Pilomatrix Carcinoma: A Benign-Mimic with Malignant Consequences - A Case Report and Review of the Current Literature.

Introduction: Pilomatrix carcinomas (PMXCs) are uncommon, locally aggressive tumors with high recurrence rates, metastatic potential, and fewer than 130 cases reported in the literature. Typically, they present as an unassuming, firm, dermal swelling and therefore are frequently mistaken for more common, benign masses, leading to undertreatment which can cause local invasion and metastatic spread. Diagnosis relies on excision with pathologic analysis; however once diagnosed, there are no current recommendations to guide treatment or surveillance for recurrence or metastases. Case Presentation: Here, we present a case of one of these rare tumors. Our case describes a 1.5 × 2.5 cm firm, mobile mass at the supraorbital rim in an otherwise healthy, young patient. Prior to removal, we suspected a benign pathology; however, excision proved difficult and pathologic diagnosis was consistent with PMXC. Following discussion with tumor board, decision was made to perform Mohs micrographic surgery and staging via CT scans with regular follow-up and surveillance scans. Conclusion: PMXCs are exceedingly rare diagnoses and present like many benign lesions. Therefore, we elected to document this case to encourage providers to keep these biologically aggressive tumors on their list of differential diagnoses in an unsuspecting mass, as well as to provide our own recommendations for treatment and screening for recurrence and metastatic spread.

Accelerated Partial Breast Irradiation for HER2-Positive Early-Stage Breast Cancer.

PURPOSE: HER2-positive (HER2+) breast cancer historically exhibited the most adverse local outcomes and, consequently, has had limited representation among trials of partial breast irradiation (PBI). We hypothesized that with contemporary HER2-targeted agents, patients may now exhibit excellent disease control outcomes after adjuvant PBI. METHODS AND MATERIALS: Using a prospectively maintained institutional database, we identified patients with HER2+ breast cancer treated with breast conserving surgery (BCS) and PBI from 2000 to 2022. Salient clinicopathologic and treatment parameters were collected. All patients received external beam PBI to 40 Gy in 10 daily fractions. Cumulative incidence functions were calculated to estimate the incidence of local recurrence (LR) with the competing risk of death. RESULTS: We identified 1248 patients who underwent PBI at our institution, of whom the study cohort comprised 52 (4%) with HER2+ breast cancer (median age, 64 years; range, 44-87). Nearly all had T1 tumors (98%; median size, 12 mm [range, 1-21 mm]). Most had estrogen receptor positive disease (88%), and all patients had negative surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. Forty-two (81%) received chemotherapy; 40 (77%), hormone therapy; and 42 (81%), HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range, 7-226 months for each patient), we observed 2 LR events at 14 and 26 months, respectively, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any breast-specific mortality events. Two deaths were observed, both without evidence of disease. CONCLUSIONS: Among a cohort of patients with HER2+ early-stage breast cancer managed with BCS and PBI, we observed a 2-year LR rate of 3.8%, with no regional or distant recurrences and excellent overall survival. These findings require confirmation with longer follow-up among larger cohorts but appear consistent with the excellent results of contemporary randomized trials of PBI unselected for HER2 status.

Can incorrect artificial intelligence (AI) results impact radiologists, and if so, what can we do about it? A multi-reader pilot study of lung cancer detection with chest radiography.

