Multilevel predictors of guideline concordant needle biopsy use for non-metastatic breast cancer.

PURPOSE: Persistent breast cancer disparities, particularly geographic disparities, may be explained by diagnostic practice patterns such as utilization of needle biopsy, a National Quality Forum-endorsed quality metric for breast cancer diagnosis. Our objective was to assess the relationship between patient- and facility-level factors and needle biopsy receipt among women with non-metastatic breast cancer in the United States. METHODS: We examined characteristics of women diagnosed with breast cancer between 2004 and 2015 in the National Cancer Database. We assessed the relationship between patient- (e.g., race/ethnicity, stage, age, rurality) and facility-level (e.g., facility type, breast cancer case volume) factors with needle biopsy utilization via a mixed effects logistic regression model controlling for clustering by facility. RESULTS: In our cohort of 992,209 patients, 82.96% received needle biopsy. In adjusted models, the odds of needle biopsy receipt were higher for Hispanic (OR 1.04, Confidence Interval 1.01-1.08) and Medicaid patients (OR 1.04, CI 1.02-1.08), and for patients receiving care at Integrated Network Cancer Programs (OR 1.21, CI 1.02-1.43). Odds of needle biopsy receipt were lower for non-metropolitan patients (OR 0.93, CI 0.90-0.96), patients with cancer stage 0 or I (at least OR 0.89, CI 0.86-0.91), patients with comorbidities (OR 0.93, CI 0.91-0.94), and for patients receiving care at Community Cancer Programs (OR 0.84, CI 0.74-0.96). CONCLUSION: This study suggests a need to account for sociodemographic factors including rurality as predictors of utilization of evidence-based diagnostic testing, such as needle biopsy. Addressing inequities in breast cancer diagnosis quality may help improve breast cancer outcomes in underserved patients.

Neuroendocrine tumors of the rectum: a 10-year review of management.

Neuroendocrine tumors of the rectum constitute approximately 19 per cent of gastrointestinal neuroendocrine tumors (NETs). The histologic characteristics of the tumor seem to be an indicative prognostic factor. Optimal treatment of NETS of the rectum has been widely debated, but more recent studies suggest that treatment depends upon the size. The medical records of 37 patients with NETS of the rectum were retrospectively reviewed. We reviewed their presentation, surgical treatment, pathology, and outcome. All pathological specimens were reviewed. Neuroendocrine tumors of the rectum were classified as either well-differentiated tumors, well-differentiated neuroendocrine carcinoma, or poorly differentiated neuroendocrine carcinoma. Evaluating tumor size, we found 35/37 patients had tumors less than 1 cm, 1 patient had a tumor between 1 and 2 cm, and one had a tumor greater than 2 cm. Pathologic evaluation of the tumors revealed that 35 of the tumors invaded the submucosa only, one invaded the muscularis propria, and one invaded the perirectal adipose tissue. The histopathologic features of the tumors revealed that 34 of the tumors were well-differentiated NETS with benign features, one tumor had invaded the submucosa, with angioinvasion, and two tumors were neuroendocrine carcinoma. Thirty-five patients underwent local excision. Eleven had reexcisions for positive margins. Two patients had local excision for recurrence, and one patient underwent low anterior resection (4 cm). Twelve patients had negative margins, 25 had positive margins. Eleven patients underwent reexcision. Six had no evidence of residual disease, and five had persistent positive margins and were offered no further treatment. Nineteen patients had positive margins and did not have reexcision. They all had tumors < 1 cm. Despite half of the lesions being resected with final pathologic positive margins, we have seen no significant influence on recurrence or overall survival. This raises the question of margin clearance in early lesions.

Savi Scout Radar Localization Versus Wire Localization for Breast Biopsy Regarding Positive Margin, Complication, and Reoperation Rates.

BACKGROUND: Breast cancer is the most commonly diagnosed noncutaneous malignancy and remains the second leading cause of cancer deaths in women. The Savi Scout (Cianna Medical, Merit Medical Systems, Inc. South Jordan, UT) is a wireless, nonradioactive, wave reflection implant system that enables surgeons to remove targeted breast lesions. Our study aims to be the largest comparison of wire and Savi Scout localization techniques for positive margin, complication, and reoperation rates. METHODS: Single-institution retrospective review of 512 patients that had Savi Scout Surgical Guidance System breast lesion biopsy or wire localized breast biopsy from May 2017 to December 2018. A RedCaps database was created and reviewed for outcomes. RESULTS: For 320 Savi scout patients, margins were positive or less than 1 mm in 18 cases (5.6%). 17 (5.3%) patients required reoperation. Surgical site occurrence was found in 7 (2.1%) patients, and 2 patients required intervention (0.6%). For 175 wire localization patients, margins were positive or less than 1 mm in 24 patients, and all required reoperation (13.7%). A surgical site occurrence was found in 13 (7.4%) patients and 5 patients required intervention (2.8%). DISCUSSION: In our series, the Savi Scout localization system resulted in a lower rate of positive margins, reoperation, and surgical site occurrence. These data suggest that Savi Scout localization is a reasonable replacement to wire localization for breast lesions and might produce superior results.

