BACKGROUND:The use of preoperative magnetic resonance imaging (MRI) for early-stage breast cancer (ESBC) is increasing, but its utility in detecting additional malignancy is unclear and delays surgical management (Jatoi and Benson in Future Oncol 9:347-353, 2013. https://doi.org/10.2217/fon.12.186 , Bleicher et al. J Am Coll Surg 209:180-187, 2009. https://doi.org/10.1016/j.jamcollsurg.2009.04.010 , Borowsky et al. J Surg Res 280:114-122, 2022. https://doi.org/10.1016/j.jss.2022.06.066 ). The present study sought to identify ESBC patients most likely to benefit from preoperative MRI by assessing the positive predictive values (PPVs) of ipsilateral and contralateral biopsies.METHODS:A retrospective cohort study included patients with cTis-T2N0-N1 breast cancer from two institutions during 2016-2021. A "positive" biopsy result was defined as additional cancer (PositiveCancer) or cancer with histology often excised (PositiveSurg). The PPV of MRI biopsies was calculated with respect to age, family history, breast density, and histology. Uni- and multivariate logistic regression determined whether combinations of age younger than 50 years, dense breasts, family history, and pure ductal carcinoma in situ (DCIS) histology led to higher biopsy yield.RESULTS:Of the included patients, 447 received preoperative MRI and 131 underwent 149 MRI-guided biopsies (96 ipsilateral, 53 contralateral [18 bilateral]). PositiveCancer for ipsilateral biopsy was 54.2%, and PositiveCancer for contralateral biopsy was 17.0%. PositiveSurg for ipsilateral biopsy was 62.5%, and PositiveSurg for contralateral biopsy was 24.5%. Among the contralateral MRI biopsies, patients younger than 50 years were less likely to have PositiveSurg (odds ratio, 0.02; 95% confidence interval, 0.00-0.84; p = 0.041). The combinations of age, density, family history, and histology did not lead to a higher biopsy yield.CONCLUSION:Historically accepted factors for recommending preoperative MRI did not appear to confer a higher MRI biopsy yield. To prevent delays to surgical management, MRI should be carefully selected for individual patients most likely to benefit from additional imaging.

A correction to this paper has been published: https://doi.org/10.1245/s10434-021-10138-3

e12663 Background: Pembrolizumab (pembro) in combination with neoadjuvant chemotherapy (NACT) became standard of care for high risk, early stage TNBC on July 26, 2021, as a result of the KEYNOTE-522 trial. Black women are disproportionately affected by TNBC with more advanced stage at diagnosis, however the KEYNOTE-522 did not collect data on race. This retrospective review evaluates response to pembro plus NACT in a racially diverse population to assess the generalizability of the trial findings to potentially under-represented patient populations. Methods: This is a single center, retrospective review of patients with stage II/III TNBC diagnosed between 08/2020 to 08/2023, treated with pembro plus NACT at Maimonides Medical Center, a safety-net hospital in Brooklyn, New York serving a diverse patient population. Exclusion criteria included age < 18 years, ER/PR/Her2 positivity, NACT without pembrolizumab and unreported race. Data were collected from electronic health records and analyzed using SPSS Statistics. Results: 50 patients met inclusion criteria, among whom 40 patients had complete information available for review. 52.5% (95% CI: 38% - 69%) of patients had a pCR. Nearly half of the patient population (47.5%) were African American. Subgroup analysis of ethnicity demonstrated a lower pCR amongst African American women, but this was not statistically significant (table). 5 patients had progression of disease with the development of distant metastasis (2 whilst on treatment and 3 following completion of therapy). 3 patients had grade 3/4 adverse events (pembro associated endocrine and cardiac dysfunction). Notably, lack of complete imaging response to treatment was significantly associated with lack of pCR (p=0.003). Conclusions: In this retrospective review of a racially diverse patient population, the pembrolizumab-NACT regimen was well tolerated with an acceptable side effect profile. While our rate of pCR is lower than the findings of the Keynote-522 trial; 52.5 % (95% CI: 38% - 69%) vs. 64.8% (95% CI: 59.9%-69.5%), our sample size is not large enough to detect a statistically significant difference. Sub-analysis of patient ethnicity demonstrated varying rates of pCR, however findings are limited by a small sample size. Additional data collection is in progress and future analysis will provide insight into a potential correlation between race and therapy response. [Table: see text]

