With DCIS incidence on the rise, up to 30

Recognition of gender diverse individuals and their unique health care needs is increasing. Population-based studies demonstrate numbers of individuals identifying as transgender and gender non-binary is growing, particularly in younger generations. Since the end of Medicare coverage exclusion for gender-affirming surgeries (GASs) and expansion in third-party coverage, patients seeking GAS have increased dramatically.Gender-affirming chest surgery (GACS) is performed at nearly twice the rate of genital surgery. The average age of patients seeking GAS is 29.8 years. With expansion in GAS availability, more individuals at or near screening age present for chest surgery. Without pre-operative imaging, breast tissue abnormalities may not be discovered until surgical pathology. We present a patient with Paget's disease of the breast (PDB) discovered after female-to-male gender-affirming chest surgery (FTM GACS) without pre-operative imaging. This case highlights the importance of routine breast surveillance prior to FTM GACS.

The Breast JournalVolume 25, Issue 2 p. 334-337 COMMENTARY Income, costs, and health care utilization may influence surgical choice in early stage breast cancer Raeshell S. Sweeting MD, Corresponding Author Raeshell S. Sweeting MD raeshell.s.sweeting@vumc.org Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, Tennessee Correspondence Raeshell S. Sweeting, Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN. Email: raeshell.s.sweeting@vumc.orgSearch for more papers by this authorLiping Du PhD, Liping Du PhD Center for Quantitative Sciences, Vanderbilt University, Nashville, TennesseeSearch for more papers by this authorYu Shyr PhD, Yu Shyr PhD Center for Quantitative Sciences, Vanderbilt University, Nashville, TennesseeSearch for more papers by this authorMary A. Hooks MD, MBA, Mary A. Hooks MD, MBA Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TennesseeSearch for more papers by this author Raeshell S. Sweeting MD, Corresponding Author Raeshell S. Sweeting MD raeshell.s.sweeting@vumc.org Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, Tennessee Correspondence Raeshell S. Sweeting, Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN. Email: raeshell.s.sweeting@vumc.orgSearch for more papers by this authorLiping Du PhD, Liping Du PhD Center for Quantitative Sciences, Vanderbilt University, Nashville, TennesseeSearch for more papers by this authorYu Shyr PhD, Yu Shyr PhD Center for Quantitative Sciences, Vanderbilt University, Nashville, TennesseeSearch for more papers by this authorMary A. Hooks MD, MBA, Mary A. Hooks MD, MBA Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TennesseeSearch for more papers by this author First published: 25 February 2019 https://doi.org/10.1111/tbj.13223Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume25, Issue2March/April 2019Pages 334-337 RelatedInformation

Haddad, Diane N. MD; Welty, Valerie F.; Blume, Jeffrey D. PhD; Hawkins, Alexander T. MD, MPH; Sweeting, Raeshell S. MD; Grogan, Eric L. MD, MPH, FACS; Aldrich, Melinda C. PhD, MPH Author Information

