Clinical Longevity of Preoperative Injection of Superparamagnetic Iron Oxide Nanoparticles for Delayed Sentinel Lymph Node Biopsy.

Diagnosis of ductal carcinoma in situ (DCIS) represents about 25% of newly diagnosed breast cancers. There is debate about the benefit of sentinel lymph node biopsy (SLNB) for further staging and guidance of therapy in patients with DCIS. Current guidelines recommend SLNB for patients undergoing breast-conserving therapy (BCT) for DCIS. Utilizing superparamagnetic iron oxide (SPIO) nanoparticles as a tracer may allow for a delayed SLNB (d-SLNB), typically within a month of injection. We present our experience with a patient who due to complications from surgery could not complete her d-SLNB for 165 days. The SPIO tracer remained active in the lymph node and remained clinically useful for this five and a half month gap from time of injection. Further study is needed to determine the clinical longevity of SPIO in a lymph node.

A Gravid Situation: General Surgery Faculty Support for Pregnant Surgical Residents.

INTRODUCTION: The perceptions of teaching faculty toward pregnant general surgery residents have been overlooked despite the daily interactions amongst these groups. METHODS: A 32-question survey designed to measure general surgery teaching faculty perceptions toward pregnant residents was distributed electronically from March 2022 to April 2022 to general surgery teaching faculty in the United States. Descriptive statistics were used to characterize responses and differences in perceptions, and qualitative analysis identified recurring themes from free-text responses. RESULTS: Among 163 respondents included in the final analysis, 58.5% were male and 41.5% were female. Despite 99.4% of surgeons feeling comfortable if a resident told them they were pregnant, 22.4% of surgeons disagreed that their institutions have supportive cultures toward pregnancy. Almost half (45.4%) have witnessed negative comments about pregnant residents and half (50.3%) believe that pregnant surgical residents are discriminated against by their coresidents. Nearly two-thirds of surgeons (64.8%) believe that someone should have a child whenever they wish during training. Given recent reports, 80.2% of surgeons recognized that female surgeons have increased risks of infertility and pregnancy complications. Recurring themes of normalizing pregnancy, improving policies, and creating a culture change were expressed. CONCLUSIONS: In this national survey, although there appears to be positive perceptions of pregnancy in surgical training amongst those surveyed, there is acknowledged necessity of further normalizing pregnancy and improving policies to better support pregnant residents. These data provide further evidence that though perceptions may be improving, changes are still needed to better support pregnancy during training.

Luminal A Versus B After Choosing Wisely: Does Lymph Node Surgery Affect Oncologic Outcomes?

BACKGROUND: In 2016, the Choosing Wisely campaign recommended against routine sentinel lymph node biopsy (SLNB) in women ≥ 70 years old diagnosed with early-stage hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer. No distinction is made between luminal A and luminal B phenotypes, despite luminal B being considered more aggressive. This study evaluates the effect of SLNB on oncologic outcomes in HER2- luminal B versus luminal A breast cancer. PATIENTS AND METHODS: We performed an IRB-approved, single institution, retrospective cohort study from 2010 to 2020 of women aged ≥ 70 years with clinically node negative, HR+ breast cancer undergoing definitive surgical treatment. Luminal status was defined by gene expression panel testing, Ki67%, and/or pathologic grading. Primary endpoints included locoregional recurrence (LRR), disease free survival (DFS), and overall survival (OS). RESULTS: SLNB did not correlate with significant differences in LRR in luminal A (p = 0.92) or luminal B (p = 0.96) disease. SLNB correlated with improved DFS (p < 0.01) and OS (p < 0.001) in luminal A disease, but not in luminal B disease (DFS p = 0.73; OS p = 0.36). On multivariate analysis, age (HR = 1.17; p < 0.01) and tumor size (HR = 1.03; p < 0.05) were associated with DFS, while SLNB was not (p = 0.71). Luminal status (HR = 0.52, p < 0.05), age (HR = 1.15, p < 0.01), and comorbidities (HR = 1.35, p < 0.05) were associated with OS, but not SLNB (p = 0.71). CONCLUSIONS: Our results suggest that SLNB may be safely omitted in patients aged ≥ 70 years with luminal B disease given similar LRR in luminal A disease. Our findings suggest that DFS and OS are driven by tumor biology, patient age, and comorbidities rather than receipt of SLNB.

Concordant care in sentinel lymph node omission following Choosing Wisely® recommendations at a comprehensive cancer center.

