Efficacy of Cemiplimab as Adjuvant or Neoadjuvant Therapy in the Treatment of Cutaneous Squamous Cell Carcinoma.

INTRODUCTION: Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer in the White population. Unfortunately, the prognosis of advanced cSCC is poor, and management can be challenging. Until recently, the choice of systemic medications was limited, and those that were available had modest efficacy. Cemiplimab is an anti-programmed cell-death protein 1 inhibitor and the first immunotherapeutic agent approved for the treatment of metastatic or locally advanced cSCC. The purpose of this study was to evaluate the efficacy of cemiplimab when used as adjuvant or neoadjuvant therapy in patients treated at our institution. METHODS: A retrospective review of patients with locally advanced or metastatic cSCC who were treated with cemiplimab as adjuvant or neoadjuvant therapy at a single institution between February 2019 and November 2022 was performed. Response to treatment was objectively assessed based on Response Evaluation Criteria in Solid Tumors, version 1.1, criteria. The primary end point was objective response rate. Secondary endpoints included time to observed response, disease-control rate, progression-free survival, overall survival, and adverse effects of therapy. RESULTS: A total of 6 patients were identified with a median age of 79 years (range, 51-90 years). Four patients had locally advanced cSCC, and 2 had distant metastasis. Cemiplimab was used as adjuvant therapy in 3 patients and neoadjuvant therapy in 2 patients. There was 1 patient in which it was used for limb salvage, who would have otherwise required an amputation. Objective response rate, complete response, and partial response were 66% (4 of 6), 33% (2 of 6), and 33% (2 pf 6), respectively. Average time to observed response was 2.9 months. Disease-control rate was 83% (5 of 6), and average progression-free survival was 10 months. Toxicity was reported in 2 patients, both of which were grade 1 severity. CONCLUSIONS: Cemiplimab has established its utility in the treatment of advanced cSCC, demonstrating clinical efficacy while generally having a tolerable adverse effect profile. Our preliminary results suggest that cemiplimab has potential as an adjuvant or neoadjuvant therapy in combination with surgery for treatment of cSCC.

Minimally Invasive Cubital Tunnel Release Utilizing Lighted Retractors: A Study of Residents Novel to this Technique Utilizing a Cadaveric Model.

The purpose of this study was to evaluate whether a minimally-invasive cubital tunnel release using lighted retractors could be performed safely and completely by residents with no prior training in this technique. Ten residents participated in the study. Postoperative dissection of the specimens was performed utilizing a detailed checklist and global rating scale to evaluate the completeness of release as well as presence of neurologic injury. Performance of residents was compared. Rho correlation analysis was used to verify validity of the assessment tools. Training year most strongly correlated with Global Rating Scale assessment values. There was a trend correlating training year with faster surgical times, and Detailed Checklist scores. Validation measurements showed strong correlations between the pass/fail grade and the Detailed Checklist and the Global Rating Scale. Complete release of the ulnar nerve in situ utilizing lighted retractors can be performed with minimal training or experience. (Journal of Surgical Orthopaedic Advances 32(3):193-198, 2023).

Survival Outcomes of Salvage Metastasectomy After Failure of Modern-Era Systemic Therapy for Melanoma.

