Assessing trends in breast care surveillance metrics after implementing surgeon-specific tracking and performance reporting in a large, integrated cancer network.

BACKGROUND: There are few quality metrics and benchmarks specific to surgical oncology. Development of a surgeon-level performance metrics system based on peer comparisons is hypothesized to positively influence surgical decision-making. This study established a tracking and reporting system comprised of evidence and consensus-based metrics to assess breast care delivered by individual surgeons. METHODS: Surgeons' performance is assessed by a surveillance tracking system of metrics pertaining to referrals and surgical elements. This retrospective analysis of prospectively collected breast care data reports on recurring 6-month and cumulative data from nine care locations from 2015 to 2021. RESULTS: Breast care was provided to 6659 patients by 41 surgeons. A total of 27 breast care metrics were evaluated over 7 years. Metrics with consistent, proficient results were retired after 18 months, including the rate of core biopsy, specimen orientation, and referrals to medical oncology, genetics, and fertility, among others. In clinically node-negative, hormone receptor-positive patients 70 years of age or older, the cumulative rate of sentinel lymph node (SLN) biopsy significantly decreased by 40% over 5.5 years (p < .001). The overall breast conservation rate for T0-T2 cancer increased 10% over 7 years. At the surgeon level, improvements were made in the median number of SLNs removed and in operative note documentation. CONCLUSIONS: Implementation of a surgeon-specific, peer comparison-based metric and tracking system has yielded substantive changes in breast care management. This process and governance structure can serve as a model for quantification of breast care at other institutions and for other disease sites.

Rate of radial scars by core biopsy and upgrading to malignancy or high-risk lesions before and after introduction of digital breast tomosynthesis.

PURPOSE: Radial scars (RS) commonly present mammographically as architectural distortions, but these lesions may be associated with non-invasive and invasive breast cancer. Digital breast tomosynthesis (DBT) has resulted in higher detection rates of architectural distortion particularly in patients with dense breast tissue. We hypothesized that rates of clinically relevant lesions confirmed surgically would be lower in patients who received DBT imaging compared with those who received standard digital breast imaging. METHODS: We performed a retrospective review of 223 patients diagnosed with pure RS by core biopsy and surgical excision before and after DBT was introduced. The rate of upgrading to malignancy or high-risk lesion was evaluated. Demographics, biopsy type, and histologic data were analyzed. Univariable logistic regression analysis was used to identify variables that may be associated with upgrading. RESULTS: The rate of identifying RS increased from 0.04-.13% (P < 0.0001) with DBT imaging. The upgrade rate on surgical specimen to invasive or non-invasive cancer was similar before and after DBT; 6% versus 3%, as were findings of a high-risk lesion; 12% versus 22%. No predictive factors were identified for patients upgraded to malignant neoplasms or high-risk lesions. CONCLUSIONS: The likelihood of identifying RS has increased with DBT imaging, but rates of upgrading to a malignant neoplasm or high-risk lesion were similar to those before DBT. Although the rate of upgrading to malignancy after DBT was low, an excisional biopsy should be considered as 22% of patients were upgraded to high-risk lesions. These patients are candidates for chemoprevention and/or high-risk surveillance.

Ductal Carcinoma In Situ with Microinvasion on Core Biopsy: Evaluating Tumor Upstaging Rate, Lymph Node Metastasis Rate, and Associated Predictive Variables.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) when ductal carcinoma in situ with microinvasion (DCISM) is identified on core biopsy is unclear. OBJECTIVE: Our aim was to assess the upstage rate to invasive cancer and axillary lymph node metastasis in patients diagnosed with DCISM, and whether predictive variables could be identified that may help inform who would most likely benefit from a surgical axillary evaluation. METHODS: We performed a retrospective review of 70 patients diagnosed with DCISM on core biopsy. Patients with concomitant or prior invasive cancer were excluded. Demographic, clinical, radiographic, histologic, and treatment data were collected. Fisher's exact test and univariable and multivariable logistic regression were performed to identify variables that may be associated with tumor upstaging and nodal metastasis. Time-to-event distributions were summarized using the Kaplan-Meier method. RESULTS: On final surgical pathology, 49 patients (70%) had a final diagnosis of DCISM or T1mi cancer, whereas 21 patients (30%) were upstaged to measurable invasive cancer (> 1 mm). One of 49 patients (2%) with DCISM on final pathology and 4 of 21 patients (19%) with measurable invasive cancer showed sentinel lymph node metastases. CONCLUSION: Although the upstage rate to measurable invasive cancer in our cohort of patients with DCISM on core biopsy was 30%, findings of a positive SLNB remain low at 7%. No predictive variables were identified to inform whether the routine practice of SLNB may be omitted in some patients with DCISM.

