Patients Older 65 Years With Early Breast Cancer Prefer Intraoperative Radiation as a Locoregional Treatment Choice.

BACKGROUND: Patients 65 years old or older with early endocrine-responsive breast cancer have many treatment options, including no radiation. This study aimed to evaluate treatment preference when intraoperative radiation therapy (IORT) is offered in this population. METHODS: The study reviewed patients 65 years old or older with a diagnosis of early-stage endocrine-responsive breast cancer in 2016-2019 at a single hospital in a large integrated health care system. Electronic medical records of multidisciplinary breast tumor board discussion, treatment options documented by the treatment team, and final treatment offered were reviewed. Variables including age at biopsy, language, endocrine treatment, and comorbidities were collected. Regression analysis was used to evaluate for variables associated with patients' choice regarding radiation treatment. RESULTS: The institutional IORT guidelines were met by 63 patients in the described age group who had a documented offer of all radiation treatment options. The median age of the patients was 70 years (interquartile range 63-77 years). Overall, 74.6% of the patients chose IORT, and 14.3% opted for whole-breast irradiation. Only 4.8% chose to omit radiation after breast-conserving surgery, and 6.3% chose mastectomy. The patients who chose IORT were more likely to receive endocrine treatment (odds ratio 3.70; p = 0.03). Age, race, language, and comorbidities were not associated with preference for IORT (p < 0.05). CONCLUSIONS: Patients 65 years old or older with early-stage endocrine-responsive breast cancer preferred to have IORT despite counsel about the lack of survival benefit. This study suggests that local cancer control with the convenient radiation delivery method is important to the described patient population.

Intraoperative Radiation Therapy: A Large Integrated Health Care System's Approach and Outcomes.

Introduction Intraoperative radiation therapy (IORT) may not be as effective in the community compared with clinical trials. Methods The authors reviewed data from the electronic health records of patients who received IORT between February 2014 and February 2020 at a single center within a large integrated health care system. The primary outcome was ipsilateral breast tumor recurrence. Results Of 5731 potentially eligible patients, 245 (4.3%) underwent IORT (mean age: 65.4 ± 0.4 years; median follow-up time: 3.5 years ± 2.2 months). According to the American Society for Radiation Oncology's accelerated partial breast irradiation guidelines based on final pathology, 51% of patients were suitable candidates for IORT, 38.4% were cautionary, and 10.6% were unsuitable. For adjuvant therapy, 6.5% had consolidative whole breast irradiation, and 66.4% received endocrine treatment. At the median follow-up time of 3.5 years, overall ipsilateral breast tumor recurrence was 3.7%. Recurrences tended to be more frequent in patients who refused or did not complete endocrine treatment than in those who received it (7.4% vs 1.9%, p = 0.07). The complication rate was 14.7%, with seroma being the most common (8.2%). Discussion The IORT ipsilateral breast tumor recurrence rate of 3.7% confirms a higher-than-expected rate compared to randomized clinical trials, possibly due to less compliance with endocrine therapy. Conclusion The authors subsequently revised their IORT protocol to require endocrine treatment as a part of the IORT treatment plan and to strongly recommend adjuvant whole breast irradiation for all patients deemed cautionary or unsuitable for IORT according to the American Society for Radiation Oncology's accelerated partial breast irradiation guidelines.

Experience with a Nonopioid Protocol in Ambulatory Breast Surgery: Opioids are Rarely Necessary and Use is Surgeon-Dependent.

CONTEXT: Surgeons write 1.8% of all prescriptions and 9.8% of all opioid prescriptions. Even small doses prescribed for short-term use can lead to abuse; thus, surgeons are uniquely able to combat the opioid epidemic by changing prescribing practices. As part of a department wide quality improvement project, we initiated a nonopioid protocol for all patients undergoing ambulatory breast surgery. OBJECTIVE: To determine the feasibility of a nonopioid protocol for patients undergoing ambulatory breast surgery and to determine if patient-related factors contribute to surgeon adherence to a nonopioid protocol in ambulatory breast surgery. DESIGN: Retrospective chart review of a prospectively collected database, with χ2 analysis and a multiple logistic regression model with the surgeon as the random effect. MAIN OUTCOME MEASURE: Protocol adherence. RESULTS: A total of 180 patients, with a median age of 63 years (range = 18-95 years), were included. Of these, 127 (70.6%) did not receive opioids; in this group there were 2 hematomas (1.6%), and 3 patients required an opioid prescription (2.4%). Fifty-three (29.4%) were prescribed opioids against protocol; in this group, there was 1 hematoma (1.9%). The operating surgeon was the only variable independently correlated with protocol adherence (p < 0.0001). Age, race/ethnicity, surgery type, and history of long-term opioid use were not. CONCLUSION: Ambulatory breast surgery patients tolerated a nonopioid pain regimen well. Surgeons' decisions, rather than patient characteristics, primarily drove the choice of pain management in our study. We believe our protocol can be improved with stricter implementation and education, which must be balanced with practitioner independence.

Two-Stage Explantation of a Magnetic Lower Esophageal Sphincter Augmentation Device Due to Esophageal Erosion.

INTRODUCTION: Implanting a magnetic lower esophageal sphincter augmentation device (LINX, Torax Medical) has become an increasingly common option in the surgical management of gastroesophageal reflux disease. As the enthusiasm for placing this device increases, experience in the management of device-related complications-including erosion-is necessary. METHODS: We report a staged approach to LINX removal in a 64-year-old female with symptoms of odynophagia secondary to partial erosion of a LINX device into the esophagus. RESULTS: The patient had a 12-bead LINX device placed in 2011 at an outside, international facility. In late 2013, she began experiencing symptoms of odynophagia. An esophagogastroduodenoscopy at our institution in October 2015 demonstrated two metallic beads eroding through the distal esophageal lumen. An elective endoscopic removal of the two visible beads was performed. A postoperative esophagram confirmed that there was no resulting esophageal perforation. The patient noted mild improvement in her symptoms. After a 12-week period to allow for complete healing, the remaining 10 beads of the LINX device were explanted laparoscopically without complication. No further procedures were undertaken. At 2 months' follow-up, the patient noted complete resolution of her symptoms. CONCLUSION: Transmural erosion of the LINX device into the esophageal lumen is a rare occurrence, with only five such complications reported in the published literature. We present the first account of LINX explantation for esophageal erosion in the United States. We demonstrated that a staged laparoendoscopic approach to LINX removal in these cases is feasible with minimal morbidity.

Myelolipoma in the spleen: a rare discovery of extra-adrenal hematopoietic tissue.

Myelolipomas are benign tumors usually found within the adrenal gland. Approximately 50 cases of extra-adrenal myelolipomas have been reported in the literature and all are associated with additional lesions. Myelolipomas contain hematopoetic cells and adipose tissue. Most commonly, they are asymptomatic and are found incidentally on radiologic imaging. Here we report a case of an isolated intrasplenic myelolipoma as an incidental finding during the work up for myasthenia gravis in an otherwise asymptomatic man. The spleen and associated mass were excised during laparotomy and the patient had an uneventful recovery.