BACKGROUND: Metastasectomy for selected patients with melanoma was associated with improved survival in the era before effective systemic therapy. Emerging evidence shows that these benefits persist even in this era of BRAF-targeted therapy and immune checkpoint inhibitor immunotherapy. This study aimed to evaluate the outcomes of salvage metastasectomy after failure of systemic therapy. METHODS: Stage 3 or 4 melanoma patients with extracranial disease progression after at least 4 weeks of systemic treatment between 2009 and 2020 were identified and categorized as resected to no evidence of disease (NED), non-progressive residual disease (NPRD), or progressive residual disease (PRD). Systemic therapy was stratified into BRAF-targeted therapy, immune checkpoint inhibitor immunotherapy, or both. The end points of overall survival (OS), progression-free survival (PFS), and locoregional disease control (LRC) were assessed using Kaplan-Meier curves. Uni- and multivariable Cox regression procedures were used to examine factors associated with OS, PFS and LRC. RESULTS: The study enrolled 190 patients. Among all the patients, the 5-year OS from metastatectomy was 52%, the 3-year PFS was 21%, and the 5-year LRC was 61%. After resection to NED, NPRD, and PRD, the 5-year OS values were 69%, 62% and 8%, respectively. Fewer lines of preoperative therapy, use of preoperative immunotherapy, and resection to NED were predictors of improved OS. After resection to NED, NPRD, and PRD, the 3-year PFS values were 23%, 24% and 10%, and the 5-year LRC values were 61%, 72% and 34%, respectively. CONCLUSIONS: Salvage metastasectomy was associated with durable survival and disease control, particularly after resection to NED, preoperative immunotherapy, and fewer lines of preoperative systemic therapy.

Medical student service learning program teaches secondary students about career opportunities in health and medical fields.

Engagement of academic medical centers in community outreach provides the public with a better understanding of basic terms and concepts used in biomedical sciences and increases awareness of important health information. Medical students at one academic medical center initiated an educational outreach program, called PULSE, that targets secondary students to foster their interest in healthcare and medicine. High school student participants are engaged in a semester-long course that relies on interactive lectures, problem-based learning sessions, mentoring relationships with medical students, and opportunities for shadowing healthcare providers. To date, the curriculum has been offered for 7 consecutive years. To determine the impact that participation in the curriculum has had on college/career choices and to identify areas for improvement, an electronic questionnaire was sent to former participants. Based on a 32% response rate, 81% of former participants indicated that participation in the course influenced their decision to pursue a medical/science-related career. More than half (67%) of respondents indicated intent to pursue a MD/PhD or other postgraduate degree. Based on responses obtained, additional opportunities to incorporate laboratory-based research and simulation sessions should be explored. In addition, a more formalized mentoring component has been added to the course to enhance communication between medical students and mentees. Health/medicine-related educational outreach programs targeting high school students may serve as a pipeline to introduce or reinforce career opportunities in healthcare and related sciences.

Clinical Diagnosis and Classification: Including Biopsy Techniques and Noninvasive Imaging.

Early detection of melanoma is important in improving patient survival. The treatment of melanoma is multidisciplinary and begins by obtaining an accurate diagnosis. The mainstays of melanoma diagnosis include examination of the lesion and surrounding areas and an excisional biopsy so that a pathologic diagnosis can be obtained. The pathology results will help guide treatment recommendations, and some information can be used for prognosis. Further workup of the patient may include laboratory studies and imaging for staging and surveillance.

A Prospective, Randomized Trial Comparing Open and Endoscopic Carpal Tunnel Release Within the Same Patient.

Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.

Intimidation and Sexual Harassment during Plastic Surgery Training in the United States.

BACKGROUND: Attending physicians, peers, other providers, and patients are sources of intellectual growth, but may also be a source of abuse and harassment. Published international studies have found that harassment within residency training is widespread but there is little data regarding plastic surgery training. The authors sought to explore the incidence of harassment experienced by plastic surgery residents currently enrolled in US integrated and independent programs. METHODS: After an IRB-approved exemption was obtained, an anonymous internet-based survey was distributed via email to all plastic and reconstructive surgery residency programs. The survey was comprised of 23 questions that focused on personal experience or knowledge of other colleagues who had encountered abuse and harassment during their training. Responses were collected during a 60-day period. The response rate was 16%. RESULTS: A total of 173 individuals completed the survey. Regarding harassment experienced by the respondents, 39.2% reported verbal abuse, 19.9% experienced sexual harassment, and 3.6% reported being physically abused during their training. Of those individuals who were sexually harassed, 72.7% were females. In many of the cases (64.5%), the instigator was a supervising physician. Most respondents did not feel comfortable reporting the abuse (74.19%). CONCLUSIONS: Abuse and sexual harassment rates among active plastic and reconstructive surgery residents in the United States are high and attention should be brought to this important issue. Further studies should be conducted to assess the extent of abuse so that it can lead to implementation of programs that provide accountability, improved support, counseling strategies, and foster appropriate professional development.

