had a higher contribution to the variation in cALND use.

Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance.

BACKGROUND: This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct. METHODS: Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale. RESULTS: Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders. CONCLUSION: The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.

Impact of Prior Unilateral Chest Wall Radiotherapy on Outcomes in Bilateral Breast Reconstruction.

BACKGROUND: The purpose of this study was to evaluate the impact of prior unilateral chest wall radiotherapy on reconstructive outcomes among patients undergoing bilateral immediate breast reconstruction. METHODS: A retrospective evaluation of patients with a history of unilateral chest wall radiotherapy was performed. In each patient, the previously irradiated and reconstructed breast was compared to the contralateral nonirradiated side, which served as an internal control. Descriptive and bivariate statistics were computed. Multiple regression statistics were computed to identify adjusted associations between chest wall radiotherapy and complications. RESULTS: Seventy patients were included in the study. The mean follow-up period was 51.8 months (range, 10 to 113 months). Thirty-eight patients underwent implant-based breast reconstruction; 32 patients underwent abdominal autologous flap reconstruction. Previously irradiated breast had a significantly higher rate of overall complications (51 percent versus 27 percent; p < 0.0001), infection (13 percent versus 6 percent; p = 0.026), and major skin necrosis (9 percent versus 3 percent; p = 0.046). After adjusting for age, body mass index, reconstruction method, and medical comorbidities, prior chest wall radiotherapy was a significant risk factor for breast-related complications (OR, 2.98; p < 0.0001), infection (OR, 2.59; p = 0.027), and major skin necrosis (OR, 3.47; p = 0.0266). There were no differences between implant-based and autologous reconstructions with regard to complications (p = 0.76). CONCLUSION: Prior chest wall radiotherapy is associated with a 3-fold increased risk of postoperative complications following immediate breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.