How Beneficial is Follow-Up Mammography in Elderly Breast Cancer Survivors?

OBJECTIVE: The aim of this study was to determine the rate of non-palpable cancer detection and benign biopsy rates for follow-up mammograms in elderly breast cancer survivors. METHODS: Women 80 years of age and older who underwent operation for ductal carcinoma in situ or invasive breast cancer from 2005 to 2010 and who had at least 6 months of follow-up were identified from a single-institution, prospectively maintained, Health Insurance Portability and Accountability Act (HIPAA)-compliant database. Patients with mammographic, other imaging, or palpable abnormalities were identified, and the results of their imaging studies and biopsies were reviewed. Number of locoregional recurrences, contralateral cancers, and benign biopsies were determined. Follow-up and survival data were recorded. RESULTS: Overall, 429 women with a mean age of 83.4 years were included. Mean follow-up was 50.0 months (range 6-113). Patients had a median of four follow-up mammograms (range 0-11). The 1466 mammograms detected 17 biopsy-proven cancers and generated 18 benign biopsies. In the 305 women who had had breast-conserving surgery, 18 (5.9 %) experienced local recurrence, 9 detected by mammography alone (mean size 1.2 cm) and 9 palpable (mean size 2.0 cm). Contralateral cancer developed in 4 (0.9 %) of the 429 patients, all detected on screening mammogram alone. CONCLUSION: Overall, 13 non-palpable breast cancers were detected in 1466 mammograms (0.9 %). While these results are acceptable for screening programs in healthy populations, further study of the need for routine follow-up imaging in the elderly, and the appropriate interval, is needed to maximize resource utilization.

Safety and efficacy of preoperative right portal vein embolization in patients at risk for postoperative liver failure following major right hepatectomy.

BACKGROUND: Right portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis. METHODS: Records of patients who underwent RPVE during 2006-2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported. RESULTS: A total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE. CONCLUSIONS: Right portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.

A prospective study of opioid use for postoperative pain management after breast operation.

BACKGROUND: The opioid epidemic has necessitated increased attention to prescribing practices. This study seeks to prospectively quantify postoperative opioid use after breast operation. METHODS: Consecutive patients undergoing breast operation at a single institution in 2018 prospectively tracked each dose of medication and completed a survey of perceptions regarding their opioid prescription. RESULTS: Of 100 patients, 88 completed log, survey, or both. The tab quantity required to fulfill the needs of 80% of patients was: Partial mastectomy (PM) 3, PM with sentinel lymph node biopsy 6, PM with bilateral reduction 8, total mastectomy 34, and bilateral mastectomy 47. Of survey respondents, 51.2% felt they had been prescribed too much pain medication. Most (83.0%) had leftover tabs, and 67.9% indicated they kept them in their home. CONCLUSIONS: The majority of patients were overprescribed opioids after breast operation. A reduction could be achieved by targeting the needs of 80% of the population.

Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection?

INTRODUCTION: Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. METHODS: Retrospective review of prospectively collected data on melanoma patients undergoing SLNB. RESULTS: 116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). CONCLUSIONS: Tumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease.

Laparoscopic surgical exploration is an effective strategy for locating occult primary neuroendocrine tumors.

BACKGROUND: Many patients with neuroendocrine tumors (NETs) have metastases at diagnosis. Despite extensive metastases the primary tumors remain small and difficult to locate. METHODS: Records of patients diagnosed with metastatic abdominal NETs from 2006 to 2010 were reviewed retrospectively. Results of preoperative imaging, procedures, and surgical explorations were compared for their efficacy at finding primary tumors. RESULTS: Sixty-three patients were identified. Seventeen percent (11 of 63) of tumors were located by preoperative testing. The sensitivities of preoperative colonoscopy (23% [n = 26]), computed tomography scan (6.7% [n = 60]), and somatostatin receptor scintigraphy (2.0% [n = 52]) were low. No tumors were found by magnetic resonance imaging (n = 9), upper endoscopy (n = 24), capsule endoscopy (n = 2), or bronchoscopy (n = 4). Surgical exploration was the most sensitive (79% [n = 63]) method of tumor detection. Seventy-two percent of surgical localizations were laparoscopic. CONCLUSIONS: Surgical exploration was superior to all other modalities for locating primary NETs. Laparoscopy had a high probability of finding occult primary neuroendocrine tumors.

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest.

BACKGROUND: Recent clinical trials have suggested no survival benefit for completion axillary node dissection (CALND) after sentinel lymph node biopsy (American College of Surgeons Oncology Group Z0011) and no clinically meaningful benefit for the routine use of immunohistochemistry (National Surgical Adjuvant Breast and Bowel Project B-32) in clinically node-negative breast cancer. METHODS: A 12-question electronic survey was distributed to members of 3 Pacific Northwest surgical societies. Surgeons were queried regarding the impact of the trial results on their surgical management of breast cancer. RESULTS: The 181 respondents reported performing fewer CALNDs (63%), fewer intraoperative frozen sections (21%), and no immunohistochemistry (12%) because of trial data. However, 28% of surgeons continued to perform CALND in patients with 1 to 2 positive sentinel lymph nodes undergoing lumpectomy and postoperative radiation. CONCLUSIONS: Recent trial data have impacted the performance of CALNDs and the pathological evaluation of sentinel lymph nodes among Pacific Northwest surgeons. Our results suggest a need for regional surgical societies to disseminate practice-changing trial data to members.

Emergency department utilization by crack-cocaine smokers in Dayton, Ohio.

The objective of this study was to determine the frequency, principal diagnoses, and correlates of emergency department (ED) visits made by persons with a history of crack-cocaine use (n = 333) over a 3-year period. Data were collected from participant self-reports and hospital records. During the study a total of 643 ED visits were made by 211 people, ranging from 53.5 to 76.7/100 persons/year. Injury and poisoning accounted for the largest single category of ED visits (29.5%). Men had lower odds of visiting the ED (OR=0.79, 95%CI=0.62-0.99), as did participants with higher levels of education (OR=0.83, 95%CI=0.73-0.94). Number of times in drug abuse treatment (OR=1.04, 95%CI=1.01-1.09), having a chronic disease (OR=1.46, 95%CI=1.06-1.99), and higher Addiction Severity Index composite medical scores (OR=1.62, 95%CI=1.15-2.29) increased the odds of an ED visit. Factors in addition to drug use are likely to affect ED utilization rates among crack-cocaine smokers.