Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ in Males: An NCDB Analysis of the Surgical Approach to DCIS in Males.

BACKGROUND: Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS. METHODS: The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier. RESULTS: Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08). CONCLUSIONS: The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.

Axillary management in breast cancer after neoadjuvant chemotherapy in the modern era: A national cancer database analysis.

BACKGROUND: Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced changes in practice. METHODS: Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status. RESULTS: Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017. CONCLUSION: Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist.

Breast infections: A review of current literature.

Breast infections are common, affect women of all ages, and are associated with significant morbidity. Despite overall prevalence, treatment varies significantly based on provider or institution and no central treatment guidelines exist to direct the management of breast infections. This article provides a summary of the current trends in management of breast infections. The etiology, epidemiology, risk factors, presentation, diagnosis, and treatment of mastitis and breast abscesses (and their relative subdivisions) are explored based on the current literature. Trends in microbiology are reviewed and an approach to antibiotic coverage is proposed. Overall, there is a lack of randomized-controlled trials focused on the treatment of breast infections. This has resulted in an absence of clinical practice guidelines for the management of breast abscesses and variable practice patterns. The development of best-care protocols or pathways could provide more uniformity in care of breast infections.

Evaluation of the SmartClip™ Nonradioactive Seed, a Novel Wireless Localization Method for the Breast: Initial Clinical Experience and Surgical Outcome.

INTRODUCTION: Wire localization has been the gold standard for breast localization of non-palpable lesions for decades. This technique remains robust but has disadvantages relative to scheduling, complications of vasovagal reactions in placement, wire migration, or transection. With more modern technologies available, several implantable markers have been developed to allow uncoupling of localization by radiology and the surgical procedure on the same day. This study summarizes our experience with the EnVisio Navigation System™ utilizing SmartClip™ as the implantable tissue localization marker. METHODS: An IRB-approved retrospective database of benign and malignant breast disease was used to perform a review of 100 consecutive patients who underwent SmartClip™ localized breast and axillary procedures in 2021. Demographic information, localization accuracy, associated surgical procedure(s) with resultant pathology findings, margin status for malignancies, and re-excision rate were collected. RESULTS: The localized breast lesion or lymph node was excised and SmartClip™ retrieved in all cases, confirmed by intraoperative specimen radiograph. The distribution of gender and race/ethnicity among the patients who underwent surgery reflects the community population and frequency of breast cancer development among men versus women. 45.1% of the cases involved malignancy, as determined pre-operatively. Positive margins requiring re-excision constituted 18.2% of cases. In twenty-six patients, two or three SmartClips™ were placed per case for either a bracketed lesion, two separate breast lesions, and/or a breast lesion and lymph node. CONCLUSION: Although this study is limited in patient number, it demonstrates safety of this technique and its reliability in guiding the surgeon directly to the lesion(s) of concern.

Clinically significant bleeding complications of percutaneous breast biopsy: 10-year analysis and a proposed management algorithm.

PURPOSE: Bleeding is a well-known risk of percutaneous breast biopsy, frequently controlled with manual pressure. However, significant bleeding complications may require further evaluation or intervention. Our objectives were to assess the rate, type, and periprocedural management of significant bleeding following percutaneous breast biopsy and to evaluate the success of any interventions. METHODS: We retrospectively reviewed percutaneous breast biopsies at our institution over a 10-year period with documented post-biopsy bleeding complications in radiology reports. Patients were included if bleeding required intervention (interventional radiology [IR], surgery, or other), imaging follow-up, or clinical evaluation for symptoms. Additional data included patient demographics, anticoagulation, history of bleeding diathesis, biopsy details, bleeding symptoms, histopathology, and intervention details, if applicable. RESULTS: Of 5820 unique patients who underwent percutaneous biopsy, 66 patients (66/5820; 1.1%) comprising 71 biopsy cases met inclusion for clinically significant bleeding with 5/71(7.0%) requiring surgery, 9/71(12.7%) requiring IR intervention, and 57/71(80.3%) requiring lower-acuity intervention including prolonged observation (5/57;7.0%), overnight admission (4/57;5.6%), aspiration (4/57;5.6%), lidocaine and suture (2/57;2.8%), primary care visit (7/57;10.0%), blood transfusion (1/57;1.4%), emergency room visit (6/57;8.5%), surgery consult (8/57;11.3%), IR consult (2/57;2.8%), and follow-up imaging (22/57;31.0%). Most patients requiring intervention by surgery or IR had acute signs of bleeding immediately after biopsy while most patients with delayed signs of bleeding required lower-acuity interventions. CONCLUSION: Clinically significant bleeding is extremely rare after percutaneous breast biopsy and is most often managed non-surgically. Developing an institutional algorithm for management of bleeding complications that consults IR before surgery may help decrease the number of patients managed surgically.

