Excellent local control with preoperative radiation therapy, surgical resection, and intra-operative electron radiation therapy for retroperitoneal sarcoma.

PURPOSE: To examine the value of surgical resection combined with preoperative external beam radiation therapy and intraoperative radiation therapy (Surg-RT) for retroperitoneal sarcoma (RPS). METHODS: Review of 63 consecutive patients with RPS from 1996 to 2011. RESULTS: Thirty-seven patients (59%) underwent Surg-RT and 26 (41%) had surgery alone. 51% of tumors were high grade and 36% of patients had locally recurrent disease. Final margin status was: R0 73%, R1 16%, R2 6%, and unknown 5%. Of those with R0 resections, 67% received Surg-RT. Median follow-up was 45 months. The 5-year local control rate was 89% for Surg-RT patients and 46% for surgery alone patients (P = 0.03). On multivariate analysis, Surg-RT was the only variable associated with a lower risk of LR (HR 0.19; CI 0.05-0.69, P = 0.003). The actuarial 5-year OS was 60% for patients receiving either Surg-RT or surgery alone. CONCLUSIONS: The combination of pre-operative radiation, surgical resection, and intraoperative radiation produces excellent local disease control for RPS. Combination therapy was associated with improved local control but not with overall survival.

Bariatric Surgery and Longitudinal Cancer Risk: A Review.

Importance: Cancer is one of the leading causes of death in the United States, with the obesity epidemic contributing to its steady increase every year. Recent cohort studies find an association between bariatric surgery and reduced longitudinal cancer risk, but with heterogeneous findings. Observations: This review summarizes how obesity leads to an increased risk of developing cancer and synthesizes current evidence behind the potential for bariatric surgery to reduce longitudinal cancer risk. Overall, bariatric surgery appears to have the strongest and most consistent association with decreased incidence of developing breast, ovarian, and endometrial cancers. The association of bariatric surgery and the development of esophageal, gastric, liver, and pancreas cancer is heterogenous with studies showing either no association or decreased longitudinal incidences. Conversely, there have been preclinical and cohort studies implying an increased risk of developing colon and rectal cancer after bariatric surgery. A review and synthesis of the existing literature reveals epidemiologic shortcomings of cohort studies that potentially explain incongruencies observed between studies. Conclusions and Relevance: Studies examining the association of bariatric surgery and longitudinal cancer risk remain heterogeneous and could be explained by certain epidemiologic considerations. This review provides a framework to better define subgroups of patients at higher risk of developing cancer who would potentially benefit more from bariatric surgery, as well as subgroups where more caution should be exercised.

PD-1 Blockade Induces Reactivation of Nonproductive T-Cell Responses Characterized by NF-κB Signaling in Patients with Pancreatic Cancer.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) trials have evaluated CTLA-4 and/or PD-(L)1 blockade in patients with advanced disease in which bulky tumor burden and limited time to develop antitumor T cells may have contributed to poor clinical efficacy. Here, we evaluated peripheral blood and tumor T cells from patients with PDAC receiving neoadjuvant chemoradiation plus anti-PD-1 (pembrolizumab) versus chemoradiation alone. We analyzed whether PD-1 blockade successfully reactivated T cells in the blood and/or tumor to determine whether lack of clinical benefit could be explained by lack of reactivated T cells versus other factors. EXPERIMENTAL DESIGN: We used single-cell transcriptional profiling and TCR clonotype tracking to identify TCR clonotypes from blood that match clonotypes in the tumor. RESULTS: PD-1 blockade increases the flux of TCR clonotypes entering cell cycle and induces an IFNγ signature like that seen in patients with other GI malignancies who respond to PD-1 blockade. However, these reactivated T cells have a robust signature of NF-κB signaling not seen in cases of PD-1 antibody response. Among paired samples between blood and tumor, several of the newly cycling clonotypes matched activated T-cell clonotypes observed in the tumor. CONCLUSIONS: Cytotoxic T cells in the blood of patients with PDAC remain sensitive to reinvigoration by PD-1 blockade, and some have tumor-recognizing potential. Although these T cells proliferate and have a signature of IFN exposure, they also upregulate NF-κB signaling, which potentially counteracts the beneficial effects of anti-PD-1 reinvigoration and marks these T cells as non-productive contributors to antitumor immunity. See related commentary by Lander and DeNardo, p. 474.