BACKGROUND: In 2016, the SSO and ABIM released a Choosing Wisely® guideline stating SLNB can be safely omitted in women ≥70 with HR â€‹+ â€‹HER-invasive breast cancer. No study evaluating concordance of care with this guideline has been performed within a comprehensive cancer center. METHODS: From 2005 to 2020, there were 382 patients with cT1-2N0 invasive carcinoma ER+/PR+ and HER2-identified as having undergone SLNB. These patients were then separated into two groups; those in the pre-guideline concordance cohort (2005-2015) and those in the post-guideline concordance (2016-2020) cohort. Axillary management concordance was trended over time. RESULTS: 382 patients from 2005 to 2020 with HR â€‹+ â€‹HER- IBC were identified. No difference was seen in SLNB pre-versus post-guidelines (p â€‹= â€‹0.35). Increased concordance was noted as age increased (p â€‹= â€‹0.0068) and adjuvant radiation therapy exclusion (p â€‹< â€‹0.0001) post-guideline release. Concordance improved over the years post-guideline release (R2 â€‹= â€‹0.45). CONCLUSIONS: Surgical guideline adoption occurs over time but may also be affected by outside decisions and factors. Further study into patterns of guideline adoption may facilitate improving adherence to guidelines.

Contralateral Prophylactic Mastectomy Decision-Making: The Partners' Perspective.

BACKGROUND: The rate of contralateral prophylactic mastectomy (CPM) continues to rise despite no improvement in survival, an increased risk of surgical complications, and negative effects on quality of life. This study explored the experiences of the partners of women who undergo CPM. METHODS: This study was part of an investigation into the factors motivating women with early-stage unilateral breast cancer and low genetic risk to opt for contralateral prophylactic mastectomy (CPM). Participating women were asked for permission to invite their partners to take part in interviews. In-depth interviews with partners were conducted using a semi-structured topic guide. A thematic analysis of the data was performed RESULTS: Of 35 partners, all men, 15 agreed to be interviewed. Most perceived their role to be strong and logical. Some hoped their wives would choose a bilateral mastectomy. All felt strongly that the final decision was up to their partners. The partners often framed the decision for CPM as one of life or death. Thus, any aesthetic effects were unimportant by comparison. The male partners had difficulty grasping the physical and emotional changes inherent in mastectomy, which made communicating about sexuality and intimacy very challenging for the couples. In the early recovery period, some noted the stress of managing home life. CONCLUSIONS: The experiences of the male partners provide insight into how couples navigate complex treatment decision-making, both together and separately. There may be a benefit to including partners in pre- and post-surgical counseling to mitigate miscommunication regarding the expected oncologic and emotional outcomes related to CPM.

General Surgery Faculty Knowledge and Perceptions of Breast Pumping Amongst Postpartum Surgical Residents.

BACKGROUND: There is a lack of data regarding the knowledge and perceptions teaching faculty possess about breast pumping among general surgery residents despite breast pumping becoming more common during training. This study aimed to examine faculty knowledge and perceptions of breast pumping amongst general surgery residents. METHODS: A 29-question survey measuring knowledge and perceptions about breast pumping was administered online to United States teaching faculty from March-April 2022. Descriptive statistics were used to characterize responses, Fisher's exact test was used to report differences in responses by surgeon sex and age, and qualitative analysis identified recurrent themes. RESULTS: 156 responses were analyzed; 58.6% were male and 41.4% were female, and the majority (63.5%) were less than 50 years old. Nearly all (97.7%) women with children breast pumped, while 75.3% of men with children had partners who pumped. Men more often than women indicated "I don't know" when asked about frequency (24.7 vs. 7.9%, p = 0.041) and duration (25.0 vs. 9.5%, p = 0.007) of pumping. Nearly all surgeons are comfortable (97.4%) discussing lactation needs and support (98.1%) breast pumping, yet only two-thirds feel their institutions are supportive. Almost half (41.0%) of surgeons agreed that breast pumping does not impact operating room workflow. Recurring themes included normalizing breast pumping, creating change to better support residents, and communicating needs between all parties. CONCLUSIONS: Teaching faculty may have supportive perceptions about breast pumping, but knowledge gaps may hinder greater levels of support. Opportunities exist for increased faculty education, communication, and policies to better support breast pumping residents.

Surveillance Mammography Behaviors in Black and White Breast Cancer Survivors: Behavioral Risk Factors and Surveillance System, 2016.

