Neoadjuvant-Adjuvant or Adjuvant-Only Pembrolizumab in Advanced Melanoma.

BACKGROUND: Whether pembrolizumab given both before surgery (neoadjuvant therapy) and after surgery (adjuvant therapy), as compared with pembrolizumab given as adjuvant therapy alone, would increase event-free survival among patients with resectable stage III or IV melanoma is unknown. METHODS: In a phase 2 trial, we randomly assigned patients with clinically detectable, measurable stage IIIB to IVC melanoma that was amenable to surgical resection to three doses of neoadjuvant pembrolizumab, surgery, and 15 doses of adjuvant pembrolizumab (neoadjuvant-adjuvant group) or to surgery followed by pembrolizumab (200 mg intravenously every 3 weeks for a total of 18 doses) for approximately 1 year or until disease recurred or unacceptable toxic effects developed (adjuvant-only group). The primary end point was event-free survival in the intention-to-treat population. Events were defined as disease progression or toxic effects that precluded surgery; the inability to resect all gross disease; disease progression, surgical complications, or toxic effects of treatment that precluded the initiation of adjuvant therapy within 84 days after surgery; recurrence of melanoma after surgery; or death from any cause. Safety was also evaluated. RESULTS: At a median follow-up of 14.7 months, the neoadjuvant-adjuvant group (154 patients) had significantly longer event-free survival than the adjuvant-only group (159 patients) (P = 0.004 by the log-rank test). In a landmark analysis, event-free survival at 2 years was 72% (95% confidence interval [CI], 64 to 80) in the neoadjuvant-adjuvant group and 49% (95% CI, 41 to 59) in the adjuvant-only group. The percentage of patients with treatment-related adverse events of grades 3 or higher during therapy was 12% in the neoadjuvant-adjuvant group and 14% in the adjuvant-only group. CONCLUSIONS: Among patients with resectable stage III or IV melanoma, event-free survival was significantly longer among those who received pembrolizumab both before and after surgery than among those who received adjuvant pembrolizumab alone. No new toxic effects were identified. (Funded by the National Cancer Institute and Merck Sharp and Dohme; S1801 ClinicalTrials.gov number, NCT03698019.).

Routine Clinical Breast Examination Is a Low-Yield Practice Among Women at High Risk of Breast Cancer.

BACKGROUND: For women at increased risk of breast cancer, the National Comprehensive Cancer Network (NCCN) guidelines recommend clinical encounters every 6-12 months. While screening mammography has corresponded with a relative risk reduction in breast cancer mortality of approximately 20%, evidence validating clinical breast examination (CBE) as an efficacious screening modality is deficient. Our study aimed to assess the conventional merit of regular CBE for breast cancer detection among individuals at increased risk of breast cancer development. METHODS: Women > 18 years with documented high-risk encounters at Corewell Health West from 1 January 2018 to 31 December 22 were retrospectively reviewed. High-risk criteria included genetic predisposition, 5-year (> 1.7%) or lifetime (> 20%) Tyrer-Cuzick and/or Gail Model risk estimations, thoracic radiotherapy before age 30 years, lobular carcinoma in-situ, or atypical hyperplasia. Patients with a history of breast cancer or bilateral prophylactic mastectomy prior to 2018 were excluded. RESULTS: Of the 9171 cumulative high-risk encounters among 2493 women, only one breast cancer was detected by CBE. CBE resulted in 1 (0.04%) cancer diagnosis compared with 30 (1.2%) detected on screening imaging and 10 (0.4%) self-reported. Of the 30 image-detected cancers, 28 (93.3%) had no detectable clinical findings at the time of preoperative consultation. Self-reported and CBE-detected cancers were more likely to be of higher clinical stage compared with imaging-detected malignancies. CONCLUSIONS: The role of routine CBE as a cancer detection modality in the high-risk patient population appears to be limited. Telemedicine can be offered to individuals who have completed screening imaging but are unable to commit and/or are inconvenienced by in-person high-risk breast cancer assessments.

Can we let our patients sleep in the hospital? A randomized controlled trial of a pragmatic sleep protocol in surgical oncology patients.

