Number Of Excisions Research Articles

A Nomogram Using Imaging Features to Predict Ipsilateral Breast Tumor Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ.

To develop a nomogram that integrates clinical-pathologic and imaging variables to predict ipsilateral breast tumor recurrence (IBTR) in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS). This retrospective study included consecutive women with DCIS who underwent BCS at two hospitals. Patients who underwent BCS between 2003 and 2016 in one hospital and between 2005 and 2013 in another were classified into development and validation cohorts, respectively. Twelve clinical-pathologic variables (age, family history, initial presentation, nuclear grade, necrosis, margin width, number of excisions, DCIS size, estrogen receptor, progesterone receptor, radiation therapy, and endocrine therapy) and six mammography and ultrasound variables (breast density, detection modality, mammography and ultrasound patterns, morphology and distribution of calcifications) were analyzed. A nomogram for predicting 10-year IBTR probabilities was constructed using the variables associated with IBTR identified from the Cox proportional hazard regression analysis in the development cohort. The performance of the developed nomogram was evaluated in the external validation cohort using a calibration plot and 10-year area under the receiver operating characteristic curve (AUROC) and compared with the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram. The development cohort included 702 women (median age [interquartile range], 50 [44-56] years), of whom 30 (4%) women experienced IBTR. The validation cohort included 182 women (48 [43-54] years), 18 (10%) of whom developed IBTR. A nomogram was constructed using three clinical-pathologic variables (age, margin, and use of adjuvant radiation therapy) and two mammographic variables (breast density and calcification morphology). The nomogram was appropriately calibrated and demonstrated a comparable 10-year AUROC to the MSKCC nomogram (0.73 vs. 0.66, P = 0.534) in the validation cohort. Our nomogram provided individualized risk estimates for women with DCIS treated with BCS, demonstrating a discriminative ability comparable to that of the MSKCC nomogram.

The Impact of Breast-Conserving Surgery Re-excision on Patient-Reported Outcomes Using the BREAST-Q.

Approximately 14% of women undergoing breast-conserving surgery (BCS) require re-excision to achieve negative margins following the Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) margin guidelines, which may influence patient-reported outcomes (PROs). Few studies have assessed the impact of re-excision on PROs following BCS. Women with stage 0-III breast cancer undergoing BCS who completed a BREAST-Q PRO measure from 2010 to 2016 were identified from a prospective database. Baseline characteristics were compared between women who underwent one BCS and those who underwent ≥ 1 re-excision surgery for positive margins (R-BCS). Linear mixed models were used to analyze associations between number of excisions and BREAST-Q scores over time. Of 2543 eligible women, 1979 (78%) had one BCS and 564 (22%) had R-BCS. Younger age, lower BMI, surgery pre-SSO Invasive Guidelines issuance, ductal carcinoma in situ (DCIS), multifocal disease, radiation therapy receipt, and endocrine therapy omission were more common in the R-BCS group. Breast satisfaction and sexual well-being were lower in the R-BCS group 2years postoperatively. There were no differences in psychosocial well-being between groups over 5 years. On multivariable analysis, re-excision was associated with lower breast satisfaction and sexual well-being (p= 0.007 and p= 0.049, respectively), but there was no difference in psychosocial well-being (p= 0.250). Women with R-BCS had lower breast satisfaction and sexual well-being 2 years postoperatively, but this difference did not remain long term. Psychosocial well-being in women who underwent one BCS were largely comparable over time to the R-BCS group. These findings may help in counseling women who are concerned about satisfaction and quality-of-life outcomes with BCS if re-excision is necessary.