Lessons from other fields of medicine, Part 1: Breast cancer.

Through the understanding of multiple etiologies, pathologies, and disease progression trajectories, breast cancer shifted historically from a singular malignancy of the breast to a complex of molecular/biological entities, translating into individualized disease-modifying treatments. As a result, this led to various de-escalations of treatment compared with the gold standard in the era preceding systems biology: radical mastectomy. Targeted therapies have minimized morbidity from the treatments and mortality from the disease. Biomarkers further individualized tumor genetics and molecular biology to optimize treatments targeting specific cancer cells. Landmark discoveries in breast cancer management have evolved through histology, hormone receptors, human epidermal growth factor, single-gene prognostic markers, and multigene prognostic markers. Relevant to the reliance on histopathology in neurodegenerative disorders, histopathology evaluation in breast cancer can serve as a marker of overall prognosis rather than predict response to therapies. This chapter reviews the successes and failures of breast cancer research through history, with focus on the transition from a universal approach for all patients to divergent biomarker development and individualized targeted therapies, discussing future areas of growth in the field that may apply to neurodegenerative disorders.

Trends and Outcomes Associated With Axillary Management of Males With Clinical N0 Breast Cancer-An NCDB Analysis.

BACKGROUND: Sentinel Lymph Node Biopsy (SLNB) is standard of care for women with clinically N0 breast cancer. However, there are no randomized controlled studies in men determining optimal surgical axillary management. METHODS: Using the National Cancer Database, males diagnosed from 2006-2016 with clinical T1-4 N0 tumors treated with primary surgery were identified and categorized by axillary management. Clinicopathologic variables were compared between two timeframes, 2006-2011 and 2012-2016. Survival analysis was performed. RESULTS: We identified 2,646 males meeting criteria. Use of SLNB increased (65.9%-72.8%, P < 0.01). For those who underwent ALND, administration of radiation (31.1% versus 48.8%, P < 0.01) and endocrine therapy (70.2% versus 80.7%, P < 0.01) increased. There was no difference in survival between timeframes (P = 0.42). For those who underwent SLNB, tumor grade (P = 0.02) and pathologic T stage (P < 0.01) were higher and more patients underwent mastectomy (74.9% versus 79.4%, P = 0.02). Administration of chemotherapy decreased (35.1% versus 27.2%, P < 0.01) and endocrine therapy increased (72.1% versus 81.3%, P < 0.01). Survival of those who underwent sentinel lymph node biopsy (SLNB) diagnosed 2012-2016 was worse than those diagnosed 2006-2011 (P = 0.01). CONCLUSIONS: Use of SLNB alone has increased while ALND has declined in males with clinically N0 breast cancer. However, patients who underwent SLNB alone in the later time period had worse clinical characteristics and experienced differences in adjuvant therapy. This suggests increased acceptance of the use of SLNB for axillary management. Further analysis is warranted to evaluate methods of axillary staging and the impact on outcomes in males with breast cancer.

National trends for axillary lymph node dissection and survival outcomes for clinical T3/T4 node-negative breast cancer patients undergoing mastectomy with positive lymph nodes.

PURPOSE: Previous studies have suggested axillary lymph node dissection (ALND) can be omitted in early breast cancer patients undergoing mastectomy with positive lymph nodes (LNs). We assessed the national utilization of ALND and overall survival (OS) for larger, locally advanced tumors in patients undergoing mastectomy with positive LNs. METHODS: The National Cancer Database from 2006 to 2016 was queried for mastectomy patients with clinical T3/T4, N0 tumors, and 1-2 positive LNs. Trends and outcomes for ALND were compared to sentinel lymph node biopsy (SLNB) alone. RESULTS: Thousand nine hundred and seventeen women were included. The proportion of ALND decreased from 70% pre-Z0011 to 52% post-Z0011. On Kaplan-Meier analysis, ALND had better OS compared to SLNB alone (p < 0.01). On multivariate analysis, age (p < 0.01), chemotherapy (p < 0.01), and hormonal therapy (p < 0.01) were associated with better OS. In patients who received adjuvant radiation therapy (ART) ALND improved OS on multivariate analysis (p < 0.01). CONCLUSION: This is the first large database study to demonstrate a national trend to forego ALND in mastectomy patients with large or locally advanced tumors (T3/T4abc) and 1-2 positive lymph nodes. This study suggests a survival benefit for ALND, particularly in patients receiving ART. Careful consideration and further investigations should be performed prior to omitting ALND this patient population.