BACKGROUND: Surveillance mammography is recommended annually for early detection of disease relapse among breast cancer survivors; yet Black women have poorer national rates of surveillance mammography compared to White women. Factors that influence racial disparities in surveillance mammography rates are poorly understood. The purpose of this study is to evaluate the contribution of health care access, socioeconomic status, and perceived health status on adherence to surveillance mammography among breast cancer survivors. METHODS: This is a secondary analysis of a cross-sectional survey among Black and White women ≥ 18 years, who reported a breast cancer diagnosis and completed breast surgery and adjuvant treatment from the 2016 Behavioral Risk Factor Surveillance System National Survey (BRFSS). Bivariate associations (chi-squared, t-test) for independent variables (e.g., health insurance, marital status) were analyzed with adherence to nationally recommended surveillance guidelines defined as two levels: adherent (received a mammogram in the last 12 months), vs. non- adherent ("received a mammogram in the last 2-5 years, 5 or more years or unsure). Multivariable logistic regression models were used to evaluate the relationship between study variables with adherence, while adjusting for potential confounders. RESULTS: Of 963 breast cancer survivors, 91.7% were White women with an average age of 65. 71.7% reported a surveillance mammogram in the last 12 months, while 28.2% did not. Diagnosed > 5 years (p < 0.001); not having a routine checkup visit within 12 months (p = 0.045); and not seeing a doctor when needed due to cost (p = 0.026), were significantly related to survivor's non-adherence to surveillance mammography guidelines. A significant interaction was found between race and residential area (p < 0.001). Compared to White women, Black women living in metropolitan/suburban residential areas were more likely to receive surveillance guidelines (OR:3.77;95% CI: 1.32-10.81); however Black women living in non-metropolitan areas were less likely to receive a surveillance mammogram compared to White women living in non-metropolitan areas (OR: 0.04; 95% CI: 0.00-0.50). CONCLUSION: Findings from our study further explain the impact of socioeconomic disparities on racial differences in the use of surveillance mammography among breast cancer survivors. Black women living in non-metropolitan counties are an important subgroup for future research and screening and navigation interventions.

Support for cancer prevention public health policies: results from a nationally representative sample of residents in the United States.

Assessing public support of health policies designed to reduce cancer risk is important for policy implementation. This study aimed to identify support for cancer prevention policies and factors associated with support. Data were obtained from the Health Information National Trends Survey. Support for three types of cancer prevention policies were evaluated: tobacco, alcohol, and junk food regulations. Linear and logistic regression analyses were employed to assess the relationship between support for the different types of policies and sociodemographic, lifestyle behaviors, and cancer beliefs. Certain policies, such as providing warning labels on cigarettes (69.9% support) and requiring specific health warnings on alcohol containers (65.1% support), were popular. Banning outdoor advertising of alcohol was not popular (34.4% support). There were individual differences associated with policy support. For example, respondents who were 75 years or older (B = 0.61, p < .001) or female (B = 0.14, p < .008) were more likely to support tobacco polices compared to their counterparts (i.e., younger or male). Respondents who identified as politically conservative (B = -0.20, p < .004) or those who endorsed high cancer fatalistic beliefs (e.g., there's not much you can do to lower your chances of getting cancer, B = -0.07, p < .012) were less likely to support alcohol policies compared to those who were liberal or had lower cancer fatalistic beliefs. Generally, support was high for most policy questions. However, support varied by different individual factors. The findings also highlight that there may be opportunities to increase understanding and awareness about cancer prevention policies, especially among some segments of the population.

It is important to assess public support of cancer preventive health policies and to know which factors, such as individual characteristics (e.g., gender and political orientation) health behaviors, and cancer beliefs, are associated with support. In this study, we assessed support of cancer prevention policies and examined different factors possibly associated with support. We analyzed data from the Health Information National Trends Survey, a nationally representative dataset. Since there were multiple questions related to support of tobacco and alcohol policies, we combined each set of questions to create two combined scores, with higher scores indicating more support. We examined the policy related to junk food individually. We found certain policies, such as including warning labels on cigarettes, were popular, with over 60% support. However, there were group differences. For example, women and those aged 55 years or older were more supportive of policies, while politically conservative respondents were less supportive of policies. Beliefs about cancer were also associated with policy support. For example, those who believed "there's not much you can do to lower your chances of getting cancer" were less supportive compared to those without that belief. These findings may help inform future policy research and public health campaigns.

Margin Management and Adjuvant Therapy for Phyllodes Tumors: Practice Patterns of the American Society of Breast Surgeons Members.