Phenotypes of primary hyperparathyroidism: Does parathyroidectomy improve clinical outcomes for all?

BACKGROUND: Primary hyperparathyroidism consists of 3 biochemical phenotypes: classic, normocalcemic, and normohormonal primary hyperparathyroidism. The clinical outcomes of patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism are not well described. METHOD: A retrospective review of patients who underwent parathyroidectomy at a single institution was performed. A logistical regression analysis of postoperative nephrolithiasis and highest percentage change in dual-energy x-ray absorptiometry scan comparison using Kruskal-Wallis test and Cox proportional hazard analysis of recurrence-free survival were performed. RESULTS: A total of 421 patients were included (340 classic, 39 normocalcemic primary hyperparathyroidism, 42 normohormonal primary hyperparathyroidism). Median follow-up was 8.8 months (range 0-126). Higher rates of multigland disease were seen in normocalcemic primary hyperparathyroidism (64.1%) and normohormonal primary hyperparathyroidism (56.1%) compared to the classic (25.8%), P < .001. There were no differences in postoperative complications. The largest percentage increases in bone mineral density at the first postoperative dual-energy x-ray absorptiometry scan were higher for classic (mean ± SD, 6.4 ± 9.1) and normocalcemic primary hyperparathyroidism (4.8 ± 11.9) compared to normohormonal primary hyperparathyroidism, which remained stable (0.2 ± 14.2). Normocalcemic primary hyperparathyroidism were more likely to experience nephrolithiasis postoperatively, 6/13 (46.2%) compared to 11/68 (16.2%) classic, and 2/13 (15.4%) normohormonal primary hyperparathyroidism, P = .0429. Normocalcemic primary hyperparathyroidism was the only univariate predictor of postoperative nephrolithiasis recurrence (odds ratio [95% confidence interval] 4.44 [1.25-15.77], P = .029). Normocalcemic primary hyperparathyroidism was significantly associated with persistent disease with 6/32 (18.8%) compared to 1/36 (2.8%) and 3/252 (1.2%) in normohormonal primary hyperparathyroidism and classic (P < .001). CONCLUSION: Three phenotypes of primary hyperparathyroidism are distinct clinical entities. Normocalcemic primary hyperparathyroidism had higher incidence of persistent disease and postoperative nephrolithiasis but demonstrated improvements in postoperative bone density. These data should inform preoperative discussions with patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism regarding postoperative expectations.

Malignant peripheral nerve sheath tumors (MPNST): the Mayo Clinic experience.

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNST) are a rare form of soft tissue sarcoma with few studies reporting on patient outcomes and prognostic variables. METHODS: A retrospective review of 175 patients diagnosed with MPNST from 1985 to 2010 was performed. Patient, tumor, and treatment characteristics were evaluated to identify prognostic variables. RESULTS: The median age of our study population was 44 years, and 51% were female. Median tumor size was 6 cm, and 61% of patients had high-grade tumors. Tumors were most commonly located on the extremities (45%), then trunk (34%) and head/neck (19%). The majority of patients underwent surgical resection (95%) and adjuvant treatment with chemotherapy (6%), radiation (42%) or both (22%). Margin status was R0 in 69%, R1 in 2%, R2 in 9%, and unknown in 20%. The local recurrence rate was 22%, and 5- and 10-year disease-specific survival (DSS) were 60% and 45%, respectively. On univariate analysis, no predictors for local recurrence were identified. Tumor size ≥ 5 cm, high tumor grade, tumor location, presence of neurofibromatosis type 1, local recurrence, and adjuvant chemotherapy were all associated with DSS. On multivariate analysis, size ≥ 5 cm [hazard ratio (HR)= 6.1, 95% confidence interval (CI) 1.5-25.0], local recurrence (HR = 4.4, 95% CI 1.7-11.4), high tumor grade (HR = 3.8, 95% CI 1.1-13.2), and truncal location (HR = 3.7, 95% CI 1.1-12.7) were poor prognostic indicators for DSS. CONCLUSIONS: High tumor grade and tumor size ≥ 5 cm predict adverse DSS for MPNST. In the context of a multidisciplinary treatment regimen, local recurrence and survival outcomes at 5 and 10 years were better than previously reported for MPNST.

The impact of obesity on breast cancer: a retrospective review.

