Jakub, James W

AbstractBackgroundWith the opioid epidemic in the United States, evaluating opioid prescribing patterns is essential. We evaluated opioids prescribed at discharge following breast surgery and their association with patient factors and pain scores.MethodsWe retrospectively identified adult patients who underwent a mastectomy for cancer at Mayo Clinic sites from January 2010 to December 2016. Pain scores and prescription data were compared across operations and patient factors by univariate and multivariable analyses.ResultsOf 4021 patients, 3782 (94.1%) received an opioid prescription. Median oral milligram morphine equivalents (MME) were similar across all site‐specific procedure groups (medians ranging from 225 to 375) while pain scores ranged from 1 to 4. Patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) reported the greatest pain scores. Pain scores did not vary with age or diagnosis for patients undergoing unilateral mastectomy or BM with lymph node surgery and IBR procedures.On multivariable analysis, variables associated with a MME discharge prescription >Q4 values included age, body mass index, site, year, inpatient status, and pain before discharge >3.ConclusionPatient‐reported pain following breast surgery varied by procedure, while MMEs prescribed remained similar. This suggests current opioid prescribing does not reflect intensity of pain and requires further research to optimize discharge opioid prescribing practices.

Background: Two-staged implant-based reconstruction (IBR) is the most common breast reconstructive modality. Recently, technological and surgical advances have encouraged surgeons to revisit prepectoral IBR. Data comparing prepectoral against subpectoral IBR in women under the age of 40 are lacking. Methods: Retrospective chart review of patients under the age of 40 years old, who underwent immediate 2-staged IBR at our institution, was performed. Patient’s demographics, clinical characteristics, operative details, and early surgical outcomes of prepectoral and subpectoral reconstruction were compared. Data with values of P < 0.05 were considered statistically significant. Results: Between 2012 and 2016, 100 patients (187 breasts) who underwent prepectoral and 69 patients (124 breasts) who underwent subpectoral IBR were included. Median follow-up was 17.9 and 17.5 months in the prepectoral and subpectoral groups, respectively. Total number of complications including both stages of reconstruction was 20 (10.7%) and 19 (15.3%) in the prepectoral and subpectoral groups, respectively (P = 0.227). Specific complications, including hematoma, seroma, skin flap necrosis, wound dehiscence, and breast infections, were not significantly different among groups. Ten (5.4%) devices, including implants and tissue expander, required explantation in the prepectoral group and 8 (6.5%) in the subpectoral group (P = 0.683). Explantation was most commonly due to infection (n = 14), and all of them occurred during the first stage (P < 0.001). Conclusions: Early complications and implant explantation rates are comparable among prepectoral and subpectoral breast reconstruction in women under 40 years old. Based on these results, we believe that prepectoral IBR is a safe, reliable, and promising reconstructive option.

Some melanomas develop a striking avidity for lymphatic spread. In spite of multiple recurrences, patients can remain years without visceral metastasis. There is clearly a biologic reason for this lymphotrophic pattern of growth and dissemination, which we have yet to uncover. In‐transit metastases have widely diverse clinical presentations and can be a stubborn disease to cure. As a result, a host of treatments exist that should be tailored to the individual patient.

Background and ObjectivesTo describe the patterns of failure in patients with in‐transit (IT) melanoma undergoing surgical excision.MethodsA retrospective review of patients who underwent their first IT lesion(s) resection between May 2005 and September 2014. Cumulative incidence of local failure (new lesion within 2 cm of IT resection) was estimated. Associations between clinicopathologic characteristics, local failure, and any recurrence were analyzed.ResultsOne hundred and thirty patients presented to our institution with IT disease over the study period and met the inclusion criteria. The 2‐year cumulative incidence of local failure was 19.5%. Twenty‐four patients developed disease within 2 cm of the resected IT disease; however, only eight were isolated local events. Cumulative incidence of local failure and of any disease differed with respect to less than 1 year disease‐free interval (DFI) from primary melanoma to first IT event, and having greater than 1 IT lesion at presentation. Incidence of local failure was not found to differ with respect to gross margin greater than 5 mm, after adjusting for DFI and greater than 1 IT lesions.ConclusionsPatients with greater than 1 IT lesion and a DFI less than 1 year are at a higher risk of failure after surgical excision of a first IT event. Very few failures were isolated local disease within 2 cm of the IT resection scar, regardless of IT excision margin.