SCD, the hereditary hemoglopinopathy, leads to painful, life-threatening vaso-occlusive crises and hemolytic anemia.1 It is estimated that there are 100,000 people in the United States living with SCD. Compared with the general population, patients with SCD are more likely to require surgery at some point during their lifetime. “Sufferers of SCD are prone to requiring surgical intervention due to secondary conditions which are directly related to their SCD,” such as cholelithiasis, splenic sequestration, and avascular necrosis of the femoral head.1 Furthermore, SCD is associated with a significantly greater risk of perioperative complications because physiologic changes that occur as a result of surgery—hypovolemia, acidosis, hypoxia, and hypothermia—increase the risk of vaso-occlusive complications.2 In addition to the more general risks of surgery, sickle cell–specific complications such as pain crises and acute chest syndrome can occur postoperatively. For patients with SCD, the prevalence of perioperative complications has been estimated as high as 30 per cent.3 Perioperative mortality of 1 per cent has been reported.1, 2 Perioperative care of patients with SCD necessitates interdisciplinary management strategies that are sensitive to unique patient needs. Despite the widespread adoption of enhanced recovery after surgery (ERAS) protocols aimed to speed recovery and reduce complications and postsurgical pain; no standard protocols or perioperative management strategies have been developed to guide care of patients with diseases that confer an increased risk of perioperative complications, such as SCD. We examined the outcomes of surgery in patients with SCD cared for by a single general surgeon who used an interdisciplinary perioperative management protocol. We performed a retrospective review of all adults ($18 years of age) with SCD that underwent a surgical procedure at the University of North Carolina (UNC) Hospital in Chapel Hill, NC, during a five-year period, from 2008 until 2013. In addition to basic demographic and clinical data, operative details, perioperative blood transfusion, perioperative complications, length of stay, readmissions, and mortality within 30 days of surgery were recorded. We identified 21 patients with SCD who underwent surgery during the five-year study period. Of these, 17 patients were cared for by single general surgeon who used an interdisciplinary perioperative management protocol. Mean patient age was 37.0 ± 16.0 years. Eleven (65%) of the patients were women. All patients reported race/ethnicity as non-Hispanic and black. Hemoglobinopathies were Hgb SS (n 4 15, 88%), Hgb Sb thalassemia (n 4 1, 6%), and Hgb SC (n 4 1, 6%). Mean preoperative hemoglobin was 9.9 ± 1.0 g/dL. For patients who received a preoperative blood transfusion, post-transfusion hemoglobin level was reported. For a detailed list of patient characteristics and operative details, see Table 1. The most common surgical procedure performed was laparoscopic cholecystectomy (n 4 12). Other procedures performed were enterocutaneous fisula takedown, bowel resection, and abdominal wall reconstruction (n 4 1); modified radical mastectomy (n 4 1); bilateral open inguinal hernia repair (n 4 1); ventral incisional hernia repair (n 4 1); and laparoscopic splenectomy and cholecystectomy (n 4 1). All procedures were performed electively. Blood transfusion was administered in 11 patients preoperatively (65%) and four patients postoperatively (24%). No patient required an intraoperative blood transfusion. Six patients were diagnosed with postoperative complications. The patient who underwent enterocutaneous fistula takedown developed an intra-abdominal abscess which necessitated operative drainage. There were three cases of acute chest Address correspondence and reprint requests to Sara Scarlet, M.D., University of North Carolina at Chapel Hill, 320 Kirkwood Drive, Chapel Hill, NC 27514. E-mail: sara.scarlet@unchealth. unc.edu.