BACKGROUND: Postoperative inpatients experience increased stress due to pain and poor restorative sleep than non-surgical inpatients. OBJECTIVES AND METHODS: A total of 101 patients, undergoing major oncologic surgery, were randomized to a postoperative sleep protocol (n = 50) or standard postoperative care (n = 51), between August 2020 and November 2021. The primary endpoint of the study was postoperative sleep time after major oncologic surgery. Sleep time and steps were measured using a Fitbit Charge 4®. RESULTS: There was no statistically significant difference found in postoperative sleep time between the sleep protocol and standard group (median sleep time of 427 min vs. 402 min; p = 0.852, respectively). Major complication rates were similar in both groups (7.4% vs. 8.9%). Multivariate analysis found sex and Charlson Comorbidity Index to be significant factors affecting postoperative sleep time and step count. Postoperative delirium was only observed in the standard group, although this did not reach statistical significance. There were no in hospital mortalities. CONCLUSION: The use of a sleep protocol was found to be safe in our study population. There was no statistical difference in postoperative sleep time or major complications. Institution of a more humane sleep protocol for postoperative inpatients should be considered.

Surgeon Burnout and Usage of Personal Communication Devices: Examining the Technology "Empowerment/Enslavement Paradox".

INTRODUCTION: Access to patients' electronic medical records (EMRs) on personal communication devices (PCDs) is beneficial but can negatively impact surgeons. In a recent op-ed, Cohen et al. explored this technology "empowerment/enslavement paradox" and its potential effect on surgeon burnout. We examined if there is a relationship between accessing EMRs on PCDs and surgeon burnout. METHODS: This was a cohort study with retrospective and prospective arms. Trainees and attendings with a background in general surgery completed the Maslach Burnout Index for Medical Personnel, a validated survey scored on three areas of burnout (emotional exhaustion, depersonalization, and low personal accomplishment). Data on login frequency to EMRs on PCDs over the previous 6 mo were obtained. Pearson correlation coefficients were calculated to determine if burnout and login frequency were associated. RESULTS: There were 52 participants included. Residents were 61.5% (n = 32) of participants. The mean login frequency over 6 mo was 431.0 ± 323.9. The mean scores (out of 6) for emotional exhaustion, depersonalization, and personal accomplishment were 2.3 ± 1.1, 1.9 ± 1.2, and 4.9 ± 0.8, respectively. There was no correlation between burnout and logins. Residents had higher median depersonalization scores (2.3 versus 1.2, P = 0.03) and total logins (417.5 versus 210.0, P < 0.001) than attendings. Participants who overestimated logins had higher median emotional exhaustion and depersonalization scores than those who underestimated (2.6 versus 1.4, P = 0.03, and 2.4 versus 0.8, P = 0.003, respectively). CONCLUSIONS: Using EMRs on PCDs is common, but frequency of logins did not correlate with burnout scores in this study. However, perception of increased workload may contribute to experiencing burnout.

Talimogene Laherparepvec (T-VEC) for the Treatment of Advanced Locoregional Melanoma After Failure of Immunotherapy: An International Multi-Institutional Experience.

BACKGROUND: Talimogene laherparepvec (T-VEC) is an oncolytic virus approved for the treatment of unresectable, recurrent melanoma. The role of T-VEC after progression on systemic immunotherapy (IO) remains undefined. The goal of this study was to characterize the efficacy of T-VEC after failure of IO in patients with unresectable metastatic melanoma. METHODS: An international, multi-institutional review of AJCC version 8 stage IIIB-IV melanoma patients treated with T-VEC after failure of IO was performed at six centers from October 2015-December 2020. Primary outcome was in-field response; secondary outcomes included analyses of in-field and overall progression-free survival (PFS) and in-field and overall disease-free survival (DFS) after a complete response. Subset analysis of T-VEC initiation sequentially after or concurrently with IO was performed. RESULTS: Of 112 patients, median age at T-VEC initiation was 69 years (range 21-93); 65 (58%) were male. Before T-VEC, 57% patients received one IO regimen, 42% received two or more, with most patients (n = 74, 66%) receiving T-VEC sequential to IO. Most were stage 3C (n = 51, 46%) at T-VEC initiation, 29 (26%) received injections to nodal disease. Over median follow-up of 14 months, in-field response at final T-VEC injection was 37% complete (CR), 14% partial (PR). T-VEC initiation sequentially or concurrently did not significantly affect in-field response (p = 0.26). Median in-field PFS was 15 months (95% confidence interval 4.6-NE). Median overall DFS after CR was 32 months (95% confidence interval 17-NE). CONCLUSIONS: T-VEC after failure of IO is effective in unresectable, metastatic stage IIIB-IV melanoma. T-VEC initiation sequentially or concurrently did not significantly affect in-field response.

Breast-Conserving Therapy is Associated with Improved Survival Compared with Mastectomy for Early-Stage Breast Cancer: A Propensity Score Matched Comparison Using the National Cancer Database.

