Uttara P. Nag

Renal medullary carcinoma: A national analysis of 159 patients

Renal medullary carcinoma (RMC) is an aggressive malignancy seen predominantly in young males with sickle cell trait. RMC is poorly understood, with fewer than 220 cases described in the medical literature to date. We used a large national registry to define the typical presentation, treatments, and outcomes of this rare tumor.

Reoperation for Margins After Breast Conservation Surgery: What’s Old Is New Again

More than 30 years after demonstration that survival after breast conservation surgery (BCS) and adjuvant radiotherapy is equivalent to survival after mastectomy,1 significant variability in the implementation of BCS remains, particularly in the rates of reoperation for margins. Breast conservation surgery is the most common oncologic operation performed in the United States, with a measurable financial and physical burden caused by repeated excisions. In this issue of JAMA Surgery, the study by Isaacs et al2 reports a mean 90-day reoperation rate of 30.9% from 2003 to 2013 in New York State, with a significant decrease over time from 38.5% to 23.1%. This study shows that almost onethird of the reoperations results in mastectomy. In 2014, Wilke et al3 similarly demonstrated that within the National Cancer Database from 2004 to 2010, the rates of repeated operations after BCS decreased from 25% to 22%. This change is seen within the context of efforts to define adequate margins for BCS.4 The recent Society for Surgical Oncology–American Society for Radiation Oncology (SSOASTRO) consensus guidelines encourage the use of “no ink on tumor” as the current standard in an era of multimodal treatment and evolving understanding of tumor biology along with tumor burden. In fact, this approach to reexcisions echoes the conclusion of Fisher et al5(p1722) in 1986 after review of pathologic findings from the National Surgical Adjuvant Breast Project that “it is most appropriate to regard lines of resection involved only when cancer is transected,” because subjective designations of close margins resulted in second operations with a low yield of residual cancer. Isaacs et al2 report notable intersurgeon variability, with rates of reoperations ranging from 0% to 100%. Studies have shown significant surgeon and institutional variation in clinical practice,6 althoughwithout data regardingmarginwidth, the proportion of this variation attributable to interpretation ofmargin status isunknown. Sourcesof inconsistencymay include surgeon training and volume, radiographic evaluation, andpathologic processing. In addition, subjective elements of surgeon bias may play a role because the authors’ multivariable analysis demonstrated that repeated excisions were significantlymore likely inyoungerpatients and thosewith fewer comorbidities.2 Establishing a rational, evidence-based approach to reexcision as originally proposedbyFisher et al5 and that has been supported by the new SSO-ASTRO guidelines has the potential to provide substantial national cost savings by eliminating reexcisions for closebutnegativemargins.7As theseguidelines for margin status are widely adopted, identification of persistent outliers to these guidelines and assessment of the effect of this practice change on surgical outcomes and value of care for early stage breast cancer should remain important goals.

SS21. Foam Sclerotherapy for Low-Flow Vascular Malformations Is Safe and Effective in Children

woman who previously had an IVC filter placement followed by a resection of a benign leiomyoma as well as a right salpingo-oophorectomy in 2015. A follow-up computed tomography scan showed propagation of IVC thrombus. The thrombus was suspected to be an intracaval extension of tumor and, therefore, she was taken for an exploration of the IVC from confluence to juxtahepatic cava, a complex retrieval of the IVC filter, and a resection of intracaval mass by a venotomy of the common iliac vein and juxtahepatic cava.

IF09. Image-Based Three-Dimensional Fusion Computed Tomography Decreases Radiation Exposure, Fluoroscopy Time, and Procedure Time During Endovascular Aortic Aneurysm Repair

had widely patent SMAs at last follow-up. Mean total seal zone length was 41.4 mm. There was a single secondary intervention for asymptomatic SMA stenosis requiring stent placement 1 year after F-EVAR. There were no Type IA endoleaks and no endoleaks related to SMA fenestrations. Five patients of the entire cohort (4.7%) required SMA stenting at the index procedure. Three of these patients had prior EVAR (n 1⁄42) or open repair (n 1⁄4 1), One patient had a pre-existing critical SMA stenosis and underwent planned SMA stenting, and in one patient, the graft was deployed imprecisely and low, and the SMA was successfully stented from a brachial approach. Conclusions: The unstented SMA in association with F-EVAR remains widely patent in the presence of fenestrations or struts and is not associated with endoleaks. The need for adjunctive SMA stenting may be related to prior aortic intervention and case complexity. Follow-up DUS and CTA surveillance confirms that SMA patency remains in the normal or <70% stenosis range after F-EVAR regardless of whether it is encompassed by a large fenestration or crossing struts.