BACKGROUND: Obesity has been linked to many adverse health consequences, including breast cancer; however, the impact on clinical presentation, tumor characteristics, and survival outcomes has yet to be clearly defined. METHODS: Retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer from 2000-2008 comparing two groups: nonobese (body mass index of <30) and obese (body mass index of ≥ 30) patients. Continuous variables, categorical variables, and survival data were analyzed. RESULTS: Of 1352 total patients, 76% were classified as nonobese and 24% were obese. When comparing age, obese patients presented less frequently than nonobese patients <50 years old (10% vs. 90%), and when comparing patients >50 years old (18% vs. 82%, P = 0.0019). Obese patients were more likely to present with disease detected by imaging when compared to nonobese patients (67% vs. 56%, P = 0.0006). Obese patients had larger tumors (1.7 cm vs. 1.4 cm, P < 0.001) and higher rates of lymph node (LN) metastases (31% vs. 25%, P = 0.026). On multivariate analysis, obesity was associated with nonpalpable tumors, larger tumors, a higher incidence of LN metastasis, lower incidence of Her2 positivity, lower incidence of multifocality, and less likely to undergo reconstruction after mastectomy. CONCLUSIONS: Obese patients clinically present at older ages with mammographically detected breast cancer at more advanced stages than nonobese patients. Strategies to encourage screening among the obese patient population are important.

Parathyroidectomy in the elderly is beneficial and safe with similar improvements in postoperative bone mineral density.

BACKGROUND: This study evaluated bone health outcomes of parathyroidectomy in elderly primary hyperparathyroidism (pHPT) patients. METHODS: A retrospective review was performed of parathyroidectomy patients with pHPT at a single institution from 2010 to 2019. Bone mineral density (BMD) improvements at postoperative dual-energy X-ray absorptiometry (DEXA) scans were analyzed between groups aged ≥75 and < 75 years using 1:1 matching on preoperative BMD. RESULTS: Patients ≥75 had BMD improvements through the second postoperative DEXA scans. While mean T-scores slightly improved in the ≥75 group during the study period, T-score improvement was more significant in the <75 group at first and third postoperative DEXA scans with +0.7 < 75 and +0.1 improvements ≥75 by the third DEXA (p = 0.026). Postoperative fragility fracture rates were similar in the ≥75 group, but significantly improved in patients <75 (10.4% preoperatively to 1.4% postoperatively, p = 0.020). Both cohorts had low complication rates with recurrent laryngeal nerve injury and permanent hypocalcemia of <1% (p = 0.316). CONCLUSIONS: Postoperative BMD improvement was similar between the two cohorts with no difference in complication rates suggesting parathyroidectomy is safe and effective in the elderly.

Long-term follow-up and individual item analysis of quality of life assessments related to laparoscopic-assisted colectomy in the COST trial 93-46-53 (INT 0146).

BACKGROUND: Postoperative outcomes of patients undergoing laparoscopic-assisted colectomy (LAC) have shown modest improvements in recovery but only minimal differences in quality of life (QOL) compared with open colectomy. We therefore sought to assess the effect of LAC on QOL in the short and long term, using individual item analysis of multi-item QOL assessments. METHODS: QOL variables were analyzed in 449 randomized patients from the COST trial 93-46-53 (INT 0146). Both cross-sectional single-time and change from baseline assessments were run at day 2, week 2, month 2, and month 18 postoperatively in an intention-to-treat analysis using Wilcoxon rank-sum tests. Stepwise regression models were used to determine predictors of QOL. RESULTS: Of 449 colon cancer patients, 230 underwent LAC and 219 underwent open colectomy. Subdomain analysis revealed a clinically moderate improvement from baseline for LAC in total QOL index at 18 months (P = 0.02) as well as other small symptomatic improvements. Poor preoperative QOL as indicated by a rating scale of ≤ 50 was an independent predictor of poor QOL at 2 months postoperatively. QOL variables related to survival were baseline support (P = 0.001) and baseline outlook (P = 0.01). CONCLUSIONS: Eighteen months after surgery, any differences in quality of life between patients randomized to LAC or open colectomy favored LAC. However, the magnitude of the benefits was small. Patients with poor preoperative QOL appear to be at higher risk for difficult postoperative courses, and may be candidates for enhanced ancillary services to address their particular needs.

Increase in contralateral prophylactic mastectomy: echoes of a bygone era? Surgical trends for unilateral breast cancer.