INTRODUCTION: Current recommendations for early-stage breast cancer are largely based on the NSABP B-06 trial demonstrating equivalent survival between mastectomy and lumpectomy. We sought to compare breast-conserving therapy (BCT) with mastectomy for treatment of early-stage breast cancer in a contemporary patient population. METHODS: A query of the NCDB PUF identified female breast cancer patients diagnosed from 2004 to 2015. Patients with stage I or II disease were included. BCT was defined as the receipt of lumpectomy plus radiation. Propensity scores were tabulated using race, age, Charlson/Deyo score, tumor site, laterality, histology, grade, size, number of nodes positive, lymph-vascular invasion, receptor status, receipt of chemotherapy, and endocrine therapy. Patients who received BCT versus mastectomy were matched using a 1:1 nearest neighbor technique. The primary outcome measured was overall survival. RESULTS: After exclusions and matching, two equal groups of 101,118 patients remained. Median follow-up was 42 months. The majority had invasive ductal histology (77%), and node-negative disease (84%). Receptor status included ER-positive (83%), PR-positive (73%), and HER2/Neu-positive (15%). Chemotherapy was received in 38% and endocrine therapy in 71%. Propensity score matching yielded equivalent groups across all target variables. The 5-year overall survival was superior for BCT compared with mastectomy (92.9% vs. 89.7%, p < 0.001; Fig. 1). This survival advantage persisted for both stage I (p < 0.001) and stage II (p < 0.001) disease on subgroup analysis. Fig. 1 Overall survival in female patients with early stage invasive breast cancer (stage I or II) undergoing breast conservation surgery with radiation compared with mastectomy. BCS breast conservation surgery CONCLUSIONS: BCT is associated with superior overall survival compared with mastectomy for early-stage breast cancer using well-matched, contemporary data.

Surgical Resection Does Not Improve Survival in Multifocal Intrahepatic Cholangiocarcinoma: A Comparison of Surgical Resection with Intra-Arterial Therapies.

BACKGROUND: Multifocal intrahepatic cholangiocarcinoma (ICC) has traditionally been treated with surgical resection when amenable. Intra-arterial therapy (IAT) for multifocal ICC has not been directly compared with surgical resection. METHODS: A single-center, retrospective review of consecutive patients treated for multifocal ICC was conducted. Patients with distant metastases or treatment with systemic chemotherapy alone were excluded. Patients were divided into two groups: surgical resection versus IAT; IAT included transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and hepatic arterial infusion (HAI) pump therapy. Subjects were also analyzed by surgical resection, TACE, and HAI pump therapy. RESULTS: Overall, 116 patients with multifocal ICC were studied, 57 in the surgical resection group and 59 in the IAT group (TACE = 41, HAI pump = 16, TARE = 2). The IAT group was characterized by a higher incidence of bilobar disease (88.1% vs. 47.4%, p < 0.001), larger tumors (median 10.6 vs. 7.5 cm, p = 0.004), higher incidence of macrovascular invasion (44.1% vs. 24.6%, p = 0.027), and higher rate of nodal metastases (57.6% vs. 28.6%, p = 0.002). Median overall survival for surgical resection was 20 months versus 16 months for IAT (p = 0.627). Multivariate analysis found that macrovascular invasion [hazard ratio (HR) 2.52, 95% confidence interval (CI) 1.56-4.09] and non-receipt of systemic chemotherapy (HR 3.81, 95% CI 2.23-6.52) were independent poor prognostic risk factors. Surgical resection was not associated with a survival advantage over IAT on multivariate analysis (p = 0.242). CONCLUSION: Despite selection bias for use of surgical resection compared with IAT, no survival advantage was conferred in the treatment of multifocal ICC.

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

BACKGROUND: Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection. METHODS: Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival. RESULTS: The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n = 6), neuroendocrine tumor (n = 1), and ocular melanoma (n = 1) in addition to hepatocellular carcinoma (n = 4). The median time from liver disease diagnosis to Y90 treatment was 5.5 months (range 2-92 months). The median time from Y90 treatment to surgery was 9.5 months (range 3-20 months). The surgical approach included right hepatectomy (n = 3), extended right hepatectomy (n = 5), extended left hepatectomy (n = 1), segmentectomy with ablation (n = 2), and segmentectomy with isolated liver perfusion (n = 1). The hospital stay was 7 days (range 4-31 days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25 months. CONCLUSION: Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.

