Factors Associated With Upstaging of Melanoma Thickness on Final Excision.

INTRODUCTION: The incidence and risk factors associated with upstaging from initial biopsy to definitive excision in cutaneous melanoma have not been established. The aim of this study was to determine the incidence of tumor stage upstaging and associated risk factors using the National Cancer Database. METHODS: A retrospective study of the National Cancer Database between 2012 and 2016 was performed. The cohort of patients undergoing excision of melanoma with available data comprised 133,592 patients. Differences in characteristics for upstaging were determined using Wilcox rank-sum, chi-square, or Fisher's exact tests. Multivariable analysis was performed using logistic regression to determine factors associated with upstaging. RESULTS: Incidence of upstaging was 5.2%. Upstaged patients were older, male, of non-White race, and of lower education level (P < 0.001). Lesions of the head/neck and lower extremity had increased incidence of upstaging compared to the trunk (P < 0.001). Nodular and acral lentiginous melanoma was associated with higher incidence of upstaging compared to superficial spreading melanoma (P < 0.001). Patients with lymphovascular invasion had increased risk of upstaging (P < 0.001). CONCLUSIONS: Upstaging of melanoma is infrequent but is significantly more prevalent in non-White patients and those with lower educational status. Provider and patient education should include the higher risk of upstaging in these groups and the possible need for further surgical intervention, such as re-excision of margins and sentinel lymph node biopsy.

Does Neoadjuvant Radiation Therapy Contribute to the Incidence of Pulmonary Complications Following Esophagectomy for Malignant Neoplasm?

BACKGROUND: Post-operative pulmonary complications (POPC) are common in patients undergoing esophagectomy and neoadjuvant radiotherapy may exacerbate POPC. This study assessed whether neoadjuvant radiation increases the incidence of POPC in patients undergoing esophagectomy for malignancy. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program database files from 2016 to 2018 were queried for patients undergoing esophagectomy for malignancy. Inverse probability treatment weighting (IPTW) was used to create balanced cohorts in which the control group received neoadjuvant chemotherapy (nCT) and the treatment cohort received neoadjuvant chemoradiotherapy (nCRT). A subset analysis was performed on patients with pre-existing pulmonary disease (PEPD). Primary outcomes were POPC and 30-day mortality. RESULTS: The all-patient analysis did not demonstrate a consistent association between neoadjuvant radiation and POPC. However, in patients with PEPD, POPC occurred more often in the nCRT cohort. Comparing nCRT to nCT and after IPTW adjustment for confounders, there was higher odds of pneumonia (aOR = 3.0, P = .002), unplanned intubation (aOR = 2.0, P = .03), and extended mechanical ventilation (aOR = 3.6, P = .002). DISCUSSION: In esophageal cancer patients with PEPD that undergo nCRT vs nCT prior to esophagectomy, the greater risk of POPCs must be weighed against the potential for improved oncologic outcomes.

Pancreatoduodenectomy: the Metabolic Syndrome is Associated with Preventable Morbidity and Mortality.

BACKGROUND: Patients with metabolic syndrome (MS) may have increased perioperative morbidity and mortality. The aim of this analysis was to investigate the association of MS with mortality, serious morbidity, and pancreatectomy-specific outcomes in patients undergoing pancreatoduodenectomy (PD). METHODS: Patients with MS who underwent PD were selected from the 2014-2018 ACS-NSQIP pancreatectomy-specific database. MS was defined as obesity (BMI ≥ 30 kg/m2), diabetes, and hypertension. Demographics and outcomes were compared by χ2 and Mann-Whitney tests, and adjusted odds ratios from multivariable logistic regression assessed the association between MS and primary outcomes. RESULTS: Of 19,054 patients who underwent PD, 7.3% (n = 1388) had MS. On univariable analysis, patients with MS had significantly worse outcomes (p < 0.05): 30-day mortality (3% vs 1.8%), serious morbidity (26% vs 23%), re-intubation (4.9% vs 3.5%), pulmonary embolism (2.0% vs 1.1%), acute renal failure (1.5% vs 0.9%), cardiac arrest (1.9% vs 1.0%), and delayed gastric emptying (18% vs 16.5%). On multivariable analysis, 30-day mortality was significantly increased in patients with MS (aOR: 1.53, p < 0.01). CONCLUSION: Metabolic syndrome is associated with increased morbidity and mortality in patients undergoing pancreatoduodenectomy. The association with mortality is a novel observation. Perioperative strategies aimed at reduction and/or mitigation of cardiac, pulmonary, thrombotic, and renal complications should be employed in this population given their increased risk.

