Consecutive Case Series of Melanoma Sentinel Node Biopsy for Lymphoseek Compared to Sulfur Colloids

Introduction: Sentinel lymph node biopsy (SLNB) is an important adjunct in the staging of patients with melanoma. Preoperative lymphoscintigraphy (LS) with radiolabeled isotopes is essential to localize sentinel nodes for removal. Our study compared the effectiveness of Lymphoseek to standard sulfur colloids (SC) in patients with melanoma undergoing SLNB. Methods: We queried our IRB-approved melanoma database to identify 370 consecutive patients who underwent SLNB from 2012-2016 with at least one year of follow up. There were 185 patients in each group. Data points included characteristics of the primary melanoma lymphoscintigraphy, and SLNB. Student’s t-test and Chi-Square were used to analyze the data with a p-value of \u3c0.05 being considered significant. Results: Patients were equally matched in regard to age, sex, and primary characteristics of their melanoma. In comparison to SC, Lymphoseek required lower radiation dosages (p\u3c0.001), shorter mapping times (p=0.008), and decreased number of sentinel nodes removed (p=0.03). There was no difference in the number of patients with positive nodes (p=0.5). Additionally, there were no statistical differences between the two radioactive tracers in regard to the number of patients with false negative SLNB. Conclusion: Lymphoseek has the potential to decrease radioactivity and mapping time in patients who need SLNB. With a decrease in the number of nodes removed without loss of sensitivity, there is a potential to avoid unnecessary node removal and thus complications such as lymphedema. Longer follow-up will help to determine if there is any increase in false negative rates despite fewer nodes removed

John Chalmers DaCosta (1863-1933): restoration of the old operating table.

John Chalmers DaCosta was an influential chairman and the first Samuel D. Gross Professor of Surgery at Jefferson Medical College in Philadelphia. He was well known throughout the field as a skilled surgeon, passionate speaker, and exceptional writer. In addition to countless accomplishments during his career, DaCosta was deeply dedicated to the preservation and commemoration of surgical history. This ideology was exemplified when he set out on a mission to recover the old wooden operating table used by many of his iconic mentors including Samuel D. Gross, Joseph Pancoast, and William W. Keen. This table was originally used for surgical demonstrations and anatomy lessons in a lecture room of the Ely Building and later in the great amphitheater of the Jefferson Sansom Street Hospital. It was found forgotten in the basement of the College Building and was promptly refurbished, donned with dedicatory plaques, and returned to its honored position in the medical college. Dr. DaCosta also contributed a detailed article recalling the history of the table and the notable leaders in surgery who taught and practiced on its surface. The old table currently stands proudly in the entranceway of the Department of Surgery where it will remain as a cherished symbol of the early beginnings of surgical practice and education

Surgical Apgar Score (SAS) Predicts Perioperative Morbidity and Length of Stay in Patients Undergoing Esophagectomy at a High-Volume Center

Background: Esophagectomy is a procedure that carries considerable morbidity. Many studies have evaluated factors to predict patients at risk and improve clinical outcomes. The aim of this study was to determine whether the SAS predicts complications, length of stay, and anastomotic leak for patients undergoing esophagectomy at a high-volume institution.https://jdc.jefferson.edu/surgeryposters/1002/thumbnail.jp

The Role of the Uncinate Margin in Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Survival Analysis

Introduction: Positive margins during pancreaticoduodenectomy for pancreatic cancer portend worse survival, but additional resection of the uncinate margin is typically unfeasible without major vascular reconstruction. The survival benefit of resecting additional neck or bile duct margins in the face of a positive uncinate is also unknown. We examined the impact of re-resection of these margins on survival. Methods: Patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy from 2006-2015. Pancreatic neck, bile duct, uncinate, and duodenal frozen section margins were assessed before and after resection of positive margins. Kaplan-Meier survival curves were compared with log-rank tests. Multivariable Cox regression was used to assess the effect of margin status on overall survival. Results: Among 508 patients identified, 388 (76.4%) underwent a pylorus-preserving procedure, 435 (85.6%) had T3 tumors, and 379 (74.6%) had nodal involvement. There were 21 instances where an uncinate margin was concurrently positive with a neck or bile duct margin; this additional neck or bile duct margin was resected in 13 cases (61.9%). Resection of additional margins when the uncinate was concurrently positive was not associated with improved survival (p=0.36). Median survival with and without positive uncinate margins was 13.8 vs. 19.7 months (p=0.04). A positive uncinate margin was associated with decreased survival independent of other margins and cancer stage (HR 1.28 [95% CI 1.00-1.65]). Conclusion: In patients with pancreatic adenocarcinoma, positive uncinate margins are associated with decreased overall survival; resection of additional margins at the neck and bile duct in those with a positive uncinate margin is not warranted

Does Intraoperative Radiation Therapy Improve Local Tumor Control in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma? A Propensity Score Analysis