OBJECTIVE: To examine whether incorrect AI results impact radiologist performance, and if so, whether human factors can be optimized to reduce error. METHODS: Multi-reader design, 6 radiologists interpreted 90 identical chest radiographs (follow-up CT needed: yes/no) on four occasions (09/20-01/22). No AI result was provided for session 1. Sham AI results were provided for sessions 2-4, and AI for 12 cases were manipulated to be incorrect (8 false positives (FP), 4 false negatives (FN)) (0.87 ROC-AUC). In the Delete AI (No Box) condition, radiologists were told AI results would not be saved for the evaluation. In Keep AI (No Box) and Keep AI (Box), radiologists were told results would be saved. In Keep AI (Box), the ostensible AI program visually outlined the region of suspicion. AI results were constant between conditions. RESULTS: Relative to the No AI condition (FN = 2.7%, FP = 51.4%), FN and FPs were higher in the Keep AI (No Box) (FN = 33.0%, FP = 86.0%), Delete AI (No Box) (FN = 26.7%, FP = 80.5%), and Keep AI (Box) (FN = to 20.7%, FP = 80.5%) conditions (all ps < 0.05). FNs were higher in the Keep AI (No Box) condition (33.0%) than in the Keep AI (Box) condition (20.7%) (p = 0.04). FPs were higher in the Keep AI (No Box) (86.0%) condition than in the Delete AI (No Box) condition (80.5%) (p = 0.03). CONCLUSION: Incorrect AI causes radiologists to make incorrect follow-up decisions when they were correct without AI. This effect is mitigated when radiologists believe AI will be deleted from the patient's file or a box is provided around the region of interest. CLINICAL RELEVANCE STATEMENT: When AI is wrong, radiologists make more errors than they would have without AI. Based on human factors psychology, our manuscript provides evidence for two AI implementation strategies that reduce the deleterious effects of incorrect AI. KEY POINTS: • When AI provided incorrect results, false negative and false positive rates among the radiologists increased. • False positives decreased when AI results were deleted, versus kept, in the patient's record. • False negatives and false positives decreased when AI visually outlined the region of suspicion.

A Pilot Study of Accelerometer-Based Biometric Data Collection among Patients Undergoing Locoregional Therapies.

This study evaluated the feasibility of measuring patient recovery after locoregional therapies (LRTs) using a wearable activity tracker (WAT). Twenty adult patients with cancer were provided with a WAT device to wear for a minimum of 7 days prior to their procedure (baseline) and for up to 30 days after their procedure (recovery). Daily step counts were continuously recorded. Patient responses to the Short Form 36-Item Health Survey (SF-36) were also collected before and after LRT. Analysis of WAT data demonstrated a mean of 4,850 daily steps taken at baseline, which decreased to 2,000 immediately after LRT and then rapidly increased to approximately 4,300 daily steps over an average of 10 days (P < .001). No significant changes were observed in SF-36 responses between baseline and follow-up assessments (P > .10). These results suggest that WAT devices capture dynamic periprocedural data not reflected in survey-based assessments and may be used to monitor patient recovery after interventional oncologic procedures.

Metaplastic carcinoma of the breast: matched cohort analysis of recurrence and survival.

PURPOSE: Metaplastic breast carcinoma (MBC) is a rare subtype of breast cancer, defined as mammary carcinoma with squamous or mesenchymal differentiation, that may include spindle cell, chondroid, osseous, or rhabdomyoid differentiation patterns. The implications of MBC recurrence and survival outcomes remains unclear. METHODS: Cases were ascertained from a prospectively maintained institutional database of patients treated from 1998 to 2015. Patients with MBC were matched 1:1 to non-MBC cases. Cox proportional-hazards models and Kaplan-Meier estimates were used to evaluate outcome differences between cohorts. RESULTS: 111 patients with MBC were matched 1:1 with non-MBC patients from an initial set of 2400 patients. Median follow-up time was 8 years. Most patients with MBC received chemotherapy (88%) and radiotherapy (71%). On univariate competing risk regression, MBC was not associated with locoregional recurrence (HR = 1.08; p = 0.8), distant recurrence (HR = 1.65; p = 0.092); disease-free survival (HR = 1.52; p = 0.065), or overall survival (HR = 1.56; p = 0.1). Absolute differences were noted in 8-year disease-free survival (49.6% MBC vs 66.4% non-MBC) and overall survival (61.3% MBC vs 74.4% non-MBC), though neither of these reached statistical significance (p = 0.07 and 0.11, respectively). CONCLUSION: Appropriately-treated MBC may exhibit recurrence and survival outcomes that are difficult to distinguish from those of non-MBC. While prior studies suggest that MBC has a worse natural history than non-MBC triple-negative breast cancer, prudent use of chemotherapy and radiotherapy may narrow these differences, although studies with more power will be required to inform clinical management. Longer follow-up among larger populations may further elucidate the clinical and therapeutic implications of MBC.

Electronic Cigarettes for Smoking Cessation: The Gap Between Behavior in Smokers and Medical Education.

