Olga Kantor

Are the ACOSOG Z0011 Trial Findings Being Applied to Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

In 2010, the ACOSOG Z0011 trial showed equivalent survival and recurrence between sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) for those with a tumor positive sentinel node (SN). We examined national trends in axillary surgery following neoadjuvant chemotherapy (NAC) for clinically node positive disease in the years prior to and after the Z0011 trial publication. 12,063 women with cT1‐4N1M0 invasive breast cancer who underwent NAC from 2006 to 2013 and had 1‐3 positive nodes on pathology were selected from the National Cancer Data Base. We defined SLNB as 1–4 nodes and ALND as ≥10 nodes examined. 2,704 women (22.4%) underwent SLNB alone and 9,359 (77.6%) underwent ALND. The rate of SLNB increased from 25.6% in 2006 to 33.3% in 2012 in patients that underwent lumpectomy (p < 0.01) and increased from 20.6% to 22.8% in patients that underwent mastectomy (p = 0.25). Patients treated at Community centers (30.4% versus 19.2% at Academic centers) and those with less positive nodes (32.2% for 1 positive node versus 10.1% for 3 positive nodes, p < 0.01) were more likely to have SLNB alone compared to ALND. On multivariate analysis, treatment with lumpectomy (OR 1.46, CI 1.28–1.67), lower number of positive nodes (OR 3.98, CI 3.29–4.82) and lobular subtype (OR 1.82, CI 1.42–2.34) were independent predictors of receiving SLNB alone after NAC. Approximately 22% of patients with cN1 breast cancer underwent SLNB alone for pN1 disease after NAC. Ongoing clinical trials will determine if recurrence and survival rates are equivalent between SLNB and ALND groups.

Breast conserving therapy for DCIS—Does size matter?

The incidence of ductal carcinoma in situ has increased dramatically with the use of screening mammography. Most patients can be considered for breast conserving therapy, depending upon patient and pathologic variables. In addition to other factors, tumor size is important to provide proper patient selection for breast conserving surgery and predict risk of local recurrence. J. Surg. Oncol. 2014 110:75–81.

Implementing a resident acute care surgery service: Improving resident education and patient care

Background. To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. Methods. We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n = 10) and postimplementation (n = 5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12 months of the service (June 2014 to June 2015). Results. During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4–44) for preresident acute care surgery residents to 30.8 ± 8.8 (range 27–36) for postresident acute care surgery residents (P < .01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P < .01 on a 6‐point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P < .01) on service evaluations of resident acute care surgery (n = 27) in comparison with other general operative services (n = 127). In addition, creation of a 1‐team consult service resulted in a more streamlined consult process with average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5–90 minutes). Conclusion. The implementation of a resident acute care surgery service has increased resident autonomy, teaching assistant cases, and satisfaction with operative case variety, as well as the efficiency of operative consultation at our institution.

Post-mastectomy radiation therapy and overall survival after neoadjuvant chemotherapy

The role of postmastectomy radiation therapy (PMRT) after neoadjuvant chemotherapy (NAC) and mastectomy is unclear, especially in patients that have post‐treatment tumor negative axillary nodes (ypN0).

Minimally invasive pancreatoduodenectomy: is the incidence of clinically relevant postoperative pancreatic fistula comparable to that after open pancreatoduodenectomy?

Background. Studies evaluating the efficacy of minimally invasive approaches to pancreatoduodenectomy (MIS‐PD) compared to open pancreatioduodenectomy (OPD) have been limited by selection bias and mixed outcomes. Methods. ACS‐NSQIP 2014–2015 pancreas procedure‐targeted data were used to identify patients undergoing PD. Intention‐to‐treat analysis was performed. Results. Of 7907 PD patients, 1277 (16%) underwent MIS‐PD: 776 (61%) robotic or laparoscopic PD, 304 (24%) hybrid, and 197 (15%) unplanned conversions. There were no differences in demographics or comorbidities. Patients undergoing MIS‐PD were less likely to have pancreatic ductal adenocarcinoma (30.9% vs 53.9%, P < 0.01) and less likely to have a dilated pancreatic duct (21.8% vs 46.7%, P < 0.01). 30‐day morbidity was less for MIS‐PD (63.6% vs 76.9%, P < 0.01), due to decreased delayed gastric emptying DGE) in the MIS‐PD group (8.6% vs 15.5%, P < 0.01). 30‐day mortality, length‐of‐stay, and readmissions were not significantly different. Patients undergoing MIS‐PD had greater rates of CR‐POPF (15.3% vs 13.0%, P = 0.03). On adjusted multivariable analysis, MIS‐PD was not associated with CR‐POPF (OR 1.05, 95% CI 0.87–1.26) but was associated with decreased DGE (OR 0.57, 95% CI 0.46–0.71). Conclusion. MIS‐PD has comparable short‐term outcomes to open PD. While CR‐POPF rates are greater for MIS‐PD, this increased risk appears related to case‐selection bias and not inherent to the MIS‐approach.