Characteristics of General Surgery Social Media Influencers on Twitter.

BACKGROUND: The influence of social media and Twitter in general surgery research, mentorship, networking, and education is growing. Limited data exist regarding individuals who control the dialogue. Our goal was to characterize influencers leading the discussion in general surgery. METHODS: Right Relevance Insight API was searched for "general surgery," and individual influencers were ranked by a comprehensive assessment of connections (followers/following) and engagement (likes, retweets, and comments). Profession, specialty, gender, and location were collected utilizing Twitter, Doximity, LinkedIn, ResearchGate, and institutional websites. American Board of Surgery and Royal College of Physicians and Surgeons of Canada were queried for board certification and academic h-index scores were acquired from Scopus. RESULTS: Eighty-eight individual influencers in general surgery were identified, with 73 holding positions in general surgery. Attending level general surgeons comprised 50%, of which 91% are board certified, and 94% completed a fellowship (surgical oncology, laparoscopic surgery, critical care/trauma, and colorectal surgery). Residents comprised 31%; 11% were nonsurgeons and 3% were not physicians. The majority of residents and fellow influencers were female (72%). Many general surgery influencers were international (51%), particularly Canadian (28% overall). The academic h-indices for these influencers (n = 73) ranged from 0 to 73 (mean 14.5 ± 8.2; median 9.5). DISCUSSION: Our data describe the positions, backgrounds, and research contributions of the top Twitter influencers in general surgery. Those engaged in social media should consider the background, expertise, and motivation of these influencers as the utilization and impact of this platform grows.

The road to academic surgical leadership: Characteristics and experiences of surgical chairpersons.

BACKGROUND: The evolving landscape of academic surgery demands leaders who are not only effective clinicians and researchers, but also administrators able to navigate complex hospital organizations, financial pressures in the era of quality measures, and inclusion of an increasingly diverse workforce. The aim of this study was to characterize achievements and assess perspectives in becoming a surgical chair in order to guide young surgeons in their career trajectories to surgical leadership. METHODS: A survey encompassing demographics, surgical training, nonmedical advanced degrees, academic advancement, and leadership experiences was sent via electronic mail to members of the American College of Surgeons Society of Surgical Chairs in December 2018. RESULTS: Of 191 Society of Surgical Chairs members, 52 (27.2%) completed the survey, with 6 (11.5%) women, 40 (76.9%) white, and the majority becoming chair between ages 46 and 60 (n = 39, 75.0%). Training beyond residency included fellowships (n = 41, 78.8%) and advanced nonmedical degrees (n = 15, 28.8%). Median H-index was 47 (range 10-120) with 126 (5-500) research publications, and grants received was 2 (0-38) for federal and 5 (0-43) for industry. Female chairs appear to have fewer nonmedical degrees (n = 1) and no difference in age at becoming chair (66.7% vs 79.6% between ages 46 and 60), H-index (26 [10-41] vs 49 [17-120]), or publications (93 [10-189] vs 150 [5,500]). Prior educational (n = 36, 69.2%) and clinical (n = 44, 84.6%) leadership roles were common, with 30 chairs (57.7%) having held both roles. Experiences which respondents felt have most helped them function as chair included serving as a clinical division director (n = 37, 71.2%), residency program director (n = 28, 53.8%), leadership courses (n = 28, 53.8%), a research career (n = 22, 42.3%), and being a vice/interim chair (n = 15, 28.8%). Personal traits felt to be most important in becoming a successful chair included being effective at communication (n = 37, 71.2%), collaborative (n = 35, 67.3%), trustworthy (n = 30, 57.7%), and a problem-solver (n = 27, 51.9%). CONCLUSION: Becoming a department surgical chair often involves not only surgical subspecialty expertise, but also nonmedical training and prior leadership roles, which help facilitate development of skills integral to navigating the collaborative and diverse nature of academic surgery in the current era.

National Trend of Axillary Management in Clinical T3/T4 N0 Patients Having Breast Conserving Therapy.

