Brittany L. Murphy

Identifying a subset of patients with DCIS who have a low likelihood of residual disease at surgical excision following a core needle biopsy

Current randomized controlled trials are investigating the outcomes of non‐surgical treatment for patients with ductal carcinoma in situ (DCIS). We sought to evaluate pre‐operative factors associated with no residual disease at definitive resection following a core needle biopsy (CNB) diagnosis of DCIS.

A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease

BackgroundApproximately 8–56% of patients with a core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) will be upstaged to invasive disease at the time of excision. Patients with invasive disease are recommended to undergo axillary nodal staging, most often requiring a second operation. We developed and validated a nomogram to preoperatively predict percentage of risk for upstaging to invasive cancer.MethodsWe reviewed 834 cases of DCIS on CNB between January 2004 and October 2014. Multivariable analysis was used to evaluate CNB and imaging factors to develop a nomogram to predict the risk of upstaging from DCIS to invasive cancer. This nomogram was validated with an external dataset of 579 similar patients between November 1998 and September 2016. An area under the receiver operating characteristic curve was constructed to evaluate nomogram discrimination.ResultsThe rate of upstaging to invasive disease was 118/834 (14.1%). On multivariable analysis, grade on CNB and imaging factors, including mass lesion, multicentric disease, and largest linear dimension, were associated with upstage to invasive disease, and was used to develop a nomogram (c-statistic 0.71). In the external validation dataset, 62/579 (10.7%) patients were upstaged to invasive disease. Our nomogram was validated in this dataset with a c-statistic of 0.71.ConclusionFor patients with a CNB diagnosis of DCIS, our validated nomogram using DCIS grade on biopsy, and imaging factors of mass lesion, multicentric disease, and largest linear dimension, may be used for preoperative assessment of risk of upstaging to invasive disease, allowing patient counseling regarding axillary staging at the time of definitive surgery.

Factors Associated With Positive Margins in Women Undergoing Breast Conservation Surgery

Objective: To identify factors predicting positive margins at lumpectomy prompting intraoperative reexcision in patients with breast cancer treated at a large referral center. Patients and Methods: We reviewed all breast cancer lumpectomy cases managed at our institution from January 1, 2012, through December 31, 2013. Associations between rates of positive margin and patient and tumor factors were assessed using χ2 tests and univariate and adjusted multivariate logistic regression, stratified by ductal carcinoma in situ (DCIS) or invasive cancer. Results: We identified 382 patients who underwent lumpectomy for definitive surgical resection of breast cancer, 102 for DCIS and 280 for invasive cancer. Overall, 234 patients (61.3%) required intraoperative reexcision for positive margins. The reexcision rate was higher in patients with DCIS than in those with invasive disease (78.4% [80 of 102] vs 56.4% [158 of 280]; univariate odds ratio, 2.80; 95% CI, 1.66‐4.76; P<.001). Positive margin rates did not vary by patient age, surgeon, estrogen receptor, progesterone receptor, or ERBB2 status of the tumor. Among the 280 cases of invasive breast cancer, the only factor independently associated with lower odds of margin positivity was seed localization vs no localization (P=.03). Conclusion: Ductal carcinoma in situ was associated with a higher rate of positive margins at lumpectomy than invasive breast cancer on univariate analysis. Within invasive disease, seed localization was associated with lower rates of margin positivity.

Trends of inguinal hernia repairs performed for recurrence in the United States

Background One of the main complications of inguinal hernia repair continues to be recurrence. Commonly cited prior reports from relatively small studies estimate this rate to be 1% to 5% in the United States. Although some reports have found higher recurrence rates, they get little attention on the national stage or in other large studies. We sought to determine the trend of inguinal hernia repairs performed for recurrence over time using large national databases. Methods We identified patients aged ≥18 years who underwent inguinal hernia repair from three sources: the Premier database (January 2010 to September 2015), the American College of Surgeons National Surgical Quality Improvement Program database (January 2005 to December 2014), and the Mayo Clinic institutions (January 2005 to December 2014). We evaluated the incidence of primary and recurrent inguinal hernia repairs stratified by sex over time using one‐tailed Cochran‐Armitage tests. Results In the Premier database, of the 317,636 inguinal hernia repairs, the proportion performed for recurrence had a small decrease in males from 11.4% in 2010 to 10.5% in 2015 (P < .0001); however, it remained constant in females (6.5% in 2010 to 6.7% in 2015, P = .46). In the National Surgical Quality Improvement Program database, of the 180,512 inguinal hernia repairs, there was no change for either sex: 10.5% to 11.2% (2005–2014, P = .12) in males and 6.2% to 7.1% (2005–2014, P = .11) in females. Within our institution, in the 9,216 patients identified, there was no change in the proportion of inguinal hernia repairs for recurrence in males: 13.3% to 11.5% (2005–2014, P = .25). In females, the proportion increased from 1.3% to 12.0% during the study period (P = .006). Conclusion Based on these larger evaluations of recurrent inguinal hernia surgery, the current literature on inguinal hernia repair recurrence is skewed and overly optimistic.

