Quality of life assessment for patients undergoing irreversible electroporation (IRE) for treatment of locally advanced pancreatic cancer (LAPC).

BACKGROUND: IRE is a non-thermal ablative modality that has been shown to be safe and efficacious in LAPC and liver tumors, but few studies have shown its effects on patients' (QOL). The goal of this study is to evaluate quality-of-life (QOL) before and after irreversible electroporation (IRE) therapy for treatment of locally advanced pancreatic carcinoma (LAPC). METHODS: Between 11/2014 and 12/2016, patients scheduled for IRE therapy for LAPC were offered QOL questionnaires (EORTC QLQ-C30 V2.0) before surgery and 1,3 and 6-months after surgery. Descriptive statistics, one-way ANOVA and effect-size calculations were used in analysis of the 15 modules. RESULTS: Eight-four prospective patients were enrolled with a median age of 59.08 years (range 27.38-75.72) all who completed 6 months QOL surveys. Global health status scale showed lower average score at 3 and 6 months(p = 0.001). Symptoms scales constipation and insomnia showed higher averages at 3 months (p = 0.007 and p = 0.003 respectively), while dyspnea had higher average at 6 months (p < 0.001). Finally, changes were noted with worse diarrhea symptoms scale at 1 and 3 months (p < 0.001). Otherwise all QOL side effects were normalized at 3 months after IRE. CONCLUSIONS: The preponderance of symptoms at 3-6 months, symptom profile, and the use of additional therapy on majority of patients suggests other interrelated clinical factors influenced results (e.g. chemotherapy toxicity). This demonstrates that IRE therapy does not adversely affect QOL in the short term in patients with LAPC.

Evaluation of Probe Angles for Synchronous Waveform 915-MHz Microwave Ablation.

BACKGROUND: The purpose of this study is to compare the ablation performance between a synchronous microwave ablation (MWA) system and a commercially available asynchronous system in ex vivo bovine liver and evaluate the efficacy of ablation at varying entrance angles. MATERIALS AND METHODS: Two 915-MHz MWA systems were used in bench top ex vivo bovine livers with various conditions (synchronous versus asynchronous). Using synchronous technology ablations to liver, kidney, or lung at angles of 0, 15, 30, and 90° were evaluated. RESULTS: Synchronous and asynchronous MWA systems created mean ablation zone volumes of 26.4 and 15.8 cm3, 62.9 and 45.4 cm3, 90.8 and 56.4, and 75.7 and 54.8 cm3 with single, double (2 microwave probes in use simultaneous) (2 cm spacing), and triple (three probes in use simultaneously) (2 cm and 3 cm spacing) antennae configurations, respectively; adjusted P-values ≤ 0.006. Ablation defects were similar across all groups when evaluated for entrance angle. Specifically, when comparing 0-degree angle to all other angles, achieved zones of ablation (ZA) were similar (mean ± standard deviation for 0-degree versus all other angles: 8.72 ± 4.84 versus 9.38 ± 4.11 cm2, P = 0.75). The use of the long-tip probe resulted in a statistically significant increase in the achieved ZA when compared to the short tip probe (10.9 ± 4.3 versus 6.5 ± 2.4, respectively; P = 0.01). CONCLUSIONS: Newly developed synchronous microwave technology creates significantly larger ablation zones when compared to an existing asynchronous commercially available system. The angle of approach does not affect the resulting ZA. This is clinically relevant as true 0-degree angle is often difficult to obtain.

Deficiency of tumor suppressor Merlin facilitates metabolic adaptation by co-operative engagement of SMAD-Hippo signaling in breast cancer.

The NF2 gene encodes the tumor and metastasis suppressor protein Merlin. Merlin exerts its tumor suppressive role by inhibiting proliferation and inducing contact-growth inhibition and apoptosis. In the current investigation, we determined that loss of Merlin in breast cancer tissues is concordant with the loss of the inhibitory SMAD, SMAD7, of the TGF-ß pathway. This was reflected as dysregulated activation of TGF-ß signaling that co-operatively engaged with effectors of the Hippo pathway (YAP/TAZ/TEAD). As a consequence, the loss of Merlin in breast cancer resulted in a significant metabolic and bioenergetic adaptation of cells characterized by increased aerobic glycolysis and decreased oxygen consumption. Mechanistically, we determined that the co-operative activity of the Hippo and TGF-ß transcription effectors caused upregulation of the long non-coding RNA Urothelial Cancer-Associated 1 (UCA1) that disengaged Merlin's check on STAT3 activity. The consequent upregulation of Hexokinase 2 (HK2) enabled a metabolic shift towards aerobic glycolysis. In fact, Merlin deficiency engendered cellular dependence on this metabolic adaptation, endorsing a critical role for Merlin in regulating cellular metabolism. This is the first report of Merlin functioning as a molecular restraint on cellular metabolism. Thus, breast cancer patients whose tumors demonstrate concordant loss of Merlin and SMAD7 may benefit from an approach of incorporating STAT3 inhibitors.

