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

Evaluating everyday explanations

People frequently rely on explanations provided by others to understand complex phenomena. A fair amount of attention has been devoted to the study of scientific explanation, and less on understanding how people evaluate naturalistic, everyday explanations. Using a corpus of diverse explanations from Reddit's "Explain Like I'm Five" and other online sources, we assessed how well a variety of explanatory criteria predict judgments of explanation quality. We find that while some criteria previously identified as explanatory virtues do predict explanation quality in naturalistic settings, other criteria, such as simplicity, do not. Notably, we find that people have a preference for complex explanations that invoke more causal mechanisms to explain an effect. We propose that this preference for complexity is driven by a desire to identify enough causes to make the effect seem inevitable

The Implementation and Efficacy of a Breast Cancer Wellness Group at Thomas Jefferson University Hospital

Abstract Introduction: Breast cancer is not only a physical disease but something that affects our patients’ mental, spiritual, emotional and social wellbeing. There has been literature that demonstrates the positive benefits of exercise, social support, and nonmedical adjuncts for breast cancer patients. There is currently a lack of wellness support within the Jefferson breast cancer community. Methods: A wellness survey will be distributed throughout the breast surgery and breast oncology clinics to assess the current level of wellness and interest in a breast cancer wellness group at TJUH. This survey will be used both before and after implementation of a wellness group to assess its efficacy within our community. Results: Pending Discussion: We believe a breast cancer wellness group will address a major need of support within our Jefferson breast cancer community. This project will not only allow us to meet this need but to assess the basic social, mental, spiritual, and emotional needs of our patients in order to improve our overall patient care.https://jdc.jefferson.edu/patientsafetyposters/1123/thumbnail.jp

“Can you send over the imaging?” Analyzing the Patient Transfer Process at TJUH

Objective Our goal was to investigate possible ways to improve the transition of care when patients are transferred to Jefferson Center City. As a quaternary care hospital with a large transfer volume, it is especially important to look for ways to optimize this process because it can improve timely patient care, reduce and eliminate unnecessary studies and diagnostic tests and save time and work that could be better spent in other aspects of treating the patient.https://jdc.jefferson.edu/patientsafetyposters/1114/thumbnail.jp

POSITIVE: Perfusion imaging selection of ischemic stroke patients for endovascular therapy.

BACKGROUND: The PerfusiOn imaging Selection of Ischemic sTroke patIents for endoVascular thErapy (POSITIVE) trial was designed to evaluate functional outcome in patients with emergent large vessel occlusion (ELVO) presenting within 0-12 hours with pre-specified bifurcated arms of early and late window presentation, who were selected for endovascular thrombectomy with non-vendor specific commercially available perfusion imaging software. Recent trials demonstrating the benefit of thrombectomy up to 16-24 hours following ELVO removed equipoise to randomize late window ELVO patients and therefore the trial was halted. METHODS: Up to 200 patients were to be enrolled in this FDA-cleared, prospective, randomized, multicenter international trial to compare thrombectomy and best medical management in patients with ELVO ineligible for or refractory to treatment with IV tissue plasminogen activator (IV-tPA) selected with perfusion imaging and presenting within 0-12 hours of last seen normal. The primary outcome was 90-day clinical outcome as measured by the raw modified Rankin Scale (mRS) with scores 5 and 6 collapsed (mRS shift analysis). RESULTS: The POSITIVE trial suspended enrollment with the release of results from the DAWN trial and was stopped after the release of the DEFUSE 3 trial results. Thirty-three patients were enrolled (21 for medical management and 12 for thrombectomy). Twelve of the 33 patients were enrolled in the 6-12 hour cohort. Despite the early cessation, the primary outcome demonstrated statistically significant superior clinical outcomes for patients treated with thrombectomy (P=0.0060). The overall proportion of patients achieving an mRS score of 0-2 was 75% in the thrombectomy cohort and 43% in the medical management cohort (OR 4.00, 95% CI 0.84 to 19.2). CONCLUSION: POSITIVE supports the already established practice of delayed thrombectomy for appropriately selected patients presenting within 0-12 hours selected by perfusion imaging from any vendor. The results of the POSITIVE trial are consistent with other thrombectomy trials. The statistically significant effect on functional improvement, despite the small number of patients, reinforces the robust benefits of thrombectomy. CLINICAL TRIAL REGISTRATION: NCT01852201