INTRODUCTION: E-cigarettes have engendered a great deal of controversy within the public health and medical communities.  Methods: Two cross-sectional surveys were administered. First, patients at an annual lung cancer screening appointment who self-identified as former smokers were asked about strategies for achieving and maintaining smoking cessation with open-ended questions. Second, medical students at a single university reported their opinion and knowledge of combustible cigarettes and e-cigarettes. RESULTS: Among the n=102 in the patient survey indicating that they used e-cigarettes or over-the-counter (OTC) nicotine replacement products for smoking cessation, 34.3% (35/102) vaped e-cigarettes, making it the second most common next to patches (47.1% {48/102}). By comparison, n=48 reported using medication. Medical student participants (n=168) were mixed regarding whether a patient should switch from traditional to electronic cigarettes (56.0% yes; 44.0% no) and reported receiving education about traditional cigarettes (92.3%) at a much higher rate than for e-cigarettes (46.4%), p<.001. CONCLUSION: Many former heavy smokers undergoing a lung cancer screen used e-cigarettes to achieve smoking cessation. However, nearly half of medical students surveyed do not think patients should switch from traditional to e-cigarettes.

How do US orthopaedic surgeons view placebo-controlled surgical trials? A pilot online survey study.

Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as 'completely' or 'mostly' unethical. Participants were also asked to rank-order the value of five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as the least valuable (even less valuable than an anecdote) and 35.7 .% viewing it as the most valuable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects.

Clinical validation and utility of Percepta GSC for the evaluation of lung cancer.

The Percepta Genomic Sequencing Classifier (GSC) was developed to up-classify as well as down-classify the risk of malignancy for lung lesions when bronchoscopy is non-diagnostic. We evaluated the performance of Percepta GSC in risk re-classification of indeterminate lung lesions. This multicenter study included individuals who currently or formerly smoked undergoing bronchoscopy for suspected lung cancer from the AEGIS I/ II cohorts and the Percepta Registry. The classifier was measured in normal-appearing bronchial epithelium from bronchial brushings. The sensitivity, specificity, and predictive values were calculated using predefined thresholds. The ability of the classifier to decrease unnecessary invasive procedures was estimated. A set of 412 patients were included in the validation (prevalence of malignancy was 39.6%). Overall, 29% of intermediate-risk lung lesions were down-classified to low-risk with a 91.0% negative predictive value (NPV) and 12.2% of intermediate-risk lesions were up-classified to high-risk with a 65.4% positive predictive value (PPV). In addition, 54.5% of low-risk lesions were down-classified to very low risk with >99% NPV and 27.3% of high-risk lesions were up-classified to very high risk with a 91.5% PPV. If the classifier results were used in nodule management, 50% of patients with benign lesions and 29% of patients with malignant lesions undergoing additional invasive procedures could have avoided these procedures. The Percepta GSC is highly accurate as both a rule-out and rule-in test. This high accuracy of risk re-classification may lead to improved management of lung lesions.

Heavy Smoking Patients Receiving a Lung Cancer Screen Want to Quit: A Call for Tailored Cessation Interventions.

Background: Lung cancer screening for current or former heavy smokers is now recommended among all asymptomatic adults 50-80 years old with a 20 pack-year history of smoking. However, little is known about the smoking-related attitudes of this population. Method: An assessment was conducted among 1,472 current smokers who presented for an annual lung cancer screen at one of 12 diagnostic imaging sites in Rhode Island between April 2019 and May 2020. Patients were asked about their use of smoking products, interest in quitting, and smoking-related attitudes. Results: Patients smoked a median of 16 cigarettes per day; 86.6% were daily cigarette smokers and 30.1% were daily cigar smokers. In total, 91.4% of patients were, to some degree, interested in quitting smoking and 71.4% were seriously thinking about quitting in the next 6 months or sooner. Patients planned on smoking less regardless of whether their lung screen was positive or negative for cancer, though they were more likely to plan on smoking less if negative (on 0-3 pt Likert scale: 0.31, 95% CI [0.27, 0.34] vs. 0.77, 95% CI [0.72, 0.81]). Confidence in quitting and belief in one's inherent ability to quit smoking varied substantially within the sample. Conclusion: Nearly all current smokers receiving a lung cancer screen have some interest in smoking cessation. Due to the heterogeneity in some smoking-related attitudes, tailored interventions for this population should be tested.