Calculation of breast volumes from mammogram: Comparison of four separate equations relative to mastectomy specimen volumes.

BACKGROUND AND OBJECTIVES: Accurately assessing breast volume (BV) relative to the volume of breast tissue to be removed could help objectively determine the optimal surgical candidates for breast conserving surgery. The objective of this study was to determine the optimal mammography-based method of BV estimation. METHODS: Mammography data was obtained for patients who underwent mastectomy for breast cancer from 2005 to 2015. This data was used to calculate BV using four previously published equations. Results were compared to mastectomy specimen volumes calculated from specimen weights and breast density. Five practitioners then independently assessed reproducibility and ease of use. RESULTS: Complete mammographic measurements were available for 65 breasts from 45 patients. Median age was 58 years (range 19-82). Mammographic breast density scores were available for 62 breasts. Of the 65 mastectomies performed, 16 (36%) were simple mastectomies. The equation BV = 1/3πRcc Rmlo Hmlo most closely approximated actual breast specimen volumes (R = 0.89, P < 0.0001). Internal correlation of calculated BV was excellent among all practitioners (lowest Pearson R = 0.963). CONCLUSIONS: Breast volumes can be reliably estimated utilizing measurements from a preoperative mammogram. This low-cost method of volumetric analysis can be employed to guide surgical decision making in treatment of patients with invasive breast cancer.

Long-term outcomes after hand-sewn versus circular-stapled (25 and 29 mm) anastomotic technique after esophagogastrectomy for esophageal cancer.

BACKGROUND: Anastomotic stricture following esophagogastrectomy (EG) can lead to significant dysphagia, necessitating interventions such as endoscopic dilatation. These post-operative complications gain importance with the increased survival rate of patients after EG. This study aimed to assess the outcomes of both circular-stapled (CS: 25 and 29 mm) and hand-sewn (HS) anastomoses after EG. METHODS: We reviewed prospectively accrued data from December 2004 to December 2014 identifying all patients undergoing EG for esophageal cancer. Immediate post-operative and long-term complications were noted. Primary outcome measures included anastomotic leak and stricture, dysphagia, and subsequent. RESULTS: A total of 142 patients were identified for analysis. The method used for reconstruction was noted: CS-EEA-25 mm (n = 30), CS-EEA-29 mm (n = 30), and HS (n = 82). Demographics, tumor pathology, and tumor locations were similar in each group. All groups experienced similar rates of anastomotic leak, stricture, and dysphagia. Furthermore, post-operative dilations for symptomatic dysphagia were required in 3 (10%), 4 (13%), and 9 (11%) patients, P = 0.91. CONCLUSION: In this cohort, the method of anastomotic construction had no bearing on the rate of complications after EG for the treatment of esophageal cancer. Furthermore, long-term need for dilations for symptomatic dysphagia was equal among all groups.

Health-related quality of life during trans-arterial chemoembolization with drug-eluting beads loaded with doxorubicin (DEBDOX) for unresectable hepatic metastases from ocular melanoma.

BACKGROUND: We have previously reported favorable response and survival rates using drug-eluting beads loaded with doxorubicin (DEBDOX) for unresectable hepatic metastases. This study investigates the quality of life (QoL) impact of DEBDOX for the treatment of unresectable hepatic metastases from melanoma. METHODS: A multi-center, prospective, non-controlled clinical trial was reviewed. QoL was assessed at baseline and after each treatment, and doxorubicin-specific effects were assessed after each treatment. RESULTS: Twenty patients received 61 DEBDOX treatments. After each treatment, at least 83% of patients reported "little" to "none" doxorubicin-related symptoms. For the 8 FACT-Hep subscales, QoL scores were unchanged through 3 treatments for 18 of 24 total time points by ANOVA, with a small-to-moderate ES change through the last treatment in 36 of 40 time points. CONCLUSIONS: Hepatic arterial therapy with DEBDOX is safe with minimal QOL changes in treating unresectable liver-dominant melanoma metastasis. CLINICAL TRIAL: NCT01010984.

Wide versus narrow margins after partial hepatectomy for hepatocellular carcinoma: Balancing recurrence risk and liver function.

BACKGROUND: The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved. METHODS: A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 ("narrow") and >5 mm ("wide") as measured on final pathologic assessment. RESULTS: One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85). CONCLUSIONS: A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence.

