Metaplastic breast carcinoma: a clinical-pathologic study of 97 cases with subset analysis of response to neoadjuvant chemotherapy.

Metaplastic breast carcinoma is a rare heterogeneous category of breast cancer, often associated with a poor prognosis. Clinical-pathologic studies with respect to varied morphologic subtypes are lacking. There is also a dearth of studies assessing the response of metaplastic breast carcinoma to neoadjuvant chemotherapy. Cases of metaplastic breast carcinoma diagnosed between 2007 and 2017 were identified. Various clinical-pathologic variables were tested for association with survival. Patients who underwent neoadjuvant chemotherapy were assessed for pathologic response. Median age at diagnosis with metaplastic breast carcinoma was 64 years. With a median follow-up of 39 months, 26 patients (27%) recurred (24 distant and 2 loco-regional). The overall survival rate of the cohort was 66% (64/97). A number of variables were associated with survival in univariable analysis; however, in multivariable analysis, only lymph node status and tumor size (pT3 vs. pT1/2) were significantly associated with all survival endpoints: recurrence-free survival, distant recurrence-free survival, overall survival and breast cancer-specific survival. Twenty-nine of 97 (30%) patients with metaplastic breast carcinoma received neoadjuvant chemotherapy. Five (17%) patients achieved pathologic complete response. Matrix-producing morphology was associated with higher probability of achieving pathologic complete response (p = 0.027). Similar to other breast cancer subtypes, tumor size and lymph node status are prognostic in metaplastic carcinomas. The pathologic complete response rate of metaplastic breast carcinoma in our cohort was 17%, higher than previously reported. Although the matrix-producing subtype was associated with pathologic complete response, there was no survival difference with respect to tumor subtypes.

Lymph Node Ratio (LNR): Predicting Prognosis after Neoadjuvant Chemotherapy (NAC) in Breast Cancer Patients.

OBJECTIVE: Axillary lymph node status is an important prognostic factor in breast cancer (BC). Residual nodal disease burden after neoadjuvant chemotherapy (NAC) is one of the important prognostic factors to determine the prognosis and in the treatment of BC. Lymph node ratio (LNR) defined as the ratio of the number of positive lymph nodes to total excised axillary lymph nodes, may be a stronger determinant of prognosis than pN in axillary nodal staging, although there is very limited data evaluating its prognostic value in the setting of NAC. In this cohort of patients, we studied the utility of LNR in predicting recurrence and overall survival (OS) after NAC. MATERIALS AND METHODS: An Institutional cancer registry was queried from 2009 to 2014 for women with axillary node-positive BC with no evidence of distant metastasis, and who received NAC followed by surgery for loco-regional treatment (axillary dissection with breast conserving surgery or total mastectomy). Patients with axillary complete response were excluded. Locoregional recurrence (LRR), distant recurrence (DR) and overall survival (OS) rates were reviewed regarding pN and LNR. RESULTS: A total of 179 patients were analyzed. Median follow up time was 24 [25%, 75%: 13-42] months. Patients with pN1 in comparison to pN2 and pN3 had lower rate of LRR (9% vs. 15% and 14%, respectively; p=0.41), lower rate of DR (14% vs. 25% and 27%, respectively, p=0.16) and increased rate of OS (89% vs. 79% and 78%, respectively, p=0.04). In comparison to patients with LNR >20%, patients with LNR ≤20% had lower LRR (9% vs. 14%, p=0.25), lower DR (13% vs. 27%, p=0.01) and improved OS (89% vs. 79%, p=0.02) rates. In the pN1 group, patients who had a LNR >20% had higher DR (22% vs. 14%, p=0.48) rates in comparison to patients with LNR ≤20%. In ER/PR (+) patients who had LNR ≤20% DR was 6% compared with 23% in patient who had LNR >20% (p=0.02), and in triple negative patients' OS rate was significantly better compared the LNR less/equal or more than 20% (71% vs 33%, p=0.001). CONCLUSION: Our study demonstrated that LNR adds valuable information for the prognosis after NAC and this additional information should be considered when deciding further treatment and follow-up for patients who had residual tumor burden on the axilla. This observation should be tested in a larger study.