Lobular breast cancer series: imaging.

The limitations of mammography in the detection and evaluation of invasive lobular carcinoma (ILC) have long been recognized, presenting real clinical challenges in treatment planning for these tumors. However, advances in mammography, ultrasound, and magnetic resonance imaging present opportunities to improve the diagnosis and preoperative assessment of ILC. The evidence supporting the performance of each imaging modality will be reviewed, specifically as it relates to the pathology of ILC and its subtypes. Further, we will discuss emerging technologies that may be employed to enhance the detection rate and ultimately result in more effective screening and staging of ILC.

Indurated vascular plaques on the legs of an 85-year-old woman.

This is a case of classic type Kaposi sarcoma occurring in an 85-year-old woman who presented with indurated vascular plaques on both legs below the knee that has been present for two years. A brief review of the literature on Kaposi sarcoma is included.

Erythema ab igne: a case report and review of the literature.

Erythema ab igne (EAI) is a rare condition since the advent of central heating. Its incidence has been rising as heating sources are being used to treat chronic pain. Multiple activities that chronically expose patients to heating sources also have been documented with this condition. We present a case of EAI induced by the use of an electric blanket.

Biopsy of a 5 mm cystic lesion on the right heel of a 48-year-old woman.

An excisional biopsy of an asymptomatic cystic lesion that had been present for several years on the right heel of a 48-year-old woman revealed a subcutaneous cyst lined by ciliated columnar epithelium. On immunostaining, the epithelial cells were positive for Pan-cytokeratin (CK AE 1/3), estrogen receptor (ER) and progesterone receptor (PR), but negative for carcinoembryonic antigen (CEA), suggesting Mullerian type of epithelium. Cutaneous ciliated cyst of Mullerian type occurs almost exclusively on the lower extremity of premenopausal women. The lesion is benign and excision is curative.

Rapidly growing hemorrhagic papule on the cheek of a 54-year-old man.

A 54-year-old man sought medical attention for a growth on his right cheek that had been present for three months. The growth began as a small, brown "pimple" that gradually increased in size over time. Physical examination revealed a 9 mm well-circumscribed erythematous nodule with a hemorrhagic crust. On dermoscopy, the lesion was completely vascular appearing, with no pigment visualized. A clinical diagnosis of pyogenic granuloma was made. The lesion was biopsied and histopathologic examination revealed a 2.8 mm thick, Clark level IV, ulcerated, amelanotic nodular melanoma. Because the literature contains reports of nodular melanoma mimicking the presentation of a pyogenic granuloma, all such lesions should be biopsied for histopathologic diagnosis.

Pink pigtail in a skin biopsy: What is your diagnosis?

Sarcoptes scabiei is an obligate ectoparasite, which burrows into the stratum granulosum of the epidermis and lays its eggs. The resultant host inflammatory response leads to intensely pruritic papules. CASE SYNOPSIS: A 63-year-old man undergoing treatment for immunoproliferative disease was suspected of having a pruritic drug eruption. Subsequent skin biopsy revealed an intracorneal burrow containing three pink, refractile pigtail-like structures, believed to be empty eggshells of S. scabiei. CONCLUSION: Traditionally, the presence of adult mites or eggs in skin scrapings or a skin biopsy is required for a definitive diagnosis of scabies. However, our case and similar cases suggest that the diagnosis of scabies can also be made on the basis of pink pigtail-like structures, remnants of eggshells, within the intracorneal burrow.

Poroma of the hip and buttock.

Poroma is a benign adnexal skin tumor seen in middle aged individuals with no sex predilection. The acral sites are the most commonly affected regions. Hip or buttock as a location of origin has rarely been reported. We report two cases of poroma, one located on the hip of a 75-year-old man and the other on the buttock of a 60-year-old man.

Does Neoadjuvant Chemotherapy for Breast Cancer Affect Lymph Node Harvest Rates?

Some authors report that patients receiving neoadjuvant chemotherapy have fewer lymph nodes harvested during axillary dissection and more dissections with < 10 nodes compared with patients who undergo surgery initially. We sought to determine whether there was a difference between these patient groups in terms of number of nodes harvested and number of dissections with < 10 nodes. Retrospective review of 258 patients diagnosed with breast cancer who underwent an axillary lymph node dissection between July 1, 2015, and December 31, 2017 was performed. Chi-squared test was used to assess differences between patient groups. Of 258 patients undergoing dissection, 48 per cent received neoadjuvant chemotherapy; 52 per cent underwent surgery as first therapeutic intervention. Mean number of nodes resected; 14.3 + 6.3 for patients with no prior chemotherapy versus 14.9 + 6.6 for patients with neoadjuvant chemotherapy (P = 0.48). For patients undergoing surgery as first intervention, 21 per cent had < 10 nodes harvested. For patients receiving neoadjuvant chemotherapy, 20 per cent had < 10 nodes harvested. Patients who received neoadjuvant chemotherapy showed no statistically significant difference in the number of lymph nodes harvested during axillary dissection compared with patients undergoing surgery as first intervention. Neoadjuvant chemotherapy does not reduce the node harvest at the time of axillary dissection.