Cheek Donor Site for Full-Thickness Skin Graft Repair of the Nasal Ala: Outcomes of a Retrospective Cohort Study.

BACKGROUND: Full-thickness skin grafts (FTSGs) are useful repairs for reconstructing nasal alar defects. Traditional donor sites include the preauricular, postauricular, and supraclavicular skin. OBJECTIVE: To evaluate esthetic outcomes and complications of nasal alar defects repaired with FTSGs from the medial cheek. MATERIALS AND METHODS: A retrospective chart review of Mohs surgery patients who had FTSG repair of the nasal ala between January 2015 and August 2020 was performed. Demographic, surgery, and follow-up visit data were reviewed. Cosmesis was rated by a facial plastic surgeon, a Mohs surgeon, and a plastic surgeon using baseline, defect, and follow-up visit photographs. RESULTS: Sixty-nine patients with FTSG repairs of nasal alar defects were identified. 51 of 69 patients (73.9%) had the cheek donor site, and 18 of 69 patients (26.1%) had a noncheek donor site. The mean (SD) rater visual analog score for both cohorts was good with no significant difference (cheek: 65.9 [13.8]; noncheek: 66.1 [15.3]; p = .96). A notable difference in the complication rate by donor site was observed (cheek: 6.9%, noncheek: 16.7%; p = .13), although it did not reach significance. CONCLUSION: The cheek is a reliable FTSG donor site for nasal alar defects after Mohs micrographic surgery, with a trend toward fewer complications.

Bilateral Regional Nodal Irradiation Using Volumetric Modulated Arc Therapy: Dosimetric Analysis and Feasibility.

PURPOSE: Dosimetric and technical challenges often limit radiation therapy (RT) target coverage for patients with breast cancer who require bilateral breast/chest wall and regional nodal irradiation (RNI). We evaluated the feasibility of using volumetric modulated arc therapy (VMAT) to administer bilateral comprehensive RNI including the internal mammary nodes. METHODS AND MATERIALS: We analyzed all patients treated at our institution with bilateral RNI using VMAT between 2017 and 2020. Medical records were reviewed to ascertain clinicopathologic features, radiotherapeutic parameters, and treatment-related adverse events. RESULTS: The cohort was comprised of 12 patients who underwent VMAT for bilateral RNI, with a median follow-up time of 14.5 months. Median volume of the lung receiving 5 Gy (V5) for the bilateral lungs was 96.1% (range, 84.5%-99.8%), and median volume of the lung receiving 20 Gy for each lung was 27.5% (range, 14.9%-38.1%). The cardiac mean dose was a median of 699 cGy (range, 527-1117 cGy). Five patients (41%) developed grade 1 cough/dyspnea, with one patient developing grade 3 dyspnea. Of note, 3 of these patients (60%) were current or former smokers. No patient received glucocorticoid therapy or required respiratory intervention, and none developed longer-term pulmonary complaints. A decline in ejection fraction occurred in one patient with a preexisting cardiac condition who also received anthracycline-based chemotherapy and trastuzumab. Only one patient experienced a locoregional recurrence with synchronous distant progression, and subsequently succumbed to the disease. No secondary cancers have been noted to date. CONCLUSIONS: VMAT appears to be a feasible and tolerable RT modality for patients with breast cancer who require bilateral comprehensive adjuvant RT with RNI to obtain excellent target coverage. No patients required medical intervention for pulmonary complaints despite a median bilateral V5 approaching 100%, providing further evidence that V5 is not predictive for complications.

Digital Breast Tomosynthesis and Digital Mammography Recall and False-Positive Rates by Time of Day and Reader Experience.