A 9-Year Teledermoscopy Service: Retrospective Service Review

Background A teledermoscopy service was established in January 2010, where patients attended nurse-led clinics for imaging of lesions of concern and remote diagnosis by a dermatologist. Objective The study aimed to review the number of visits, patient characteristics, the efficiency of the service, and the diagnoses made. Methods We evaluated the waiting time and diagnosis of skin lesions for all patient visits from January 1, 2010, to May 31, 2019. The relationships between patient characteristics and the diagnosis of melanoma were specifically analyzed. Results The teledermoscopy clinic was attended by 6479 patients for 11,005 skin lesions on 8805 occasions. Statistically significant risk factors for the diagnosis of melanoma/melanoma in situ were male sex, European ethnicity, and Fitzpatrick skin type 2. Attendance was maximal during 2015 and 2016. The seasonal variation in visits 2011-2018 revealed a consistent peak at the end of summer and a dip at the end of winter. In the year 2010, 306 patients attended; 76% (233/306) of these were discharged to primary care and 24% (73/306) were referred to hospital for specialist assessment. For patients diagnosed by the dermatologist with suspected melanoma from January 1, 2010, to May 31, 2019, the median waiting time for an imaging appointment was 44.5 days (average 57.9 days, range 8-218 days). The most common lesions diagnosed were benign naevus (2933/11,005, 27%), benign keratosis (2576/11,005, 23%), and keratinocytic cancer (1707/11,005, 15%); melanoma was suspected in 5% (507/11,005) of referred lesions (Multimedia Appendix 1). The positive predictive value of melanoma/melanoma in situ was 61.1% (320 true positives and 203 false positives). The number needed to treat (ie, the ratio of the total number of excisions to the number with a histological diagnosis of melanoma/melanoma in situ) was 2.02. Conclusions Diagnoses were comparable to the experience of other teledermoscopy services. Teledermoscopy using a nurse-led imaging clinic can provide efficient and convenient access to dermatology by streamlining referrals to secondary care and prioritizing patients with skin cancer for treatment. Conflicts of Interest None declared.

Comparison of patient pathways in the early detection of skin cancer - a claims data analysis.

Regarding skin cancer screening, patients in Germany have the choice between a direct screening by dermatologists or an initial screening by general practitioners followed by dermatological screening if further examination is required. The aim of this study is to evaluate whether screening by general practitioners is associated with risk selection in subsequent dermatological screenings. We conducted a retrospective observational study based on claims data from a German health insurance company (Barmer GEK). Patient pathways in skin cancer screenings between 2008 and 2016 were analyzed, and differences between the two groups were tested at 95% confidence intervals. A total of 495,000 initial and 111,000 secondary examinations by dermatologists were analyzed. The proportion of subsequent excisions was lower in initial screenings by dermatologists. To diagnose one person with non-melanoma skin cancer or melanoma, five or 23 to 42 excisions were necessary, depending on the type of excision considered. The number of examinations to identify one patient ranged from 25 to 53 for non-melanoma skin cancer and 42 to 165 for melanoma. For melanoma, the number of excisions and screenings to diagnose skin cancer was lower in secondary examinations. The results indicate a risk selection through initial examinations by general practitioners. However, there are other aspects that should be taken into account when comparing the two pathways.

Obesity is Not Associated With Need for Skin Grafting After Hidradenitis Excision

Hidradenitis suppurativa (HS) is a chronic, debilitating disease associated with inflammation, recurrent abscesses, and fistulae of skin containing apocrine sweat glands. We hypothesize that the need for skin grafting after vacuum-assisted closure was decreased with increasing body mass index (BMI). Seventy-one consecutive patients with excisions for HS were retrospectively evaluated for demographic data, number of excisions, the total area of excised skin, need for skin grafting, and BMI. Patients were stratified for BMI and underwent logistic regression to compare all other variables. Average for BMI was 30.8 ± 7.72, age was 36.89 ±13.52, area excised was 743 cm2 ± 774 cm2, mean operating room trips were 2.62 ± 1.59, and skin grafting was 0.52 ± 0.55. Patients were 60% male. Forty out of 71 patients were obese. There was no correlation between age, BMI, sex, thenumber of excisions, amount of skin excised, or need for a skin graft. There was a statistically significant relationship between the amount of skin excised and the need for skin grafting (P = .006). The amount of skin affected by HS appears to be independent of patient BMI. The need for skin grafting is solely dependent upon the amount of tissue excised. This knowledge will help preoperative planning for all patients with HS, regardless of BMI.

Surgical management of the recurrent laryngeal nerve in thyroidectomy: American Head and Neck Society Consensus Statement.