ASO Author Reflections: Improving Patient Selection for Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy

The accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NCT) for clinically nodepositive breast cancer can be indistinct due to the increased rates of false-negative findings with this approach. According to clinical trial data, approximately 30–40% of patients will achieve an axillary pathologic complete response to NCT, obviating the need for axillary lymph node dissection (ALND) in these cases. A number of recent clinical trials evaluating the feasibility of SLNB after NCT demonstrate that in addition to using dual tracers, obtaining multiple sentinel nodes (including the clipped node from the initial positive biopsy) may help to reduce the false-negative rate to acceptable levels. However, identification of suitable candidates for this approach can be challenging. The authors’ goal was to develop a predictive model based on clinical factors to facilitate patient selection and support the appropriate use of SLNB after NCT. PRESENT

ASO Author Reflections: Bilateral Mastectomy After Neoadjuvant Therapy: An Ever-Increasing Trend?

Neoadjuvant chemotherapy was initially used in the context of large tumors and locally advanced disease. The early randomized trials of neoadjuvant chemotherapy (National Surgical Adjuvant Breast and Bowel Project [NSABP] B-18 and B-27) demonstrated an increase in patients eligible for breast-conserving surgery after neoadjuvant chemotherapy. During the past decade, neoadjuvant therapy has been used increasingly for earlierstage disease such as node-positive, hormone receptornegative, or human epidermal growth factor receptor 2 (HER2)neu-positive disease to learn more about the biology and tumor response to therapy, which has been linked to prognostic indicators such as disease-free and overall survival. During the same period, a trend of increasing rates for bilateral mastectomy have been observed. The authors were interested in seeing whether the trend of increasing bilateral mastectomy for breast cancer was being replicated for patients undergoing neoadjuvant therapy, particularly patients with a tumor complete response to neoadjuvant therapy who in the past would have undergone breast-conserving surgery. PRESENT

Clinical accuracy of preoperative breast MRI for breast cancer

It is unclear if breast magnetic resonance imaging (MRI) is more accurate than mammography (MGM) and ultrasound (U/S) in aggregate for patients with invasive cancer.

The extent of vascular resection is associated with perioperative outcome in patients undergoing pancreaticoduodenectomy

BACKGROUND Few studies have examined the relation between extent of vascular resection and morbidity following pancreaticoduodenectomy (PD) with vein resection (PDVR). METHODS Patients undergoing PD for malignancy were identified using the American College of Surgeons National Surgical Quality Improvement Project from 2006 to 2013. Current procedural terminology codes were used to characterize PDVR. RESULTS 9235 patients underwent PD, 977 (10.6%) had PDVR - 640 with direct and 224 with graft repair. PDVR had longer operative times (456 ± 136 vs 374 ± 128 min, p < 0.05) and higher intraoperative transfusions (1.8 ± 3.4 vs 4.3 ± 4.9 units, p < 0.05) than PD alone. On adjusted multivariable regression, PDVR with either direct or graft repairs was associated with higher rates of overall morbidity (OR [odds ratio] 1.50 for direct, 1.74 for graft, p < 0.05), bleeding (OR 2.18 for direct, 3.26 for graft, p < 0.05), and DVT (OR 2.12 for direct, 2.62 for graft, p < 0.05) compared to PD alone. Graft repair was further associated with increased risk of reoperation (OR 1.59), septic shock (OR 2.77) and 30-day mortality (OR 2.72), all p < 0.05. DISCUSSION The risk of significant morbidity and mortality for PDVR is associated with the extent of vascular resection, with graft repairs having increased morbidity and mortality rates.

The Impact of Facility Volume on Rates of Pathologic Complete Response to Neoadjuvant Chemotherapy Used in Breast Cancer

BackgroundPatient and tumor factors have been associated with rates for pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) for breast cancer, but variation in pCR rates across facilities has not been studied.MethodsThis study used the National Cancer Data Base to identify women with clinical stages 1–3a breast cancer undergoing NAC from 2010 to 2013. Generalized estimation equation models were used to examine the relationship between facility characteristics and pCR rates, with adjustment for patient and tumor factors, while accounting for patient clustering at facilities. Analyses were stratified by tumor molecular subtype.ResultsOverall, 16,885 women underwent NAC, of whom 3130 (18.5%) were hormone receptor-positive (HR+) and human epidermal growth factor 2-positive (HER2+), 7045 (41.7%) were HR+HER2−, 1847 (10.9%) were HR−HER2+, and 4863 (28.8%) were HR−HER2−. Overall, 4002 of the patients (23.7%) achieved a pCR. The pCR rates were 29.5% for HR+HER2+, 10.8% for HR+HER2−, 45.3% for HR−HER2+, and 30.5% for HR−HER2− tumors. Multivariable analysis showed that pCR rates were significantly higher at high-volume facilities (>75th vs. <25th percentile) for all tumor subtypes except HR+HER2− tumors. Facility location and type were not significant. Adjustment for time from NAC to surgery decreased the likelihood of a pCR in high- versus low-volume facilities, but facility volume remained significantly associated with pCR.ConclusionFacility volume, not location or type, was significantly associated with higher pCR rates in this exploratory analysis. Time to surgery has a modest impact on pCR rates across facilities, but further study to identify other potentially modifiable factors is needed.