Sarcopenia and survival in patients undergoing pancreatic resection.

BACKGROUND: Recent studies have suggested that lean core muscle area may predict outcomes from major abdominal surgeries. Pancreatic resections have been independently analyzed less frequently. METHODS: Pancreatic resections from 2005 to 2012 were reviewed. Sarcopenia was defined as the lowest tertile for lean psoas muscle area (LPMA). Preoperative risk factors, including comorbidities, albumin, weight loss, age and gender, were analyzed with a primary endpoint of overall survival. Secondary endpoints included complications, discharge destination and readmission. RESULTS: The study sample of 270 patients had complications in 42% of patients, with 26% developing serious complication. The majority (80%) were discharged home, and 1.9% died in the peri-operative period. The mean length of follow up was 31.2 months (range 0-94), and 37% required at least one readmission. LPMA was predictive of discharge destination for females (p = 0.038). Sarcopenia was predictive of readmission in males, compared to subjects in the second LPMA tertile (HR 0.3; 95% CI: 0.1-0.9). In all male subjects, including a subset with adenocarcinoma, patients with sarcopenia were more likely to die than males in the highest LPMA tertile (HR: 2.6; 95% CI: 1.4-4.8 and HR: 2.4; 95% CI: 1.2-4.9, respectively). In all patients with pancreatic ductal adenocarcinoma, transfusion (HR: 1.9; 95% CI: 1.1-3.4) and positive margins (HR: 2.0; 95% CI: 1.2-3.3) were the only factors predictive of overall survival. CONCLUSIONS: Sarcopenia appears to be a predictor of overall survival in male patients undergoing pancreatic resections, but not specifically for patients with pancreatic ductal adenocarcinoma. As prospective data in future studies are identified, sarcopenia may become a useful tool in predicting outcomes.

Breast-Conserving Surgery in Bilateral Breast Cancer.

BACKGROUND: Bilateral breast cancer (BBC) may present as synchronous (SBC) or metachronous breast cancer (MBC). Optimal surgical management of BBC patients is not well-defined. In this study, we report on histopathology, treatment, and outcomes in BBC patients. METHODS: Upon Institutional Review Board approval, we identified BBC patients diagnosed and treated for invasive breast cancer between 1999 and 2007. Retrospective chart review for demographics, histopathology, treatment, and outcomes was performed, and factors associated with BCS choice were collected. Contraindication to BCS was defined as any of the following one-breast findings: multicentric disease, tumor considered too large for BCS, and a patient without a nominal breast size for acceptable cosmetic results. McNemar's test for matched pairs (binary variables) or the paired t test (continuous variables) were used to examine if a pathologic characteristic differed within a cancer pair. Kaplan-Meier methods estimated overall survival (OS). RESULTS: A total of 203 BBC patients (119 SBC, 84 MBC) comprised our study group. Histopathologic characteristics of the first and second cancers diagnosed in both the SBC and MBC patients were very similar in histologic type and molecular profiles. Overall, 57% of MBC patients underwent breast-conserving surgery (BCS) at initial diagnosis versus 34% of patients with SBC. BCS contraindications were similar in both groups: 16 (34%) MBC patients and 28 (36%) SBC patients. Kaplan-Meier OS estimates at 5 and 10 years were 86 and 78% for MBC, and 87 and 77% for SBC patients, respectively. CONCLUSIONS: OS was excellent for both the MBC and SBC groups. Contraindications to BCS did not differ between groups. However, patients with SBC were less likely to undergo BCS compared with patients with MBC at the time of initial diagnosis.

A multidisciplinary approach for abdominal venous involvement in oncologic resections.

BACKGROUND: An aggressive surgical approach to locally advanced malignancy is being increasingly used in the absence of distant metastatic disease. This includes resection and reconstruction of major venous structures. We investigated the results of using a multidisciplinary surgical approach in these instances. METHODS: The study data were obtained from a university-affiliated hospital from January 1, 2006, to December 31, 2012. All patients who underwent an oncologic resection using a multidisciplinary approach with vascular surgery consultation were included in the analysis. Primary outcomes analyzed included rate of margin positivity, postoperative venous patency, and survival. Secondary outcome measures included operative time, estimated blood loss, and length of hospital stay. RESULTS: A total of 23 patients met criteria for study. Venous involvement included the portal and/or superior mesenteric vein and inferior vena cava in 14 and 9 patients, respectively. Nine patients had clear vascular involvement before surgery and received preoperative consultation. Overall margins were positive in 56.5%, whereas the rate of vascular margin positivity was 30.4%. The postoperative venous patency rate was 65.0%. There were no perioperative mortalities, and median survival was 10 months (range, 4-80). CONCLUSIONS: Major venous resections and reconstructions in oncologic surgery are safe but associated with a high rate of positive margins. Future efforts should focus on identifying patients in the preoperative phase to provide opportunity for optimal multidisciplinary planning.

