Intraoperative Radiotherapy for Breast Cancer Treatment in a Rural Community.

BACKGROUND: Access to health care poses particular challenges for patients living in rural communities. Intraoperative radiotherapy (IORT) offers a treatment alternative to traditional whole-breast radiation therapy (WBRT) for select patients. This study aimed to analyze the use of IORT for patients undergoing breast-conserving surgery at an academic institution located in a rural state. METHODS: A retrospective review analyzed all patients at a single institution with a diagnosis of ductal carcinoma in situ (DCIS) or invasive breast cancer from April 2012 to January 2017 who were undergoing breast-conserving surgery with either IORT or WBRT. Student's t test or Fisher's exact test was used to make statistical comparisons. RESULTS: Patients undergoing IORT (n = 117) were significantly older than patients treated with WBRT (n = 191) (65.6 vs 58.6 years; p < 0.001) and had smaller tumors on both preoperative imaging (1.04 vs 1.66 cm; p < 0.05) and final pathology (0.99 vs 1.48 cm; p < 0.05). Patients receiving IORT lived farther from the treating facility than patients treated with WBRT (67.2 vs 30.8 miles; p < 0.05). To account for biases created in the IORT selection criteria, subgroup analysis was performed for women receiving WBRT who fulfilled IORT selection criteria, and distance traveled remained significant (67.2 vs 31.4 miles; p < 0.05). Neither recurrence nor survival differed between the IORT and WBRT groups. Medicare reimbursement for IORT was approximately 50% more than for WBRT. CONCLUSIONS: For women from rural communities, IORT appears to be an attractive option because these women tend to be older and to live farther from the treatment facility.

Management of contralateral axillary sentinel lymph nodes detected on lymphoscintigraphy for breast cancer.

BACKGROUND: Detection of a contralateral axillary sentinel lymph node (SLN) during lymphoscintigraphy for breast cancer is rare, and its significance and management are unclear. The purpose of this study was to review our experience and analyze our results together with similar patients in the literature to identify common characteristics and propose a management strategy. METHODS: A PubMed search was performed for articles describing patients in whom contralateral axillary drainage was identified on lymphoscintigraphy. Additionally, a chart review was performed of all patients who had lymphoscintigraphy for breast cancer at our institution. RESULTS: At our institution, two of 988 (0.3 %) consecutive patients were identified with contralateral axillary drainage on lymphoscintigraphy. Twenty-seven publications describing 105 patients with contralateral axillary drainage were found. This comprised our study group of 107 patients. Lymphoscintigraphy patterns varied depending on the history and type of prior surgery. A history of chest/axillary surgery was significantly associated with absence of an ipsilateral SLN (p < 0.05). This was observed in 84.2 % of patients with prior axillary lymph node dissection versus 33.3 % with prior SLN. Contralateral SLN biopsy was attempted in 85 patients (79.4 %); 22 (20.6 %) were positive for tumor. In 17 patients (15.9 %), the contralateral node was the only positive SLN. CONCLUSIONS: These findings suggest that contralateral uptake on lymphoscintigraphy, though rare (0.2 %), is clinically significant and such nodes should undergo excision. Because contralateral uptake is significantly associated with prior chest/axillary surgery, routine lymphoscintigraphy should be considered in this group, as it has potential to change disease stage and management.

Applications of Narrative Medicine to Surgical Education.

Narrative medicine describes the application of story to medical education and practice. Although it has been implemented successfully in many medical schools as a part of undergraduate medical education, applications to the residency environment have been relatively limited. There are virtually no data concerning the adoption of narrative medicine within surgical residencies. This paper provides a brief introduction to the formal discipline of narrative medicine. We further discuss how storytelling is already used in surgical education and summarize the literature on applications of narrative medicine to residents in other specialties. The relevance of narrative medicine to the ACGME core competencies is explored. We conclude with specific suggestions for implementation of narrative medicine within surgical residency programs.

Management of pregnant women with breast cancer.

Pregnancy complicates the diagnosis and treatment of breast cancer. Surgical treatment options of mastectomy or breast-conservation can be used as for non-pregnant patients. Sentinel lymph node biopsy can be safely used with lymphoscintigraphy. Chemotherapy is appropriate in the second and third trimesters, however, radiation therapy should be delayed until after delivery. Multidisciplinary care, including High-Risk Obstetrics, remains the best approach to managing this complex patient population.

The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors.