Rib fractures and their association With solid organ injury: higher rib fractures have greater significance for solid organ injury screening.

BACKGROUND: The purpose of this study was to identify patients with rib injuries who were at risk for solid organ injury. METHODS: A retrospective chart review was performed of all blunt trauma patients with rib fractures during the period from July 2007 to July 2012. Data were analyzed for association of rib fractures and solid organ injury. RESULTS: In all, 1,103 rib fracture patients were identified; 142 patients had liver injuries with 109 (77%) associated right rib fractures. Right-sided rib fractures with highest sensitivity for liver injury were middle rib segment (5 to 8) and lower segment (9 to 12) with liver injury sensitivities of 68% and 43%, respectively (P < .001); 151 patients had spleen injuries with 119 (79%) associated left rib fractures. Left middle segment rib fractures and lower segment rib fractures had sensitivities of 80% and 63% for splenic injury, respectively (P < .003). CONCLUSIONS: Rib fractures higher in the thoracic cage have significant association with solid organ injury. Using rib fractures from middle plus lower segments as indication for abdominal screening will significantly improve rib fracture sensitivity for identification of solid organ injury.

Standard Dosing of Enoxaparin for Venous Thromboembolism Prophylaxis Is Not Sufficient for Most Patients Within a Trauma Intensive Care Unit.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI >30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese (P = 0.73). However, elevated BMI (P < 0.05) and abdominal wall thickness (P < 0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation (P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

The safety of low molecular-weight heparin after blunt liver and spleen injuries.

BACKGROUND: Anticoagulation is routinely administered to all trauma patients owing to the high incidence of venous thromboembolism (VTE). However, the timing of administration of anticoagulation is not clearly defined when patients have blunt spleen or liver injuries because of the perceived risk of hemorrhage with early administration. METHODS: A retrospective chart review was performed of all blunt trauma patients who sustained blunt liver and/or spleen injuries during the 5-year period from 2007 to 2011. Data were collected for all patients managed with nonoperative therapy for these injuries while also receiving routine prophylactic anticoagulation with low molecular-weight heparin. Patients were categorized based on the initiation of enoxaparin therapy after injury: early (<48 hours), intermediate (48 to 72 hours), and late (>72 hours). Primary and secondary outcomes were designated as need for operative or radiologic intervention secondary to spleen or liver hemorrhage, number of transfusions, and incidence of VTE. RESULTS: Three hundred and twenty-eight patients were included. There were no enoxaparin-related hemorrhagic complications or hemorrhage necessitating operative intervention. Patients in the early, intermediate, and late groups received an average of .9, .93, and 1.55 units of blood, respectively. There was 1 pulmonary embolism in the early group, and there were 6 VTE complications in the late group (3 deep venous thromboses and 3 pulmonary embolisms). CONCLUSIONS: There are currently no standards for the initiation of prophylactic anticoagulation in trauma patients with blunt liver and spleen injuries. Early administration may be safe and reduce the incidence of thrombotic complications in patients with blunt spleen and liver injuries. Prospective studies in this area are warranted.

Larger ATV engine size correlates with an increased rate of traumatic brain injury.

INTRODUCTION: Since the introduction of all-terrain vehicles (ATV) to the United States in 1971, injuries and mortalities related to their use have increased significantly. Furthermore, these vehicles have become larger and more powerful. As there are no helmet requirements or limitations on engine-size in the State of Alabama, we hypothesised that larger engine size would correlate with an increased incidence of traumatic brain injury (TBI) in patients following an ATV crash. METHODS: Patient and ATV data were prospectively collected on all ATV crashes presenting to a level one trauma centre from September 2010 to May 2013. Collected data included: demographics, age of driver, ATV engine size, presence of helmet, injuries, and outcomes. The data were grouped according to the ATV engine size in cubic centimetres (cc). For the purposes of this study, TBI was defined as any type of intracranial haemorrhage on the initial computed tomography scan. RESULTS: There were 61 patients identified during the study period. Two patients (3%) were wearing a helmet at the time of injury. Patients on an ATV with an engine size of 350 cc or greater had higher Injury Severity Scores (13.9 vs. 7.5, p ≤ 0.05) and an increased incidence of TBI (26% vs. 0%, p ≤ 0.05) when compared to patients on ATV's with an engine size less than 350 cc. CONCLUSIONS: Patients on an ATV with an engine size of 350 cc or greater were more likely to have a TBI. The use of a helmet was rarely present in this cohort. Legislative efforts to implement rider protection laws for ATVs are warranted.

microRNA-29 negatively regulates EMT regulator N-myc interactor in breast cancer.