"I have noticed in operations of this kind, which I have seen performed by others upon the living, and in a number of excisions, which I have myself performed on the dead body, that most of the difficulty in the separation of the tumor has occurred in the region of these ligaments…. This difficulty, I believe, to be a very frequent source of that accident, which so commonly occurs in removal of goiter, I mean division of the recurrent laryngeal nerve." Sir James Berry (1887).

An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015

Analyses of skin cancer procedures adjusted for population changes are needed. To describe trends in skin cancer-related biopsies and procedures in Medicare beneficiaries. An ecological study of Medicare claims for skin biopsies and skin cancer procedures in 2000 to 2015. Biopsies increased 142%, and skin cancer procedures increased 56%. Mohs micrographic surgery (MMS) utilization increased on the head/neck, hands/feet, and genitalia (increasing from 11% to 27% of all treatment procedures) but was low on the trunk/extremities (increasing from 1% to 4%). Adjusted for increased Medicare enrollment (+36%) between 2000 and 2015, the number of biopsies and MMS procedures performed per 1000 beneficiaries increased (from 56 to 99 and from 5 to 15, respectively), whereas the number of excisions and destructions changed minimally (from 18 to 16 and from 19 to 18, respectively). Growth in biopsies and MMS procedures slowed between each time period studied: 4.3 additional biopsies per year and 0.9 additional MMS procedures per year per 1000 beneficiaries between 2000 and 2007, 2.2 and 0.5 more between 2008 and 2011, and 0.5 and 0.3 more between 2012 and 2015, respectively. Medicare claims-level data do not provide patient-level or nonsurgical treatment information. The increased number of skin cancer procedures performed was largely the result of Medicare population growth over time. MMS utilization increased primarily on high- and medium-risk and functionally and cosmetically significant locations where tissue sparing and maximizing cure are critical.

Marjolin's Ulcer in Chronic Hidradenitis Suppurativa: A Rare Complication of an Often Neglected Disease.

Hidradenitis suppurativa (HS) is a chronic, debilitating disease with definitive treatment consisting of wide surgical excision of all affected tissue. Originally described in burns, Marjolin's ulcer (MU) has been described in a variety of wound types, including hidradenitis. HS patients often have long delays to diagnosis and management of their chronic wounds, leading to increased risk of MU. A retrospective review of our burn database was performed from 2008 to 2014. Seventy-two consecutive patients taken to the operating room for HS were retrospectively evaluated for demographic data, number of excisions, total area of excised skin, need for skin grafting, pathology results, and outcome. Fifty-eight percent of patients were male. Mean age was 36.88 ± 13.52 years. Mean size of excision was 743.71 ± 774.75 cm. Total number of operative procedures was 187, averaging 2.612 per patient, with 52% of patients undergoing skin grafting. Two patients had confirmed pathology of squamous cell carcinoma. Both were women with perineal HS and had metastatic disease on further workup. Both patients underwent chemotherapy and radiation with progression of their disease. The incidence of MU of 2.78% in this study is similar to the 2% incidence described historically in the burn population. All practitioners who treat HS patients should be aware of the devastating complication of MU arising in the chronic wound bed. We recommend that all excised tissue be sent to pathology for evaluation, and to consider early wide local excision of any chronically inflamed tissues to alleviate the risk of MU for this patient population.