BACKGROUND: Phyllodes tumors (PTs) are rare breast neoplasms with variable clinical behavior by histologic type: benign, borderline, or malignant. Until recently, management guidelines recommended one approach for all subtypes. METHODS: A 21-question survey was sent to American Society of Breast Surgeon members to evaluate management patterns by subtype. Surgeon demographics, decisions regarding management of margins, re-excision, surveillance, and synoptic reporting were collected. Chi-square or analysis of variance (ANOVA) were used as appropriate, with significance set at p < 0.05. RESULTS: A total of 493 of 2969 surveys were completed for a response rate of 18.3%. Among the survey takers, 55% were fellowship trained, 72% were in practice > 10 years, and 82% performed > 100 breast cases per year. Although 25% of respondents enucleate a mass with clinical suspicion of a PT alone, this decreased to 18% if a preoperative core biopsy performed was suggestive of PT. For margin management, 47% do not re-excise positive margins for benign PTs, but 96% would for a borderline or malignant PTs (p < 0.001). Only 2% perform axillary staging for malignant PTs, and 90% refer borderline or malignant PTs for radiation. Two-year surveillance was performed by about half of respondents for benign PT. However, two-thirds of respondents would increase surveillance to 5 years for borderline or malignant PTs. Only 38% report a templated synoptic pathology report at their institution. CONCLUSION: PT management patterns are evolving but still variable when looking at initial margin intent, decision for re-excision, radiation referral, pathologic reporting, and surveillance. This suggests the need for more specific management guidelines by subtype given differences in clinical behavior.

Eat, sleep, play: health behaviors and their association with psychological health among cancer survivors in a nationally representative sample.

BACKGROUND: Cancer survivors are able to live much longer today than in the past due to advances in treatment. The promotion of health behaviors is important to address among cancer survivors. Not only can health behaviors reduce the risk of comorbidities, but they may also be key to improving psychological health among cancer survivors, such as psychological distress, perceptions of one's general health, and distress of cancer mortality (i.e., cancer fatalism). Our overall goal is to 1) determine which individual health behaviors (e.g., fruit consumption, physical activity, and sleep) are associated with psychological health among cancer survivors and 2) determine if the number of health behaviors engaged in is associated with better psychological health among cancer survivors. METHODS: Using data from the HINTS 5 Cycle III survey (N = 856 cancer survivors), we compared whether participants who met guidelines for seven health behaviors (e.g., fruit and vegetable consumption, moderate physical activity, sleep duration) had improved psychological health. Multiple ordinal regression models controlling for sociodemographic variables were used to determine if meeting more recommendations was related to psychological health and then specifically which behaviors were of greatest importance to psychological health. RESULTS: Meeting guidelines for sleep quality and moderate physical activity was associated with higher general health and meeting guidelines for vegetable intake and better sleep quality was associated with less psychological distress. Although the associations were not significant, cancer survivors who met more of the health behavior guidelines reported higher general health, lower psychological distress, and less distress about what could be done to lower one's chances to get cancer. CONCLUSIONS: Meeting the guidelines for individual and multiple health behaviors is associated with favorable psychological health among cancer survivors. The findings can contribute to the development of health behavior interventions that focus on multiple health behaviors to improve psychological health and quality of life among cancer survivors.

The Impact of Preoperative Breast Volume on Development of Mastectomy Skin Flap Necrosis in Immediate Breast Reconstruction.

BACKGROUND: Mastectomy skin flap necrosis (MSFN) can significantly impact outcome after immediate breast reconstruction. Several techniques exist to predict MSFN, but these may require additional testing and information, and they are often not available before surgery. We aim to identify whether breast volume, as calculated from preoperative mammography, can be used as a preoperative predictor of MSFN. METHODS: A retrospective chart review from 2010 to 2020 resulted in 378 patients who underwent immediate implant-based breast reconstruction. Complete imaging data were available for 278 patients and 441 reconstructed breasts. Demographic, perioperative, and outcomes data were collected. Measurements from preoperative diagnostic mammograms were used to calculate breast volume. Univariate and multivariate analyses were used to evaluate the association of variables available preoperatively, including breast volume from mammogram and MSFN. Secondary analyses were performed for need for reoperation and loss of reconstruction. RESULTS: On univariate analysis of MSFN development, demographic variables found to be significantly associated with MSFN included body mass index (P = 0.04), diabetes (P = 0.03), and breast volume calculated from routine mammography (P ≤ 0.0001). Average preoperative breast volume via mammography without and with MSFN was 970.6 mL (95% confidence interval [CI], 908.9-1032.3) and 1298.3 mL (95% CI, 1140.0-1456.5) (P < 0.0001), respectively. Statistically significant intraoperative variables for MSFN development included prolonged operative time (P = 0.005), greater initial tissue expander fill volumes (P ≤ 0.001), and prepectoral implant location (P = 0.02). Higher initial tissue expander fill volumes in implant-based reconstructions were associated with increased rates of MSFN, 264.1 mL (95% CI, 247.2-281.0) without MSFN and 349.9 mL (95% CI, 302.0-397.8) in the group with MSFN, respectively (P < 0.001). On multivariate analysis, preoperative imaging volume (P = 0.02) was found to be significant, whereas body mass index and diabetes lost significance (P = 0.40) in association with MSFN. CONCLUSIONS: The results of this study establish an association between larger breast volume on preoperative imaging and development of MSFN. This may be useful as a tool for more appropriate patient selection and guidance in the setting of immediate breast reconstruction.