BACKGROUND In-transit cutaneous metastases occur in 5% to 10% of patients with melanoma. Recently, topical diphenylcyclopropenone (DPCP) has been described as a treatment option. OBJECTIVE To evaluate efficacy of DPCP in treatment of in-transit cutaneous melanoma. METHODS The authors retrospectively reviewed the records of 13 consecutive patients with in-transit metastases treated with topical DPCP between March 1, 2013, and January 31, 2017. The authors recorded the response of in-transit cutaneous melanoma lesions treated with DPCP measured by clinical examination. RESULTS Among the 13 patients, 9 patients completed at least a 1-month course of DPCP treatment. Of these 9 patients, 6 (66.7%) maintained either stable disease or had a partial or complete regression, and 3 (33.3%) had progressive disease. Patients with less burden of disease (e.g., <15 lesions) responded more favorably than those with a greater burden of disease (e.g., >25 lesions or plaques). Both patients who received DPCP alone had progression of their cutaneous lesions. One patient who did not become sensitized to DPCP died within 2 months, and his anergy likely reflecting immense burden of disease. CONCLUSION Topical DPCP is a low-cost, patient-applied treatment option for in-transit melanoma, most effective for patients with relatively low tumor burden and localized disease.

BackgroundPatients with regionally advanced melanoma are at high risk of distant failure and unlikely to be cured by surgery alone. Neoadjuvant therapy may provide benefit in these patients.ObjectivesTo evaluate our experience with neoadjuvant systemic therapy in high‐risk stage III patients.MethodsRetrospective review of patients with advanced stage III disease who received neoadjuvant therapy between August 2009 and August 2016 at Mayo Clinic Rochester.ResultsTwenty‐three cases met our inclusion criteria, 16 with resectable disease and 7 with unresectable disease. No patients with resectable disease and one patient with borderline resectable disease progressed regionally, prohibiting surgical resection. Five of seven patients with unresectable disease were down‐staged to a resectable state. Six of twenty‐three (26%) had a CR and five are alive at last follow‐up. Fifteen of twenty three patients (65%) progressed with a median progression free survival of 11 months; however, the 5 year overall survival estimate was 84%.ConclusionsNeoadjuvant systemic therapy is a reasonable approach for patients with advanced but resectable/borderline resectable disease and the risk of losing regional control is low. Our data also suggest some patients with unresectable disease will be converted to resectable and a complete clinical response to treatment can be obtained in approximately one quater of patients.

Background and ObjectivesCurrent randomized controlled trials are investigating the outcomes of non‐surgical treatment for patients with ductal carcinoma in situ (DCIS). We sought to evaluate pre‐operative factors associated with no residual disease at definitive resection following a core needle biopsy (CNB) diagnosis of DCIS.MethodsEight hundred and thirty‐four operations for DCIS were performed at our institution between January 2004 and October 2014. We evaluated patient and biopsy tumor characteristics to determine pre‐operative factors associated with no residual disease at surgical resection using uni‐ and multivariable analyses.ResultsSixty‐nine patients (8%) had no residual disease on final pathology. On multivariable analysis, low‐ or intermediate‐grade lesions, <1 cm in size on mammography, and lesions where ≥90% of calcifications were removed correlated with finding no residual disease on final pathology, c‐statistic 0.84. Of the 14 patients with all three low‐risk factors, 36% had no residual disease on final pathology.ConclusionsAlthough our multivariable analysis performed well, its clinical utility would be limited as we were unable to identify a subset of patients with DCIS in whom the probability of finding no residual disease is low enough to consider routine use of non‐surgical management.