Screening for Skin Cancer in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Skin cancer, primarily melanoma, is a leading cause of morbidity and mortality in the United States. To provide an updated systematic review for the US Preventive Services Task Force regarding clinical skin cancer screening among adults. MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials were searched for relevant studies published from January 1, 1995, through June 1, 2015, with surveillance through February 16, 2016. English-language studies conducted in asymptomatic populations 15 years and older at general risk for skin cancer. Relevant data were abstracted, and study quality was rated. Melanoma incidence and mortality, harms from cancer screening, diagnostic accuracy, and stage distribution. No randomized clinical trials were identified. There was limited evidence on the association between skin cancer screening and mortality. A German ecologic study (n = 360,288) found a decrease of 0.8 per 100,000 melanoma deaths in a region with population-based skin cancer screening compared with no change or slight increases in comparison regions. The number of excisions needed to detect 1 skin cancer from clinical visual skin examinations varied by age and sex; for example, 22 for women 65 years or older compared with 41 for women aged 20 to 34 years. In 2 studies of performing visual skin examination, sensitivity to detect melanoma was 40.2% and specificity was 86.1% when conducted by primary care physicians (n = 16,383). Sensitivity was 49.0% and specificity was 97.6% when skin examinations were performed by dermatologists (n = 7436). In a case-control study of melanoma (n = 7586), cases diagnosed with thicker lesions (>0.75 mm) had an odds ratio of 0.86 (95% CI, 0.75-0.98) for receipt of a physician skin examination in the prior 3 years compared with controls. Eight cohort studies (n = 236,485) demonstrated a statistically significant relationship between the degree of disease involvement at diagnosis and melanoma mortality, regardless of the characterization of the stage or lesion thickness. Tumor thickness greater than 4.0 mm was associated with increased melanoma mortality compared with thinner lesions, and late stage at diagnosis was associated with increased all-cause mortality. Only limited evidence was identified for skin cancer screening, particularly regarding potential benefit of skin cancer screening on melanoma mortality. Future research on skin cancer screening should focus on evaluating the effectiveness of targeted screening in those considered to be at higher risk for skin cancer.

Recurrence rates for ductal carcinoma in situ: Analysis of 2,996 patients treated with breast-conserving surgery over 30 years.

32 Background: Randomized trials of radiation after breast-conserving surgery (BCS) for DCIS found substantial rates of recurrence, with half of recurrences invasive. Decreasing local recurrence rates for invasive breast carcinoma have been observed, and are largely attributed to systemic therapy improvements. Here we examine recurrence rates after BCS for DCIS over 3 decades at one institution. Methods: We retrospectively reviewed a prospectively maintained database of DCIS patients undergoing BCS from 1978–2010. Cox proportional hazard models were used to investigate the association between treatment period and recurrence, controlling for other variables. Results: 363 (12%) recurrences among 2996 cases were observed. Median follow-up for patients without recurrence was 75 months (range 0–30 years); 732 were followed for ≥ 10 years. The 5-year recurrence rate for 1978–1998 was 13.6% versus 6.6% for 1999–2010 (hazard ratio [HR] 0.62, p < 0.0001). After controlling for age, family history, presentation (radiologic vs clinical), nuclear grade (non-high vs. high grade), necrosis, number of excisions ( ≤ 2 vs ≥ 3), margin status (positive/close vs negative), radiation, and endocrine therapy, treatment period remained significantly associated with recurrence, with later years associated with a lower HR (0.74, p = 0.02) compared to earlier. After stratification by radiation use, and adjustment for 7 other factors, the decrease in recurrence rates was limited to those without radiation (HR 0.62, p = 0.003); there was no decline in recurrence rates among those receiving radiation (HR 1.13, p = 0.6). Conclusions: Recurrence rates for DCIS have fallen over time. Increases in screen-detection, negative margins, and use of adjuvant therapies only partially explain the decrease. The unexplained decline is limited to women not receiving radiation, suggesting it is not due to changes in radiation efficacy, but may be due to improvements in radiologic detection and pathologic assessment. The lower recurrence risk observed for DCIS patients treated in more recent years is important for patient education, especially in view of the widely reported recent increase in use of mastectomy.

Decreasing Recurrence Rates for Ductal Carcinoma In Situ: Analysis of 2996 Women Treated with Breast-Conserving Surgery Over 30 Years.

