Primary Malignant Melanoma of the Gastroesophageal Junction Treated With Immunotherapy: A Case Report.

INTRODUCTION: Primary malignant melanoma of the esophagus constitutes 0.1% to 0.5% of all primary malignant esophageal neoplasms. Melanocytes are present within the squamous epithelium of the esophagus in the stratum basale layer with melanocytosis rare within the esophagus. Primary esophageal melanoma is aggressive and has a poor survival rate; 80% of patients have metastatic disease at diagnosis. Resection surgery is usually first-line treatment for localized primary malignant esophageal melanoma, but recurrence rates remain high. Tumor-specific immunotherapy has shown promising results. We report a case of primary malignant esophageal melanoma with metastasis to the liver treated with immunotherapy. CASE PRESENTATION: A 66-year-old woman presented with 2 months of progressive dysphagia and 3 episodes of hematemesis the previous night. Endoscopic examination showed a hypervascular distal esophageal mass. Biopsy was positive for S-100, SOX-10, and HMB-45 and showed rare mitotic figures with scattered pigment, consistent with melanoma. She was scheduled for esophagectomy initially, but instead pursued immunotherapy after liver metastasis was diagnosed during preop magnetic resonance imaging. Immunotherapy consisted of 8 cycles of pembrolizumab, followed by 4 months nivolumab and ipilimumab. The patient remains in remission 3 years after completing immunotherapy. DISCUSSION/CONCLUSIONS: Our patient was diagnosed with primary malignant esophageal melanoma of the distal esophagus with metastasis to the liver, a presentation that typically has a poor prognosis. Despite this, remission was achieved with immunotherapy without surgical intervention. Only a small number of cases of primary esophageal melanoma treated with immunotherapy have been reported-one showcasing tumor stabilization following several cycles of therapy with eventual metastasis, while our patient had a stable response to treatment. Further exploration of medical management with immunotherapy should be conducted, as it represents an alternative treatment for patients who do not have the option of surgical management.

No Geographic Distribution Change Among Residency Applicants in the Neurology Match During COVID-19.

Objectives The COVID-19 pandemic posed a novel challenge for the 2020-2021 Match cycle resulting in a virtual interview season. The advent of virtual interviews raised concerns for both programs and medical students. The possibility of an impact on the application strategies for medical students resulting in students being more likely to remain in the region or state of their medical school was considered. We investigated whether there was a change in the geographic distribution of residency applicants for the class of 2025 (matched in 2021) as compared to the previous three application cycles (classes of 2022-2024) across all 168 neurology residency programs within the United States. Methods Publicly available data from neurology program websites were compiled to record the location of resident medical schools and matched programs for the residency classes of 2022-2025. Missing or ambiguous information was cross-referenced to social media, (e.g. LinkedIn and Twitter). Statistical analyses were conducted utilizing SPSS 26 (IBM SPSS 26 Statistics for Windows, Armonk, NY).  Results Across all four classes, regional retention (students matching in the same region) was 70.2% for the Northeast, 59.6% for the Midwest, 52.9% for the South, and 59.4% for the West. No significant change between the residency class of 2025 and the previous three classes was present. Discussion No significant change to the geographic trends for candidates was seen with the virtual interview process for the 2020-2021 neurology Match. As has been seen in other fields, a strong regional preference, with the majority of residents matching to programs in the same regions as their medical school, was seen for neurology.

A Reflection and Discussion Exercise on Racial Justice and Equity.

Background: Residents have valuable perspectives about diversity and equity in medical training, yet many graduate medical education curricula lack dedicated activities focused on such issues. Objectives: To describe and report feasibility and acceptability of an innovation that uses individual reflection and group discussion to create conversation in our residency program about equity and injustice through the lens of the Black Lives Matter movement. Methods: In July 2020, we sent a survey with reflection prompts to all postgraduate year 2 and above internal medicine residents. In the discussion session (during required academic time), we presented 10 of the residents' responses to the reflection prompts. After each response was read aloud, the residents had an open discussion. We used thematic analysis to analyze the responses to the reflection prompts. Acceptability was tracked through free-text comments in the survey. Feasibility was measured by the time and resources needed to conduct the session. Results: We received responses from 24 out of 72 (33%) residents. We identified 10 codes that fell into 4 themes. The most commonly identified codes included anger or frustration toward events, self-reflection on privilege, increased awareness and discussion of racism in daily life, and life being minimally impacted/homeostasis. The 4 overarching themes were (1) awareness, (2) motivation for change, (3) emotional response, and (4) self-reflection. Conclusions: Using a format of reflection and sharing of anonymous responses was an inexpensive and effective method to begin a discussion about equity and injustice in medicine.