Differential expression of prognostic factors and effect on survival in young (< or =40) breast cancer patients: a case-control study.

The belief that young women develop more aggressive forms of breast cancer than other women is controversial. The purpose of this study was to determine if women 40 years of age and under with breast cancer have more negative prognostic indicators and a higher 5-year mortality than those women over 40 years of age. From January 1998-December 2002, all women with breast cancer were identified from our tumor registry. Women with metastatic disease at presentation were excluded from our study. The women were divided into two groups, women under 40 (cases) and women 40 and over (controls). Seventy-eight cases were identified and matched to 228 controls. These cohorts were matched 3:1 (cases:controls) based on tumor staging. The data collected on each patient included prognostic factors such as tumor size, tumor type, estrogen and progesterone receptors, Her2/neu, and Ki-67. Information on surgical procedure, postoperative therapy, recurrence, and mortality was also gathered. The mean ages for cases and controls were 35 and 59 years, respectively. The rates of modified radical mastectomy were similar in the two groups, but young women were more likely to have breast reconstruction (33.7% vs 9.8%). The rates of breast conservation therapy were actually lower in the group under 40 (32.5% vs 37.6%). Tumors in the 40 and under group were more frequently estrogen receptor negative (33.8% vs 21.9%: P = 0.046) and progesterone receptor negative (50.0% vs 35.5%: P = 0.033). Younger women also experienced a greater prevalence of Ki-67 (P < 0.001) and higher levels of Her2/neu overexpression (P = 0.013). Women over 40 were more likely to receive hormonal therapy (39.7% vs 36.1%). Women over 40 had a lower overall rate of recurrence. A difference in overall survival does exist between these two groups of women, which trends toward significance. The women 40 and under had a lower overall 5-year survival. The reason for this difference remains unclear. Although we demonstrate a higher percentage of younger women with negative biochemical markers, the only factors independently and significantly related to higher mortality were estrogen receptor negativity and tumor stage at presentation.

The impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial: An institutional review.

BACKGROUND: Axillary dissection (AD) was historically recommended for all patients with breast tumor involvement discovered by sentinel lymph node biopsy (+SLNB). However, after the ACOSOG Z0011 trial, omission of AD became the recommendation for selected patients with a +SLNB. We report the impact of ACOSOG Z0011 on the completion AD rate in patients with +SLNB at our institution. METHODS: We retrospectively reviewed all patients diagnosed with breast cancer between March 2009 and February 2013 (n = 1781). This cohort was divided into two groups: 1) those diagnosed BEFORE Z0011 and 2) those diagnosed AFTER Z0011. We calculated both the percentage of patients with a +SNLB who underwent AD and, from those patients, the percentage who did and did not meet the Z0011 criteria. RESULTS: The BEFORE group contained 849 patients; 144 had +SLNB and from those 113 underwent AD. The AFTER group contained 932 patients: 139 had +SLNB and from those 73 underwent AD. The completion AD rate in the BEFORE group was 78.5%, compared to 52.5% in the AFTER group (p < 0.001). From the patients who met the Z0011 criteria, 75.6% of the BEFORE patients underwent AD, compared to only 2.2%% in the AFTER group (p < 0.001). Among those who did not meet the Z0011 criteria, a similar percentage of patients underwent AD in each group (BEFORE 79.8%, AFTER 74.4%, p = 0.384). CONCLUSION: Following the publication of the ACOSOG Z0011 trial, we experienced a significant decrease in the completion AD rate among patients with a +SLNB who met the Z0011 inclusion criteria.

Treatment and outcomes of melanoma with a Breslow's depth greater than or equal to one millimeter in a regional teaching hospital.

Local control and regional lymph node evaluation are the primary treatment goals for cutaneous primary melanoma. Historically, primary lesions were excised with large 3- to 5-cm radial margins. Recent clinical trials have suggested that similar survival and recurrence rates can be achieved with smaller margins of excision. In addition to excision of the primary lesion, the presence or absence of nodal metastasis is the single most powerful predictor of survival in patients with melanoma. Based on the available trials, the standard of care for a melanoma 1 mm or greater in depth is a wide local excision with a 2-cm margin and a sentinel lymph node biopsy (SLNB). The application of this standard in regional teaching hospitals is unknown. We performed a retrospective review of a cancer registry at a teaching hospital in South Carolina. This analysis included all patients who underwent surgery for melanoma at our institution between July 1997 and March 2003. Our single inclusion criterion was that the primary melanoma had to be 1 mm or greater in depth. Only 42 per cent of the patients underwent excision with a radial margin >2 cm, and only 60 per cent of the patients underwent SLNB. As time progressed, the use of SLNB at our institution increased; but, even as late as 2003, some patients did not receive SLNB. Adherence to standards did not appear to have an effect on overall survival. In conclusion, the current standard for the treatment of invasive melanoma greater than or equal to 1 mm in thickness is a 2-cm margin of excision and a SLNB. In this regional teaching hospital, surgical treatment and staging of melanoma did not strictly adhere to the standard.