Midface Fracture Simulation and Repair: A Computer-Based Algorithm.

We introduce a novel computer-based method to digitally fixate midfacial fractures to facilitate more efficient intraoperative fixation. This article aims to describe a novel computer-based algorithm that can be utilized to model midface fracture reduction and fixation and to evaluate the algorithm's ability to produce images similar to true postoperative images. This is a retrospective review combined with cross-sectional survey from January 1, 2010, to December 31, 2015. This study was performed at a single tertiary care, level-I trauma center. Ten patients presenting with acute midfacial traumatic fractures were evaluated. Thirty-five physicians were surveyed regarding the accuracy of the images obtained using the algorithm. A computer algorithm utilizing AquariusNet (TeraRecon, Inc., Foster City, CA) and Adobe Photoshop (Adobe Systems Inc., San Jose, CA) was developed to model midface fracture repair. Preoperative three-dimensional computed tomographic (CT) images were processed using the algorithm. Fractures were virtually reduced and fixated to generate a virtual postoperative image. A survey comparing the virtual postoperative and the actual postoperative images was produced. A Likert-type scale rating system of 0 to 10 (0 being completely different and 10 being identical) was utilized. Survey participants evaluated the similarity of fracture reduction and fixation plate appearance. The algorithm's capacity for future clinical utility was also assessed. Survey response results from 35 physicians were collected and analyzed to determine the accuracy of the algorithm. Ten patients were evaluated. Fracture types included zygomaticomaxillary complex, LeFort, and naso-orbito-ethmoidal complex. Thirty-four images were assessed by a group of 35 physicians from the fields of otolaryngology, oral and maxillofacial surgery, and radiology. Mean response for fracture reduction similarity was 7.8 ± 2.5 and fixation plate similarity was 8.3 ± 1.9. All respondents reported interest in the tool for clinical use. This computer-based algorithm is able to produce virtual images that resemble actual postoperative images. It has the ability to model midface fracture repair and hardware placement.

Assessment of a Novel Computer Algorithm for Printing a 3-Dimensional Nasal Prosthetic.

Importance: The introduction and evaluation of a novel technique to create nasal prostheses with 3-dimensional (3-D) imaging software may circumvent the need for an anaplastologist. Objectives: To describe a novel computer algorithm for the creation of a 3-D model of a nose and to evaluate the similarity of appearance of the nasal prosthesis with that of the individual's nose. Design, Setting, and Participants: A prospective pilot study with a cross-sectional survey was conducted from August 1 to October 31, 2016, at a tertiary care academic center. Five volunteers were used for creation of the nasal prostheses, and 36 survey respondents with a medical background were involved in evaluating the nasal prostheses. Exposures: A computer algorithm using a 3-D animation software (Blender; Blender Foundation) and Adobe Photoshop CS6 (Adobe Systems) were used to create a 3-D model of a nose. Photographs of 5 volunteers were processed with the computer algorithm. The model was then printed using a desktop 3-D printer. Attending physicians, residents, and medical students completed a survey and were asked to rate the similarity between the individuals' photographs and their 3-D printed nose on a Likert-type scale. Main Outcomes and Measures: The similarity between 3-D printed nasal models and photographs of the volunteers' noses based on survey data. Results: Thirty-six survey respondents evaluated 4 views for each of the 5 modeled noses (from 4 women and 1 man; mean [SD] age, 26.6 [5.7] years). The mean (SD) score for the overall similarity between the photographs and the 3-D models was 8.42 (1.34). The mean scores for each nasal comparison ranged from 7.97 to 8.62. According to the survey, respondents were able to match the correct 3-D nose to the corresponding volunteers' photographs in 171 of 175 photographs (97.7%). All surveyed clinicians indicated that they would consider using this tool to create a temporary prosthesis instead of referring to a prosthodontist. Conclusions and Relevance: This algorithm can be used to model and print a 3-D prosthesis of a human nose. The printed models closely depicted the photographs of each volunteer's nose and can potentially be used to create a temporary prosthesis to fill external nasal defects. The appropriate clinical application of this technique is yet to be determined.