Background: Locoregional recurrence (LRR) is an important factor after pancreaticoduodenectomy (PD) for pancreatic cancer. IORT administered to the resection bed may improve local tumor control. Methods: We performed a retrospective analysis of patients who underwent PD at Thomas Jefferson University Hospital (TJUH) between 1995 and 2005 to identify patients who underwent resection with and without intraoperative radiation therapy (IORT). Data collected included age, gender, complications, margin status, stage, survival, and recurrence. Unadjusted analyses of the IORT and non-IORT groups were performed using Fisher’s chi-square method for discrete variables and Wilcoxon Rank Sum test for continuous variables. To account for biases in patient selection for IORT, a propensity score was calculated for each patient and adjusted statistical analyses were performed for survival and recurrence outcomes. Results: Between January 1995 and November 2005, 122 patients underwent PD for perimpullary tumors, including 99 pancreatic cancers. Of this group, 37 patients were treated with IORT, and there was adequate follow-up information for a group of 46 patients who underwent PD without IORT. The IORT group contained a higher percentage of Stage IIB or higher tumors (65%) than in the non-IORT group (39.1%), though differences in stage did not reach significance (p = 0.16). There was a non-significant decrease in the rate of LRR in patients who had IORT (39% non-IORT vs. 23% IORT, p = 0.19). The median survival time of patients who received IORT was 19.2 months, which was not significantly different than patients managed without IORT, 21.0 months (p=0.78). In the propensity analyses, IORT did not significantly influence survival or recurrence after PD. Conclusions: IORT can be safely added to management approaches for resectable pancreatic cancer, with acceptable morbidity and mortality. IORT did not improve loco-regional control and did not alter survival for patients with resected pancreatic cancer. IORT is an optional component of adjuvant chemoradiation for pancreatic cancer. In the future, IORT may be combined with novel therapeutic agents in the setting of a clinical trial in order to attempt to improve outcomes for patients with pancreatic cancer. Annals of Surgical Oncology, Volume 16, Edition 8, August, 2009, pages 2116-22, “Does intraoperative radiation therapy improve local tumor control in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma? A propensity score analysis”. Authors: Showalter TN, Rao AS, Anné PR, Rosato FE, Rosato EL, Andrel J, Hyslop T, Xu X, Berger AC

Nipple Sparing Mastectomy: A Review of Outcomes at a 1 Single Institution

Introduction Nipple sparing mastectomy (NSM) offers patients who are not candidates for breast conserving treatment an aesthetically pleasing alternative to traditional mastectomy. Some studies have demonstrated its oncologic safety while others have demonstrated residual occult tumor cells at the nipple areolar complex (NAC). These data prompt further review of oncologic outcomes after NSM. Methods A single institution retrospective chart review of all NSMs performed by 4 breast surgeons at Thomas Jefferson University Hospital over a span of 2012-2019. In this cohort we review the reconstruction performed, axillary lymph node status, surgical margins, final pathology, loss of the NAC, recurrence rates, and follow-up. Results In our cohort we reviewed 170 NSMs performed on 105 patients. All patients were female and the average age was 46.9 years. Prophylactic procedures were performed on 43% of patients with 17.1% of patients being BRCA positive. Of those undergoing NSM for cancer (n=94) the associated pathology was 28.8% DCIS, 32.9% IDC, and 3.5% ILC (This accounts for some patients with multiple diagnoses on final pathology). Sentinel lymph node biopsy (SLNB) was performed in 52.9% of cases with 10.6% of cases being positive for axillary disease. Margins were positive in 10.6% (n=10) of cases performed for cancer with 8.5% (n=8) of cases having positive margin at the NAC and the remainder being at the deep margin. Based on margin positivity 2.4% (n=4) of patients underwent redo surgery with 1 patient requiring re-resection at the NAC margin and 3 patients having total NAC resection. Total loss of NAC occurred in 5.9% (n=10) of cases due to positive margins (n=3) and necrosis (n=7). Recurrence occurred in 7.2% (n=7) of cases who underwent NSM for cancer. Locoregional recurrence in breast tissue, skin, or axilla occurred in 4.1% (n=4) of cases with 0 recurrences at the NAC. Distant recurrence occurred in 4.1% (n=4) of cases at both liver and bone. Average time to recurrence was 27.3 months. Of the 170 NSM performed 98% had immediate tissue expander placement with 60% converting to permanent sub-pectoral implant reconstruction, 14% latissimus dorsi flap reconstruction, 0.6% delayed deep inferior epigastric artery perforator free flap reconstruction, and 5.2% undergoing delayed free transversus abdominus muscle flap reconstruction. Of all the cases reviewed there was only 1 death. Our average follow-up was 26.7 months. Conclusion We demonstrate similar numbers in our analysis as other studies that have looked at oncologic outcomes after NSM. Although we demonstrate evidence of occult disease at the NAC margin when performing NSM there was no evidence of recurrence at the NAC demonstrating its efficacy and safety. With proper patient selection this procedure can be safely offered as an aesthetically appealing alternative to traditional mastectom