BACKGROUND: The ACOSOG Z0011 trial has essentially eliminated axillary lymph node dissection (ALND) in breast conserving therapy (BCT) patients with clinical T1/T2 and 1-2 positive sentinel lymph nodes (SLNs). Currently, ALND is recommended for positive SLNs unless ACOSOG Z0011 criteria are applicable. We aimed to assess the national trends and axillary management before and after the publication of ACOSOG Z0011 for larger tumors. METHODS: An IRB-approved study evaluated the National Cancer Database from 2006 to 2016. Women with clinical T3/T4, N0 who otherwise fit ACOSOG Z0011 criteria were included. Neoadjuvant systemic therapy or known nodal disease was excluded. Clinicopathologic data were compared between two timeframes based on ACOSOZ Z0011 publication and by axillary management. Patients were categorized into SLNB alone (1-5 lymph nodes examined) and ALND (≥10 lymph nodes examined) groups. RESULTS: A total of 230 women fit inclusion criteria, of whom 36% underwent ALND. ALND use decreased from 54% in 2006 to 14% in 2016 (P < 0.01). Comparing ALND to SLNB alone within the pre-Z0011 era, comprehensive community cancer programs had higher proportions of ALND, whereas academic centers had higher rates of SLND alone (P = 0.03). Comparing similar axillary management between eras, SLNB-alone patients in the post-Z0011 era had higher pT and pN stages, were less likely to be Her2 positive, and were more likely to receive systemic treatment. CONCLUSIONS: There is a national trend to forgo ALND in women who have tumors larger than those included in the Z0011 criteria without any clear clinicopathologic indications.

Screening of populations at high risk for breast cancer.

The approach to screening patients at high risk for breast cancer has thus far been challenging to standardize, given limited high-level evidence in this population. The approach has evolved given the development of more effective screening modalities, including digital breast mammography, magnetic resonance imaging, and other emerging technologies. This review will discuss identification of high-risk patients, approaches to genetic counseling and testing, and evidence behind screening modalities and algorithms in this special population.

Characteristics and diagnosis of pregnancy and lactation associated breast cancer: Analysis of a self-reported regional registry.

BACKGROUND: Pregnancy-associated breast cancer (PABC) is the most common malignancy in pregnancy. However due to its infrequent occurrence, PABC continues to be poorly understood. METHODS: We performed a retrospective study using self-reported data from 1079 eligible women in a regional breast cancer registry. RESULTS: The PABC cases were more likely than non-PABCs to be younger than age 35 and have nodal involvement at diagnosis. Despite diagnosis at a young age, there was not an association between PABC and family history. For method of diagnosis, PABC was found on self-exam, while non-PABCs were found on mammography. CONCLUSION: In conclusion, PABC is rarely detected by mammography and diagnosis is highly dependent on detection during self-breast exam. Women who are or recently were pregnant should be encouraged to perform regular self-breast exams to report any changes for further evaluation. Patient and clinician education regarding risk and realities of PABC is essential.

Incidence and predictors of neuropathic pain following breast surgery.

PURPOSE: Neuropathic pain (NPP) following breast surgery extends morbidity in the postoperative period. The incidence and etiology of postoperative NPP remains unclear and under-reported in literature. This study aims to define the incidence of neuropathic pain following breast surgery and to identify patient characteristics that are predictors for developing postoperative NPP. METHODS: Consecutive female patients undergoing breast resection surgery over a 5-year period (2008-2012) with 1-year minimum follow-up were included in this single-center study. Retrospective chart review was performed to identify patient specific characteristics including the development of post-operative NPP. Data was analyzed using univariate and multivariate logistic regression. RESULTS: A total of 470 patients were identified for study inclusion. The incidence of postoperative NPP was 14.7 % (69 of 470). Significant predictors for the development of postoperative NPP in the univariate analyses included history of diabetes mellitus, diabetic neuropathy, or fibromyalgia, concomitant axillary surgery, axillary node dissection, and taxane-based chemotherapy regimen. Multivariate analysis identified African American race [odds ratio (OR) = 1.78; 95 % CI = 1.01-3.17; p = 0.05), history of diabetes mellitus (OR = 1.98; 95 % CI = 1.0-3.74; p = 0.01) or fibromyalgia (OR = 2.75; 95 % CI = 1.13-6.69; p = 0.03), and taxane-based chemotherapy regimen (OR = 2.85; 95 % CI = 1.23-6.58; p = 0.01) as being independently associated with the development of postoperative NPP. CONCLUSIONS: NPP is a significant risk following breast surgery. African American race, history of either diabetes mellitus or fibromyalgia, and treatment with taxane-based chemotherapy regimens are all associated with an increased risk of NPP.

The changing face of mastectomy: an oncologic and cosmetic perspective.