Invasive stage III breast implant-associated anaplastic large cell lymphoma successfully treated with incomplete resection.

A woman with history of bilateral breast augmentation 15 years prior presented with right breast swelling, peri-implant effusion and a palpable inferomedial mass. Effusion aspiration demonstrated pleiomorphic cells consistent with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Further diagnostic studies confirmed stage III disease with a 4.7 cm right breast mass and fluorodeoxyglucose uptake in an internal mammary chain lymph node. The patient underwent surgery with incomplete resection due to invasion of the chest wall followed by chemotherapy and radiation therapy. BIA-ALCL typically presents as an indolent effusion, however advanced disease carries a worse prognosis. This case highlights successful treatment without recurrence past the one-year mark as well as the need for multidisciplinary management when dealing with advanced disease.

Prospective Evaluation of Radar-Localized Reflector-Directed Targeted Axillary Dissection in Node-Positive Breast Cancer Patients after Neoadjuvant Systemic Therapy.

BACKGROUND: This is a prospective, single-institution study to evaluate feasibility and accuracy of radar-localized reflector (RLR)-targeted axillary dissection (TAD) in node-positive breast cancer patients after neoadjuvant systemic therapy (NST). METHODS: Patients with biopsy-proven T1-2, N1-3 disease were eligible. Before NST, a marker clip and/or RLR was placed into the positive node. After NST, RLR was inserted if not placed previously. All patients underwent RLR TAD followed by axillary lymph node dissection (ALND). Primary end points of the trial were feasibility of RLR TAD and false negative rate (FNR). RESULTS: Between 2017 and 2021, 101 patients with N1-3 disease underwent NST. Five patients withdrew from the study, 1 was ineligible, and there were 9 technical failures, thus our final study cohort comprised 86 patients. RLR TAD was performed with probe guidance and confirmed with intraoperative specimen radiograph. After RLR TAD, ALND was performed. Median number of RLR TAD nodes removed was 2 (range 1-10), and the RLR TAD nodes remained positive in 56 patients. Median number of ALND nodes removed was 18 (range 4-46). Accounting for 9 technical failures, feasibility was 90%. All technical failures occurred with attempted placement of RLR after NST. Feasibility rate was 100% when RLR placement occurred at diagnosis. Of the evaluable 86 patients, RLR TAD accurately predicted axillary status in 83 patients, with FNR of 5.1%. CONCLUSION: We demonstrate high accuracy of RLR TAD, especially when RLR is placed before NST. For patients who present with N1-3 disease, this is another step towards axillary surgery de-escalation strategies.

The Value of Tyrer-Cuzick Versus Gail Risk Modeling in Predicting Benefit from Screening MRI in Breast Cancer.

OBJECTIVE: Breast cancer is the most commonly diagnosed malignancy in US women. Risk assessment tools such as the Gail and Tyrer-Cuzick (TC) models calculate risk for breast cancer based on modifiable and non-modifiable factors in order to guide screening and prevention for high-risk patients. Screening with magnetic resonance imaging (MRI) in addition to mammography is recommended in high-risk patients (>20% lifetime risk on TC or other familial based models). Currently, no published data indicate these recommendations improve cancer detection. MATERIALS AND METHODS: With the aim to determine what percentage lifetime risk (LR%) is associated with a statistically significant increase in cancer detection, the Virginia Commonwealth University (VCU) breast imaging database was reviewed to identify patients who received screening MRI. RESULTS: The receiver operating characteristics (ROC) curves for the Gail and TC models and the rate of cancer detection correlated to 20% LR% were calculated. The Gail model was considered the control model as it is NOT considered a validated screening tool for MRI. TC is not more accurate than Gail when predicting benefit of breast MRI screening. (area under the curve (AUC): 0.6841, 0.6543 respectively, p = 0.828). Univariate analysis failed to demonstrate a statistically significant relationship between the Gail or TC LR % and diagnosis of breast cancer when using 20% as the cutoff for high-risk classification (p = 1.0, 0.369 respectively). Neither the TC nor the Gail risk calculators demonstrated a significant correlation between risk and the likelihood of diagnosis of breast cancer when screened with MRI. CONCLUSION: Larger cohort studies are necessary to determine the risk percentage most predictive of a breast cancer diagnosis using MRI as screening.