Success of Preoperative Radiotherapy in Inflammatory Breast Cancer with Inadequate Response to Taxane-Based Chemotherapies

Inflammatory breast cancer is a locally-aggressive and highly malignant cancer which often carries a poor prognosis for afflicted patients. Multi-modality treatment is often required, and taxane-based chemotherapy has shown improved outcomes and allowed for the pursuit of mastectomies, which are critical to disease control. Inadequate response to taxane-based chemotherapy indicates aggressive disease, and the role of preoperative radiotherapy for treatment in this patient group and its effects on patient outcomes and toxicity has not been studied. This study evaluates the effectiveness of preoperative radiotherapy on this patient group. Inflammatory breast cancer patients between 2012-2018 who were not deemed appropriate for resection following taxane-based chemotherapy leading to their referral for preoperative radiotherapy were identified. Patient, disease, and pre-surgical treatment characteristics were collected. A statistical analysis of surgical outcomes with regards to conversion to resectability, surgical margins, treatment response, complication rates, and locoregional recurrence was performed. 9 patients received neoadjuvant radiation following their inadequate response to taxane-based chemotherapy. 8 of 9 patients converted to resectable disease, 100% of which achieved R0 mastectomy. Median residual primary disease was 1cm, with a grade 1 toxicity being noted in 1 patient which resolved with conservative management. A single low cervical recurrence was observed 4 years after mastectomy. Based on the results of this study, preoperative radiation should be considered in inflammatory breast cancer patients who do not demonstrate adequate response to taxane-based chemotherapy. Use of preoperative radiotherapy in this patient group may lead to the improvement of patient outcomes and a decrease in treatment toxicity

Measurements of neutrino oscillation in appearance and disappearance channels by the T2K experiment with 6.6 x 10(20) protons on target

111 pages, 45 figures, submitted to Physical Review D. Minor revisions to text following referee comments111 pages, 45 figures, submitted to Physical Review D. Minor revisions to text following referee comments111 pages, 45 figures, submitted to Physical Review D. Minor revisions to text following referee commentsWe thank the J-PARC staff for superb accelerator performance and the CERN NA61/SHINE Collaboration for providing valuable particle production data. We acknowledge the support of MEXT, Japan; NSERC, NRC, and CFI, Canada; CEA and CNRS/IN2P3, France; DFG, Germany; INFN, Italy; National Science Centre (NCN), Poland; RSF, RFBR and MES, Russia; MINECO and ERDF funds, Spain; SNSF and SER, Switzerland; STFC, UK; and the U. S. Deparment of Energy, USA. We also thank CERN for the UA1/NOMAD magnet, DESY for the HERA-B magnet mover system, NII for SINET4, the WestGrid and SciNet consortia in Compute Canada, GridPP, UK, and the Emerald High Performance Computing facility in the Centre for Innovation, UK. In addition, participation of individual researchers and institutions has been further supported by funds from ERC (FP7), EU; JSPS, Japan; Royal Society, UK; and DOE Early Career program, USA

A Prospective Randomized Controlled Trial of the Effects of Vitamin D Supplementation on Cardiovascular Disease Risk

Vitamin D (VitD) supplementation has been advocated for cardiovascular risk reduction; however, supporting data are sparse. The objective of this study was to determine whether VitD supplementation reduces cardiovascular risk. Subjects in this prospective, randomized, double-blind, placebo-controlled trial of post-menopausal women with serum 25-hydroxyvitamin D concentrations >10 and <60 ng/mL were randomized to Vitamin D3 2500 IU or placebo, daily for 4 months. Primary endpoints were changes in brachial artery flow-mediated vasodilation (FMD), carotid-femoral pulse wave velocity (PWV), and aortic augmentation index (AIx). The 114 subjects were mean (standard deviation) 63.9 (3.0) years old with a 25-hydroxyvitamin D level of 31.3 (10.6) ng/mL. Low VitD (<30 ng/mL) was present in 47% and was associated with higher body-mass index, systolic blood pressure, glucose, CRP, and lower FMD (all p<0.05). After 4 months, 25-hydroxyvitamin D levels increased by 15.7 (9.3) ng/mL on vitamin D3 vs. −0.2 (6.1) ng/mL on placebo (p<0.001). There were no significant differences between groups in changes in FMD (0.3 [3.4] vs. 0.3 [2.6] %, p = 0.77), PWV (0.00 [1.06] vs. 0.05 [0.92] m/s, p = 0.65), AIx (2.7 [6.3] vs. 0.9 [5.6] %, p = 0.10), or CRP (0.3 [1.9] vs. 0.3 [4.2] mg/L, p = 0.97). Multivariable models showed no significant interactions between treatment group and low VitD status (<30 ng/mL) for changes in FMD (p = 0.65), PWV (p = 0.93), AIx (p = 0.97), or CRP (p = 0.26).In conclusion, VitD supplementation did not improve endothelial function, arterial stiffness, or inflammation. These observations do not support use of VitD supplementation to reduce cardiovascular disease risk