Expression of PD-L1 in Patients With Malignant Peritoneal Mesothelioma: A Pilot Study.

INTRODUCTION: Frequency of PD-L1 expression and the role of immunotherapy in malignant peritoneal mesothelioma (MPM) have not been well characterized. The purpose of this study was to determine PD-L1 expression in patients with MPM and perform an exploratory analysis for associations between PD-L1 and its biological behavior in MPM. METHODS: Tumor samples were collected from patients undergoing surgical interventions between January 2018 and June 2020. Specimens were stained with anti-PD-L1 antibodies (Dako 22c3) and positivity was determined by tumor proportion score (TPS) or combined positive score (CPS) being ≥1%. RESULTS: Twenty one samples were obtained from 21 patients. Sixteen of 21 (76%) samples were CPS positive and 9 of 21 (43%) were TPS positive. Three samples had more aggressive biphasic/sarcomatoid histology and a high CPS and TPS (CPS: 3, 75, 95%; TPS: 2, 60, 90%). On an exploratory analysis, as the CPS or TPS threshold increased, there was a trend towards worse survival. CONCLUSIONS: MPM has a high frequency of PD-L1 expression, which may be associated with more aggressive tumor biology. These data provide the foundation for continued evaluation of checkpoint inhibition in patients with MPM.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Evaluation of a Gene Expression Profiling Assay in Primary Cutaneous Melanoma.

BACKGROUND: A significant proportion of deaths from cutaneous melanoma occur among patients with an initial diagnosis of stage 1 or 2 disease. The Decision-Dx Melanoma (DDM) 31-gene assay attempts to stratify these patients by risk of recurrence. This study aimed to evaluate this assay in a large single-institution series. METHODS: A retrospective chart review of all patients who underwent surgery for melanoma at a large academic cancer center with DDM results was performed. Patient demographics, tumor pathologic characteristics, sentinel node status, gene expression profile (GEP) class, and recurrence-free survival (RFS) were reviewed. The primary outcomes were recurrence of melanoma and distant metastatic recurrence. RESULTS: Data from 361 patients were analyzed. The median follow-up period was 15 months. Sentinel node biopsy was performed for 75.9% (n = 274) of the patients, 53 (19.4%) of whom tested positive. Overall, 13.6% (n = 49) of the patients had recurrence, and 8% (n = 29) had distant metastatic recurrence. The 3- and 5-year RFS rates were respectively 85% and 75% for the class 1A group, 74% and 47% for the class 1B/class 2A group, and 54% and 45% for the class 2B group. Increased Breslow thickness, ulceration, mitoses, sentinel node biopsy positivity, and GEP class 2B status were significantly associated with RFS and distant metastasis-free survival (DMFS) in the univariate analysis (all p < 0.05). In the multivariate analysis, only Breslow thickness and ulceration were associated with RFS (p < 0.003), and only Breslow thickness was associated with DMFS (p < 0.001). CONCLUSION: Genetic profiling of cutaneous melanoma can assist in predicting recurrence and help determine the need for close surveillance. However, traditional pathologic factors remain the strongest independent predictors of recurrence risk.

Larvae of Musca domestica (common house fly) found intraoperatively in a male breast abscess.

A 62-year-old male with type 2 diabetes mellitus presented to our nationally accredited breast center with bilateral breast masses present for 7 years and new-onset pink nipple discharge for several months. Mammography and ultrasound demonstrated a left 2.7 retroareolar cystic lesion and a right 2.1 cm retroareolar solid lesion. Given the suspicious nature of the bilateral breast discharge, core needle biopsies were performed to rule out underlying malignancy. The biopsies revealed benign results, but the discordance between the biopsy, imaging, and suspicious discharge led to the decision to perform bilateral excisional biopsies. Intraoperatively, a small organism resembling a larva was encountered. The abnormal tissue was sent for histopathological examination, along with the organism, which was identified as the larvae of Musca domestica, or common house fly.

Safe extubation during the COVID-19 pandemic.

Extubation of patients with Coronavirus Disease 2019 (COVID-19) is a high risk procedure for both patients and staff. Shortages in personal protective equipment (PPE) and the high volume of contact staff have with COVID-19 patients has generated an interest in ways to reduce exposure that might be feasible especially during pandemic times and in resource limited healthcare settings. The development of portable barrier hood devices (or intubation/extubation boxes) is an area of interest for many clinicians due to the theoretical reduction in aerosolization of SARS-CoV-2, the causative virus for COVID-19. We present a review of the current literature along with recommendations concerning safe extubation during the COVID-19 pandemic. In addition, a focused summary on the use of portable barrier hood devices, during the recent surge of COVID-19 is highlighted.