Wide Local Excision Before Sentinel Lymph Node Biopsy in Melanoma.

BACKGROUND: Current guidelines suggest that wide local excision of thick melanomas be delayed until sentinel lymph node biopsies can be performed. OBJECTIVE: To examine the literature and determine if there is a scientific basis for delaying wide local excision of thick melanomas. MATERIALS AND METHODS: A narrative review of the literature was undertaken to examine all available studies on the subject. RESULTS: There is no evidence that prior excision compromises sentinel lymph node identification. There are multiple unsubstantiated suggestions that large rotation flaps may lead to false negatives. CONCLUSION: There is no basis for delaying wide local excision of thick melanomas until a sentinel lymph node biopsy can be performed.

Use of the 40-gene Expression Profile (40-GEP) Test in Medicare-eligible Patients Diagnosed with Cutaneous Squamous Cell Carcinoma (cSCC) to Guide Adjuvant Radiation Therapy (ART) Decisions Leads to a Significant Reduction in Healthcare Costs.

Objective: Adjuvant radiation therapy (ART) is often recommended for high-risk cSCC patients but carries significant costs and risks. This study aims to determine if utilizing the 40-GEP test to guide ART can reduce healthcare costs in cSCC management. Methods: Medical claims data with new diagnoses of cSCC for the 12 months ending June 2022 in the Medicare (≥65 years) population (source: IQVIA claims database) were obtained and normalized to the general population for missingness. CPT codes associated with radiation therapy within one-year post diagnosis were used to establish adjuvant RT use (defined as 'ART'). Average weighted direct costs for four major ART modalities were calculated from published studies and (IQVIA). Sensitivity analysis was used to assess the financial impact of ART treatment using varying distributions of 40-GEP Class results. Results: Normalized medical claims data identified 22,917 Medicare-eligible cSCC patients who received ART within the United States. The weighted average direct cost for ART, which includes the four most used CPT code-defined modalities (IGRT, IMRT, IMPT, and XRT), was $60,693 per patient, amounting to an annual projected ART cost of $1.4 billion. Using the distribution of 40-GEP results from published studies, utilization of a 40-GEP test result to avoid ART in these patients could save up to $972 million in Medicare-eligible population. Sensitivity analysis shows, depending upon the distribution of the 40-GEP results, that for every 10% of Class 2A test results omitting ART, an extra $38-66 million in annual savings is expected. Limitations: Potential limitations include a need for more comprehensive patient information and the cost of ART-related complications. Conclusion: Utilizing the 40-GEP test results to guide ART decision-making would result in material savings to Medicare.

The Integrated i31-GEP Test Outperforms the MSKCC Nomogram at Predicting SLN Status in Melanoma Patients.

BACKGROUND/AIM: Sentinel lymph node biopsy (SLNB) for patients with cutaneous melanoma is primarily a prognostic procedure that broadly identifies patients who may have disease progression and may warrant additional intervention. However, 88% of patients undergoing SLNB receive a negative result and of those, some will succumb to their disease. One clinical utility of the integrated 31-GEP test, which combines gene expression data with clinicopathologic factors to provide a personalized, precise risk of SLN positivity, is SLNB guidance. This study compared the i31-GEP for SLNB to a nomogram that predicts SLN positivity using only clinicopathologic factors. PATIENTS AND METHODS: Patients with T1-T2 tumors and known SLN status (N=465) were analyzed by the i31-GEP for SLNB and a nomogram developed at Memorial Sloan Kettering Cancer Center (MSKCC). A 5% risk threshold was used to conform with national guidelines. RESULTS: In patients with <5% predicted risk, SLN positivity was 2.7% (3/111) for i31-GEP versus 10.0% (11/110, p=0.026) for MSKCC. In each T-category, the i31-GEP maintained a false-negative rate below the 5% risk threshold in those predicted to have a <5% risk, while the MSKCC nomogram did not. CONCLUSION: Integrating the 31-GEP with traditional factors outperformed a nomogram that uses clinicopathologic factors alone to predict SLN status. Incorporating the i31-GEP into clinical practice could improve identification of patients for SLNB, resulting in better risk-aligned management.

Pectoralis Major Repair: A Biomechanical Analysis of Modern Repair Configurations Versus Traditional Repair Configuration.

BACKGROUND: Pectoralis major (PM) ruptures are increasingly common, and a variety of surgical techniques have been described. However, tested techniques have demonstrated diminished strength with inadequate restoration of the footprint and suture failure at relatively low loads. Purpose/Hypothesis: The purpose was to biomechanically compare PM transosseous suture repair (current gold standard) to modern PM repair techniques that use larger caliber sutures, suture tape, and unicortical button fixation (UBF). The null hypothesis was that there would be no mechanical difference between repair techniques and no difference in the amount of footprint restoration. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-four fresh-frozen cadaveric shoulders controlled for age and bone mineral density were randomized equally to 4 groups: (1) UBF, suture tape; (2) UBF, No. 5 suture, suture tape; (3) bone trough with No. 2 suture; and (4) native PM tendon group; all groups were tested to failure. The specimens were tested under cycling loads (10 N to 125 N) with a final load-to-failure test at 1 mm/s. Failure modes were classified by location and cause of rupture based on optical markers, while tendon footprint length was measured to determine amount of footprint restoration. RESULTS: For fixation strength, the mean peak load was significantly greater in the native tendon (1816 ± 706 N) versus UBF/No. 5 suture/suture tape (794 ± 168 N), UBF/suture tape (502 ± 201 N), and bone trough (492 ± 151 N) ( P < .001 for all). UBF/No. 5 suture/suture tape featured the lowest displacement superiorly (1.09 ± 0.47 mm) and inferiorly (1.14 ± 0.39 mm) with a significant difference compared with bone trough. With regard to tendon footprint reapproximation, cortical button fixation best approximated native tendon footprint length versus bone trough. CONCLUSION: Based on peak failure load, the UBF/No. 5 suture/suture tape construct demonstrated 61% greater construct strength than a traditional bone trough technique. Moreover, displacement after cyclic loading was by far smallest in the UBF/No. 5 suture/suture tape construct. Therefore, repair constructs with larger caliber suture and suture tape provide a measurable improvement in construct strength versus traditional PM repair techniques in a biomechanical model and may be advantageous for repair. CLINICAL RELEVANCE: Cortical button fixation with larger caliber suture and suture tape allows for a significantly better PM repair than more traditional techniques at the time of surgery, which may ultimately result in improved clinical outcomes if implemented in surgical practice.