The management of ballistic injury to the breast is poorly described because it is frequently overshadowed by significant and morbid associated injuries in the abdomen and thorax.1 For example, one prospective analysis demonstrated that of 22 recorded gunshot wounds to the breast over a three-year period, 64 per cent was associated with major intra-thoracic injury, 45 per cent was associated with major intra-abdominal injury, and overall mortality was as high as 71 per cent. Only three of these patients had wounds confined to only the breast.2 Management of high-impact penetrating injuries can be more complex than other soft tissue injuries elsewhere because of the implications on cosmesis and future reconstructive options. We present the course, management, and cosmetic results of one patient treated at our Level I trauma center who sustained a significant ballistic injury to the right breast. A 42-year-old female with a history of depression, obesity (BMI 4 46), and poorly controlled diabetes (HgA1c 4 8.1) was transferred to our facility after a self-inflicted 0.243-caliber rifle wound. On arrival at the trauma bay, she was noted to be hypotensive with an opening blood pressure of 71/46 that increased to 112/84 after administration of two units of uncrossmatched trauma blood. Her penetrating survey was notable for three right breast wounds: a wellcircumscribed medial wound and two small wounds along the lateral breast and axilla. In addition, she had four small wounds on the right upper extremity with no associated neurovascular deficits. A portable chest radiograph demonstrated extensive right lung opacification. A contrasted CT scan of the chest demonstrated moderate consolidation of the right lung without pneumothorax and a bullet track through the right breast with associated ballistic fragments and air (Fig. 1). Her breast wound was treated with bedside debridement and packing, and her care was eventually transferred to psychiatry because of suicidal intent. Approximately two weeks from the date of injury, the patient presented with increasing drainage and malodor from her progressively enlarging lateral breast wound (Fig. 2, panel A). She denied fevers and had a normal white blood cell count of 9.6 · 103 cells/mL. On examination, her lateral wound had enlarged to 8 · 7 cm, with necrosis of the skin edges and wound bed. A large soft tissue defect tracking to the posterior aspect of the nipple was noted with overlying skin discoloration and induration. The medial wound appeared clean and viable. Recognizing the extent of tissue damage to the breast, the decision was made to begin serial debridements to attempt to preserve as much breast parenchyma as possible. Mastectomy was considered; however, she presented with gross contamination which would have hindered wound closure. As a result, she underwent a series of four debridements aimed at wound decontamination and maintenance of breast contour. At her initial debridement, she was found to have frank pus in her breast and large areas of necrotic tissue. A penrose drain was placed between the two wounds which tracked across the breast. The wound was packed with Dakin’s soaked gauze. Tissue and fluid were sent for Gram stain and culture to guide antibiotic therapy. During her second debridement, multiple small contained pockets of purulent material were encountered in areas of the breast containing imbedded bullet fragments. Review of presenting CT demonstrated a pattern of injury consistent with this finding. She initially did well after the second debridement but began to develop malodorous drainage and increased pain on POD 2 from the 2nd debridement. She was taken for a third debridement at which time the nipple areola complex was removed because of devitalization of the nipple. Additional pockets of purulent material were encountered around small bullet fragments. Finally, we performed final operative wound exploration. The wound base was Address correspondence and reprint requests to Raeshell S. Sweeting, Vanderbilt University, Nashville, TN 37232. E-mail: raeshell.s.sweeting@vanderbilt.edu.

Axillary lymph node status is an independent prognostic indicator in breast cancer. Intraoperative identification of metastatic carcinoma in sentinel lymph nodes may allow for concurrent axillary lymph node dissection at the time of primary tumor excision. A retrospective review of patients undergoing primary breast cancer excision with sentinel lymph node sampling was performed. Sensitivity and specificity of imprint cytology (touch prep) with and without the incorporation of gross evaluation was determined using permanent section results as the gold standard. Five hundred sixteen lymph nodes were analyzed by imprint cytology in 213 patients, and 203 lymph nodes were analyzed in 74 patients incorporating gross examination. Sensitivity and specificity for the detection of macrometastases by touch prep alone were 60% and 99% respectively with 4 patients undergoing same-day axillary dissection for only micrometastatic disease. False negative causes included lack of transfer of malignant cells in 8 cases and misinterpretation of tumor cells in 6 cases. Incorporating gross examination in the modified protocol resulted in reduced sensitivity of 38%, but achieved the desired 100% specificity and positive predictive value. Imprint cytology alone did not reliably distinguish between micro- and macrometastatic disease. Gross assessment combined with imprint cytology allows for improved assessment of volume of axillary disease, but is an insensitive technique.

• Mammogram guidelines are based on studies with limited representation of black women. • Breast cancer incidence and mortality are worse for black women compared to white. • Additional study is needed to make guidelines applicable to black women.