BACKGROUND: The history of surgical treatment of breast cancer is rich with contributions from many surgeons over the centuries. Among the recent advances in technique is the nipple-sparing mastectomy, which reflects the emerging focus on cosmetic outcomes. METHODS: We took a backward glance at the literature illustrating the evolution of surgical management of breast cancer, culminating with nipple-sparing mastectomy. The growing clinical data with nipple-sparing mastectomy are explored. RESULTS: The demand for nipple-sparing mastectomy has been steadily increasing at many institutions. Based on the clinical data reported, nipple-sparing mastectomy is an oncologically safe procedure for selected women who have or are at high risk for breast cancer. CONCLUSIONS: For women facing mastectomy and their surgeons, the optimal aesthetic result centers on preservation of the nipple. However, nipple-sparing mastectomy is technically challenging, with long-term safety not yet confirmed. Evidence-based data are needed to document local tumor recurrence, distant metastasis, cosmetic outcomes, patient satisfaction, and procedural complications.

Excellent outcomes with adjuvant toremifene or tamoxifen in early stage breast cancer.

BACKGROUND: Fareston (toremifene) and tamoxifen, both selective estrogen receptor modulators, are therapeutically equivalent treatments for metastatic breast cancer. We hypothesized that toremifene as compared with tamoxifen given as adjuvant therapy for early stage breast cancer would result in equivalent survival with an improved side effect profile, therefore, providing superior therapeutic efficacy. METHODS: The North American Fareston versus Tamoxifen Adjuvant trial assigned 1813 perimenopausal or postmenopausal women with hormone receptor (HR)-positive invasive breast cancer to adjuvant treatment with either tamoxifen or toremifene. The primary outcomes evaluated were disease-free survival (DFS) and overall survival (OS). RESULTS: Median follow-up was 59 months. The baseline characteristics of the 2 treatment groups were well-balanced. On the basis of intent-to-treat, 5-year actuarial DFS was not significantly different between tamoxifen and toremifene (91.2% [standard error of the mean [SE] 1.2%] vs 91.2% [SE 1.1%], respectively). Similarly, 5-year actuarial OS was not significantly different between tamoxifen and toremifene (92.7% [SE 1.1%] vs 93.7% [SE 1.0%], respectively). Controlling for patient age, tumor size, and tumor grade, a Cox multivariate survival analysis found no difference between patients randomized to toremifene versus tamoxifen in terms of OS (OR = 0.951; 95% confidence interval [CI], 0.623-1.451, P = .951) or DFS (OR = 1.037; 95% CI, 0.721-1.491, P = .846). Adverse events were similar in the 2 groups. CONCLUSIONS: Women treated with adjuvant hormonal therapy enjoyed excellent DFS and OS. No significant differences were found between treatment with either tamoxifen or toremifene. Treatment of HR-positive patients with either tamoxifen or toremifene is appropriate.

Traumatic diaphragmatic injury: experience from a level I trauma center.

OBJECTIVE: Traumatic diaphragmatic injuries (TDI) are uncommon but associated with substantial morbidity and mortality. We sought to analyze patients with TDI at a large trauma center and associated county coroner to identify characteristics predictive of increased mortality. METHODS: We queried a level I university trauma center and associated county coroner databases containing >20,000 patients to identify patients with ICD-9 diagnoses pertaining to TDI from January 1992 through May 2005. Once identified, hospital records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the Student t-test, chi-square analysis, analysis of variance, and multiple logistic regression. RESULTS: TDI were identified in 254 individuals. Two hundred (79%) survived to undergo operation. Of the 81 (32%) deaths, 33 (41%) occurred before arrival at the trauma center. Survivors were younger, had lesser injury severity scores (ISS), were more likely to be female, and had more bilateral injuries (P < or = .002 all) than nonsurvivors. By multiple logistic regression analyses, increased age (odds ratio [OR], 1.044; 95% confidence interval [CI], 1.015-1.074; P = .0029) and greater ISS (OR, 1.145; 95% CI, 1.103-1.188; P < .0001) were predictors of the probability of death in all patients. CONCLUSION: Although TDI may indicate substantive trauma burden in any patient, those with greater ISS and advanced age are at the greatest risk of death.

The University of Cincinnati College of Medicine Department of Surgery.

The University of Cincinnati College of Medicine Department of Surgery has a legacy of discovery, transformation, and education that began more than 200 years ago. Through collaborations with related disciplines at the University of Cincinnati, industry, the government and military, as well as our partners in the community, we look forward to new innovations to continue the legacy and our ongoing mission to provide the best possible surgical care, research, and education of our future surgeon leaders. Our mission remains: 1) To provide comprehensive surgical services for Cincinnati and the surrounding region; 2) To train the next generation of surgeon leaders; 3) To advance the state-of-the-art and scientific basis of the discipline of surgery; and 4) To provide leadership in ensuring surgical health care for all members of the Cincinnati community. These principles have always been part of our legacy and ongoing challenges as an academic department of surgery. It is a proud tradition that we embrace and will carry into the future.