Pancreatic schwannoma, an extremely rare and challenging entity: Report of two cases and review of literature.

Pancreatic schwannoma is a rare benign tumor, for which the preoperative and intraoperative definitive diagnosis is quite challenging. We present the clinical, radiological and pathologic features of two primary pancreatic schwannomas identified in our pathology database over a period of 30 years at our tertiary care hospital. To better understand the clinico-pathological and radiological features of this entity, we provide a comprehensive review of 73 cases described in the English literature, along with our two cases. This review will especially focus on preoperative and intraoperative diagnosis to assess their accuracy for pancreatic schwannoma. The three most common preoperative diagnoses based on imaging for pancreatic schwannomas were cystic neoplasm (56%), pancreatic neuroendocrine tumor (29%) and mucinous cystic neoplasm (26%). Imaging could not definitely diagnose pancreatic schwannoma in any of the reported cases. To obtain a definite diagnosis before surgery, 25 cases underwent imaging-guided fine-needle aspiration (FNA)/biopsy, of which 60% were correctly reported as benign with definite diagnosis of pancreatic schwannoma in 48%. A higher diagnostic accuracy was observed in biopsies (71%) than FNA (37%). In addition, an intraoperative frozen section was carried out in 15 cases, and 47% were correctly diagnosed. Despite relatively low accuracy, preoperative histological assessment can be helpful in surgical managment. A core tissue specimen is recommended to improve the diagnostic accuracy in this setting.

Recurrence and treatment trends of pancreatic neuroendocrine tumors.

INTRODUCTION: The management of recurrent pancreatic neuroendocrine tumors has changed with improvements in both systemic and locoregional therapies. This study aims to describe the patterns of recurrence and respective treatments and evaluate the changes in multimodality treatment. METHODS: This is a single-institution retrospective study of patients diagnosed with a pancreatic neuroendocrine tumor from 2004 to 2022. The primary outcome was time to recurrence. Secondary outcomes included overall survival and therapeutic modality. Time to event probabilities were calculated using the Kaplan-Meier method; probabilities were compared using log-rank tests. Cox proportional hazards multivariable modeling with competing risks yielded subdistribution hazard ratios. RESULTS: Of 284 patients with a primary pancreatic neuroendocrine tumor, 189 underwent upfront surgical resection and were included in the analysis. Of the 182 patients with a well-differentiated G1 or G2 tumor, 44 patients (24%) experienced a recurrence. Mean time to recurrence was 57 months, with the liver as the most common site (77%, 34/44). On adjusted Cox proportional hazards modeling, only nodal positivity (subdistribution hazard ratio, 4.06; 95% confidence interval, 1.31-12.03, P = .013) was associated with a greater risk of recurrence. There was an increase in adoption of newer liver-directed and systemic therapies in the latter half of the study period, with increased use of therapies such as liver embolization and peptide receptor radionucleotide therapy for recurrences occurring after 2010. CONCLUSIONS: Of the patients with well-differentiated pancreatic neuroendocrine tumors managed with upfront surgical resection, one quarter developed recurrent disease. Nodal positivity was the most significant risk factor for recurrence. The majority of patients received multimodality therapies for recurrent disease.

Post Night Shift Education for Interns: A Pilot Program.

BACKGROUND: Night float rotations are associated with decreased feedback, educational conference attendance, and operative time. Interns are also more isolated and spend less time on teams. We therefore developed a novel post night shift initiative to address these shortcomings and examined its impact on the educational experience and sense of belonging among interns. METHODS: A program of weekly senior resident-led post night shift sessions was instituted at a university-based general surgery residency program for the first quarter of the academic year. Four interns and one senior resident participated in each session. Feedback surveys were administered. A previously validated Belonging in Surgery survey was also administered to all general surgery interns at the end of the quarter. RESULTS: Eleven interns had night float rotations within the first 3 months of the academic year. The intern feedback survey response rate was 93% (10/11). All intern respondents attended at least 3 sessions. Interns felt that the sessions increased familiarity with each other (85%) and senior residents (92%), improved clinical decision making (77%), and provided a safe space for discussion (69%). The senior resident survey response rate was 86% (n = 14). All senior residents enjoyed teaching the sessions and felt that they improved their familiarity with interns. The intern belonging survey response rate was 84% (16/19). Categorical interns had significantly higher belonging scores than preliminary interns at the end of the first quarter (mean 48.1 vs 41.6, p = 0.009). There was a trend toward decreased belonging scores for interns who had night float rotations early in the year which did not meet statistical significance (42.9 vs 47.4, p = 0.059). CONCLUSION: This novel program improved intern decision-making, familiarity with other residents, and comfort calling senior residents for assistance overnight. There was no statistically significant difference in belonging between interns who started residency on night float versus those who did not. Similar programs may help address concerns regarding missed learning opportunities and decreased sense of community during these rotations.