Background: Breast cancer treatment-related lymphedema (BCRL) arises from a mechanical insufficiency following cancer therapies. Early BCRL detection and personalized intervention require an improved understanding of the physiological processes that initiate lymphatic impairment. Here, internal magnetic resonance imaging (MRI) measures of the tissue microenvironment were paired with clinical measures of tissue structure to test fundamental hypotheses regarding structural tissue and muscle changes after the commonly used therapeutic intervention of manual lymphatic drainage (MLD).Methods and Results: Measurements to identify lymphatic dysfunction in healthy volunteers (n = 29) and patients with BCRL (n = 16) consisted of (1) limb volume, tissue dielectric constant, and bioelectrical impedance (i.e., non-MRI measures); (2) qualitative 3 Tesla diffusion-weighted, T-1-weighted and T-2-weighted MRI; and (3) quantitative multi-echo T-2 MRI of the axilla. Measurements were repeated in patients immediately following MLD. Normative control and BCRL T2 values were quantified and a signed Wilcoxon Rank-Sum test was applied (significance: two-sided p < 0.05). Non-MRI measures yielded significant capacity for discriminating between arms with versus without clinical signs of BCRL, yet yielded no change in response to MLD. Alternatively, a significant increase in deep tissue T-2 on the involved (pre T-2 = 0.0371 +/- 0.003 seconds; post T-2 = 0.0389 +/- 0.003; p = 0.029) and contralateral (pre T-2 = 0.0365 +/- 0.002; post T-2 = 0.0395 +/- 0.002; p < 0.01) arms was observed. Trends for larger T-2 increases on the involved side after MLD in patients with stage 2 BCRL relative to earlier stages 0 and 1 BCRL were observed, consistent with tissue composition changes in later stages of BCRL manifesting as breakdown of fibrotic tissue after MLD in the involved arm. Contrast consistent with relocation of fluid to the contralateral quadrant was observed in all stages.Conclusion: Quantitative deep tissue T-2 MRI values yielded significant changes following MLD treatment, whereas non-MRI measurements did not vary. These findings highlight that internal imaging measures of tissue composition may be useful for evaluating how current and emerging therapies impact tissue function.

BACKGROUND: Numerous organizations have identified access to emergency surgical care as a crisis. One barrier is the financial disincentive associated with caring for this patient population. We sought to identify contributing factors by analyzing endemic data during the development of an acute care surgery (ACS) service at an academic health care system. METHODS: Financial data (receipts, payer mix, and dollar/relative value unit [RVU]) and productivity measures (OR procedures and RVUs) were obtained for a surgical division for 6-month periods before and after transition to an ACS model. Using national data, a sensitivity analysis was performed to identify salary targets required for an ACS surgeon to have equitable career reimbursement using standard financial modeling (net present value) with comparable surgical specialists. RESULTS: Post-ACS, operative volume increased 25%, work RVUs increased 21%, but net receipts increased only 11%. Dollar/RVU decreased primarily due to a higher proportion of uncompensated care. As a result, the dollar/RVU for ACS patients was 28% lower in comparison to non-ACS specialties. Increasing ACS salaries proportionate to the observed dollar/RVU discount realigned ACS economic value with other specialties in aggregate. CONCLUSION: A national shortage of ACS surgeons exists due to in part financial misalignment. We demonstrated that despite an increase in clinical activity, transition to an ACS model resulted in a relative reduction in payment. A rational systems-based approach to ACS development that objectively targets the RVU reimbursement disparity would reduce economic disincentives related to careers in ACS and potentially address the emergency surgical care crisis.

Background: Local recurrence (LR) rates in patients with retroperitoneal sarcoma (RPS) are high, ranging from 40% to 80%, with no definitive studies describing the best way to administer radiation. Intraoperative electron beam radiation therapy (IOERT) provides a theoretical advantage for access to the tumor bed with reduced toxicity to surrounding structures. The goal of this study was to evaluate the role of IOERT in high-risk patients.Methods: An institutional review board approved, single institution sarcoma database was queried to identify patients who received IOERT for treatment of RPS from 2/2001 to 1/2009. Data were analyzed using the Kaplan-Meier method, Cox regression, and Fisher Exact tests.Results: Eighteen patients (median age 51 y, 25-76 y) underwent tumor resection with IOERT (median dose 1250 cGy) for primary (n = 13) and recurrent (n = 5) RPS. Seventeen patients received neoadjuvant radiotherapy. Eight high-grade and 10 low-grade tumors were identified. Median tumor size was 15 cm. Four patients died and two in the peri-operative period. Median follow-up of survivors was 3.6 y. Five patients (31%) developed an LR in the irradiated field. Three patients with primary disease (25%) and two (50%) with recurrent disease developed an LR (P = 0.5). Four patients with high-grade tumors (57%) and one with a low-grade tumor (11%) developed an LR (P = 0.1). The 2- and 5-y OS rates were 100% and 72%. Two-and 5-y LR rates were 13% and 36%.Conclusions: Using a multidisciplinary approach, we have achieved low LR rates in our high-risk patient population indicating that IOERT may play an important role in managing these patients. (C) 2013 Elsevier Inc. All rights reserved.