OBJECTIVES: Surgical therapy for invasive breast cancer includes breast conservation therapy (BCT), unilateral mastectomy (UM), or bilateral mastectomy, including contralateral prophylactic mastectomy (CPM) with or without reconstruction (± R). The goal of this study was to determine factors associated with CPM. METHODS: A breast cancer database collected from 2000 through 2008 was retrospectively reviewed. Treatment groups analyzed included BCT, UM ± R, and CPM ± R. Variables were compared using ANOVA F-tests and chi-square tests. Multivariate analysis was performed using logistic regression. RESULTS: A total of 1,391 patients underwent surgery for invasive breast cancer: 69% BCT, 21% UM, and 10% bilateral mastectomy. Of those undergoing bilateral mastectomy, 30% had bilateral cancer and were excluded from analysis. The rate of CPM increased significantly from 0 to 20% (p < 0.001), whereas the rate of UM remained relatively stable. Factors associated with CPM included younger age, significant family history, genetic testing, positive BRCA gene mutation, and preoperative magnetic resonance imaging (MRI). Tumor characteristics associated with CPM included positive axillary lymph node metastases and triple-negative disease (ER-/PR-/HER2 normal). Breast reconstruction was more common among women who underwent CPM (p < 0.001). On multivariate regression comparing BCT with CPM, younger age, larger tumors, multifocal disease, and MRI significantly predicted CPM. Comparing UM with CPM, only age and genetic testing significantly predicted CPM. CONCLUSIONS: The rate of bilateral mastectomy for unilateral breast cancer is increasing. This is particularly true for younger patients with strong family history. The availability of breast reconstruction may play a role and the effects of stage and multifocal disease needs further exploration.

Use of preoperative magnetic resonance imaging for invasive lobular cancer: good, better, but maybe not the best?

BACKGROUND: Invasive lobular cancer (ILC) of the breast is difficult to diagnose clinically and radiologically. It is hoped that preoperative magnetic resonance imaging (MRI) can improve evaluation of extent of disease. METHODS: Patients diagnosed with ILC at a single institution from 2001 to 2008 who underwent clinical breast examination (CBE), mammography, ultrasound, and MRI were studied retrospectively. Concordance between tumor size on imaging/CBE and pathologic size was defined as size within ± 0.5 cm. Pearson correlation coefficients (R) were calculated for each modality. Local recurrence and re-excision rates were compared with those patients with ILC who did not undergo preoperative MRI. RESULTS: Seventy patients with ILC had all imaging modalities, including CBE, performed preoperatively. The sensitivity for detection of ILC by MRI was 99%. MRI-based tumor size was concordant with pathologic tumor size in 56% of tumors. MRI overestimated tumor size by >0.5 cm in 31% of tumors. Correlation of tumor size on imaging with final pathology was better for MRI (R = 0.75) than for mammography (R = 0.65), CBE (R = 0.63), or ultrasound (R = 0.45, all P < 0.01). Preoperative MRI was associated with lower reoperation rates for close/positive margins (P > 0.05). CONCLUSIONS: For ILC, MRI has better sensitivity of detection and correlation with tumor size at pathology than CBE, mammography, or ultrasound. However, 31% of cases are overestimated by MRI, and correlation remains only at 0.75. The select use of MRI for preoperative estimation of tumor size in ILC is supported by our data, but the need for improvement and refinement of imaging remains.

Triple-negative breast cancers: unique clinical presentations and outcomes.

BACKGROUND: Triple-negative (TN) breast cancers lack estrogen receptor (ER), progesterone receptor (PR), and HER2/neu amplification (HER2). Few studies have been dedicated to characterizing this subset of cancer. MATERIALS AND METHODS: Retrospective review of a prospectively collected database of patients treated for invasive breast cancer at a single institution. Three tumor marker groups were compared: TN [ER-/PR-/HER2-], HER2+ [ERx/PRx/HER2+], and ER+ [ER+/PRx/HER2-]. RESULTS: Over 8 years, 123 TN, 210 HER2+, and 728 ER+ patients were identified. On average, TN patients were younger (mean age TN 59.7, HER2+ 62.0, ER+ 64.5 years, P = 0.0001). They were referred for genetic testing more frequently (17% TN, 10% HER2+, 10% ER+, P = 0.055) and were most likely to have a BRCA mutation identified if tested (24% TN, 10% HER2+, 4% ER+, P = 0.019). TN tumors were larger (mean size 2.1 cm TN, 2.0 cm HER2+, 1.8 cm ER+, P = 0.031) and most commonly detected by breast exam (54% TN, 43% HER2+, 42% ER+, P = 0.025). Lymph node involvement was least common with TN tumors (21% TN, 37% HER2+, 32% ER+, P = 0.013), and angiolymphatic invasion was less common for TN than HER2+ (18% TN, 24% HER2+, 15% ER+, P = 0.006). TN patients had significantly higher local or regional recurrence (5.7% TN, 2.9% HER2+, 1.0% ER+, P = 0.001), and the worst 5-year overall survival, although this did not reach statistical significance (85% ± 6% TN, 94% ± 2% HER2+, 91% ± 2% ER+). CONCLUSIONS: TN breast cancers are associated with unique patient presentations, tumor characteristics, and clinical outcomes of which clinicians and investigators should be aware.