Resident Self-Efficacy in Grantsmanship Lags Behind Key Funding Deadlines.

PURPOSE: Extramural funding is critical to career success and advancement in academic surgery, and surgical residents can apply for both societal and federal funding. Many federal funding mechanisms require proposals to be submitted before residents' formal research years. METHODS: To better understand the resident experience with grantsmanship, we distributed a validated grantsmanship self-efficacy assessment inventory for voluntary completion at our academic general surgery training program with 2 years of dedicated research. The survey covers 3 domains: conceptualizing, designing and analyzing, and funding a study. All questions are scored 0 to 10 with 0 indicating no confidence and 10 indicating complete confidence. Median scores for the 3 domains were calculated for all respondents and compared between training years using Kruskal-Wallis with post-hoc Dunn testing. RESULTS: Forty-four surveys were completed with a response rate of 84%. Resident self-efficacy in grantsmanship improved throughout the training years with the greatest changes being in their comfort with conceptualizing and funding a study. Dunn testing identified specific differences between PGY2 and PGY7 comfort with conceptualizing studies (median 5 vs. 7.5, p = 0.003) and understanding of funding mechanisms (median 2.0 vs. 7, p = 0.003). CONCLUSIONS: While comfort with conceptualizing and funding studies does increase throughout the training years, this often develops after critical funding deadlines have already passed and can disadvantage surgical residents interested in academic careers. A curriculum that emphasizes familiarity with the grant writing and funding processes may better facilitate long term career success.

Myofibroblastoma in the Liver: A Case Report and Review of Literature.

Myofibroblastoma is a rare benign mesenchymal tumor first described in the breast. It is also known as mammary-type myofibroblastoma outside of the breast, more frequently located along the embryonic milk line. Exceptionally, myofibroblastoma can occur at visceral locations. We present a case of myofibroblastoma detected incidentally in the liver. A well-circumscribed mass, grossly measuring 6.2 cm in the liver parenchyma, was found on imaging studies. Histologically, the lesion is characterized by benign spindle cells in a hyalinized collagenous stroma, with positive staining for SMA and ER, focal positivity for CD34, negative for desmin, and loss of RB1. This rare tumor at such an unusual location makes it diagnostically challenging, especially on core biopsy of the lesion. To our knowledge, this is the second case of myofibroblastoma in the liver reported in the English literature and the first such case with a detailed pathology description.

Pulling Back from the Brink: A Multi-Pronged Approach to Address General Surgery Resident Clinical Work Hour Adherence.

PURPOSE: The conflict between prioritizing education for surgical trainees, promoting trainee wellness, and maintaining optimal patient care has remained challenging since the introduction of the Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions in 2003. There is still a dearth of research examining which interventions successfully enable duty hour adherence. This study assessed the impact of a combination of strategic interventions on improving clinical work hour adherence. METHODS: Monthly clinical work hour submission rates were assessed for all general surgery residents at a single university-based residency program over a 3-year period (2018-2021). Interventions targeted 3 domains and were implemented between academic years 2018 to 2019 (control) and 2020 to 2021 (intervention): 1) improving the accuracy and transparency of work hour reporting, 2) facilitating more timely interventions, and 3) structural scheduling changes. All 80-hour work week and continuous work hour violations were assessed. Findings were also compared to the corresponding ACGME Resident Survey results. RESULTS: There was no significant difference in the rate of monthly work hour submissions pre- and postintervention (78% vs 75%, p = 0.057). However, the number of total reported monthly violations decreased significantly (mean 13.8 vs 2.4, p < 0.01), including decreases in both 80-hour work week and continuous work hour violations (mean 4.7 vs 1.6, p < 0.001 and 9.1 vs 0.8, p < 0.001, respectively). Reported compliance also increased on the annual ACGME resident surveys, where 61% vs 95% of residents felt they were compliant with the 80-hour work week and 71% vs 95% felt they were compliant with the continuous work hours (2018-19 vs 2020-21). CONCLUSION: Innovative strategies addressing schedule changes, the culture of work hour reporting, and early intervention significantly decreased the number of duty hour violations at our institution. Reported resident compliance also improved based on ACGME Resident Survey data. These data may inform similar multifaceted approaches at other institutions to improve overall work hour adherence.

