Chondrolipoma of the Breast: A Myofibroblastoma Variant or a Distinct Lesion?

The entity commonly referred to as chondrolipoma is a rare and enigmatic breast lesion with unclear histogenesis and a complete lack of molecular characterization. It is uncertain whether it represents a hamartoma, choristoma, or a distinct neoplasm, including possibly a variant of mammary-type myofibroblastoma. We report two additional chondrolipomatous lesions of the breast. The lesions had varying histologic and immunohistochemical features similar to myofibroblastoma, including the loss of retinoblastoma (Rb) protein expression in one lesion. Molecular analysis by chromosomal microarray analysis performed on a second lesion did not demonstrate a loss of 13q14 or 16q typical of myofibroblastoma. Our findings further support the concept that at least a subset of breast lesions that historically have been classified as chondrolipoma are related to myofibroblastoma. However, the lack of myofibroblastoma-specific molecular alterations in one lesion suggests chondrolipomas may also have varying origins.

Machine Learning-Based Prediction of Distant Recurrence in Invasive Breast Carcinoma Using Clinicopathological Data: A Cross-Institutional Study.

Breast cancer is the most common type of cancer worldwide. Alarmingly, approximately 30% of breast cancer cases result in disease recurrence at distant organs after treatment. Distant recurrence is more common in some subtypes such as invasive breast carcinoma (IBC). While clinicians have utilized several clinicopathological measurements to predict distant recurrences in IBC, no studies have predicted distant recurrences by combining clinicopathological evaluations of IBC tumors pre- and post-therapy with machine learning (ML) models. The goal of our study was to determine whether classification-based ML techniques could predict distant recurrences in IBC patients using key clinicopathological measurements, including pathological staging of the tumor and surrounding lymph nodes assessed both pre- and post-neoadjuvant therapy, response to therapy via standard-of-care imaging, and binary status of adjuvant therapy administered to patients. We trained and tested four clinicopathological ML models using a dataset (144 and 17 patients for training and testing, respectively) from Duke University and validated the best-performing model using an external dataset (8 patients) from Dartmouth Hitchcock Medical Center. The random forest model performed better than the C-support vector classifier, multilayer perceptron, and logistic regression models, yielding AUC values of 1.0 in the testing set and 0.75 in the validation set (p < 0.002) across both institutions, thereby demonstrating the cross-institutional portability and validity of ML models in the field of clinical research in cancer. The top-ranking clinicopathological measurement impacting the prediction of distant recurrences in IBC were identified to be tumor response to neoadjuvant therapy as evaluated via SOC imaging and pathology, which included tumor as well as node staging.

Safety of Inhaled Amphotericin B Lipid Complex as Antifungal Prophylaxis in Lung Transplant Recipients.

Inhaled formulations of amphotericin B are the most widely used antifungal prophylactic agents in lung transplant recipients, yet there are limited data on their safety. We performed a single-center retrospective cohort study of 603 consecutive patients who underwent lung transplantation between 2012 and 2017 and received antifungal prophylaxis with inhaled amphotericin B lipid complex (iABLC) from the day of transplantation until hospital discharge. Of 603 patients, 600 (99.5%) received ≥1 dose of iABLC, and 544 (90.2%) completed the recommended prophylactic course. In total, 4,128 iABLC doses (median, 5; range, 1 to 48 per patient) were administered; 24 patients received >3 months of therapy. Only one (0.2%) patient discontinued therapy due to a drug-attributable adverse event. During the first posttransplant year, 80 (13.3%) patients died (median time to death, 171 days; interquartile range [IQR], 80 to 272 days), and 3,352 (median, 6 per patient) lung biopsies were performed; 414 (68.7%) patients developed biopsy-proven acute cellular rejection. One-year adverse events in our cohort of lung transplant recipients treated with iABLC during transplant hospitalization matched national outcomes for rejection, graft loss, and death. iABLC is a safe and well-tolerated antifungal prophylactic agent in lung transplant recipients.

Invasive Fungal Infection After Lung Transplantation: Epidemiology in the Setting of Antifungal Prophylaxis.