A technique to address peritoneal dialysis catheter malfunction.

BACKGROUND: A 66-year-old male with a history of severe ischemic myopathy and renal failure underwent a combined heart and kidney transplant. Postoperative failure of the transplanted kidney eventually led to the need for peritoneal dialysis (PD). METHODS: After one month, the PD catheter was laparoscopically repositioned after it was found to have migrated from its correct position in the pelvis and twisted and clogged in the omentum. After one more month, the same complication recurred. Laparoscopy was again used to clear the clogged catheter and reposition it. This time, a testicular prosthesis was sewn to the catheter and used as an anchoring weight for the proper position in the pelvis. RESULTS: Six months after anchoring with the testicular prosthesis, the peritoneal dialysis catheter continues to function appropriately, and the patient has no complaints. CONCLUSIONS: Mal-positioned peritoneal dialysis catheters may be repositioned and anchored by using a testicular prosthesis in the event that weighted catheters are not available.

The diagnostic value of splenectomy in patients without a definitive preoperative diagnosis.

BACKGROUND: The purpose of this study was to describe the diagnostic value and therapeutic benefit of diagnostic splenectomy. METHODS: Retrospective review was performed of patients undergoing splenectomy with an unknown diagnosis (UD), a hematologic malignancy (HM) or idiopathic thrombocytopenic purpura. Surgical indications and postoperative outcomes were evaluated. RESULTS: 113 splenectomy patients were identified. Of the UD patients undergoing splenectomy, 46% (n = 16) received a definitive diagnosis postoperatively. A change in diagnosis occurred in 12% (n = 4) of HM patients. Complete symptom relief was observed more often in UD patients who received a definitive diagnosis after splenectomy 69% (n = 11), compared to the 47% (n = 9) who did not receive definitive diagnosis postoperatively. CONCLUSIONS: The diagnostic ability of splenectomy was 46% when the diagnosis was unknown preoperatively. Additionally, a majority of patients experienced relief of symptoms postoperatively. Splenectomy may be a useful diagnostic and therapeutic tool in select UD and HM patients.

Making an informed choice: Which breast reconstruction type has the lowest complication rate?

INTRODUCTION: The aim of this study was to investigate long-term breast reconstruction outcomes at a single institution in order to offer data-driven counseling for patients. METHODS: A retrospective review was performed of 399 patients who underwent mastectomy with 1-stage implant-based breast reconstruction (IBBR), 2-stage IBBR, or autologous tissue reconstruction (ATR) for invasive breast cancer or ductal carcinoma in situ at our institution from 2010 to 2017. Complications were classified as major for any unplanned return to the operating room (OR). RESULTS: Overall complication rates were similar among 1-stage IBBR (59%), 2-stage IBBR (60%), and ATR (52%, p = 0.54). Factors independently associated with major complications were diabetes (OR = 25.4 95% CI: 3.2-202.4; p = 0.002), and 1-stage IBBR vs. ATR (1-stage: OR = 2.0 95% CI: 1.0-4.0; p = 0.04). Bilateral procedures were also at increased risk of major complications on univariate analysis (OR = 1.59 95% CI: 1.0-2.5; p = 0.04). CONCLUSIONS: Long-term breast reconstruction complication rates are higher than previously anticipated. Patients should be counseled that IBBR is associated with higher rates of complications, including unplanned return to the OR, compared to ATR.

How accurate are resting energy expenditure prediction equations in obese trauma and burn patients?