A contemporary analysis of palliative procedures in aborted pancreatoduodenectomy: Morbidity, mortality, and impact on future therapy.

BACKGROUND: Periampullary malignancies are often unresectable tumors that frequently cause biliary or duodenal obstruction. Advances in endoscopic and percutaneous options have lessened the need for operative palliation. Nevertheless, many patients are still found to be unresectable at the time of exploration, making palliative bypass a consideration. Several prior studies have examined the morbidity of operative palliation, but many were conducted over lengthy time periods, and few have examined the impact of these procedures on future therapy. This study is a contemporary analysis of the short- and long-term outcomes of palliative bypass procedures for unresectable periampullary malignancies at a single high-volume institution. METHODS: We identified a contemporary cohort of patients in whom a pancreatoduodenectomy was planned for periampullary malignancy but instead underwent an aborted procedure. Patients were divided into 5 procedure groups: laparoscopy only, laparotomy with or without cholecystectomy, gastrointestinal bypass, biliary bypass, and double bypass (gastrointestinal and biliary). Data regarding the patient cohort, procedures, morbidity/mortality, and the interval to initiation of systemic therapy were collected prospectively and reviewed retrospectively. RESULTS: Between July 2011 and November 2018, 128 out of 615 (17%) patients had an aborted pancreatoduodenectomy; 113 out of 128 patients had pancreatic adenocarcinoma, and 86 (67.1%) had duodenal or biliary obstruction at the time of operation. Patients who underwent laparoscopy only (n = 34) had no operative complications and a 90-day mortality of 6%; 88% of these patients went on to receive systemic therapy (median 21 days postprocedure). Double bypass was associated with a far lesser complication rate than in prior studies; 17% of patients had some complication(s), but only 9% had a severe complication. The 90-day all-cause mortality was 13%, and only 71% of these patients went on to receive systemic therapy (median 47 days postprocedure). Notably, 27 out of 34 (79%) of patients who underwent laparoscopy alone needed additional procedures for local obstruction, whereas only 5 out of 42 (12%) double bypass patients needed additional interventions. Median survival for the entire cohort was 10.3 months. CONCLUSION: Palliative procedures in this cohort had a far lesser complication rate than that of historical series. Palliative procedures, however, delayed systemic therapy, and a fair number of patients never received additional treatments. Palliative procedures markedly decreased the need for future interventions. Intraoperative decisions regarding palliative procedures must incorporate the functional status and motivations of the patient; these procedures are increasingly safe but may still affect survival.

It's all in for the HER family in tumorigenesis.

The EGF receptor family is a group of receptor tyrosine kinases that have been implicated in the development of a variety of malignancies. As such, they have been targeted in the generation of pharmacologic agents, several of which have been approved as anti-tumor therapeutics. The lone exception is ERBB4, for which the function and relationship to cancer are not yet clear and no targeted therapies exist. The paper under evaluation demonstrates a role for ERBB4 mutations in the development of melanoma. It identifies ERBB4 mutations present in melanomas that augment proliferation and cell survival and thus contribute to dysregulated growth. Furthermore, it shows that agents targeting the EGF receptor family can reduce the proliferation of melanoma cells harboring these mutations. These findings further emphasize the role of the ERBB subfamily in tumorigenesis and establish ERBB4 as a new target in the development of anti-tumor strategies.