Background Digital breast tomosynthesis (DBT) image interpretation might be more cognitively demanding than interpretation of digital mammography (DM) images. The time of day of interpretation might affect recall and false-positive (FP) rates, especially for DBT. Purpose To determine whether recall and FP rates vary by time of day of interpretation for screening mammography for breast cancer performed with DM and DBT. Materials and Methods This is a retrospective study examining 97 671 screening mammograms interpreted by 18 radiologists between January 2018 and December 2019 at one of 12 community radiology sites. The association between the time of day of interpretation, the type of image interpreted (DM vs DBT), and radiologist experience (≤5 posttraining years vs >5 posttraining years) and the likelihood of a patient being recalled from screening mammography and the likelihood of whether the interpretation was FP or true positive were analyzed. Analyses were conducted using generalized linear mixed modeling with a binary distribution and sandwich estimation where observations were nested by radiologist. Results Screening mammograms interpreted by 18 radiologists were reviewed (40 220 DBTs, 57 451 DMs). Nine radiologists had 5 or fewer posttraining years of experience, and nine had more than 5 posttraining years of experience. The overall recall rates for DM (10.2%) and DBT (9.0%) were different (P = .006); FP rate also differed (9.8% DM, 8.6% DBT; P = .004). For radiologists with 5 or fewer posttraining years of experience, odds of recall increased 11.5% (odds ratio [OR] = 1.12, P = .01) with every hour when using DBT, but this was not found for DM (OR = 1.09, P = .06); DBT and DM were different (OR = 1.12 vs 1.09, P = .02). For radiologists with more than 5 posttraining years of experience, no evidence of increase in recall was observed for DBT (OR = 1.02, P = .27) or DM (OR = 1.0, P = .80), and there was no evidence that these were different (OR = 1.02 vs 1.0, P = .13). Conclusion Patients were more likely to be recalled when their screening digital breast tomosynthesis images were interpreted later in the day by less-experienced radiologists. © RSNA, 2022 Online supplemental material is available for this article.

Development and Pilot Implementation of a Remote Monitoring System for Acute Toxicity Using Electronic Patient-Reported Outcomes for Patients Undergoing Radiation Therapy for Breast Cancer.

PURPOSE: We aimed to develop and study the implementation of a remote system for toxicity assessment and management of acute side effects of breast radiation using electronic patient-reported outcomes (ePROs). METHODS AND MATERIALS: A response-adapted Patient-Reported Outcomes Common Terminology Criteria for Adverse Events-based assessment for breast radiation toxicity was administered weekly during and for 8 weeks after radiation from June 2019 to July 2020. The care team received alerts when "severe" symptoms were reported by patients, who were then contacted. Treatment, clinic, and sociodemographic characteristics were abstracted from patient records. A subsample of patients and care team members was qualitatively interviewed at follow-up. RESULTS: Overall, 5787 assessments were sent to 678 patients, of whom 489 (72%) completed 2607 assessments (45%). Moderate or greater toxicity was reported by 419 responders (86%; 95% CI, 82%-89%). Clinician alerts for severe toxicity were generated for 264 assessments among 139 unique patients, of which 83% occurred posttreatment. The proportion of surveys that prompted an alert was significantly higher after treatment (219 [13%]) than during treatment (45 [5%]) (P < .001). Survey completion rates in the posttreatment period were higher among patients undergoing partial breast irradiation than postmastectomy radiation (incidence rate ratio, 0.70; 95% CI, 0.60-0.81) (P < .001) despite these patients experiencing less severe toxicity. Interviews (15) found that patients had a positive experience with ePROs, although many thought the primary purpose was for research rather than symptom management. CONCLUSIONS: With the majority of toxicity occurring after breast radiation has ended, remote symptom monitoring with ePROs appears to fill a gap in clinical practice, particularly for patients undergoing shorter courses of radiation. It is important to properly onboard patients and explain that the purpose of ePROs is to aid clinical care. Further research is needed to determine whether the costs associated with ePROs can be offset by reducing routine clinic visits and whether this approach is acceptable and appropriate.

Treating Pain With Open-Label Placebos: A Qualitative Study With Post-Surgical Pain Patients.

Prior research has shown that Open Label Placebos (OLPs; that is, placebos described honestly as inactive pills) are effective for a variety of clinical conditions, including pain. However, little is known about patient attitudes towards OLPs. We conducted qualitative interviews with n = 11 patients (73% female) who recently had hand or wrist surgery and took ≥ 1 opioid pill. Interview topics included: pain management, the placebo effect, and in particular, attitudes towards OLPs. Interviews were analyzed inductively and content-coded. Five themes were identified: 1) Role of the mind in pain and illness, 2) Shortcomings of opioids are the strengths of OLPs, 3) Perceptions of OLP effectiveness, 4) Relational aspects of OLP administration, and 5) Practical considerations for OLP implementation. Most patients agreed that, because of their transparency, OLPs are ethical. Participants indicated some degree of reluctance about using OLPs, but the majority said they would take OLPs if prescribed by a doctor. Patients noted that the primary disadvantage of opioids is their potency, which can lead to addiction or side-effects; by contrast, the primary advantage of placebos is their inertness. Results suggest that OLPs appear to be well received as a postoperative pain treatment among the patients in this study. PERSPECTIVE: This qualitative study examines how hand surgery patients view OLPs, which are placebos described honestly as inactive pills. OLPs were generally well received by patients as a treatment for pain after surgery and could be considered as an adjunctive treatment to potentially reduce reliance on prescription opioids.