Randomized trials of radiation after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) found substantial rates of recurrence, with half of the recurrences being invasive. Decreasing local recurrence rates for invasive breast carcinoma have been observed and are largely attributed to improvements in systemic therapy. In this study, we examine recurrence rates after BCS for DCIS over 3 decades at one institution. We retrospectively reviewed a prospectively maintained database of DCIS patients undergoing BCS from 1978 to 2010. Cox proportional hazard models were used to investigate the association between the treatment period and recurrence, controlling for other variables. Overall, 363 (12%) recurrences among 2996 cases were observed. Median follow-up for patients without recurrence was 75 months (range 0-30 years); 732 patients were followed for ≥10 years. The 5-year recurrence rate for the period 1978-1998 was 13.6 versus 6.6% for the period 1999-2010 [hazard ratio (HR) 0.62, p < 0.0001]. Controlling for age, family history, presentation, nuclear grade, necrosis, number of excisions, margin status, radiation, and endocrine therapy, treatment period remained significantly associated with recurrence, with later years associated with a lower HR (0.74, p = 0.02) compared to earlier. After stratification by radiation use, association of recurrence with treatment period persisted in those treated without radiation (HR 0.62, p = 0.003). Recurrence rates for DCIS have fallen over time, with increases in screen detection, negative margins, and use of adjuvant therapies only partially explaining this decrease. The unexplained decline persists in women not receiving radiation, suggesting it is not due to changes in radiation efficacy but may be due to improvements in radiologic detection and pathologic assessment.

Management of challenging congenital melanocytic nevi: Outcomes study of serial excision

BackgroundLarge congenital melanocytic nevi (CMN) cause significant deformity and are at risk for malignant degeneration. Techniques used to remove difficult CMN include serial excision, skin grafting, or tissue expansion. Some authors prefer skin grafting or tissue expansion if several stages would be required to serially resect the CMN. The purpose of this study was to determine the efficacy of serial excision for CMN requiring ≥3 procedures. MethodsMedical records and clinical images of patients with CMN treated between 2007 and 2013 were reviewed. Inclusion criteria were: (1) lesions that required ≥3 serial excisions to remove and (2) CMN that could have been treated reasonably with skin grafting or tissue expansion. Patient age, gender, location of the lesion, size of the CMN, number of serial excisions, and complications were recorded. ResultsThe study included 21 patients. Lesions were located on the lower extremity (38.1%), head/neck (33.3%), upper extremity (14.3%), or trunk (14.3%). Nevus size was 2.2%±1.2% total body surface area. The age during the first operation was 4.3years (range 3months to 15years). The number of excisions was 3.5±0.7, spaced 8.2±4.3months apart. Partial suture line dehiscence occurred after 2/72 operations and seroma resulted after 1/72 operations; there were no infections. ConclusionChallenging CMN amenable to serial excision can be removed effectively and safely using this technique. Children are left with a favorable linear scar, do not have donor or recipient site morbidity from skin grafting, and are not subjected to potential tissue expander complications and injections required for expansion.

Perioperative Breast MRI Is Not Associated with Lower Locoregional Recurrence Rates in DCIS Patients Treated With or Without Radiation

For women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery (BCS), the benefit of magnetic resonance imaging (MRI) remains unknown. Here we examine the relationship of MRI and locoregional recurrence (LRR) and contralateral breast cancer (CBC) for DCIS treated with BCS, with and without radiotherapy (RT). A total of 2,321 women underwent BCS for DCIS from 1997 to 2010. All underwent mammography, and 596 (26 %) also underwent perioperative MRI; 904 women (39 %) did not receive RT, and 1,391 (61 %) did. Median follow-up was 59 months, and 548 women were followed for ≥8 years. The relationship between MRI and LRR was examined using multivariable analysis. There were 184 LRR events; 5- and 8-year LRR rates were 8.5 and 14.6 % (MRI), respectively, and 7.2 and 10.2 % (no-MRI), respectively (p = 0.52). LRR was significantly associated with age, menopausal status, margin status, RT, and endocrine therapy. After controlling for these variables and family history, presentation, number of excisions, and time period of surgery, there remained no trend toward association of MRI and lower LRR [hazard ratio (HR) 1.18, 95 % confidence interval (CI) 0.79-1.78, p = 0.42]. Restriction of analysis to the no-RT subgroup showed no association of MRI with lower LRR rates (HR 1.36, 95 % CI 0.78-2.39, p = 0.28). No difference in 5- or 8-year rates of CBC was seen between the MRI (3.5 and 3.5 %) and no-MRI (3.5 and 5.1 %) groups (p = 0.86). We observed no association between perioperative MRI and lower LRR or CBC rates in patients with DCIS, with or without RT. In the absence of evidence that MRI improves outcomes, the routine perioperative use of MRI for DCIS should be questioned.