BACKGROUND: As more women survive breast cancer, long-term complications that affect quality of life, such as lymphedema of the arm, gain greater importance. Numerous studies have attempted to identify treatment and prognostic factors for arm lymphedema, yet the magnitude of these associations remains inconsistent. METHODS: A PubMed search was conducted through January 2008 to locate articles on lymphedema and treatment factors after breast cancer diagnosis. Random-effect models were used to estimate the pooled risk ratio. RESULTS: The authors identified 98 independent studies that reported at least one risk factor of interest. The risk ratio (RR) of arm lymphedema was increased after mastectomy when compared with lumpectomy [RR = 1.42; 95% confidence interval (CI) 1.15-1.76], axillary dissection compared with no axillary dissection (RR = 3.47; 95% CI 2.34-5.15), axillary dissection compared with sentinel node biopsy (RR = 3.07; 95% CI 2.20-4.29), radiation therapy (RR = 1.92; 95% CI 1.61-2.28), and positive axillary nodes (RR = 1.54; 95% CI 1.32-1.80). These associations held when studies using self-reported lymphedema were excluded. CONCLUSIONS: Mastectomy, extent of axillary dissection, radiation therapy, and presence of positive nodes increased risk of developing arm lymphedema after breast cancer. These factors likely reflected lymph node removal, which most surgeons consider to be the largest risk factor for lymphedema. Future studies should consider examining sentinel node biopsy versus no dissection with a long follow-up time post surgery to see if there is a benefit of decreased lymphedema compared with no dissection.

Measurement of uterine radiation exposure from lymphoscintigraphy indicates safety of sentinel lymph node biopsy during pregnancy.

BACKGROUND: There is an increased incidence of breast cancer occurring during pregnancy. Controversy exists as to the safety of performing lymphoscintigraphy during pregnancy and no studies have reported the measured dose of uterine radiation. METHODS: We performed an institutional review board (IRB)-approved prospective study of uterine radiation resulting from lymphoscintigraphy. Abdominal, perineal, and urinary radiation was measured in 14 breast cancer patients and total uterine dose was calculated. RESULTS: The average dose of 99m-Tc sulfur colloid was 39 +/- 20 MBq (1.04 +/- 0.53 mCi). Measured abdominal and pelvic radiation exposure demonstrated no correlation with patient age or body mass index. The average abdominal radiation exposure was 1.17 +/- 0.87 microGy. The average perineal radiation exposure was 0.23 +/- 0.17 microGy. The average dose to the uterus from bladder radioactivity determined from voided urine was 0.44 +/- 0.44 microGy. The average radiation dose to the uterus (average of abdominal and perineal doses plus contribution from bladder dose) was 1.14 +/- 0.76 microGy. One patient was 16 weeks pregnant at the time of sentinel lymph node biopsy (SLNB) and total calculated uterine dose was 1.67 microGy, suggesting that pregnancy does not significantly alter measured uterine radiation. These data were compared with the average background radiation, which is 3,000 microGy per year or 8.2 microGy per day. CONCLUSIONS: The measured uterine dose of radiation from lymphoscintigraphy for SLNB was significantly less than the average daily background radiation. We conclude that lymphoscintigraphy does not expose the fetus to significant radiation and concern of radiation exposure should not preclude the use of SLNB during pregnancy.

Differences in the pattern of presentation and treatment of proximal and distal gastric cancer: results of the 2001 gastric patient care evaluation.

BACKGROUND: While the overall incidence of gastric cancer has declined in the United States of America, the incidence of proximal gastric cancers has increased. The purpose of this analysis was to highlight key differences between proximal and distal gastric cancer as they relate to presentation and treatment. METHODS: Data on 6,099 patients diagnosed with gastric adenocarcinoma were collected as a patient care evaluation under the auspices of the American College of Surgeons Commission on Cancer. The chi-square (chi (2)) test was used for comparisons of proportions across levels of categorical variables by site. RESULTS: The proximal cancer group included 1,924 patients (87% cardia, 13% fundus) and the distal cancer group included 1,311 patients (85% antrum, 15% pylorus). Proportionately, proximal cancer cases were male (P < 0.01), younger (P < 0.01), and White (P < 0.01); whereas, distal gastric cancer cases were Black (P < 0.01), Hispanic (P < 0.01), and Asian (P = 0.01). Surgery alone (without adjuvant chemotherapy or radiation) was utilized more frequently in distal disease (39.5%) compared to proximal disease (25.7%) (P < 0.01). Preoperative adjuvant therapy was utilized more frequently in proximal disease (41.7%) compared to distal disease (2.1%) (P < 0.01). CONCLUSIONS: The populations that developed proximal verses distal gastric cancer differed with respect to sex, age, and racial background. Cancer-directed treatments also differed based upon tumor location. Understanding these differences may someday enable us to identify important high-risk populations, prevention strategies, and ultimately best treatment strategies. Long-term survival differences will be explored when follow-up data become available.