Is a "retained fundus" seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?

BACKGROUND: Postoperative upper gastrointestinal series (UGI) has never been shown to be effective in ruling out leaks or obstruction after gastric bypass or sleeve gastrectomy. In sleeve gastrectomies, UGI will define the shape of the sleeve and rule out a retained fundus that was not optimally excised during surgery. OBJECTIVES: We aimed to investigate the impact of a "retained fundus" on weight loss to determine whether UGIs can be used to gauge success of the operation and predict outcome. SETTING: Urban community teaching hospital, United States. METHODS: Retrospective study analyzing routine UGIs performed on 203 consecutive patients. Exclusion criteria included low quality UGI (absence of a still image of complete fill with contrast), revisions from gastric band to sleeve, absence of weight-loss data, postoperative leak, and postoperative stenosis. RESULTS: A total of 149 patients were included. Mean excess weight loss at one year for groups 1 through 4 was 67.3%, 72.7%, 67.8%, and 65.9%, respectively. There was no significant statistical difference in excess weight loss between the optimal group and the group of both mild and severe retained fundus (P = .22). The weight loss remained equivalent even when comparing the optimal sleeves with only those with severe retained fundus (P = .19). There was a statistically significant difference in quality of sleeve gastrectomies on UGI with surgical experience showing less retained fundus on the UGIs (P = .006) in the latter half of the series. CONCLUSION: Retained fundus does not seem to cause inferior weight loss in the early postoperative period. Thus, UGI cannot predict weight loss outcomes in the short term.

Case study: reduction of gluteal implant infection rates with use of retention sutures.

The intramuscular technique has been the most popular technique among plastic surgeons for gluteal implantation. Complication rates of up to 30% including infection, hematoma, seromas, and dehiscence are reported in several studies. One main question that arises is whether the wound dehiscence occurs first followed by infection or vice versa. We present a case study of 3 patients who received gluteal augmentation. We used an alternative technique in closure of the gluteal flap which included the use of retention sutures along the sacral incision. Follow-up included postoperative day 2, every week for 6 weeks, and then every month for 6 months. Postoperatively patients were advised to not sleep in supine position for 3 weeks and avoid pressure to the area. The 3 patients remained infection free at 2 days and weekly for 6 weeks. The use of retention sutures along the flap closure site may be a useful and simple technique to avoid high gluteal implant infection rates that have been reported in the literature. We plan to apply this technique to all of our future gluteal augmentations and track long-term results. Preventing complications will result in improved aesthetic results, increased patient satisfaction, less frequent office visits, and less financial cost to both patient and physician.

Outcome analysis of single incision vs traditional multiport sleeve gastrectomy: a matched cohort study.

BACKGROUND: Single incision laparoscopy remains controversial due to technical challenges which may cause suboptimal outcomes. This study aims to evaluate the feasibility and equivalency of the single incision sleeve gastrectomy (SISG) when compared to the traditional multiport sleeve gastrectomy (MPSG) approach in a matched cohort evaluating technical aspects and postoperative results. METHODS: This is a retrospective analysis of prospectively collected data in a consecutive cohort of 113 SG (MPSG = 77, SISG = 36). The 36 patients who underwent SISG were included as the case group. Thirty-six MPSG patients were included in the control group, in 1:1 ratio with cases after matching for BMI, age, race, gender, and additional demographic data. Operative time (OT) in minutes and length of stay (LOS) in days was measured and excess weight loss (EWL) at 6 months and 1 year was collected and evaluated. RESULTS: Mean BMI was equivalent (SISG 43.06, MPSG 43.72, p = 0.36). Mean OT for the SISG was 116.78 and 118.25 for the MPSG (p = 0.84), and mean LOS was 1.80 for the SISG and 1.75 for the MSPG (p = 0.75). EWL at 6 months was 58.4 % for the SISG and 58.5 % for the MPSG (p = 0.98) and 72.3 and 74.1 % (p = 0.77) for 1 year, respectively. There were no leaks in either group. There was one reoperation for postoperative bleeding in the MPSG group. CONCLUSIONS: Sleeve gastrectomy can be performed safely using single incision techniques with equivalent outcomes for weight loss.