The Role of Axillary Lymph Node Dissection versus Sentinel Lymph Node Dissection in Breast Cancer Patients with Clinical N2b-N3c Disease Who Receive Adjuvant Radiotherapy.

BACKGROUND: For breast cancer with advanced regional lymph node involvement, axillary lymph node dissection (ALND) remains the standard of care for staging and treating the axilla despite the presence of undissected lymph nodes. The benefit of ALND in this setting is unknown. OBJECTIVES: We sought to describe national patterns of care of axillary surgery and its association with overall survival (OS) among women with cN2b-N3c breast cancer who receive adjuvant radiotherapy. PATIENTS AND METHODS: We identified female patients with cN2b-N3c breast cancer from 2012 to 2017 from the National Cancer Database. Clinical and demographic information were analyzed using Wilcoxon rank sum and χ2 tests. Predictors of receipt of ALND and predictors of death were identified with multivariable logistic regression modeling. Inverse probability of treatment weighting was implemented to adjust for differences in treatment cohorts. The Kaplan-Meier method was used to evaluate OS. RESULTS: We identified 7167 patients. Of these, 922 (13%) received SLNB and 6254 (87%) received ALND; 7% were cN2b, 19% cN3a, 24% cN3b, 19% cN3c, and 31% cN3, not otherwise specified. Predictors of receipt of ALND were age 50-69 years [odds ratio (OR) 1.3, p < 0.01], cN3a (OR 7.6, p < 0.01), cN3b (OR 2.8, p < 0.01), and cN3c (OR 4.2, p < 0.01). Predictors of death included cN3c (OR 1.9, p < 0.01), age 70-90 years (OR 1.5, p = 0.01), and positive surgical margins (OR 1.5, p < 0.01). After cohort balancing, ALND was not associated with improved OS when compared with SLNB (HR 0.99, p = 0.91). CONCLUSIONS: ALND in patients with advanced nodal disease was not associated with improved survival compared with SLNB for women who receive adjuvant radiotherapy.

The impact of a positive COVID-19 test on timeliness of radiation in patients receiving brachytherapy.

BACKGROUND: Delays in initiating and completing brachytherapy may have adverse oncologic outcomes for patients with cervical, uterine, and prostate cancer. The impact of the COVID-19 pandemic on brachytherapy in the United States has not been well-characterized. OBJECTIVES: We aim to evaluate how a positive COVID-19 test affected timeliness of treatment for patients undergoing brachytherapy for cervical, uterine, and prostate cancer. METHODS: We queried the National Cancer Database to identify patients diagnosed with cervical, uterine, and prostate cancer in 2019 and 2020 who received brachytherapy in their treatment. Patients who tested positive for COVID-19 between cancer diagnosis and start of radiation were compared to those who did not test positive for COVID-19. Time in days from cancer diagnosis to initiation of radiation was compared using two-sample t-tests with p < 0.05 signifying significant differences. RESULTS: We identified 38,341 patients with cervical (n = 6,925), uterine (n = 18,587), and prostate cancer (n = 12,829). Rates of COVID-19 positivity were cervical cancer (n = 135; 2%), uterine cancer (n = 236; 1.3%), and prostate cancer (n = 141; 1%). Of those, 35% of cervical, 49% of uterine, and 43% of prostate cancer patients tested positive between their cancer diagnosis and initiation of radiation. Median days to radiation was significantly longer in these patients: 78 versus 51 for cervical cancer (p < 0.01), 150 versus 104 for uterine cancer (p < 0.01), and 154 versus 124 for prostate cancer (p < 0.01). CONCLUSIONS: For patients with cervical, uterine, and prostate cancer diagnosed between 2019-2020, testing positive for COVID-19 after their cancer diagnosis was associated with a delay to initiation of radiation by 4-7 weeks.

A Young Adult with White Matter Changes and Recurrent Stroke Symptoms.

White matter changes on MRI can be a diagnostic puzzle as a large group of inflammatory, autoimmune, infectious, and neoplastic conditions can present in this way. An otherwise healthy 36-year-old male presented with his second episode of unilateral weakness, the first episode occurring five years previously. He did not have sensory or cerebellar symptoms with the current or previous episode. He reported that his grandfather, father, two of his aunts, and an uncle had multiple sclerosis (MS), dying in their 40s-50s from their disease. The MRI during his first hospitalization revealed acute ischemia as well as diffuse white matter hyperintensities. The current MRI revealed new ischemic changes as well as progression of the white matter hyperintensities with notable temporal lobe involvement. While small vessel disease and multiple sclerosis can present similarly, the history of stroke, lesion distribution, and family history suggested an alternative diagnosis. Due to high clinical suspicion, genetic testing was performed for CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and confirmed the diagnosis. This case report describes the approach to the adult with white matter changes and describes the typical presentation and findings of CADASIL, the most common heritable cause of stroke and vascular dementia in adults.

Biopsychosocial Pain Management and its Effect on Postoperative Opioid Use.

INTRODUCTION: Medical use and overuse of opioids have become an increasing problem over the past several decades. Postoperative pain control is the strongest indication for the use of opioid analgesics. Previous studies have demonstrated benefit from complementary and alternative therapy (CAT) for postoperative pain relief. A prior study conducted by Riswold et al. found that a unit staff training session on CAT improved patient experiences postoperatively following total joint replacement. The study was limited in that it did not examine if there were any changes in opioid usage following this intervention. METHODS: This study is a continuation of the Riswold et al. study on CAT training intervention. In July 2017, a four-hour staff training session on alternative comfort measures and pain medication administration took place. Opioid administration data was extracted from the PYXIS software for all patients who had received more than three opioid administrations across their hospital stay in the three months prior to CAT training and the three months post-training. Opioid administrations were converted to total oral morphine equivalents. The pre- and post-intervention groups were compared using independent sample t-tests using SPSS software. RESULTS: Statistically significant reduction of total oral morphine equivalents occurred following CAT training intervention (p=.034, CI 2.76, 69.81). Average oral morphine equivalents per day (p=0.023, CI 1.26, 16.57) and per administration (p=0.00048, CI 0.64, 2.25) also were significantly reduced following the CAT training intervention. CONCLUSION: This study strengthens the findings of prior studies, showing that CAT can improve patient satisfaction while also reducing overall opioid burden for post-surgical patients.

Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report.

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.