The drowning whipple: perioperative fluid balance and outcomes following pancreaticoduodenectomy.

BACKGROUND AND OBJECTIVES: Given the high incidence of postoperative morbidity following pancreaticoduodenectomy (PD), efforts at improving patient outcomes are vital. We sought to determine the impact of perioperative fluid balance on outcomes following PD in order to identify a targeted strategy for reducing morbidity. METHODS: A retrospective review of consecutive PDs from 2008 to 2012 was completed. Cumulative fluid balances were recorded at 0, 24, 48, and 72 hr postoperatively and patients were divided into quartiles. Multivariate analyses were performed accounting for age, gender, diagnosis, ASA class, estimated blood loss, colloid and blood product use, and hemoglobin nadir. The predefined primary outcome measures were 90-day morbidity (Clavien grade ≥ III), mortality, and hospital readmission. RESULTS: One hundred sixty-nine PDs were performed during the study period. The 90-day morbidity and mortality rates for the cohort were 40.2% and 3.0%, respectively, while hospital length of stay was 13.6 ± 6.7 days (mean ± SD). Higher fluid balance at 48 and 72 hr postoperatively was an independent predictor of morbidity and length of stay on multivariate analysis. CONCLUSIONS: Higher postoperative fluid balance is associated with increased postoperative morbidity and longer hospital stay following PD. Efforts at maintaining a fluid-restrictive strategy should be emphasized in this population.

Timing of mastectomy and the effect on the likelihood of outpatient surgery and cost savings in breast cancer patients.

BACKGROUND: Same-day discharge after mastectomy has potential patient- and hospital-level benefits; however, few data are available regarding factors affecting the likelihood of same-day discharge in order to address barriers. We sought to evaluate factors contributing to same-day discharge, focusing on the timing of mastectomy during the operative day. METHODS: We conducted a single-institution retrospective review of patients who underwent mastectomies for malignancy over a 3-y time frame. Clinicopathologic variables were collected along with a binary variable for mastectomy start time (morning versus afternoon). Our primary endpoint was rate of same-day discharge. A multivariable logistic regression model was constructed from significant univariate variables to determine independent predictors of same-day discharge. A secondary endpoint was a cost-utility analysis for morning versus afternoon start time, using hospital cost data. RESULTS: There were 451 patients included in the analysis. Factors associated with same-day discharge rate included the American Society of Anesthesiologists score, use of a preoperative regional anesthesia block, type of mastectomy performed, individual surgeon variation, and a morning start for the mastectomy. On multivariable analysis, morning start was a strong independent predictor of same-day discharge (odd ratio = 2.83; 95% CI, 1.75-4.60). The cost-utility analysis favored a morning start, with average cost savings of $550 per patient. CONCLUSION: Despite patient- and surgeon-specific variations, simple scheduling policies can improve same-day discharge rates after mastectomy, leading to improved hospital bed use and cost reduction.

Utility and costs of surveillance imaging for low- and very low-risk gastrointestinal stromal tumors.

BACKGROUND: There is limited evidence on the optimal surveillance approach in patients with low- and very low-risk gastrointestinal stromal tumors, resulting in inconsistent and arbitrary approaches to surveillance in this population. In this study, we reviewed our institutional approach to surveillance in patients with low- and very low-risk gastrointestinal stromal tumors and the costs associated with detecting recurrence. METHODS: We retrospectively reviewed consecutive adult patients treated for low- and very low-risk gastrointestinal stromal tumors at our institution from 2010 to 2019. Data collected included patient and tumor characteristics, surgical management, and postoperative follow-up. Surveillance-related expenses were calculated using estimates of average costs obtained from our institution. A cost analysis was performed to evaluate estimated yearly costs based on the surveillance strategy used. RESULTS: There were 60 patients included. The mean age at diagnosis was 63.9 (±12.5) years. The primary tumor was typically in the stomach (73%; n = 44). Computed tomography scan of the abdomen and pelvis with intravenous contrast was the most common surveillance modality (total = 226 scans). No recurrences were identified. Median follow-up duration was 49.0 (interquartile range = 19.5-61.5) months. The mean number of surveillance images per patient was 4 (±2.6). Surveillance imaging was obtained more frequently than just annually in 83% (n = 50) of patients, with an estimated yearly cost of $2,840.77 (interquartile range = $2,273.62-$3,895.92) and no detection of recurrence. CONCLUSION: In this study population, patients with low- and very low-risk gastrointestinal stromal tumors underwent frequent imaging studies for surveillance with little yield and at substantial cost. Further multi-institutional studies on practice patterns and outcomes of surveillance are warranted to better inform standardized surveillance recommendations.

