In 2014, SSO-ASTRO published guidelines which recommended “no ink on tumor” as adequate margins for patients undergoing breast conservation for invasive breast cancer. In 2016, new SSO-ASTRO-ASCO ...guidelines recommended 2 mm margins for DCIS. We evaluated whether these guidelines affected re-excision rates at our institution.
Patients treated with breast conservation surgery from January 1, 2010–March 1, 2016 were identified. Re-excision rates, tumor characteristics, and presence of residual disease were recorded. The 2016 guidelines were retrospectively applied to the same cohort and expected re-excision rates calculated.
Re-excision rates did not significantly decline before and after 2014 guideline adoption (11.9% before, 10.9% after; p = 0.65) or when the 2016 guidelines were retrospectively applied (8.4%; p = 0.10).
The 2014 and 2016 guidelines had minimal impact on our re-excision rates, as most re-excisions were done for DCIS and 2016 guidelines supported our prior institutional practices of 2 mm margins for these patients.
Breast infections: A review of current literature Ammann, Allison M.; Pratt, Catherine G.; Lewis, Jaime D. ...
The American journal of surgery,
February 2024, 2024-Feb, 2024-02-00, 20240201, Letnik:
228
Journal Article
Recenzirano
Breast infections are common, affect women of all ages, and are associated with significant morbidity. Despite overall prevalence, treatment varies significantly based on provider or institution and ...no central treatment guidelines exist to direct the management of breast infections. This article provides a summary of the current trends in management of breast infections. The etiology, epidemiology, risk factors, presentation, diagnosis, and treatment of mastitis and breast abscesses (and their relative subdivisions) are explored based on the current literature. Trends in microbiology are reviewed and an approach to antibiotic coverage is proposed. Overall, there is a lack of randomized-controlled trials focused on the treatment of breast infections. This has resulted in an absence of clinical practice guidelines for the management of breast abscesses and variable practice patterns. The development of best-care protocols or pathways could provide more uniformity in care of breast infections.
•Breast infections are common in both lactating and non-lactating individuals, and prompt treatment is important.•Ultrasound evaluation and minimally invasive treatment of breast abscesses has become the standard of care.•A paucity of published guidelines regarding breast infection treatment stems from the lack of randomized control trials.
Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced ...changes in practice.
Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status.
Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017.
Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist.
Early blood product resuscitation reduces trauma patient mortality from hemorrhage. This mortality benefit depends on a system that can rapidly identify actively bleeding patients, initiate massive ...transfusion protocol (MTP), and mobilize resources to the bedside. We hypothesized that process improvement efforts that identify patients early and mobilize appropriate blood products to the bedside for immediate use would improve mortality.
Pre-implementation, MTP activation was at the discretion of the trauma surgeon, and only PRBCs were immediately available. In June 2016, the Assessment of Blood Consumption (ABC) score was incorporated in our pre-hospital triage process, and a process for thawed plasma to be available was developed. We performed a retrospective review of patients who were hypotensive on arrival or had MTP activated. We compared mortality and MTP component ratios 15 months pre- vs 15 months post-implementation.
Activations of MTP increased 6-fold, while the specificity of the process remained the same. In patients receiving MTP, appropriate blood product transfusion ratios increased 44%. Overall and penetrating trauma mortality improved by 23% and 41%, respectively. When divided by the Injury Severity Score (ISS), penetrating trauma mortality decreased by 65% for the ISS subgroup 15 to 24 and by 38% for ISS subgroup ≥ 25. Length of stay, ICU length of stay, and readmission rates were not significantly different.
Delivery of balanced blood product resuscitation is essential to confer mortality benefits. Process improvement directed at early recognition of the hemorrhagic patient, immediate product availability, and product delivery to the bedside for transfusion allows for mortality reduction without increased resource use.
Background
Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma
in situ
(DCIS). This study examined trends in management and survival for males with DCIS.
...Methods
The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher’s exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan–Meier.
Results
Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio OR, 0.58; 95% confidence interval CI, 0.36–0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15–0.67). Overall survival did not differ significantly between the four treatment methods (
p
= 0.08).
Conclusions
The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.
Background
Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials ...challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy.
Patients and Methods
Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use.
Results
From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables.
Conclusions
There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics.
...can you tell us anything about the rate of ultimate re-excision, that is, the mastectomy rate before and after you adopted the guidelines? The discussion in our manuscript addresses several of ...your questions and concerns, but a key point is that we wanted to keep our group very realistic of our true practice. ...palpable tumors were included as well as nonpalpable tumors, that required wire localization. ...you noted that our volume changed over the study time period.
INTRODUCTIONResuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing ...preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODSRetrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTSDuring the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSIONPPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