Lymphedema following breast cancer: The importance of surgical methods and obesity.

BACKGROUND: Breast cancer-related arm lymphedema is a serious complication that can adversely affect quality of life. Identifying risk factors that contribute to the development of lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine the association between the development of arm lymphedema and both treatment and personal (e.g., obesity) risk factors. METHODS: Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010, who met eligibility criteria, were asked to complete a short computer assisted telephone interview about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was characterized by a reported physician-diagnosis, a difference between arms in the circumference (> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using logistic regression. RESULTS: Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated by both axillary dissection and radiation therapy were more likely to have arm lymphedema than treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity level was not associated with lymphedema. CONCLUSIONS: Surgical methods, cancer characteristics and obesity were found to contribute to the development of arm lymphedema. Vigorous arm activity post-surgery was not found to increase the risk of arm lymphedema.

Laparoscopic surgery for the prevention, palliation, and cure of gastrointestinal malignancies.

The development of surgical laparoscopic techniques has revolutionized the way surgeons approach many diseases, including cancer. This article briefly discusses the historical development of surgical laparoscopy; describes laparoscopic surgical techniques, with a focus on techniques for common intra-abdominal malignancies; and reviews laparoscopic management of common gastrointestinal malignancies.

Laparoscopic gastrointestinal surgery.

In the short time since LC was first performed in humans, minimal-access surgical techniques have been applied to the full spectrum of surgical therapy of gastrointestinal diseases. For many gastrointestinal diseases, [figure: see text] laparoscopy seems to offer advantages over traditional open surgery. The long-term results of laparoscopic surgery for cancer await the results of prospective clinical trials currently underway and caution is urged when laparoscopic curative resection is performed. On the horizon are significant improvements in technology that should lead to further applications and advances in laparoscopic gastrointestinal surgery.

Spectrum of general surgery in rural Iowa.

PURPOSE: One-quarter of the United States of America's population lives in rural areas, but only 12.3% of physicians live and work in rural areas. Nearly one-quarter of the counties in Iowa boast a patient-to-physician ratio of 3000:1. The number of rural surgeons is decreasing, and current residency programs may not optimally train graduates for the spectrum of surgical practice seen in rural areas. The scope of surgical practice differs between rural and non-rural surgeons, and in this study, we identified the types of surgery performed by 6 rural Iowa surgeons and compared the practices of rural and non-rural surgeons in Iowa. METHODS: Data from personal interviews and questionnaires with rural Iowa general surgeons and rural Iowa hospital administrators and results from the Iowa General Surgeon Practice Opportunity Survey were analyzed retrospectively. RESULTS: In 1995, 31 general surgeons were recruiting a general surgeon partner, of which 25 were in rural Iowa communities. Eighteen rural Iowa Hospital administrators were actively recruiting a general surgeon during the same time period. In September 2000, many of these positions remained unfilled. A total of 4963 surgical procedures were performed by 6 rural Iowa general surgeons in Iowa in 1995. Endoscopic, alimentary, and obstetrics and gynecologic procedures were the most frequently performed. Excluding endoscopy, 26% of all procedures performed were procedures not among the Accreditation Council of Graduate Medial Education (ACGME) list of requirements for graduating surgical residents. CONCLUSIONS: Rural Iowa general surgeons perform a large volume of surgery and more subspecialty procedures than do their non-rural counterparts. Surgical residency programs need to more adequately train residents interested in rural general surgery in an effort to increase the pool of graduating surgical residents trained to deal with the scope of procedures a rural practice offers. This will help reduce the shortage of rural general surgeons in the United States of America.

Review of risk factors for the development of contralateral breast cancer.

BACKGROUND: Women treated for breast cancer have an increased risk for developing metachronous contralateral breast cancer (CBC). Patient perception of this risk is often overestimated and has been found to contribute to the decision to undergo contralateral prophylactic mastectomy. An individual's risk is dependent on both patient and tumor characteristics. This review examines and summarizes the current literature on the factors that affect CBC risk. DATA SOURCES: English-language publications with the keyword "contralateral breast cancer" were identified through a MEDLINE literature search. CONCLUSIONS: The global incidence of CBC is decreasing, a trend that is attributed to more effective adjuvant therapies. Patients with BRCA germ-line mutations demonstrate the highest risk for CBC. In the absence of known genetic mutations, patients with strong family histories who are diagnosed at young ages (<35 years) with estrogen receptor-negative index tumors appear to have a higher incidence of CBC.