Acquired Melanocytic Nevi in Childhood and Familial Melanoma

In the surveillance of familial melanoma, the identification of children at greater risk of developing melanoma later in life would serve as a helpful tool. To determine whether acquired melanocytic nevi in childhood are an indicator of risk of melanoma in children from families with familial melanoma. A 20-year follow-up study of a cohort of children from families with familial melanoma. Phenotypical data on melanocytic nevi were collected from a random sample of 133 members of families with familial melanoma 2 to 18 years of age with variable risks of being a mutation carrier. More than 20 years of follow-up data (gene-carrier status, diagnosis of melanoma, and excisions of nevi) were collected. In a subgroup of 40 people, childhood phenotypical data were compared with data on nevus numbers in adulthood. Survival analyses, correlation analyses, and t tests were calculated to examine associations. Nevus count and distribution in childhood were correlated with the occurrence of melanoma and mutation carrier status. Significant risk factors for melanoma were found, specifically in the group with the highest risk of being a mutation carrier: total number of atypical nevi in childhood (hazard ratio [HR], 1.21; 95% CI, 1.02-1.44; P = .03), the nevus count of atypical nevi on the buttocks (HR, 14.00; 95% CI, 2.94-66.55; P = .001), and the number of excisions during follow-up (HR, 1.27; 95% CI, 1.23-1.31; P < .001). The analysis also found a correlation between the distribution of nevi in childhood and adulthood and the distribution of melanomas (correlation, 0.89; 95% CI, 0.67-0.96; and correlation, 0.99; 95% CI, 0.98-1.00; P < .001, respectively for both). Numbers and distribution of melanocytic nevi in childhood are major indicators of the risk of melanoma in patients from families with familial melanoma.

Charlotte Brontë’s Busy Scissors Revising Villette

The number of excisions in Charlotte Brontë’s manuscripts escalated from one in Jane Eyre to twenty-eight in Shirley and to seventy-one in Villette. The number of pages that contain other kinds of cancellations (crossing-out, x-es, rows of l-s) and emendations is also higher in Villette. The large number of cancellations and excisions, as well as the diversification of excision typology, indicate an increasing level of authorial control which might have been triggered by Charlotte Brontë’s effort to experiment with internal monologue, a rudimentary phase of stream of consciousness, and self-reflexivity.

Association of MRI and locoregional recurrence (LRR) rates in ductal carcinoma in situ (DCIS) patients treated with or without radiation therapy (RT).

57 Background: Perioperative MRI is frequently obtained in women with breast cancer; however, studies have not shown decreased rates of re-excision, and some report unnecessary increases in mastectomy rates. We examined LRR rates among women with DCIS who underwent perioperative MRI as compared to those who did not. Methods: All women who underwent breast-conserving surgery for DCIS in 1997-2010 were included from a prospectively maintained database. Patient characteristics and rates of LRR were compared in women with and without an MRI. Univariate and multivariate analyses were performed. Analysis was repeated in the subset of women who did not receive RT. Results: 2,321 cases were identified; 596 had MRI and 1,725 did not. Women who had MRI were younger, more likely to be premenopausal, have a family history of breast cancer, have a clinical presentation, receive RT and endocrine therapy, be treated in later years, and had fewer close/positive margins. At median follow-up of 57 months there were 184 IBTRs; 5-year LRR rates were 8.5% (MRI) and 7.2% (no MRI) (p = 0.52), and 8-year rates were 14.6% and 10.2%, respectively. MRI was not associated with lower LRR rates after adjustment for age, menopausal status, family history, presentation, adjuvant therapy, margin status, number of excisions, and year of surgery in both the entire cohort and in the subgroup who did not receive RT. Select factors from multivariate analysis for patients with all covariates available are shown in the Table. Conclusions: We observed no association between perioperative MRI and LRR rates for patients with DCIS, even when RT was not given. The benefit of perioperative MRI for DCIS remains uncertain. [Table: see text]