Neoadjuvant Chemotherapy and Radiation Improves Recurrence-free and Overall Survival in Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma.

OBJECTIVE: The objective of this study is to analyze the outcomes of patients with resectable/borderline resectable PDAC who receive total neoadjuvant therapy vs upfront surgery. METHODS AND ANALYSIS: Patients who were treated at a single institution from 2006 to 2021 were included. The primary outcome was overall survival (OS). Secondary outcomes included disease free survival (DFS), rates of lymph node positivity, and R0 resection. All survival analyses were performed with intention-to-treat. RESULTS: 26 patients received neoadjuvant chemotherapy and radiation (TNT), 28 received neoadjuvant chemotherapy only (NAC), and 168 received upfront surgery. Demographics were comparable across all three groups. Patients who received TNT or NAC had longer OS and DFS compared to the surgery first patients (P < .01). Patients who received TNT had a lymph node positivity rate of 0% at time of surgery compared to 5.3% and 13.3% in the NAC and surgery-first groups, respectively (P < .01). The rate of R0 resection did not differ between groups (P = .17). CONCLUSION: Patients with resectable/borderline resectable PDAC who receive neoadjuvant therapy have longer OS and RFS relative to those who receive upfront surgery.

Contemporary approaches to the axilla in breast cancer.

Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.

Starting a minimally invasive inguinal lymphadenectomy program: Initial learning experience and outcomes.

BACKGROUND: There is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program. METHODS: This is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications. RESULTS: There were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0-160.0), or 130.5 minutes (range, 89.0-345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%). CONCLUSION: Minimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve.

Pancreatic Cancer: A Review of Current Treatment and Novel Therapies.

Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For those that present with localized disease, a multidisciplinary approach is necessary to maximize survival and optimize outcomes. The quality and safety of surgery for pancreatic cancer have improved in recent years with increasing adoption of minimally invasive techniques and surgical adjuncts. Systemic chemotherapy has also evolved to impact survival. It is now increasingly being utilized in the neoadjuvant setting, often with concomitant radiation. Increased utilization of genomic testing in metastatic pancreatic cancer has led to better understanding of their biology, thereby allowing clinicians to consider potential targeted therapies. Similarly, targeted agents such as PARP inhibitors and immune checkpoint- inhibitors have emerged with promising results. In summary, pancreatic cancer remains a disease with poor long-term survival. However, recent developments have led to improved outcomes and have changed practice in the past decade. This review summarizes current practices in pancreatic cancer treatment and the milestones that brought us to where we are today, along with emerging therapies.

Apixaban for Extended Thromboprophylaxis After Oncologic Resection: Outcomes and Cost Analysis.

BACKGROUND: Patients undergoing oncologic resection are at risk of developing venous thromboembolism (VTE), and this can lead to increased morbidity and hospital costs. Low-molecular weight heparin (LMWH) is recommended as extended thromboprophylaxis (ETP) in high-risk patients and has been shown to reduce rates of VTE. METHODS: This is a retrospective review of consecutive patients undergoing resection for oncologic indications at a single institution from May 2016 to May 2019. This study evaluated the use of apixaban as ETP at discharge. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), or mesenteric/portal venous thromboembolism at 30, 60, and 90 days postoperatively. RESULTS: A total of 600 patients were included; 449 patients received no ETP, and 151 patients received apixaban. PE occurred in 1.1, 1.6, and 2.3% of patients without ETP and 0, 0, and .7% of patients in the apixaban group (at 30, 60, and 90 days; P = .338, P = .201, and P = .306, respectively). DVT occurred in 1.8, 2.1, and 2.8% of patients without ETP and 0, 0, and 1.4% in the apixaban group (P = .211, P = .121, and P = .535, respectively). The total cost, including ETP and readmission for VTE, per patient was US $5.51 more in the apixaban group. CONCLUSION: Apixaban therapy for ETP did not produce a statistically significant reduction in VTE events in our patients. Future studies should include more patients in a prospective multicenter trial.