Introduction: The lack of racial diversity depicted in medical education texts may contribute to an implicit racial bias among clinicians. This bias influences outcomes, as familiarity with the various cutaneous manifestations of disease is essential to making an accurate diagnosis. To better understand the racial disparities in breast surgery, we sought to determine the extent of skin tone representation depicted in images of breast surgery and pathology textbooks.Methods: Textbooks were screened for color images of conditions with sufficient skin tissue present to assign the Fitzpatrick skin phototype (FSP). Figures were independently assigned an FP score (range: 1-6), and subdivided into "light skin" (FP 1-3) and "dark skin" (FP 4-6). Number of figures in each category and percentage of patients with each skin tone were calculated.Results: 557 figures were included. Among 12 textbooks reviewed, seven textbooks were from the discipline of surgery, while five were pathology-related. Textbook year of publication spanned from 1996 to 2018. Overall, 533 (95.7%) figures depicted patients with light skin color versus 24 (4.3%) with dark skin color. There was no association between FP score and year of textbook publication (P = 0.69). Conclusions: Patient images in breast textbooks are overwhelmingly of light skin tones, excluding patients with darker skin tones. The dearth of images depicting dark skinned individuals did not improve over time. Inclusion of patients of color in future textbooks may help reduce racial disparities within breast cancer care.& COPY; 2023 Elsevier Inc. All rights reserved.

INTRODUCTION:The rate of mastectomy in lumpectomy-eligible patients with unilateral breast cancer is increasing. We sought to investigate the association between magnetic resonance imaging (MRI) and surgical management of patients with early-stage breast cancer by comparing the rate of mastectomy as first surgery in patients with and without preoperative MRI. METHODS:A bi-institutional retrospective study included patients diagnosed between 2016 and 2020. Lumpectomy-eligible patients with in situ and invasive cancer were included. Those receiving preoperative therapy, MRI before diagnosis, or with known bilateral cancer were excluded. The risk factors for bilateral and multicentric disease were accounted for. Fisher's exact and chi-square tests compared categorical variables, Wilcoxon two-sample test analyzed continuous variables, and multivariate analyses were performed with Poisson regression. RESULTS:Four hundred twenty-eight participants met inclusion criteria. Patients who received MRI were younger (58 versus 67 y; P < 0.001) and had denser breasts (group 3 or 4; 61% versus 25%; P < 0.001). Mastectomy rate was twice as high in patients undergoing MRI (32% versus 15%, rate ratio 2.16; P < 0.001), which remained significant in multivariate analysis (rate ratio 2.0; P < 0.001). Contralateral mastectomy (12% versus 4%; P = 0.466) and reexcision (13% versus 12%; P = 0.519) rates were similar. Time to surgery was greater in those receiving MRI alone and MRI biopsy (34 [no MRI] versus 45 [MRI] versus 62 [MRI biopsy]; P < 0.001 for both). CONCLUSIONS:MRI receipt is associated with a doubled rate of mastectomy in lumpectomy-eligible patients. Future work is needed to standardize patient selection for MRI to those with the highest likelihood of having additional undiagnosed disease.