Outcomes and feasibility of nipple-sparing mastectomy for node-positive breast cancer Patients

BACKGROUND While nipple-sparing mastectomy (NSM) is gaining acceptance for risk reduction and for treatment of early stage breast cancer, node-positive disease remains a relative contraindication. Our aim was to evaluate the use and outcomes of NSM in node-positive breast cancer patients. METHODS We identified 240 cancers in 226 patients (14 bilateral) scheduled for NSM and operated on between 1/2009 and 6/2014. We compared outcomes for 58 node-positive vs 182 node-negative patients. RESULTS Intraoperative conversion to skin-sparing mastectomy was similar for node-positive and node-negative patients, 10% and 7%, as was 1-year success of NSM, 84% and 90%, respectively. Five-year locoregional disease-free estimates were 82% (95% CI 68%-99%) for node-positive and 99% (95% CI 96%-100%) for node-negative patients, P = .004; however, there were no nipple-areolar recurrences among node-positive patients. CONCLUSIONS With careful consideration of biologic and anatomic risk factors for recurrence, these data suggest that NSM is a reasonable option for selected node-positive breast cancer patients.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

Background. Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes. Methods. Adults (≥18 years) with acute cholecystitis during 2013–2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30‐day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics. Results. There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0–6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68). Conclusion. Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

Minimal cosmetic revision required after minimally invasive pectus repair

BackgroundDespite surgical correction procedures for pectus deformities, remaining cosmetic asymmetry may have significant psychological effects. We sought to evaluate factors associated with plastic surgery (PS) consultation and procedures for these deformities at an academic institution.MethodsWe reviewed patients aged 0–21 diagnosed with a pectus excavatum or carinatum deformity at our institution between January 2001 and October 2016. Pectus diagnoses were identified by ICD-9/ICD-10 codes and surgical repair by CPT codes; patients receiving PS consultation were identified by clinical note service codes. Student’s t tests, Fisher’s exact tests, and Chi-squared tests were utilized.Results2158 patients were diagnosed with a pectus deformity; 442 (20.4%) underwent surgical correction. 19/442 (4.3%) sought PS consultation, either for pectus excavatum [14/19 (73.7%)], carinatum [4/19 (21.0%)], and both [1/19 (5.3%)], (p = 0.02). Patients seeking PS consultation were more likely to be female (p < 0.01), have scoliosis (p = 0.02), or undergo an open repair (p < 0.01). The need for PS consultation did not correlate with Haller index, p = 0.78.ConclusionPS consultation associated with pectus deformity repair was rare, occurring in < 5% of patients undergoing repair. Patients who consulted PS more commonly included females, patients with scoliosis, and those undergoing open repair. These patients would likely benefit most from multidisciplinary pre-operative discussions regarding repair of the global deformity.

Cross-sectional imaging to evaluate the extent of regional nodal disease in breast cancer patients undergoing neoadjuvant systemic therapy

PURPOSE Cross-sectional imaging often is performed in breast cancer patients undergoing neoadjuvant systemic therapy (NST) and may identify level III axillary and extra-axillary nodal disease. Our aim was to investigate associations of radiologic nodal staging with pathological N (pN) stage at operation and to explore how this might aid surgical and radiotherapy treatment planning. MATERIALS AND METHODS With IRB approval, we reviewed pre-treatment breast MRI, PET/CT, and CT imaging and clinicopathologic data on 348 breast cancer patients with imaging available for review undergoing NST followed by operation at our institution 1/2008-9/2013. We defined abnormal lymph node findings on MRI, CT, and PET/CT to include cortical thickening, FDG-avidity and loss of fatty hilum. Patients were assigned a radiologic nodal (rN) stage based on imaging findings. Statistical analysis was performed using JMP 10.1 software RESULTS: Pre-NST imaging included axillary ultrasound in 338 patients (97%), breast MRI in 305 (88%) and PET/CT or CT in 215 (62%). 213 patients (61%) were biopsy-proven axillary lymph node-positive (LN+) pre-treatment. cT stage was T1 in 9%, T2 in 49%, T3 in 29%, T4 in 12%; median tumor size was 4cm. Pre-treatment rN stage across all the patients was rN0 in 86 (25%), rN1 in 173 (50%), and rN3 in 89 (26%). rN3 disease included level III axillary, supraclavicular and suspicious internal mammary lymph nodes in 47 (53%), 32 (37%) and 45 (52%), respectively. Of patients LN+ at diagnosis, 78 (37%) were rN3. After NST, 162 patients (47%) were node-positive at operation with a median (mean) of 3 (5.9±0.4) positive lymph nodes including 128 of 213 (60%) LN+ at diagnosis. Pre-NST rN stage correlated with the likelihood and extent of axillary disease at operation, p=0.002. Fifty four of 89 rN3 patients (61%) were node-positive at operation with a median (mean) of 5 (8±1) positive nodes. rN3 patients had larger nodal metastases (median 9 vs 6mm) and more frequent extranodal extension (61% vs 43%) than rN0/rN1 patients, both p<0.03. CONCLUSIONS Information on rN stage from pre-NST cross-sectional imaging informs the likelihood and extent of axillary nodal disease at operation. This information may be used for surgical and radiotherapy treatment planning and to inform patient expectations.