BACKGROUND: Lung transplant recipients commonly develop invasive fungal infections (IFIs), but the most effective strategies to prevent IFIs following lung transplantation are not known. METHODS: We prospectively collected clinical data on all patients who underwent lung transplantation at a tertiary care academic hospital from January 2007-October 2014. Standard antifungal prophylaxis consisted of aerosolized amphotericin B lipid complex during the transplant hospitalization. For the first 180 days after transplant, we analyzed prevalence rates and timing of IFIs, risk factors for IFIs, and data from IFIs that broke through prophylaxis. RESULTS: In total, 156 of 815 lung transplant recipients developed IFIs (prevalence rate, 19.1 IFIs per 100 surgeries, 95% confidence interval [CI] 16.4-21.8%). The prevalence rate of invasive candidiasis (IC) was 11.4% (95% CI 9.2-13.6%), and the rate of non-Candida IFIs was 8.8% (95% CI 6.9-10.8%). First episodes of IC occurred a median of 31 days (interquartile range [IQR] 16-56 days) after transplant, while non-Candida IFIs occurred later, at a median of 86 days (IQR 40-121 days) after transplant. Of 169 IFI episodes, 121 (72%) occurred in the absence of recent antifungal prophylaxis; however, IC and non-Candida breakthrough IFIs were observed, most often representing failures of micafungin (n = 16) and aerosolized amphotericin B (n = 24) prophylaxis, respectively. CONCLUSIONS: Lung transplant recipients at our hospital had high rates of IFIs, despite receiving prophylaxis with aerosolized amphotericin B lipid complex during the transplant hospitalization. These data suggest benefit in providing systemic antifungal prophylaxis targeting Candida for up to 90 days after transplant and extending mold-active prophylaxis for up to 180 days after surgery.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

INTRODUCTION: In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes. METHODS: A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed. RESULTS: The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery. CONCLUSIONS: Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

Fibrous dysplasia: an overview of disease process, indications for surgical management, and a case report.

INTRODUCTION: First described by Von Recklinghausen in 1891, fibrous dysplasia is a developmental defect of osseous tissue such that bone is produced with an abnormally thin cortex and marrow is replaced with fibrous tissue that demonstrates characteristic ground-glass appearance on x-ray examination. The underlying defect in fibrous dysplasia is a mutation of the GNAS1 gene, which leads to constitutive activation of gene products that preclude the maturation of osteoprogenitor cells and lead to development of abnormal bone matrix, trabeculae, and collagen, produced by undifferentiated mesenchymal cells. There exists a mainly self-limiting form of fibrous dysplasia classified as monostotic, which is characterized by dysplastic bone in a single location that remains relatively stable throughout life and a polyostotic form, which can exhibit aggressive growth placing adjacent structures at risk for compressive sequelae. METHODS: We present the surgical management of an unusual case of monostotic fibrous dysplasia, which exhibited aggressive growth with mass effect, and late presentation, both uncharacteristic features for the monostotic form. The authors also performed a comprehensive review of the literature and discuss the disease process, management options, and indications for surgical treatment. RESULTS: An overview of the disease process and management options is presented. The authors also present details of reconstruction in an unusual form of symptomatic monostotic fibrous dysplasia. CONCLUSION: Conservative management is usually the mainstay of therapy in asymptomatic cases of fibrous dysplasia. In patients fulfilling criteria for surgical management, craniofacial reconstruction offers a viable option in the surgeon's armamentarium, providing good functional and cosmetic outcomes.

Pricing of common cosmetic surgery procedures: local economic factors trump supply and demand.

BACKGROUND: The pricing of cosmetic surgery procedures has long been thought to coincide with laws of basic economics, including the model of supply and demand. However, the highly variable prices of these procedures indicate that additional economic contributors are probable. OBJECTIVES: The authors sought to reassess the fit of cosmetic surgery costs to the model of supply and demand and to determine the driving forces behind the pricing of cosmetic surgery procedures. METHODS: Ten plastic surgery practices were randomly selected from each of 15 US cities of various population sizes. Average prices of breast augmentation, mastopexy, abdominoplasty, blepharoplasty, and rhytidectomy in each city were compared with economic and demographic statistics. RESULTS: The average price of cosmetic surgery procedures correlated substantially with population size (r = 0.767), cost-of-living index (r = 0.784), cost to own real estate (r = 0.714), and cost to rent real estate (r = 0.695) across the 15 US cities. Cosmetic surgery pricing also was found to correlate (albeit weakly) with household income (r = 0.436) and per capita income (r = 0.576). Virtually no correlations existed between pricing and the density of plastic surgeons (r = 0.185) or the average age of residents (r = 0.076). CONCLUSIONS: Results of this study demonstrate a correlation between costs of cosmetic surgery procedures and local economic factors. Cosmetic surgery pricing cannot be completely explained by the supply-and-demand model because no association was found between procedure cost and the density of plastic surgeons.

Sushruta: father of plastic surgery.