Spine stereotactic radiosurgery for metastatic thyroid cancer: a single-institution experience.

OBJECTIVE: Patients with metastatic thyroid cancer have prolonged survival compared to those with other primary tumors. The spine is the most common site of osseous involvement in cases of metastatic thyroid cancer. As a result, obtaining durable local control (LC) in the spine is crucial. This study aimed to evaluate the efficacy of spine stereotactic radiosurgery (SSRS) in patients with metastatic thyroid cancer. METHODS: Information on patients with metastatic thyroid cancer treated with SSRS for spinal metastases was retrospectively evaluated. SSRS was delivered with a simultaneous integrated boost technique using single- or multiple-fraction treatments. LC, defined as stable or reduced disease volume, was evaluated by examining posttreatment MRI, CT, and PET studies. RESULTS: A total of 133 lesions were treated in 67 patients. The median follow-up duration was 31 months. Dose regimens for SSRS included 18 Gy in 1 fraction, 27 Gy in 3 fractions, and 30 Gy in 5 fractions. The histology distribution was 36% follicular, 33% papillary, 15% medullary, 13% Hurthle cell, and 3% anaplastic. The 1-, 2-, and 5-year LC rates were 96%, 89%, and 82%, respectively. The median overall survival (OS) was 43 months, with 1-, 2-, and 5-year survival rates of 86%, 74%, and 44%, respectively. There was no correlation between the absolute biological equivalent dose (BED) and OS or LC. Patients with effective LC had a trend toward improved OS when compared to patients who had local failure: 68 versus 28 months (p = 0.07). In terms of toxicity, 5 vertebral compression fractures (2.8%) occurred, and only 1 case (0.6%) of greater than or equal to grade 3 toxicity (esophageal stenosis) was reported. CONCLUSIONS: SSRS is a safe and effective treatment option with excellent LC and minimal toxicity for patients with metastatic thyroid cancer. No association with increased radiation dose or BED was found, suggesting that such patients can be effectively treated with reduced dose regimens.

A giant left atrial mass-Clinical treatment dilemma.

A 74-year-old female current 75 pack-year smoker presented with shortness of breath and mild hemoptysis. Chest computed tomography showed a large right upper lobe mass compressing the superior vena cava, invading the right pulmonary veins, and occupying the majority of the left atrium. Brain magnetic resonance imaging revealed a 13 mm right parietal lesion with surrounding edema consistent with metastasis. A 3D TEE showed a large mobile mass in the left atrium. Bronchoscopy confirmed that the tumor mass was consistent with a moderately to poorly differentiated squamous cell carcinoma. She underwent chemotherapy, radiation, and immune therapy. She was also started on warfarin for anticoagulation after the initial chemotherapy with resolution of the left atrial mass. We feel that the patient most likely had carcinogenic thrombus in the pulmonary veins and left atrium.

Do Patterns of Reconstruction Choices After Mohs Surgery Vary by Specialty? A Pilot Study of Mohs Surgeons and Facial Plastic Surgeons.

BACKGROUND: Differences in approach to repair a specified defect after Mohs micrographic surgery (MMS) between specialties have not been previously examined. OBJECTIVE: To assess the difference in frequency of which reconstruction repairs are selected after MMS, among Mohs surgeons and facial plastic surgeons (FPS), and evaluate whether the level of satisfaction with the final repair outcome differed between specialties. MATERIALS AND METHODS: The study was approved by the Saint Louis University Institutional Review Board. A link to the survey was distributed to members of American College of Mohs Surgery (ACMS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), between January and May 2016. RESULTS: The reconstructive procedure selected most often ("top choice") was not significantly different between Mohs surgeons and FPS for the majority of the images. There was no material difference in how dermatologists and FPS rate the aesthetic outcome of the 3 presented closure types, with the exception of one closure type-nose with graft. CONCLUSION: Mohs surgeons were found to more likely cluster around a single preference for their reconstruction technique compared with FPS, in which a higher percentage of surgeons also selected other options.