Diagnostic imaging for diverticulitis.

The misdiagnosis rate of diverticulitis based solely on clinical and laboratory criteria is high and given the potential severity of diverticulitis and its complications, early and routine radiologic evaluation is recommended. Imaging is used to establish the diagnosis and its extent and severity, and to detect the presence of any complications so that management can be directed appropriately. The most widely used examinations for the diagnosis of diverticulitis are ultrasound, barium enema, computed tomography (CT), and recently, magnetic resonance imaging. Over the past decade CT has replaced barium enema mainly because of its ability to identify extracolonic extent of disease. CT scan remains the procedure of choice in the acute, symptomatic stage. Nevertheless, diverticulitis often remains a clinical diagnosis; thus communication between the clinician and the radiologist remains imperative to facilitate effective testing.

Mycobacterium mucogenicum: report of a skin infection associated with etanercept.

Mycobacterium mucogenicum is a recently characterized organism that rarely may cause human infections. This rapidly growing mycobacterium is commonly identified in tap water. Both immunosuppressed and immunocompetent patients may develop infections from Mycobacterium mucogenicum. Some patients have experienced lethal disease, including sepsis. Infections occurring in the skin and soft tissues have been described only after a preceding injury. We present the first case of infection with Mycobacterium mucogenicum occurring in a patient on the TNF-alpha antagonist etanercept and without any prior soft tissue injury.

Fibroepithelioma of Pinkus with pleomorphic epithelial giant cells.

Fibroepithelioma of Pinkus is a rare, indolent variant of basal cell carcinoma (BCC). The presence of pleomorphic giant cells in such a tumor is extremely rare and to our knowledge, only one such case has been previously reported in the literature. We report another case occurring as a pedunculated, gluteal lesion in an 82-year-old man. The nodule was lightly pigmented, polypoid, and measured 1.0 cm in greatest dimension. Immunohistochemical staining confirmed that the giant cells were of epithelial origin and that the proliferative rate of these cells was low.

Angiosarcoma of the scalp mimicking a sebaceous cyst.

A 58-year-old Caucasian woman presented with a cystic lump behind the right ear that was clinically diagnosed as an infected sebaceous cyst. The lesion was treated with incision and drainage followed by antibiotics for 3 months. Because there was no resolution, a biopsy was performed that revealed a high grade angiosarcoma. She expired 2 months later. Cutaneous angiosarcoma is an extremely aggressive tumor. Therefore early diagnosis and management is crucial in providing better patient care.

Possible implantation carcinoma of the scalp following craniotomy for metastatic renal cell carcinoma.

We report a case of a 50-year-old man who developed a possible implantation carcinoma of the scalp within the craniotomy scar 19 months after a metastatic renal cell tumor nodule was removed from the brain. The English literature on the implantation carcinoma is briefly reviewed.

Multiple subcutaneous nodules associate with Mycobacterium abscessus infection following removal of an infected Groshon vascular catheter tip.

A 41-year-old man with a history of septic right leg underwent a below-the-knee amputation. One month after amputation and removal of Groshon catheter tip, he developed disseminated subcutaneous abscesses attributed to Mycobacterium abscessus.

Punch biopsies of melanoma: a diagnostic peril.

Excisional or incisional biopsies of melanoma are used to determine depth of tumor invasion and to plan subsequent treatment. Accurate determination of depth of melanoma invasion is critical for treatment decisions and prognosis. Incisional or punch biopsies can be perilous for histopathologic determination of invasion, and both over- and underestimation of invasion can occur when using incisional methods. Likewise, histologic factors can lead to over- and underestimation of invasion. Prognosis and treatment of melanoma are primarily determined by depth of tumor invasion. We discuss several scenarios that can lead to over- and underestimation of depth of invasion in incisional biopsy specimens. We therefore discourage incisional or punch biopsies of suspected melanoma and recommend that depth of invasion not be reported on these types of specimens.

Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ.

BACKGROUND: Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS). METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided. RESULTS: One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%). CONCLUSIONS: We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.