A novel computer algorithm for modeling and treating mandibular fractures: A pilot study.

OBJECTIVES/HYPOTHESIS: To describe a novel computer algorithm that can model mandibular fracture repair. To evaluate the algorithm as a tool to model mandibular fracture reduction and hardware selection. STUDY DESIGN: Retrospective pilot study combined with cross-sectional survey. METHODS: A computer algorithm utilizing Aquarius Net (TeraRecon, Inc, Foster City, CA) and Adobe Photoshop CS6 (Adobe Systems, Inc, San Jose, CA) was developed to model mandibular fracture repair. Ten different fracture patterns were selected from nine patients who had already undergone mandibular fracture repair. The preoperative computed tomography (CT) images were processed with the computer algorithm to create virtual images that matched the actual postoperative three-dimensional CT images. A survey comparing the true postoperative image with the virtual postoperative images was created and administered to otolaryngology resident and attending physicians. They were asked to rate on a scale from 0 to 10 (0 = completely different; 10 = identical) the similarity between the two images in terms of the fracture reduction and fixation hardware. RESULTS: Ten mandible fracture cases were analyzed and processed. There were 15 survey respondents. The mean score for overall similarity between the images was 8.41 ± 0.91; the mean score for similarity of fracture reduction was 8.61 ± 0.98; and the mean score for hardware appearance was 8.27 ± 0.97. There were no significant differences between attending and resident responses. There were no significant differences based on fracture location. CONCLUSION: This computer algorithm can accurately model mandibular fracture repair. Images created by the algorithm are highly similar to true postoperative images. The algorithm can potentially assist a surgeon planning mandibular fracture repair. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:331-336, 2017.

Bell's Palsy.

Bell's palsy is unilateral, acute onset facial paralysis that is a common condition. One in every 65 people experiences Bell's palsy in the course of their lifetime. The majority of patients afflicted with this idiopathic disorder recover facial function. Initial treatment involves oral corticosteroids, possible antiviral drugs, and protection of the eye from desiccation. A small subset of patients may be left with incomplete recovery, synkinesis, facial contracture, or hemifacial spasm. A combination of medical and surgical treatment options exist to treat the long-term sequelae of Bell's palsy.

Comparison of SPECT/CT and planar MIBI in terms of operating time and cost in the surgical management of primary hyperparathyroidism.

We conducted a retrospective study to compare operating times and costs in patients who underwent guided parathyroidectomies with either (1) technetium-99m ((99m)Tc) multiplex ion-beam imaging (MIBI) parathyroid scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images or (2) sestamibi dual-phase (99m)Tc MIBI planar parathyroid scintigraphy alone preoperatively. Our study population was made up of the first 24 patients at our facility who had undergone SPECT/CT parathyroid imaging with technetium-99m ((99m)Tc) MIBI and a group of 24 patients who had undergone MIBI planar imaging alone. Patient demographics, preoperative laboratory test results, operating times, and hospital charges were analyzed. We found that less operating time was required for the planar MIBI group than in the SPECT/CT group (mean: 135 vs. 158 min), although the difference was not statistically significant. Likewise, the total cost of treatment was lower in the planar MIBI group (mean: $10,035 vs. $11,592); the difference was statistically significant by one measure (p × 0.02, Wilcoxon rank sum test) but not by another (p × 0.06, Student t test). Although SPECT/CT is efficient for patients with small and difficult-to-localize adenomas, it has yet to demonstrate greater efficacy or cost-effectiveness than planar MIBI for routine parathyroidectomy in patients with primary hyperparathyroidism when an easily identifiable parathyroid adenoma is localized.