Efficacy of Targeted Axillary Dissection With Radar Reflector Localization Before Neoadjuvant Chemotherapy.

INTRODUCTION: For clinically node positive breast cancer patients treated with neoadjuvant chemotherapy (NAC), targeted axillary dissection (TAD) can be used to stage the axilla. TAD removes the sentinel lymph node (SLN) and tagged positive nodes, which can be identified via radar reflector localization (RRL). As it can be challenging to localize a previously positive node after NAC, we evaluated RRL prior to NAC. METHODS: We performed a retrospective chart review of breast cancer patients with node positive disease treated with NAC who underwent TAD with RRL. We compared retrieval of radar reflector and clip, timing of localization, and, if a node was positive, whether the radar reflector node or SLN was positive. RESULTS: Seventy-nine patients fulfilled inclusion criteria; 32 were placed pre-NAC (mean 187 d before surgery) and 47 were placed post-NAC (mean 7 d before surgery). For pre-NAC placement, 31 of 32 radar reflectors and 31 of 32 clips were retrieved. For post-NAC placement, 47 of 47 radar reflectors and 46 of 47 clips were retrieved. There was no significant difference in radar reflector or clip retrieval rates between pre-NAC and post-NAC groups (P = 0.41, P = 1, respectively). Thirty of 32 patients with pathologic complete response avoided an axillary lymph node dissection. Of 47 patients with a positive lymph node, 32 were both the SLN and radar reflector node, 11 were radar reflector alone, and four were the SLN. CONCLUSIONS: RRL systems are an effective way to guide TAD, and RRL makers can be safely placed prior to NAC.

Enhanced Recovery After Surgery and Postoperative Nausea and Length of Stay in Mastectomy Patients With Reconstruction.

INTRODUCTION: Surgery is a mainstay of curative breast cancer treatment and is associated with postoperative nausea and vomiting (PONV) negatively impacting the patient experience. Enhanced recovery after surgery (ERAS) protocols are a combination of evidence-based strategies applied to traditional perioperative practices with the goal to reduce postoperative complications. ERAS protocols have been traditionally underutilized in breast surgery. We investigated if the implementation of an ERAS protocol was associated with decreased rates of PONV as well as length of stay (LOS) in patients undergoing mastectomy with breast reconstruction. METHODS: We conducted a retrospective chart review case-control study in which we compared PONV and LOS between ERAS cases and non-ERAS controls. Our data set consisted of 138 ERAS cases and 96 non-ERAS controls. All patients were >18 y old and underwent mastectomy with immediate implant or tissue expander-based reconstruction between 2018 and 2020. The non-ERAS group consisted of procedure-matched controls that were treated prior to implementation of the ERAS protocol. RESULTS: In univariate comparisons, patients who underwent the ERAS protocol had significantly decreased postoperative nausea (mean 37.5% of controls versus 18.1% of ERAS, P < 0.001) and shorter LOS (1.21 versus 1.49 d, P < 0.001). Using a multivariable regression to control for potential confounders, ERAS protocol was associated with less postoperative nausea (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.13-0.5), LOS 1 d versus > 1 d (OR = 0.19, 95% CI = 0.1-0.35), and less postoperative ondansetron use (OR = 0.03, 95% CI = 0.01-0.07). CONCLUSIONS: Our results indicate that implementation of the ERAS protocol in women undergoing mastectomy with immediate reconstruction is associated with improved patient outcomes in postoperative nausea and LOS.

Screening Practices for Breast and Nonbreast Cancers in High-Risk Mutation Carriers.

INTRODUCTION: Women with breast cancer often undergo genetic testing and may have a pathogenic variant associated with multiple cancers. This study examines the current screening practices for breast and nonbreast cancers in mutation carriers. METHODS: An institutional retrospective chart review of patients with BRCA1, BRCA2, ATM, CHEK2, BARD1, BRIP1, PALB2, and TP53 mutations were identified. Adherence to recommended screening based on National Comprehensive Cancer Network guidelines was analyzed. RESULTS: Six hundred sixty-two patients met inclusion criteria: 220 patients with BRCA1, 256 patients with BRCA2, 58 patients with PALB2, 51 patients with ATM, 48 patients with CHEK2, 14 patients with BRIP1, 10 patients with BARD1, and 5 patients with TP53. Overall, 214 (46%) of eligible patients completed recommended breast imaging. Of 106 patients eligible for pancreatic cancer screening, 20 (19%) received a magnetic resonance cholangiopancreatography and 16 (15%) received an endoscopic ultrasound. On multivariable analysis, age was associated with improved breast imaging adherence: patients in age groups 40-55 (adjusted odds ratio 2.05, 95% confidence interval 1.18-3.55) and age 56-70 (adjusted odds ratio 2.16, 95% confidence interval 1.18-3.95, P = 0.012) had better adherence than younger patients. CONCLUSIONS: Increases in genetic testing and updates to National Comprehensive Cancer Network guidelines provide an opportunity for improved cancer screening. While recommended breast cancer screenings are being completed at higher rates, there is a need for clear protocols in this high-risk population.