Background: Lumpectomy with radiation (breast conservation) and mastectomy have equivalent overall survival. However, recent studies suggest that patients undergoing breast conservation have lower rates of recurrence compared to those undergoing mastectomy. A 2013 meta-analysis by Houssami, et al. found that the rate of mastectomy in patients who had preoperative MRI was 16%, twice as high as that in patients who did not have preoperative MRI. A multi-institutional analysis was performed to investigate the possible impact of modern MRI on the surgical management of early-stage breast cancer (ESBC). Methods: A retrospective comparative cohort study included patients with in-situ and invasive breast cancer eligible for breast conservation surgery from two institutions (NY and FL). Patients who received preoperative systemic therapy were excluded. Eligibility for breast conservation was defined as clinical stage Tis-2. Risk factors for the bilateral or multicentric disease were compared between the two groups including breast density, menopausal status, and concerning family history. The rate of ipsilateral mastectomy in lumpectomy-eligible women was compared between patients who did and did not receive preoperative MRI. Chi-square analysis was used to compare rates between groups. P values <0.05 were considered statistically significant. Results: 505 patients diagnosed between 1/2016-4/2019 (NY) and 2/2020-12/2020 (FL) underwent primary surgery for ESBC. 434 did not receive neoadjuvant therapy and were included in the analysis. 292 (67.3%) had preoperative MRI. There was no difference in the proportion of patients who were premenopausal or who met the criteria for genetic testing by family history. The largest dimension on preoperative imaging was similar between the two groups. Patients who had MRI were younger (median age 58 vs. 68, p<0.001) and more likely to have group 3 or 4 breast density (64.5% vs. 27.1%, p<0.001). Patients who underwent preoperative MRI were twice as likely to undergo mastectomy as their first surgery (32.6% vs. 15.3%, p<0.001). The rate of re-excision was similar between the two groups (MRI 13.0% vs. no MRI 10.8% p=0.511). Of note, the final pathologic size of the invasive or in-situ component was similar between the two groups (Table 1). Conclusion: Younger age and greater breast density are associated with preoperative MRI receipt and all three factors likely play a role in choosing mastectomy. Young women with dense breasts represent a unique cohort of patients that may be particularly susceptible to cancer-related worry and anxiety related to additional biopsies, and therefore may be more likely to opt against continued breast imaging. Since approximately 70% of patients with ESBC undergo preoperative MRI, future work should focus on mitigating these challenges to improve shared decision-making. Table 1.Comparison of ESBC Patients Who Did and Did Not Receive MRIMRI (n=292) %, median (IQR)No MRI (n=142)%, median (IQR)p-valueAge58 years (50-65)68 years (60-76)<0.001bPremenopausal27%21%0.108Dense Breasts65%27%<0.001bMeet Criteria for Genetic Testing40%38%0.207Imaging Size13 mm (9-21)12 mm (8-20)0.315Mastectomy as First Surgery33%15%<0.001bPlan for Repeat Surgerya20%24%0.402Re-excision13%11%0.511Pathologic Size (Invasive)13 mm (8-20)13 mm (9-22)0.482Pathologic Size (DCIS)10 mm (5-20)8 mm (3-15)0.093aRepeat surgery includes re-excision, completion mastectomy, and axillary dissectionbDenotes significant p-values. Citation Format: Peter A Borowsky, Seraphina Choi, Orly Morgan, Amy K White, Claudya Morin, Jose Net, Susan Kesmodel, Neha Goel, Yamini Patel, Alexa Griffiths, Joshua A Feinberg, Aaron Kangas-Dick, Charusheela Andaz, Christina Giuliano, Natalie Zelenko, Donna-Marie Manasseh, Patrick Borgen, Kristin E Rojas. The association of preoperative MRI with surgical decision-making in patients with early-stage breast cancer: A multi-institutional analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-03-20.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