BACKGROUND: N-Myc Interactor is an inducible protein whose expression is compromised in advanced stage breast cancer. Downregulation of NMI, a gatekeeper of epithelial phenotype, in breast tumors promotes mesenchymal, invasive and metastatic phenotype of the cancer cells. Thus the mechanisms that regulate expression of NMI are of potential interest for understanding the etiology of breast tumor progression and metastasis. METHOD: Web based prediction algorithms were used to identify miRNAs that potentially target the NMI transcript. Luciferase reporter assays and western blot analysis were used to confirm the ability of miR-29 to target NMI. Quantitive-RT-PCRs were used to examine levels of miR29 and NMI from cell line and patient specimen derived RNA. The functional impact of miR-29 on EMT phenotype was evaluated using transwell migration as well as monitoring 3D matrigel growth morphology. Anti-miRs were used to examine effects of reducing miR-29 levels from cells. Western blots were used to examine changes in GSK3ß phosphorylation status. The impact on molecular attributes of EMT was evaluated using immunocytochemistry, qRT-PCRs as well as Western blot analyses. RESULTS: Invasive, mesenchymal-like breast cancer cell lines showed increased levels of miR-29. Introduction of miR-29 into breast cancer cells (with robust level of NMI) resulted in decreased NMI expression and increased invasion, whereas treatment of cells with high miR-29 and low NMI levels with miR-29 antagonists increased NMI expression and decreased invasion. Assessment of 2D and 3D growth morphologies revealed an EMT promoting effect of miR-29. Analysis of mRNA of NMI and miR-29 from patient derived breast cancer tumors showed a strong, inverse relationship between the expression of NMI and the miR-29. Our studies also revealed that in the absence of NMI, miR-29 expression is upregulated due to unrestricted Wnt/ß-catenin signaling resulting from inactivation of GSK3ß. CONCLUSION: Aberrant miR-29 expression may account for reduced NMI expression in breast tumors and mesenchymal phenotype of cancer cells that promotes invasive growth. Reduction in NMI levels has a feed-forward impact on miR-29 levels.

Traditional versus early-access grafts for hemodialysis access: a single-institution comparative study.

In those patients requiring urgent hemodialysis, the use of early-access grafts may reduce the need for temporary hemodialysis catheters and their resultant complications such as infection and central venous stenosis. We review a consecutive group of patients undergoing placement of a traditional polytetrafluoroethylene (PTFE) graft as compared with a cohort of patients who underwent insertion of a trilaminate PTFE vascular graft (TPVG). During the period from January 2008 to December 2009, 65 sequential patients received a traditional PTFE graft with 78 subsequent patients having a TPVG inserted. Factors examined included use of temporary hemodialysis catheters during the period of graft maturation, incidence of infection, and primary and secondary graft patency. For all patients, incidence was reported as observed during the first year after graft insertion. With the use of the TPVG, need for temporary hemodialysis catheters was reduced from 91 to 32 per cent, and 1-year overall graft patency was improved from 36 to 77 per cent (P < 0.01). We report that the use of a trilaminate PTFE graft allowed early access, reduced the need for temporary hemodialysis catheters, decreased overall graft complication rates, and significantly improved 1-year patency.

Helmet use is associated with a decrease in intracranial hemorrhage following all-terrain vehicle crashes.

BACKGROUND: With the recent increase in size and horsepower of all-terrain vehicles (ATVs), it is imperative that preventable injuries be identified to protect the large population using ATVs. Currently, many states have no laws regulating ATV or helmet use. By identifying preventable injuries, the legislature can design appropriate laws to protect both children and adults. METHODS: A retrospective review of all patients with ATV injuries presenting between the years 2005 and 2010 was conducted. The data were grouped in several ways for analysis. This included age less than 9 years, weight less than 30 kg, crash at night, substance abuse, and presence of a helmet. RESULTS: There were 481 patients included in the study. Only 28 (8%) were using a helmet at the time of the crash. Helmet use was associated with less intracranial hemorrhage (3% vs. 22%, p = 0.01) and a decreased incidence of loss of consciousness (14% vs. 35%, p = 0.01). Patients testing positive for alcohol intoxication with or without drugs were significantly more likely to have intracranial hemorrhage, to crash at night, to have facial fracture, to have rib fracture, to arrive intubated, and to have a higher Injury Severity Score (ISS) (p < 0.01 for all). CONCLUSION: With the recent increase in size and horsepower of ATVs, it is imperative that preventable injuries be identified to help protect a growing population of ATV operators. This study reveals a high rate of intracranial hemorrhage following an ATV crash in operators who do not use a helmet. Legislative efforts to implement strict helmet laws for ATV operators may be warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth.