Immediate-access grafts provide comparable patency to standard grafts, with fewer reinterventions and catheter-related complications

Background No independent comparisons, with midterm follow‐up, of standard arteriovenous grafts (SAVGs) and immediate‐access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare “real‐world” performance of SAVGs and IAAVGs. Methods Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients’ comorbidities, graft configuration, operative characteristics, and follow‐up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft‐related complications, time to first cannulation, time to tunneled catheter removal, catheter‐related complications, and overall survival. Patency was determined from the time of the index procedure; χ2, Kaplan‐Meier, and Cox regression analyses were used, with the P value set as significant at < .05. Results There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients’ characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs 6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P = .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P = .73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P = .73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P = .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy‐five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1‐19 days) compared with the SAVG group (31 days; IQR, 26‐47 days; P < .01). Of all pre‐existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22‐50 days) vs 49 days (IQR, 39‐67 days) in the SAVG group (P < .01). Catheter‐related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045). Conclusions IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter‐related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs.

Jejunal arterial access for retrograde mesenteric stenting

&NA; Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a “mini‐laparotomy” and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.

Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment

BACKGROUND Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults. METHODS We queried the NCDB (2004-2014) for female patients with phyllodes tumor histology, excluding patients with missing age or survival data. Patients were stratified by age (pediatric <21, adult ≥21), and compared based on patient characteristics, treatment patterns, and survival. RESULTS We identified 2787 cases of phyllodes tumor (2725 adult, 62 pediatric). Median age was 17years in children and 52years in adults. Margin positivity rates and median tumor size were similar between adults and children. Treatment was discordant with NCCN guidelines in 28.6% of adults and 14.5% of children through use of axillary staging, chemotherapy, adjuvant endocrine therapy, and radiotherapy. Five-year and ten-year survival were comparable between both groups. CONCLUSION Children and adults present with similarly sized phyllodes tumors. Trends reveal high margin positivity rates, and overtreatment with regional axillary staging and systemic adjuvant therapies. Particularly in children, treatment decisions must consider risks of adjuvant therapy including radiation-related second primary cancers, given uncertain benefit. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.

Cervical seatbelt sign is not associated with blunt cerebrovascular injury in children: A review of the national trauma databank

BACKGROUND Blunt cerebrovascular injury (BCVI) is a rare consequence of blunt trauma. There appears to be benefit to an aggressive approach to screening for BCVI due to catastrophic sequelae of unrecognized injury. However, screening for BCVI carries extensive cost and oncologic risk to young patients. Foundational BCVI studies examined adults primarily, leaving question to the effectiveness of these criteria in children. We sought to evaluate BCVI screening criteria developed in primarily adult populations using a nationally representative pediatric dataset. METHODS We queried the 2008-2014 National Trauma Data Bank for patients with BCVI. Patients were stratified by age (adults>18yrs, pediatric≤18yrs). Screening factors from the Modified Denver Criteria and Modified Memphis Criteria (GCS≤8, C1C3 cervical fracture, cervical subluxation, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, significant blood loss, coma, stroke, and hanging) were examined using univariate analysis and backwards-stepwise logistic regression to verify predictors of BCVI. RESULTS Blunt injury occurred in 2,174,244 adults and 422,181 children; 5970 adults and 809 children sustained BCVI. In univariate analysis, all screening factors correlated with BCVI in both groups (p < 0.001). When comparing BCVI patients, children more commonly experienced GCS≤8, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, and coma (p < 0.05). In multivariable analysis, seatbelt sign was not associated with pediatric BCVI. CONCLUSION Many adult-associated BCVI risk factors apply to children. Although children more commonly experience seatbelt sign, it does not independently cause increased BCVI risk. Given the rarity of pediatric BCVI, prospective multi-institutional studies are warranted to establish screening criteria specific to children.

PC178 Age Associated With Mortality and Outcomes in Pediatric Vascular Trauma

two patients. Viabahn stents were then deployed, covering the injured popliteal lumen, with three-vessel runoff and palpable pedal pulses in all cases (Fig 2). Conclusions: Endovascular repair of popliteal artery injury in the setting of posterior knee dislocation is feasible. It may lead to decreased patient morbidity, shorter operative times, and quicker time to reperfusion. Further study will facilitate better understanding of long-term patency rates and clinical outcomes.

VESS27. Alternative Access for Fistula Cannulation in the Obese: Midterm Results from VWING Registry

Author Disclosures: T. Chuter: Cook Medical, Inc: royalties, intellectual property/patents, other financial or material support; W. Gasper: Nothing to disclose; J. S. Hiramoto: Cook Medical, Inc: royalties, intellectual property/patents, other financial or material support; S. Kaushik: Nothing to disclose; B. Ramanan: Nothing to disclose; L. M. Reilly: Nothing to disclose; S. Vartanian: Nothing to disclose.