Abstract Pancreatic cancer is a highly aggressive cancer that is resistant to most drug therapies. Lung cancer is the number one cause of cancer deaths in the US and worldwide. Both of these tumors are known to have high levels of Ras oncogenic mutations (50 and 90% respectively). AKT is known to phosphorylate and inactive Glycogen Synthase Kinase 3 (GSK3). Additionally, GSK3 has been shown to play a role in oncogenesis in pancreatic cancer and lung cancer. Given the high level of AKT activity in transformed cells these two processes would appear to be at odds. However, much of the work on GSK3 has focused on the beta subunit. We have found that the alpha subunit plays a role in tumor proliferation and AKT activity. We see a significant effect of knockdown of GSK3β in Ras transformed pancreatic (Panc1, MiaPaca) and lung cancer (A549) cell lines in proliferation assays, with an approximately 70% decrease in growth compared to siControl cells. In contrast, the knockdown of the GSK3β subunit resulted in no decrease in cell proliferation in A549 cells compared to a 45% decrease in Panc 1 cells. Additionally, knockdown of GSK3β resulted in decreased levels of AKT activity by Western blot analysis as compared to siControl and GSK3β. Previous studies have focused on the role of the beta subunit of GSK3 in oncogenesis. Additionally, AKT has been studied as an upstream regulator rather than a downsteam target of GSK3. Our early studies suggest that the GSK3β subunit may play a significant role in the growth of Ras driven tumors cell lines upstream of AKT, and should be a potential target for therapeutic strategies. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2225. doi:1538-7445.AM2012-2225

Women with locally advanced breast cancer (LABC) who are breast conservation (BCT) candidates after neoadjuvant chemotherapy have the best long-term outcome and low local-regional recurrence (LRR) rates. However, young women are thought to have a higher risk of LRR based on historical data. This study sought to evaluate LRR rates in young women who undergo BCT after neoadjuvant chemotherapy. We identified 122 women aged 45 years or younger with American Joint Committee on Cancer (AJCC) Stage II to III breast cancer, excluding T4d, treated with neoadjuvant chemotherapy from 1991 to 2007 from a prospective, Institutional Review Board-approved, single-institution database. Data were analyzed using Fisher eExact test, Wilcoxon tests, and the Kaplan-Meier method. Median follow-up was 6.4 years. Fifty-four (44%) patients had BCT and 68 (56%) mastectomy. Forty-six per cent were estrogen receptor-positivity and 28 per cent overexpressed Her2. Mean pretreatment T size was 5.6 cm in the BCT group and 6.7 cm in the mastectomy group (P = 0.04). LRR rates were no different after BCT compared with mastectomy (13 vs 18%, P = 0.6). Higher posttreatment N stage (P < 0.001) and AJCC stage (P = 0.008) were associated with LRR but not pretreatment staging. Disease-free survival was better for patients achieving BCT, with 5-year disease-free survival rates of 82 per cent (95% CI, 69 to 90%) compared with 58 per cent (95% CI, 45 to 69%) for mastectomy (P = 0.03). Young women with LABC who undergo BCT after neoadjuvant chemotherapy appear to have similar LRR rates compared with those with mastectomy. This suggests that neoadjuvant chemotherapy may identify young women for whom BCT may have an acceptable risk of LRR.