We sought to determine if lumpectomy patients who received perioperative opioid-sparing multimodal analgesia reported less pain when compared with those who received traditional opioid-based care. A prospective cohort of patients undergoing lumpectomy who received an opioid-sparing multimodal analgesia protocol [no opioids group (NOP)] was compared with a large cohort of patients who received traditional care [opioids group (OG)]. In-hospital and discharge opioids were compared using oral morphine equivalents (OMEs). Postoperative day one and week one pain scores were compared using the Kruskal–Wallis test. Overall, 1153 patients underwent lumpectomy: 634 patients received the protocol (NOP), and 519 patients did not (OG). Median pain scores were significantly lower in the NOP cohort when compared with the OG cohort the day after surgery (2 vs. 0, p < 0.001) and the week after surgery (1 vs. 0, p < 0.001). NOP patients were significantly less likely to report severe pain (7–10 on a 10-point scale) the day after surgery compared with OG patients (15.7% vs. 6.9%, p = 0.004). Patients in the NOP cohort were discharged with a median of zero OMEs (range 0–150), while patients in the OG were discharged with a median of 90 OMEs (range 0–360; p < 0.001). Implementation of an opioid-sparing multimodal analgesia protocol for lumpectomy patients resulted in superior pain control without a routine opioid prescription. Surgeons can improve their own patients’ outcomes while addressing the larger societal issue of the opioid crisis by adopting similar protocols that decrease the quantity of opioids available for diversion.

BACKGROUND:We investigated the utility of an automated chemiluminescent SARS-CoV-2 IgG antibody assay platform in quantifying the amount of binding antibodies present in donated convalescent plasma.METHODS:A total of 179 convalescent plasma units were analyzed for the presence of SARS-CoV-2 IgG antibodies using the Beckman-Coulter chemiluminescent immunoassay (CLIA) platform. The equipment-derived numerical values (S/Co ratio) were recorded. Aliquots from the same units were subjected to enzyme-linked immunosorbent assay (ELISA) that detects IgG antibodies against the receptor-binding domain (RBD) of the SARS-CoV-2 S1 protein. The relationship between ELISA titers and CLIA S/Co values was analyzed using linear regression and receiver operating characteristics (ROC) curve.RESULTS:Twenty-one samples (11.7%) had S/Co values of less than 1.0 and were deemed negative for antibodies and convalescent plasma had S/Co values between >1.0 and 5.0 (70/179, 39.1%). Fifteen units (8.4%) had negative ELISA titer. The majority of the units (95/179. 53.1%) had titers ≥1:1024. The sensitivities of ELISA to CLIA were comparable (90.5% vs 88.3%, respectively; p=0.18). There was positive linear correlation between CLIA S/Co values and ELISA IgG titer (Rho = 0.75; Spearman's rank = 0.82, p-value = <0.0001). The agreement between the two methods was fair, with a κ index of 0.2741. Using the ROC analysis, we identified a CLIA S/Co cutoff value of 8.2, which gives a sensitivity of 90% and a specificity of 82% in predicting a titer dilution of ≥1:1024.CONCLUSION:The utility of automated antibody detection systems can be extended from simply a screening method to a semi-quantitative and quantitative functional antibody analysis. CLIA S/Co values can be used to reliably estimate the ELISA antibody titer. Incorporation of chemiluminescent-based methods can provide rapid, cost-effective means of identifying anti-SARS-CoV-2 antibody titers in donated plasma for use in the treatment of COVID-19 infection.

A 62-year-old male with type 2 diabetes mellitus presented to our nationally accredited breast center with bilateral breast masses present for 7 years and new-onset pink nipple discharge for several months. Mammography and ultrasound demonstrated a left 2.7 retroareolar cystic lesion and a right 2.1 cm retroareolar solid lesion. Given the suspicious nature of the bilateral breast discharge, core needle biopsies were performed to rule out underlying malignancy. The biopsies revealed benign results, but the discordance between the biopsy, imaging, and suspicious discharge led to the decision to perform bilateral excisional biopsies. Intraoperatively, a small organism resembling a larva was encountered. The abnormal tissue was sent for histopathological examination, along with the organism, which was identified as the larvae of Musca domestica , or common house fly.

ONCOLOGY sat down with Patrick I. Borgen, MD, to discuss the latest trends in surgical and medical oncology, the transformation of breast cancer treatment over the course of his career, and the role he played within that evolution.

