Michael C. Lowe

Management of Papillary Breast Lesions Diagnosed on Core-Needle Biopsy: Clinical Pathologic and Radiologic Analysis of 276 Cases with Surgical Follow-Up

BACKGROUND Clinical management of papillary breast lesions (PBLs) remains controversial. The objective of this study was to identify pathologic and radiologic predictors of malignancy from a large cohort of PBLs diagnosed on core-needle biopsy (CNB). STUDY DESIGN Retrospective review of the institutional pathology database identified all PBLs diagnosed from 2001 to 2009 and surgically excised within 6 months of diagnosis. PBLs were divided into intraductal papilloma (IDP) and IDP associated with atypical ductal or lobular hyperplasia (ADH/ALH). Surgical pathology of all lesions was reviewed and upgrade was defined as a change to a lesion of greater clinical significance, including ALH, ADH, lobular, or ductal carcinoma in situ (LCIS or DCIS), and invasive ducal carcinoma (IDC). RESULTS We identified 276 patients (mean age 56 years; range 23 to 88 years) with PBLs on CNB. Seventy-nine patients (28.6%) upgraded to a lesion of greater clinical significance. Of the 234 (84.7%) had IDP only, 42 (17.9%) upgraded to ADH, and 21 (8.9%) to DCIS or IDC. Of the 42 (15.3%) patients with associated ADH or ALH on CNB, 16 (38.0%) upgraded to DCIS or IDC. The majority of patients (n = 173, 62.6%) had no breast symptoms. All patients had an abnormal mammogram and/or ultrasound that prompted the CNB. Among all clinical and radiographic variables analyzed, older age alone was predictive of upgrade. CONCLUSIONS Frequent upgrade to a high-risk lesion or cancer is observed with IDPs diagnosed on CNB without adequate identifiable clinical and radiographic risk factors. Surgical excision should be performed for all IDPs to delineate subsequent clinical management.

Prognostic factors for overall survival after radiosurgery for brain metastases from melanoma.

Objectives:Brain metastases (BM) cause significant morbidity and mortality in patients with melanoma. We aimed to identify prognostic factors for overall survival (OS) in patients undergoing stereotactic radiosurgery (SRS) for BM from melanoma. Methods:We identified 135 patients treated with SRS at Emory University between 1998 and 2010 for BM from melanoma. We recorded patient age, number and size of all BM, Karnofsky Performance Status (KPS), presence of extracranial metastases, serum lactate dehydrogenase (LDH), use of whole-brain radiation therapy (WBRT), use of temozolomide, and surgical resection of BM. We used the Kaplan-Meier method to calculate OS, and we compared time-to-event data with the log-rank test. We performed Cox multivariate analysis to identify factors independently associated with OS. Results:Median OS for all patients was 6.9 months. Patients with KPS≥90, 70 to 80, and <70 had median OS of 10.4, 6.1, and 4.5 months, respectively (P=0.02). Patients with LDH<240 had median OS of 7.8 months versus 3.5 months for LDH≥240 (P=0.01). Patients receiving WBRT had median OS of 7.3 months versus 6.5 months for patients not receiving WBRT (P=0.05). KPS and LDH (but not WBRT) were significantly associated with OS on multivariate analysis. Conclusions:In addition to previously identified prognostic factors for OS in patients with BM from melanoma, serum LDH is independently associated with OS. If this finding is confirmed in a prospective manner, the serum LDH level should be included in future prognostic algorithms for patients with melanoma and BM who are to receive SRS.

Epidemiology of Diseases of the Groin

The epidemiology of diseases of the groin varies rather markedly by the type of disease. Patients with melanoma tend to be younger than patients with nonmelanoma skin cancers and than those with squamous cell carcinomas of the penis and vulva. UV exposure predisposes to melanoma and nonmelanoma skin cancers, while HPV infection and tobacco use are associated with squamous cell carcinomas of the vulva and penis. Management of cancers that affect the groin depends on the type of cancer, but surgery remains the best chance for cure in almost cases, with anal squamous cell carcinoma being the exception. This chapter introduces the comparative epidemiology of diseases of the groin in an effort to provide context for treatment algorithms for each of the specific disease processes.