BACKGROUND: While the prevalence of obesity continues to increase in our society, outdated resting energy expenditure (REE) prediction equations may overpredict energy requirements in obese patients. Accurate feeding is essential since overfeeding has been demonstrated to adversely affect outcomes. OBJECTIVES: The first objective was to compare REE calculated by prediction equations to the measured REE in obese trauma and burn patients. Our hypothesis was that an equation using fat-free mass would give a more accurate prediction. The second objective was to consider the effect of a commonly used injury factor on the predicted REE. METHODS: A retrospective chart review was performed on 28 patients. REE was measured using indirect calorimetry and compared with the Harris-Benedict and Cunningham equations, and an equation using type II diabetes as a factor. Statistical analyses used were paired t test, +/-95% confidence interval, and the Bland-Altman method. RESULTS: Measured average REE in trauma and burn patients was 21.37 +/- 5.26 and 21.81 +/- 3.35 kcal/kg/d, respectively. Harris-Benedict underpredicted REE in trauma and burn patients to the least extent, while the Cunningham equation underpredicted REE in both populations to the greatest extent. Using an injury factor of 1.2, Cunningham continued to underestimate REE in both populations, while the Harris-Benedict and Diabetic equations overpredicted REE in both populations. CONCLUSIONS: The measured average REE is significantly less than current guidelines. This finding suggests that a hypocaloric regimen is worth considering for ICU patients. Also, if an injury factor of 1.2 is incorporated in certain equations, patients may be given too many calories.

Teaching surgical residents dome-down laparoscopic cholecystectomy in an academic medical center.

BACKGROUND: Although laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure in the United States, complications may still arise, especially when acute inflammation or aberrant anatomy is present. In these situations, surgeons may choose to convert to a variation of the traditional laparoscopic cholecystectomy, the "dome-down" approach. We assessed the best approach to teaching this technique as a secondary method in an academic teaching hospital. METHODS: Surgical residents were first given didactic instruction on the dome-down laparoscopic cholecystectomy, then trained in the animate laboratory, and finally graduated to the operating room. Following training, the residents completed a 7-question questionnaire to assess their reaction to this method. The charts of 98 patients who underwent dome-down laparoscopic cholecystectomy were retrospectively reviewed to assess the complications associated with the procedure, the average operative time, and length of hospital stay. RESULTS: The resident questionnaire showed that the learning curve was dramatically affected when an adequate number of cases were performed. The mean number needed to gain competency was 14.7. The use of animate simulators was also important. The mean operative time was 78.40 minutes, with most cases performed by postgraduate year-2 and -3 residents. Only one complication, bile peritonitis, arose early in the study. CONCLUSION: Dome-down laparoscopic cholecystectomy must be taught to surgical residents as a secondary approach to use when faced with a difficult case. The most important factor in teaching this technique is exposure to an adequate number of cases. The use of animate simulators and didactic training is also helpful.

Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics.

BACKGROUND: Many surgeons experience work-related pain and musculoskeletal symptoms; however, comprehensive reporting of surgeon ailments is lacking in the literature. We sought to evaluate surgeons' work-related symptoms, possible causes of these symptoms, and to report outcomes associated with those symptoms. MATERIALS AND METHODS: Five major medical indices were queried for articles published between 1980 and 2014. Included articles evaluated musculoskeletal symptoms and ergonomic outcomes in surgeons. A meta-analysis using a fixed-effect model was used to report pooled results. RESULTS: Forty articles with 5152 surveyed surgeons were included. Sixty-eight percent of surgeons surveyed reported generalized pain. Site-specific pain included pain in the back (50%), neck (48%), and arm or shoulder (43%). Fatigue was reported by 71% of surgeons, numbness by 37%, and stiffness by 45%. Compared with surgeons performing open surgery, surgeons performing minimally invasive surgery (MIS) were significantly more likely to experience pain in the neck (OR 2.77 [95% CI 1.30-5.93]), arm or shoulder (OR 4.59 [2.19-9.61]), hands (OR 2.99 [1.33-6.71], and legs (OR 12.34 [5.43-28.06]) and experience higher odds of fatigue (8.09 [5.60-11.70]) and numbness (6.82 [1.75-26.65]). Operating exacerbated pain in 61% of surgeons, but only 29% sought treatment for their symptoms. We found no direct association between muscles strained and symptoms. CONCLUSIONS: Most surgeons report work-related symptoms but are unlikely to seek medical attention. MIS surgeons are significantly more likely to experience musculoskeletal symptoms than surgeons performing open surgery. Symptoms experienced do not necessarily correlate with strain.