Assessment of Postoperative Pain After Mohs Micrographic Surgery

Mohs micrographic surgery (MMS) has the highest cure rate for the treatment of cutaneous malignancies and is usually performed in an outpatient setting with local anesthesia. Although most patients experience minimal discomfort during the procedure, postoperative pain after MMS has not been well-characterized. The objective of this study was to evaluate the amount of postoperative pain after MMS and to determine whether the degree of pain is correlated with factors such as tumor location, size, number of excisions, or age or sex of the patient. One hundred fifty-eight patients with skin cancer treated with MMS were included in this study. Information recorded for each study participant included age, sex, diagnosis, tumor location, number of sites, number of Mohs excision stages, and type of repair performed. A daily log was given to patients to record the amount of pain experienced using the Wong-Baker pain scale and any analgesics that were taken for the 8 consecutive days beginning on the day of surgery. The majority of patients reported some degree of pain on day 0 (mean pain score 1.97±1.46) and day 1 (mean pain score 1.15±1.20); the fraction of patients reporting pain and the severity of that pain diminished steadily thereafter. By day 7, only 25 patients (16%) were experiencing any pain (average pain score 0.21). Only 26 patients (16%) required prescription analgesics on the day of surgery (day 0) and fewer on subsequent days. Seventy-seven of the patients used acetaminophen on day 0 (55%), which rapidly declined each subsequent day. Greater reported pain was significant for scalp procedures and multiple same-day procedures. No significant differences in pain scores were noted with regard to age or sex. Postoperative pain after MMS was associated with only mild to moderate pain on the day of surgery and the first postoperative day. Most pain was effectively managed using oral acetaminophen, with a minority of patients requiring prescription analgesics. Surgery on the scalp was significantly more painful than on other sites. Patients can be reassured that MMS and reconstruction is well-tolerated and associated with only mild to moderate discomfort postoperatively.

Timing in adjuvant chemotherapy (CTX) initiation among women with breast cancer (BC) at National Comprehensive Cancer Network (NCCN) centers: An analysis from the NCCN Outcomes Database.

6022 Background: Receipt of quality care has two important dimensions: that patients receive both appropriate and timely care. The primary aim was to examine time from BC diagnosis to CTX and identify factors associated with longer time. Methods: In the NCCN Outcomes Database, we identified 5,583 women with stage I-III BC diagnosed in 2003-2008 who received adjuvant CTX at 10 NCCN centers within 32 weeks (wks) of diagnosis. Patients with neoadjuvant therapy were excluded. Multivariate ANCOVA models were constructed to examine adjusted mean Time to Chemotherapy (TTC) from the date of pathological diagnosis. Results: Mean TTC was 11.8 wks. Many sociodemographic and clinical factors were associated with longer TTC. Factors with the largest effects are listed in Table 1. Minimal prolongation of TTC was associated with initial mastectomy versus lumpectomy (3 day greater TTC, p=0.01). Greater prolongation of TTC was observed between Caucasian and African American (AA) women diagnosed at another center prior to presentation (2.1 wks, p<0.001) than at the NCCN center (1.0 wk, p=0.13), and among patients with Medicare (2.7 wks, p<0.001) versus Managed Care (MCO, 1.2 wks, p<0.001) or Medicaid (0.9 wks, p=0.99). Interactions were significant between ethnicity and both insurance (p=0.03) and diagnosing institution (p=0.02). Conclusions: Some delay in TTC associated with clinical factors (21 gene RT PCR assay or number of excisions) may be unavoidable but should be minimized. Opportunities for improvement at the system level (insurance and transfers in care) were observed. Observed disparity in TTC for AA women appears to be exacerbated by transferring care and insurance related issues. % patients Mean TTC difference, wks Race/ethnicity Caucasian 78 Ref Hispanic 7 +0.7** AA 9 +1.6*** Asian 4 0.5 Other 2 0.0 Insurance MCO 78 Ref Medicare 10 +0.6* Medicaid 7 +2.6*** Other 4 0.4 Diagnosing institution NCCN 26 Ref Non-NCCN 74 +1.2*** Excisional procedures 1 64 Ref 2 31 +2.1*** ≥3 5 +5.6*** Reconstruction prior to CTX No 82 Ref Yes 18 +2.5*** 21-gene RT PCR assay No 94 Ref Yes 6 +2.2*** *p<0.05, **p<0.01, ***p<0.001