Nipple-sparing Mastectomy for the Management of Recurrent Breast Cancer

Introduction For patients who have an ipsilateral breast cancer recurrence following prior breast‐conserving surgery and radiation, total mastectomy generally is recommended. However, little is known about the suitability and outcomes of nipple‐sparing mastectomy (NSM) with immediate breast reconstruction for the treatment of recurrent breast cancer, prompting this investigation. Patients and Methods From 1008 patients scheduled for NSM for breast cancer treatment at our institution between January 2009 and June 2016, we identified all patients who underwent surgery for ipsilateral recurrent breast cancer. We analyzed patient, tumor, and treatment variables, nipple preservation rates, and cancer outcomes. Results Twenty‐one patients with ipsilateral recurrent disease were scheduled for NSM with immediate breast reconstruction, of whom 19 had received prior whole breast radiation. Two patients (10%) underwent intraoperative conversion to skin‐sparing mastectomy for atypia or ductal carcinoma in situ in the central nipple ducts. Postoperative complications requiring intervention occurred in 2 patients: focal flap necrosis requiring debridement in 1 patient and seroma aspiration in another. Three patients received planned (pre‐ and/or postoperative) hyperbaric oxygen therapy. After 14.6 months median follow‐up (range, 3‐48.5 months), all 19 patients retained their native nipple‐areolar complex and are disease‐free. Conclusions NSM may be performed in carefully selected patients with recurrent breast cancer, despite prior ipsilateral surgery and radiation, with successful preservation of the nipple‐areolar complex and an acceptably low complication rate. Our data suggest no short‐term adverse effect of NSM on oncologic outcomes. Micro‐Abstract We identified 21 patients scheduled for nipple‐sparing mastectomy (NSM) for ipsilateral recurrent breast cancer. Two patients underwent intraoperative conversion to skin‐sparing mastectomy, whereas 19 had a NSM. Two NSM patients had complications requiring intervention. At follow‐up, all 19 patients retained their native nipple‐areolar complex and are disease‐free. NSM may be appropriate for selected patients with locally recurrent breast cancer.

Incorporation of Treatment Response, Tumor Grade and Receptor Status Improves Staging Quality in Breast Cancer Patients Treated with Neoadjuvant Chemotherapy

BackgroundImproved staging systems that better predict survival for breast cancer patients who receive neoadjuvant chemotherapy (NAC) by accounting for clinical pathological stage plus estrogen receptor (ER) and grade (CPS+EG) and ERBB2 status (Neo-Bioscore) have been proposed. We sought to evaluate the generalizability and performance of these staging systems in a national cohort.MethodsThe National Cancer Database (2006–2012) was reviewed for patients with breast cancer who received NAC and survived ≥90 days after surgery. Four systems were evaluated: clinical/pathologic American Joint Committee on Cancer (AJCC) 7th edition, CPS+EG, and Neo-Bioscore. Unadjusted Kaplan–Meier analysis and adjusted Cox proportional hazards models quantified overall survival (OS). Systems were compared using area under the curve (AUC) and integrated discrimination improvement (IDI).ResultsOverall, 43,320 patients (5-year OS 76.0, 95% confidence interval [CI] 75.4–76.5%) were included, 12,002 of whom had evaluable Neo-Bioscore. AUC at 5 years for CPS+EG (0.720, 95% CI 0.714–0.726) and Neo-Bioscore (0.729, 95% CI 0.716–0.742) were improved relative to AJCC clinical (0.650, 95% CI 0.643–0.656) and pathologic (0.683, 95% CI 0.676–0.689) staging. Both CPS+EG (IDI 7.2, 95% CI 6.6–7.7%) and Neo-Bioscore (IDI 9.8, 95% CI 8.0–11.6%) demonstrated superior discrimination when compared with AJCC clinical staging at 5 years. Comparison of CPS+EG with Neo-Bioscore yielded an IDI of 2.6% (95% CI 0.9–4.5%), indicating that Neo-Bioscore is the best staging system.ConclusionsIn a heterogenous national cohort of breast cancer patients treated with NAC and surgery, the incorporation of chemotherapy response, tumor grade, ER status, and ERBB2 status into the staging system substantially improved on the AJCC TNM staging system in discrimination of OS. Neo-Bioscore provided the best staging discrimination.