ASO Author Reflections: Optimizing the Outcomes for Patients: The Evolution of the Management of Regional Disease in Patients with Melanoma

Evolution in the management of the lymph node basin over the past two decades has been remarkable. That transformation is largely attributable to the work of Dr. Donald Morton, whose landmark Multicenter Selective Lymphadenectomy Trial (MSLT)-1 and MSLT-2 were designed to address the role that surgery should play in patients with microscopic regional disease. MSLT-1 demonstrated that sentinel lymph node biopsy (SLNB) accurately identifies nodal metastatic disease, confirmed the obsolete role of elective lymphadenectomy, and demonstrated a survival benefit to early intervention in the subset of patients harboring regional metastases. Since this trial, the utilization of SLNB has significantly reduced the number of patients undergoing lymphadenectomy for bulky disease, which is associated with higher morbidity. MSLT-2 demonstrated that most patients achieved complete regional control with SLNB alone, and provided support that completion lymphadenectomy (CLND) does not impact overall survival. Taken together, these studies argue for a reduction in the extent of surgery needed to achieve regional control, which reduces surgical morbidity. PRESENT

Revisiting the Strait of Messina: The Balance Between Optimal Oncologic Outcomes and Complications From Surgery

The discourse regarding the balance of oncologic benefit and complication profile for lymphadenectomy has been front and center in both breast cancer and melanoma for well over a decade. arguably, inguinal lymphadenectomy has been a lightning rod for this debate because of the high morbidity that has repeatedly been reported from this procedure. The authors of this editorial admittedly have contributed to the ongoing rhetoric by developing and reporting a novel approach to inguinal lymphadenectomy. Combined with ongoing investigation into the role and utility of completion lymphadenectomy, this has led the melanoma community aggressively to revisit groin dissection in the therapeutic armamentarium of the melanoma surgeon. In this issue of Annals of Surgical Oncology, Faut et al. analyze the impact of changes in perioperative care on the outcomes from inguinal lymphadenectomy. They grouped their analysis by three major changes related to mobility, splinting, and duration of hospitalization. Importantly, they meticulously analyzed the data for incidence of complications and included patients who underwent both superficial and combined superficial and deep lymphadenectomies. One could argue that these two populations are not the same and so inclusion of both in this manuscript weakens its conclusions, but nonetheless, the authors draw our attention to the challenge of surgery in this area of the body. While this group is trained and does use minimally invasive lymphadenectomy, the present report does not investigate the impact of that procedure on outcomes; all patients in the study underwent open inguinal lymphadenectomy. Recent series (including the Faut series in this issue) estimating the morbidity from inguinal lymphadenectomy have been more comprehensive in reporting adverse outcomes than historical series. Modern data report complication rates ranging from 19–77 %, with the majority observing an estimated 50 % of patients with a wound complication. This type of meticulous analysis has led to considerable discussion in the melanoma community about the true accuracy of reported complication rates after inguinal lymphadenectomy. While this debate may never be put to rest, it can be argued that it is irrelevant, because there is no debate that the rate of complications is significant. If one is to accept that the complication rate from this procedure is simply ‘‘too high’’ (whether that number is 20 or 50 %), then the discussion about reducing morbidity is valid and the call to arms of the group from Groningen is worthy of acknowledgement. Including the current article, a number of modifications to surgical technique have been advocated to reduce morbidity from inguinal lymphadenectomy, and while minimally invasive surgery may be the most impactful, there are still significant complications even with this approach. Arguably, the optimal way to reduce complications is to avoid surgery altogether. Two trials, the Multicenter Selective Lymphadenectomy Trial-II and the EORTC’s MiniTub registry trial, prospectively are analyzing the outcome of patients who do not undergo completion lymphadenectomy after a positive sentinel lymph node biopsy (SLNB). The melanoma community eagerly awaits the results of these trials, especially as recent data imply that some patients may avoid completion lymphadenectomy without adversely impacting overall Society of Surgical Oncology 2016

Evaluation of the effects of neoadjuvant therapy on stage specific outcome estimates in patients with completely resected gastric cancer.

139 Background: The current AJCC staging system for gastric cancer is based on pathologic staging and fails to take into consideration the effects of neoadjuvant therapy. We hypothesize that patients receiving neoadjuvant therapy have a worse outcome than patients with identical pathologic stage not receiving neoadjuvant therapy. Methods: We queried a prospectively maintained gastric cancer database for patients undergoing potentially curative resection for gastric adenocarcinoma between 1985 and 2012. Disease-specific survival (DSS) was estimated by Kaplan-Meier methods. The relationship between DSS and previously identified clinical risk factors was evaluated using Cox regression method. Results: A total of 2,752 patients were identified; of these 904 received neoadjuvant therapy and 1,848 received no neoadjuvant therapy. Patients receiving neoadjuvant therapy were younger (60.7 vs. 65.7 years) and more often male (72.9% vs. 62.4%). Their tumors were more often at the GE junction, but histology, differe...