The Role of Radiation Therapy in Locally Advanced Breast Cancer in a Patient With Li-Fraumeni Syndrome.

Li-Fraumeni syndrome (LFS) is associated with many different cancers, including early onset breast cancer. Due to an increased risk of radiation-induced malignancy, radiation therapy is often avoided in this patient population. This case study evaluates a 38-year-old female with a history of juvenile granulosa cell tumor of the ovary and malignant phyllodes tumor of right breast, who subsequently developed bilateral invasive ductal carcinoma and was treated with bilateral mastectomies. Studies show that in a high-risk patient, post-mastectomy radiation therapy (PMRT) should not be ruled out due to a history of LFS, as the benefit of PMRT may outweigh the risk of a radiation-induced malignancy.

Ursodiol Prescriptions Following Bariatric Surgery: National Prescribing Trends and Outcomes.

BACKGROUND: Rapid weight loss after bariatric surgery is a risk factor for gallstone development. Numerous studies have shown that ursodiol after surgery decreases rates of gallstone formation and cholecystitis. Real-world prescribing practices are unknown. This study aimed to examine prescription patterns for ursodiol and reassess its impact on gallstone disease using a large administrative database. METHODS: The Mariner database (PearlDiver, Inc.) was queried using Current Procedural Terminology codes for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2011 and 2020. Only patients with International Classification of Disease codes for obesity were included. Patients with pre-operative gallstone disease were excluded. The primary outcome was gallstone disease within 1 year, which was compared between patients who did and did not receive an ursodiol prescription. Prescription patterns were also analyzed. RESULTS: Three hundred sixty-five thousand five hundred patients fulfilled inclusion criteria. Twenty-eight thousand seventy-five (7.7%) patients were prescribed ursodiol. There was a statistically significant difference in development of gallstones (p < 0.001), development of cholecystitis (p = .049), and undergoing cholecystectomy (p < 0.001). There was a statistically significant decrease in the adjusted odds ratio (aOR) for the development of gallstones (aOR 0.81, 95% CI: 0.74, 0.89), development of cholecystitis (aOR 0.59, 95% CI: 0.36, 0.91), and undergoing cholecystectomy (aOR 0.75, 95% CI: 0.69, 0.81). CONCLUSION: Ursodiol significantly decreases the odds of development of gallstones, cholecystitis, or cholecystectomy within 1 year following bariatric surgery. These trends hold true when analyzing RYGB and SG separately. Despite the benefit of ursodiol, only 10% of patients received an ursodiol prescription postoperatively in 2020.

Lobular Neoplasia.

Lobular neoplasia (LN) is a term that describes atypical epithelial lesions originating in the terminal duct-lobular unit (TDLU) of the breast, including atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). LN is both a risk factor and nonobligate precursor to invasive breast cancer. A diagnosis of LCIS is associated with a 7-to-10-fold increased risk of breast cancer compared with the general population. When classic LN is diagnosed on a core needle biopsy (CNB), the patient may proceed with either increased screening or excisional biopsy of the lesion. Physicians should counsel patients diagnosed with LN on the risk of developing invasive carcinoma and inform them of the current screening and chemoprevention recommendations to reduce risk.

Antithrombotic prescriptions for many general surgery patients significantly increases the likelihood of post-operative bleeding complications.

BACKGROUND: The investigators hypothesized that despite cessation recommendations for peri-operative antithrombotic management in the elective setting, the use of these drugs is likely associated with increased odds for bleeding complications. METHODS: Humana® insurance claims (22 million covered lives) from 2007 through 2017 were analyzed. Only patients undergoing elective general surgery procedures were included. Patient Safety Indicator 09 (PSI-09) coding for post-operative hemorrhage and hematoma were analyzed. RESULTS: Despite the existence of peri-operative management guidelines, patients prescribed antithrombotic agents were 2.3 times more likely to develop post-operative bleeding complications (OR: 2.3436, 95% CI: 2.2155-2.4792, P < 0.0001). Nearly all antithrombotics prescribed in the pre-operative period led to a two-fold increased likelihood of post-operative bleeding-the odds ratios of enoxaparin and rivaroxaban approached seven. CONCLUSION: The data should remind surgeons to closely monitor the peri-operative management and post-operative course of patients pre-operatively prescribed antithrombotics-especially enoxaparin and rivaroxaban given the high risk of postoperative bleeding complications.