Do No Harm, Except to Ourselves? A Survey of Symptoms and Injuries in Oncologic Surgeons and Pilot Study of an Intraoperative Ergonomic Intervention.

BACKGROUND: Occupational symptoms and injuries incurred over a surgical career are under- reported, yet they have an impact on daily surgical practice. We assessed the frequency, consequences, and risk factors for occupational injury in oncologic surgeons and evaluated the feasibility of intraoperative foot mat use to mitigate occupational symptoms. STUDY DESIGN: Oncologic surgeons completed a survey of demographic information and occupational symptoms and injuries. Multivariate logistic regression was used to identify factors associated with occupational symptoms and injuries. A randomized cross-over pilot study of intraoperative foot mat use was conducted. RESULTS: One hundred twenty-seven surgeons completed surveys (response rate: 58%). The most commonly reported symptoms were fatigue, discomfort, stiffness, and back pain. An occupational injury was reported by 27.6% of surgeons. Of those injured, 65.7% received treatment, with 17.4% of those treated requiring surgery for their injury. In multivariate analysis, factors significantly associated with occupational injury were male sex (odds ratio [OR] 3.00, 95% CI 1.08 to 8.38), mean case length of 4 hours or more (OR 2.72, 95% CI 1.08 to 6.87), using a step to operate (OR 3.06, 95% CI 1.02 to 9.15), and neck pain (OR 4.81, 95% CI 1.64 to 14.12). In the foot mat pilot study (n = 20), mat use was associated with discomfort (OR 7.57, 95% CI 1.19 to 48.00), but no significant differences in leg volume change due to mat use were found. CONCLUSIONS: Most oncologic surgeons experience musculoskeletal symptoms from operating. Of the 28% of surgeons with an occupational injury, most required treatment. Intraoperative foot mat use was associated with increased discomfort.

The success of sentinel lymph node biopsy after neoadjuvant therapy: A single institution review.

BACKGROUND: The appropriate management of the axilla among women undergoing neoadjuvant therapy is in evolution. METHOD: A retrospective review of a prospective database of women with breast cancer who underwent neoadjuvant systemic therapy using endocrine/chemotherapy (NE/CT) from 2002 to 2015 was performed. RESULTS: We reviewed 253 women: triple negative breast cancer (30%), ER+HER2- (44%) breast cancer and HER2+ (25%) disease. The mean age was 55 years (SD = 12). 197 patients were analyzed based on their axillary disease. 33 patients (35%) who had clinical N1-3 disease prior to neoadjuvant therapy had no axillary metastases at definitive surgery. There were no significant differences in overall survival or local/regional recurrence between patients who underwent axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), or SLNB+ALND (p = 0.05061 and p = 0.33). CONCLUSION: SLNB is a viable technique in patients with breast cancer undergoing NE/CT. Patients with pre-neoadjuvant therapy proven axillary disease may be a candidate for SLNB as opposed to planned ALND with good multidisciplinary review of their response and localization of previously positive lymph nodes.

Trends in mastectomy and reconstruction for breast cancer; a twelve year experience from a tertiary care center.

BACKGROUND: Many surgical options exist for breast cancer, including breast conserving therapy (BCT), mastectomy with reconstruction (MAST+RECON) or without reconstruction (MAST). Long-term results regarding oncologic outcomes are few and primarily retrospective studies. METHODS: A retrospective review of a prospectively collected database of patients undergoing breast surgery for breast cancer from 2002 to 2014 was performed. Patients were separated into 3 time periods for analysis: 2002 to 2005, 2006 to 2009, and 2010 to 2014. Recurrence outcomes were compared at 4 years between MAST+RECON patients. RESULTS: Two thousand seventy-six patients were identified: 61.2% underwent BCT, 19.7% had MAST, and 19.1% had MAST+RECON. BCT patients were older and had smaller tumors. MAST+RECON increased in prevalence, whereas BCT decreased. Implant-based reconstruction and conservative mastectomy rates increased over the study period. Four-year local recurrence-free rates were similar in nipple-sparing and skin-sparing mastectomy groups. CONCLUSIONS: BCT usage has decreased, trending toward immediate, nipple-sparing mastectomy, implant-based reconstruction. Surgeons should be aware of trends to optimally offer patients their surgical options.