Sushruta is considered the "Father of Plastic Surgery." He lived in India sometime between 1000 and 800 BC, and is responsible for the advancement of medicine in ancient India. His teaching of anatomy, pathophysiology, and therapeutic strategies were of unparalleled luminosity, especially considering his time in the historical record. He is notably famous for nasal reconstruction, which can be traced throughout the literature from his depiction within the Vedic period of Hindu medicine to the era of Tagliacozzi during Renaissance Italy to modern-day surgical practices. The primary focus of this historical review is centered on Sushruta's anatomical and surgical knowledge and his creation of the cheek flap for nasal reconstruction and its transition to the "Indian method." The influential nature of the Sushruta Samhita, the compendium documenting Sushruta's theories about medicine, is supported not only by anatomical knowledge and surgical procedural descriptions contained within its pages, but by the creative approaches that still hold true today.

Retrospective analysis of never events in panniculectomy and abdominoplasty patients and their financial implications.

In 2008, the Centers for Medicare and Medicaid Service adapted a list from the National Quality Forum consisting of 10 hospital-acquired conditions, also known as never events. Deeming such events as preventable in a safe-hospital setting, reimbursement is no longer provided for treatments arising secondary to these events. A retrospective chart review identified 90 panniculectomy and abdominoplasty patients. The hospital-acquired conditions examined include surgical-site infections (SSI), vascular-catheter associated infections, deep venous thrombosis/pulmonary embolism, retained foreign body, catheter-related urinary tract infection, manifestations of poor glycemic control, falls and trauma, air embolism, pressure ulcers (stages III and IV), and blood incompatibility. Information regarding age, American Society of Anesthesiologists (ASA) classification, body mass index, smoking, and chemotherapy were collected. Patients were divided into 2 groups, namely, those who developed never events and those with no events. Of the 90 patients, 14 (15.5%) developed never events because of SSI. No events occurred in the remaining 9 categories. Statistically significant risk factors included American Society of Anesthesiologists classification, age, and diabetes mellitus. The most common never event was SSI. In light of the obvious prevalence of the risk factors in patients who develop these events, the question of whether never events are truly unavoidable arises. Despite this, awareness of the impact on patient care, health care and hospital reimbursement is vital to understanding the new paradigm of the "one size fits all."

A plastic surgeon's guide to applying smartphone technology in patient care.

BACKGROUND: The vast array of information technology available to plastic surgeons continues to expand. With the recent introduction of smartphone application ("app") technology to the market, the potential for incorporating both social media and app technology into daily practice exists. OBJECTIVES: The authors describe and evaluate the smartphone applications most pertinent to plastic surgery. METHODS: Smartphone apps from all available markets were analyzed for various factors, including popularity among general consumers, ease of use, and functionality. Using various advertising guidelines from plastic surgery societies as well as the US Food and Drug Administration, each app's content was further analyzed within the context of ethical obligations. RESULTS: The apps with the highest number of ratings were those offering the option to upload photos and morph each photo according to the user's own preference. The title of apps also appears to play a role in popularity. A majority of apps demonstrated the same features available on websites. CONCLUSIONS: The applicability of social media marketing via smartphone apps has the potential to change future patient-surgeon interactions by offering more personalized and user-friendly encounters. The role of smartphone apps is important to the future of plastic surgery as long as plastic surgeons maintain an active role in the development of these apps to ensure their value.

Reconstruction of massive localised lymphoedema of the scrotum with a novel fasciocutaneous flap: A rare case presentation and a review of the literature.

Massive localised lymphoedema (MLL) is a benign lymphoproliferative soft-tissue overgrowth in the morbidly obese patient. The diagnosis may be challenging, and is a form of secondary lymphoedema, often described as idiopathic scrotal elephantiasis. The lesion presents as a large mass in the morbidly obese, and patients seek treatment late in the disease course due to limitation of daily living or excoriation and wound breakdown. Resection, followed by reconstruction, is indicated in these cases. We present a unique case of a morbidly obese 52-year-old male with massive enlargement of the scrotum present for several years duration, despite massive weight loss (88.85 kg) from gastric bypass surgery and no other identifiable cause of lymphoedema. Scrotal lymphoedematous tissue was resected and scrotal reconstruction with a novel posterior fasciocutaneous flap from the scrotum was performed in addition to penile reconstruction with a skin graft and local fasciocutaneous flaps as well as a panniculectomy. Histologically, the tissue was characterised by marked oedema with dermal fibrosis and patchy mild perivascular chronic inflammation. Postoperative follow-up revealed wound integrity and patient satisfaction with the outcome. MLL is an important disease process with distinct clinical and histopathologic characteristics that often requires complex reconstruction. Although there are several opposing classification schema, we propose the incorporation of idiopathic scrotal elephantiasis into the diagnostic category of MLL.