The response to neoadjuvant chemotherapy predicts clinical outcome and increases breast conservation in advanced breast cancer.

BACKGROUND: The aim of this study was to determine outcomes in patients with breast cancer treated with neoadjuvant chemotherapy. METHODS: Seventy-two consecutive patients receiving neoadjuvant chemotherapy for breast cancer were enrolled. RESULTS: Mastectomy was avoided in 46% of patients, and 42% converted to negative nodes after neoadjuvant chemotherapy. Thirteen patients (18%) achieved a pathologic complete response, which was associated with the estrogen receptor (ER)-negative/human epidermal growth factor receptor 2 (Her2)-negative subtype (58%) and was significantly less likely to occur in the ER+/Her2- subtype (2%) (P < .01). Patients with the ER+/Her2+ subtype were most likely to have no response or progression during chemotherapy, compared with those with the ER-/Her2- subtype (50% vs 0%, P = .01). Five-year survival for patients achieving a pathologic complete response was 100%, compared with 74% in the group with partial response and 48% in the group with no response or progression (P = .01). CONCLUSIONS: Neoadjuvant chemotherapy for patients with advanced breast cancer provided prognostic information, allowed evaluation of response to chemotherapy, decreased the mastectomy rate, and potentially reduced the need for axillary lymph node dissection.

Effect of introducing hematoma ultrasound-guided lumpectomy in a surgical practice.

BACKGROUND: Preoperative needle localization (NL) is the gold standard for lumpectomy of nonpalpable breast cancer. Hematoma ultrasound-guided (HUG) lumpectomy can offer several advantages. The purpose of this study was to compare the use of HUG with NL lumpectomy in a single surgical practice. STUDY DESIGN: Patients with nonpalpable lesions who underwent NL or HUG lumpectomy from January 2007 to December 2009 by a single surgeon were identified from a breast surgery database. Ease of scheduling, volume excised, re-excision rates, operating room time, and health care charges were the main outcomes variables. Univariate and multivariate analyses were performed to compare the 2 groups. RESULTS: Lumpectomy was performed in 110 patients, 55 underwent HUG and 55 underwent NL. Hematoma ultrasound-guided lumpectomy was associated with a nearly 3-fold increase in the odds ratio of additional tissue being submitted to pathology (p = 0.039), but neither the total amount of breast tissue removed, nor the need for second procedure were statistically different between the 2 groups. Duration of the surgical procedure did not vary between the 2 groups; however, the time from biopsy to surgery was shorter for HUG by an expected 9.7 days (p = 0.019), implying greater ease of scheduling. Mean charges averaged $250 less for HUG than for NL, but this difference was not statistically significant. CONCLUSIONS: Hematoma ultrasound-guided is equivalent to NL with regard to volume of tissue excised, need for operative re-excision, and operating room time. Adoption of HUG in our practice allowed for more timely surgical care.

Sampling of secondary margins decreases the need for re-excision after partial mastectomy.

BACKGROUND: We analyzed factors that influenced the need for re-excision after partial mastectomy. METHODS: We conducted a retrospective study of 470 breast cancer patients treated with partial mastectomy with main outcome measures of re-excision, conversion to mastectomy, and recurrence. RESULTS: Of 470 patients, 146 (31%) underwent re-excision for inadequate margins and 42 (8.9%) required mastectomy. Twelve (2.6%) patients had local recurrence of disease with a mean follow-up of 4.2 years. Factors found on multivariate analysis increasing the likelihood of re-excision include wire localization (2.4-fold), tumor or ductal carcinoma in situ (DCIS) close to the margins (<0.2 cm; 12.5-fold), margins involved with tumor or DCIS (25.3-fold), and seen by a non-breast specialist (2.25-fold). Taking secondary margins at initial operation reduced odds ratio of re-excision by 52% (P = .006) without a difference in volume of breast tissue removed (P = .33). Inadequate margins without re-excision had 12.% overall recurrence compared with a 6% recurrence with adequate margin and no re-excision (P = .069). CONCLUSION: One third of patients treated with partial mastectomy required re-excision, but 89% avoided the need for mastectomy. Taking secondary margins during the initial procedure decreased the need for re-excision by half. The recurrence rate was identical whether clear margins were obtained after primary partial mastectomy or re-excision.

Chair of surgery.

There are several essential qualities required for success as a chair of surgery. These include determination and resilience, thoughtful planning, superb organization skills, a balance of hard (accounting, management and finance) and soft skills (interpersonal including faculty development), and careful execution is absolutely essential as is a commitment to maintaining momentum.