OBJECTIVE: The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." METHODS: During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." RESULTS: During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"' were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." CONCLUSIONS: In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.

Improved rate of pancreatic fistula after distal pancreatectomy: parenchymal division with the use of saline-coupled radiofrequency ablation.

BACKGROUND: Postoperative pancreatic fistula (POPF) is the most common significant complication after distal pancreatectomy (DP) and results in substantial morbidity. Many different methods are available to divide the pancreatic parenchyma and achieve stump closure, but demonstrating an improvement in the incidence of POPF has been difficult. METHODS: A single-institution, retrospective review was conducted to evaluate all hand-assisted laparoscopic DP performed from October 2008 to July 2011 utilizing saline-coupled radiofrequency ablation (RFA) as the exclusive method of achieving division of the pancreatic parenchyma and closure of the proximal pancreatic remnant. All significant complications within the perioperative period were noted. RESULTS: Thirty-four patients met the criteria for inclusion in the study. One patient was lost to follow-up and thus excluded. Three patients (9.1%) demonstrated a POPF; two were treated with prolonged placement of the intraoperative drain (grade A: 6.1%) and the third was treated with endoscopic cystogastrostomy (grade C: 3.0%). One other significant complication (3.0%) of a perforated gastric ulcer that required partial gastrectomy occurred. CONCLUSIONS: The use of saline-coupled RFA alone for pancreatic parenchymal division and closure after DP is safe and effective. This study found an overall significant complication rate of 6.1%, and a rate of clinically significant POPF of 3.0%.

Micro-RNA-632 downregulates DNAJB6 in breast cancer.

DNAJB6 is a constitutively expressed member of the HSP40 family. It has been described as a negative regulator of breast tumor progression and a regulator of epithelial phenotype. Expression of DNAJB6 is reported to be compromised with tumor progression. However, factors responsible for its downregulation are still undefined. We used a knowledge-based screen for identifying miRNAs capable of targeting DNAJB6. In this work, we present our findings that hsa-miR-632 (miR-632) targets the coding region of DNAJB6. Invasive and metastatic breast cancer cells express high levels of miR-632 compared with mammary epithelial cells. Analysis of RNA from breast tumor specimens reveals inverse expression patterns of DNAJB6 transcript and miR-632. In response to exogenous miR-632 expression, DNAJB6 protein levels are downregulated and the resultant cell population shows significantly increased invasive ability. Silencing endogenous miR-632 abrogates invasive ability of breast cancer cells and promotes epithelial like characteristics noted by E-cadherin expression with concomitant decrease in mesenchymal markers such as Zeb2 and Slug. Thus, miR-632 is a potentially important epigenetic regulator of DNAJB6, which contributes to the downregulation of DNAJB6 and plays a supportive role in malignant progression.

Current operative management of breast cancer: an age of smaller resections and bigger cures.

Surgical resection was the first effective treatment for breast cancer and remains the most important treatment modality for curative intent. Refinements in operative techniques along with the use of adjuvant radiotherapy and advanced chemotherapeutic agents have facilitated increasingly focused breast cancer operations. Surgical management of breast cancer has shifted from extensive and highly morbid procedures, to the modern concept obtaining the best possible cosmetic result in tandem with the appropriate oncological resection. An ever-growing comprehension of breast cancer biology has led to substantial advances in molecular diagnosis and targeted therapies. An emerging frontier involves the breast cancer microenvironment, as a thorough understanding, while currently lacking, represents a critical opportunity for diagnosis and treatment. Collectively, these improvements will continue to push all therapeutic interventions, including operative, toward the goal of becoming more focused, targeted, and less morbid.

Outcomes using a bioprosthetic mesh at the time of permanent stoma creation in preventing a parastomal hernia: a value analysis.

PURPOSE/METHODS: A retrospective review of the medical records of all patients who had a prosthetic placed at the time of stoma creation for the prevention of a parastomal hernia was performed. The purpose of this study was to evaluate the safety, efficacy, and cost-effectiveness of bioprosthetics. RESULTS: A bioprosthetic was used in 16 patients to prevent the occurrence of a parastomal hernia. The median follow-up was 38 months. There were no mesh-related complications, and no parastomal hernias occurred. On value analysis, to be cost-effective, the percentage of patients who would have subsequently needed surgical repair of a parastomal hernia would have to be in excess of 39% or the bioprosthetic would have to cost less than $2,267 to $4,312. CONCLUSIONS: These data show the safety and efficacy of using a bioprosthetic at the time of permanent stoma creation in preventing a parastomal hernia and defines the parameters for this approach to be cost-effective.