Abstract The rarity of male breast cancer continues to limit its study despite increasing incidence rates, particularly within the past decade [Speirs V, Shaaban AM. The rising incidence of male breast cancer. Breast Cancer Res Treat 2009;115:429–30]. Although this trend appears to be substantially documented, male patients with breast cancer have been and continue to be excluded from landmark breast cancer trials. Currently, there are no standardized breast cancer screening protocols in place for men, including those with pathogenic BRCA mutations. As a result, men with breast cancer typically present at a later stage, and on average, 8–10 years later than females [Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. Ann Oncol 2013;24:1434–43]. As the incidence of disease continues to rise, the need for algorithmic standardization with regards to screening, diagnosing, treating and managing male breast cancer has become imperative. We report the case of a 71-year-old male who presented with spontaneous bloody nipple discharge and was found to have bilateral ductal carcinoma in situ.

Using prior mammograms from patients with delays in their breast cancer diagnoses, we sought to describe in-vivo growth kinetics of untreated breast cancer to determine if the time they became clinically apparent can be predicted. Patient and tumor characteristics were collected from those who presented with “missed,” untreated breast cancer to a breast center in a single institution. Only patients whose biopsied masses revealed estrogen receptor-positive, Her2-negative (ER+/Her2−) invasive cancers were included. Two attending radiologists reviewed images from prior mammograms. Rates of change in volume were calculated in mm3/day, and a logarithmic equation was used to calculate tumor volume doubling time (TVDT). A Spearman's Rho correlation was performed for the continuous variables, and the Mann–Whitney U and Kruskal–Wallis tests were used to compare categorical data. A p value < 0.05 was considered statistically significant. Logistic regression was performed to determine if patient or tumor characteristics were correlated to tumor growth velocity. Of the 36 ER+/Her2− invasive breast cancers included in the analysis, 13 (36%) were at least cT2 (of TNM), 7 (19%) were grade 3, and 7 (19%) were node positive at diagnosis. Grade (p = 0.043) and pathologic invasive tumor size (p = 0.001) were positively correlated to tumor growth velocity. Median TVDT was 385 days (23–1897). Age, nodal positivity, Oncotype Dx® Recurrence Score, time of diagnostic delay, and spheroid-ellipsoid discrepancy (SED) were not related to tumor growth velocity in this sample. In this cohort of patients with untreated ER+/Her2− invasive breast cancers, grade and pathologic tumor size were found to be positively correlated to growth velocity. The growth rates in a homogeneous group of tumors varied widely and could not be predicted. One possible explanation for this finding is that other difficult-to-measure biologic factors such as tumor microenvironment may play a greater role in tumor progression than traditional clinicopathologic characteristics.

Obese patients are at increased risk of persistent pain and chronic opioid dependence after surgery. We sought to evaluate the impact of an Enhanced Recovery After Surgery (ERAS) protocol in breast surgery patients to determine whether multimodal analgesia was effective for both obese and non-obese patients. A prospective cohort of patients undergoing breast surgery who received an opioid-sparing ERAS protocol was compared with patients who did not receive ERAS, including a historical cohort. Pain scores were compared with respect to body mass index (BMI). Obesity was defined as BMI ≥ 30, and moderate to severe pain was defined as 4–10 of a 10-point scale. Postoperative day one and week one pain scores were compared using the Kruskal–Wallis test. A combined contemporary and historical cohort of 1353 patients underwent lumpectomy and mastectomy without reconstruction. The present analysis comprises 622 patients with pain scores who did and did not receive ERAS between 2015 and 2018. The two groups were demographically similar. The day after surgery, those who received ERAS reported lower rates of moderate to severe pain, regardless of BMI (obese: 46.3% vs. 21.8%, p < 0.001; non-obese: 36.3% vs. 19.4%, p = 0.002). One week after surgery, obese patients who received ERAS had higher rates of persistent pain compared with non-obese patients (18.6% vs. 11.1%, p = 0.042). An opioid-sparing ERAS protocol utilizing multimodal analgesia significantly improved postoperative pain control for obese and non-obese patients. However, it appears that obese patients are still at relatively greater risk for persistent pain after surgery.