Primary Malignant Melanoma of the Gastroesophageal Junction Treated With Immunotherapy: A Case Report.

INTRODUCTION: Primary malignant melanoma of the esophagus constitutes 0.1% to 0.5% of all primary malignant esophageal neoplasms. Melanocytes are present within the squamous epithelium of the esophagus in the stratum basale layer with melanocytosis rare within the esophagus. Primary esophageal melanoma is aggressive and has a poor survival rate; 80% of patients have metastatic disease at diagnosis. Resection surgery is usually first-line treatment for localized primary malignant esophageal melanoma, but recurrence rates remain high. Tumor-specific immunotherapy has shown promising results. We report a case of primary malignant esophageal melanoma with metastasis to the liver treated with immunotherapy. CASE PRESENTATION: A 66-year-old woman presented with 2 months of progressive dysphagia and 3 episodes of hematemesis the previous night. Endoscopic examination showed a hypervascular distal esophageal mass. Biopsy was positive for S-100, SOX-10, and HMB-45 and showed rare mitotic figures with scattered pigment, consistent with melanoma. She was scheduled for esophagectomy initially, but instead pursued immunotherapy after liver metastasis was diagnosed during preop magnetic resonance imaging. Immunotherapy consisted of 8 cycles of pembrolizumab, followed by 4 months nivolumab and ipilimumab. The patient remains in remission 3 years after completing immunotherapy. DISCUSSION/CONCLUSIONS: Our patient was diagnosed with primary malignant esophageal melanoma of the distal esophagus with metastasis to the liver, a presentation that typically has a poor prognosis. Despite this, remission was achieved with immunotherapy without surgical intervention. Only a small number of cases of primary esophageal melanoma treated with immunotherapy have been reported-one showcasing tumor stabilization following several cycles of therapy with eventual metastasis, while our patient had a stable response to treatment. Further exploration of medical management with immunotherapy should be conducted, as it represents an alternative treatment for patients who do not have the option of surgical management.

A Reflection and Discussion Exercise on Racial Justice and Equity.

Background: Residents have valuable perspectives about diversity and equity in medical training, yet many graduate medical education curricula lack dedicated activities focused on such issues. Objectives: To describe and report feasibility and acceptability of an innovation that uses individual reflection and group discussion to create conversation in our residency program about equity and injustice through the lens of the Black Lives Matter movement. Methods: In July 2020, we sent a survey with reflection prompts to all postgraduate year 2 and above internal medicine residents. In the discussion session (during required academic time), we presented 10 of the residents' responses to the reflection prompts. After each response was read aloud, the residents had an open discussion. We used thematic analysis to analyze the responses to the reflection prompts. Acceptability was tracked through free-text comments in the survey. Feasibility was measured by the time and resources needed to conduct the session. Results: We received responses from 24 out of 72 (33%) residents. We identified 10 codes that fell into 4 themes. The most commonly identified codes included anger or frustration toward events, self-reflection on privilege, increased awareness and discussion of racism in daily life, and life being minimally impacted/homeostasis. The 4 overarching themes were (1) awareness, (2) motivation for change, (3) emotional response, and (4) self-reflection. Conclusions: Using a format of reflection and sharing of anonymous responses was an inexpensive and effective method to begin a discussion about equity and injustice in medicine.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND: Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care. MATERIALS AND METHODS: This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality. RESULTS: There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49). CONCLUSION: Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.