Nomogram for Predicting the Risk of Local Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ

While the mortality associated with ductal carcinoma in situ (DCIS) is minimal, the risk of ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) is relatively high. Radiation therapy (RT) and antiestrogen agents reduce the risk of IBTR and are considered standard treatment options after BCS. However, they have never been proven to improve survival, and in themselves carry rare but serious risks. Individualized estimation of IBTR risk would assist in decision making regarding the various treatment options for women with DCIS. From 1991 to 2006, 1,868 consecutive patients treated with BCS for DCIS were identified. A multivariate Cox proportional hazards model was constructed using the 1,681 in whom data were complete. Ten clinical, pathologic, and treatment variables were built into a nomogram estimating probability of IBTR at 5 and 10 years after BCS. The model was validated for discrimination and calibration using bootstrap resampling. The DCIS nomogram for prediction of 5- and 10-year IBTR probabilities demonstrated good calibration and discrimination, with a concordance index of 0.704 (bootstrap corrected, 0.688) and a concordance probability estimate of 0.686. Factors with the greatest influence on risk of IBTR in the model included adjuvant RT or endocrine therapy, age, margin status, number of excisions, and treatment time period. The DCIS nomogram integrates 10 clinicopathologic variables to provide an individualized risk estimate of IBTR in a woman with DCIS treated with BCS. This tool may assist in individual decision making regarding various treatment options and help avoid over- and undertreatment of noninvasive breast cancer.

The role of magnetic resonance imaging in the breast cancer patient.

Abstract Abstract #P3-1 Breast conserving therapy (BCT) is well established. Using standard guidelines, most patients are eligible, and those who are not can be identified with a high degree of accuracy with clinical evaluation and mammography. Local recurrence rates have decreased since the initial trials of BCT. Magnetic resonance imaging (MRI) identifies cancer not found by clinical exam or mammography. Improved definition of the extent of carcinoma in the breast has the potential to improve patient outcomes in the short term by decreasing the number of patients requiring conversion from BCT to mastectomy, or decreasing the number of excisions needed to obtain negative margins. Elimination of patients with extensive disease would be expected to decrease the rate of local recurrence of BCT in the long term.&amp;#x2028; We examined the effect of MRI on short term outcomes in 577 patients seen between 2004-2006. MRI did not decrease positive margins at initial lumpectomy (21.6% MRI vs 14% no MRI) or conversion from BCT to mastectomy (9.8%MRI vs 5.9% no MRI). MRI was associated with a 19-day delay in surgery, and after controlling for stage, the odds ratio of mastectomy was 1.8 in the MRI group (p= .024). Solin et al (JCO, 2008) examined the effect of MRI on local recurrence in 756 patients. After adjustment for patient and tumor features, 8-year local recurrence rates were 3% and 4% in the MRI and no-MRI groups, and contralateral cancer rates did not differ. A meta-analysis of 2763 breast cancers found that MRI detected additional disease in 16% of cases, a rate significantly higher than the 5-8% 10-year rates of local recurrence observed in most modern studies of BCT. These observations raise important questions regarding unnecessarily radical surgery performed for MRI findings which may not result in improved outcomes.&amp;#x2028; MRI is of benefit in selected, relatively uncommon circumstances including:&amp;#x2028; a) Axillary adenopathy with occult primary tumor&amp;#x2028; b) Paget's disease without evidence of tumor&amp;#x2028; c) Assessing response to neoadjuvant therapy in patients desiring BCT&amp;#x2028; d) Major discrepancy among clinical and conventional imaging findings&amp;#x2028; Conclusion: Breast cancer is well documented by pathologic studies to be a multifocal /centric disease. This occult disease has been successfully treated with RT. MRI is a technology capable of finding some of this disease, but how this benefits patients is unclear. In the absence of this information, MRI should not be a part of routine pre-surgical evaluation. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr P3-1.