Body mass index, depression, and suicidality: The role of self-esteem in bariatric surgery candidates.

BACKGROUND: Previous research suggests a relationship between weight and depression/suicidality, although few studies have examined the mechanisms underlying this association. This study examined the mediating role of self-esteem in the relationship between BMI and depression/suicidality, as well as the moderating role of gender in the mediated pathways. METHODS: As part of a screening process in consideration for bariatric surgery, 3,101 adults (81.4% female, 18.6% male) were assessed one time. Five univariate mediation and five univariate moderated-mediation models were hypothesized and analyzed. For the mediation models, we entered five outcome variables separately: 1) severity of depressed mood, 2) diagnosis of Major Depressive Disorder, 3) lifetime history of suicide attempts, 4) suicidal ideation at the time of evaluation, and 5) severity of suicidality, BMI as the independent variable, and self-esteem as the mediator. For the moderated-mediated models, gender was examined as a moderator to examine whether self-esteem was a stronger mediator for one gender, compared to the other. RESULTS: Findings supported the mediating role of self-esteem across all five outcomes. Further, the mediated effect was moderated by gender, such that the mediation effect was stronger for males, compared to females. LIMITATIONS: The majority of the sample consisted of White females, limiting broad applicability of findings. All variables were assessed simultaneously, at baseline, limiting the ability to make causal attributions. CONCLUSIONS: Study findings suggest that self-esteem may help explain the relationship between BMI and depression/suicidality, particularly for men. Thus, interventions targeting self-esteem may be useful for improving psychological outcomes among those presenting for bariatric surgery.

Spine Stereotactic Radiosurgery for Patients with Metastatic Thyroid Cancer: Secondary Analysis of Phase I/II Trials.

BACKGROUND: Metastatic deposits to the spine in thyroid cancer patients represent the most common site of bone involvement and can contribute to pain, neurologic deficits, and death. This study sought to determine the efficacy and safety of spine stereotactic radiosurgery (SSRS) for thyroid cancer patients. METHODS: Thyroid cancer patients with spine metastases were selected and analyzed from a cohort of patients who were prospectively enrolled in two single-institution Phase I/II studies. SSRS was delivered in single or multi-fraction schedules. Dose regimens ranged from 16-18 Gy in one fraction to 27-30 Gy in three to five fractions. Toxicity was graded according to the NCI-CTC toxicity scale. Local control was determined by serial post-treatment magnetic resonance imaging scans showing no evidence of progressive disease. Patients were followed until date of death or date of last known visit for survival analyses. Local control and overall survival rates were carried out using Kaplan-Meier estimates. The log-rank test was used to assess the equality of the survivor function across groups. A p-value of ≤0.05 was considered to be statistically significant. RESULTS: A total of 27 spine lesions were treated in 23 patients over a six-year period. Median follow-up was 28.9 months (range 5-93 months). Local control was 88% at two years and 79% at three years. In patients with progressive disease following conventional radiation therapy, local control for salvage SSRS remained at 88% at three years. Patients requiring upfront surgical intervention and treated with adjuvant SSRS achieved sustained control rates of 86% at three years. Overall survival rates were 85% and 67% at one and two years, respectively. In patients classified with oligoprogression and controlled extra-spinal disease, overall survival was significantly higher than those with evidence of systemic progression (81% vs. 45% at two years; p = 0.01). Univariate analysis did not show significant correlations between local control and age, systemic disease status, prior (131)I therapy, SSRS fraction regimen, spine location, histological subtype, or time from initial diagnosis to evidence of spinal metastasis. No patient experienced any grade 3-5 toxicity. Pain flare was reported in 30% of patients, with only three patients (13%) requiring narcotics or short-course steroids. There was no evidence of vertebral body fracture in any patient that achieved local control in the treated area. CONCLUSIONS: SSRS for thyroid metastases as a primary or adjuvant/salvage therapy is well tolerated and yields high rates of local control.