Factors Affecting Healing in the Treatment of Hidradenitis Suppuritiva

Background: Hidradenitis suppurativa (HS) is a chronic and debilitating condition which causes recurrent painful nodules. Patients often progress to develop subdermal abscesses, chronic induration, and suppurative draining sinus tracts. HS causes significant debility and morbidity in patients’ body image, and overall quality of life. Despite this, there is typically a 5-­14 year delay in diagnosis from symptom onset. Treatment of HS depends on disease stage, goals of care, access to care, and frequency of symptoms. We have developed a hidradenitis suppurativa multidisciplinary program (HSMP). We present our experience with surgical treatment for patients with HS who follow in the HSMP. Methods: We retrospectively reviewed the outcomes of all patients referred through the HSMP for surgical treatment to plastic surgery at a single institution from January 2013­December 2015. Inclusion criteria included adults with a diagnosis of HS and exclusion criteria included patients with less than 2 years follow up after surgery. Types of surgical interventions included incision and drainage with fulguration, excision with wound left open, and excision with primary repair. Demographic data, participation in a multidisciplinary program, type of surgery, healing rates, and potential factors contributing to wound healing were retrospectively reviewed in all cases using multivariate analysis. Results: Two hundred forty ­eight patients met inclusion criteria with a total of 810 involved sites. Overall, 59% of patients had Hurley stage 3 disease at the time of surgery. Healing rates of 80% were observed in stage 1 and 2 and 74% observed in stage 3. Hurley stage was not a significant predictor of healing (P = 0.09). Surgical treatment consisted of 38% incision and drainage, 44% excision without closure, and 17% excision with primary closure. Incisional and excisional treatments healed 78% and 79%, respectively, at 2 years. Primarily repaired defects (grafts and flaps) were 68% healed at 2 years. Observed healing rates were uniform regardless of the number of sites involved (P = 0.959). Participation in the multidisciplinary program was the strongest predictor of healing (78% vs 45%, P = 0.004). Gender, age, body mass index, tobacco use, diabetes, pre-surgery hemoglobin, and family history of HS were statistically not significant. Continuation of immune modulating therapy within 2 weeks of surgery was a predictor of reduced healing (odds ratio 0.23, P = 0.004), while holding biologics for at least 2 weeks was not significant (odds ratio 1.99, P = 0.146). Conclusion: Participation in a multidisciplinary program is a strong predictor of long­term success when treating HS. Hurley score and number of involved sites did not correlate with successful healing after surgery. If taking biologics, we identified 2 weeks as an appropriate break from biologics before and after surgical intervention. Healing rates were highest with ablative procedures (incision and drainage, excision) alone.https://scholarlycommons.henryford.com/merf2019clinres/1055/thumbnail.jp

Perianal Pigmented Variant of Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is a low-to-intermediate grade cutaneous sarcoma with reported at 3 per 1,000,000 individuals. It is a locally aggressive tumor which originates in the dermis and invades deeper structures. Up to 90% of cases of DFSP are associated with a translocation between chromosomes 17 and 22. These tumors have a high risk of local recurrence but very rarely exhibit metastatic spread. Several histologic variants exist, including fibrosarcomatous DFSP, and in this case, pigmented DSFP. Pigmented dermatofibrosarcoma protuberans, otherwise also known as a Bednar tumor, is a rare variant of DFSP first described in 1956 which accounts for less than 5% of all DSFP cases. It is distinguished by the presence of melanin containing dendritic cells within the tumor. Histologically, tumor cells are arranged in compact spindle shaped bundles. These tumors may be derived from neuroectodermal cells although no consensus has been reached. DSFP occurs equally in men and women and most commonly occurs in young to middle aged adults. These cutaneous sarcomas typically present on the trunk, back and shoulders as a slow-growing mass or plaque that may be hyperpigmented. Less that 1% present on genitalia, and only two DSFP cases to date have been reported involving the perianal region.https://scholarlycommons.henryford.com/merf2019caserpt/1085/thumbnail.jp

Patient and disease pre-operative factors influencing surgical procedure choice for breast cancer treatment

Background/Objective: To address disparities of care in breast cancer treatment, it is important to understand pre‐operative factors that could affect the surgical decision‐making process. Methods: This prospective cohort study evaluates patient‐reported outcomes in women undergoing breast cancer treatment at a metropolitan health care system. Each new breast cancer case undergoes tumor board discussion, and patients have same‐day consultations with various specialties. Based on their procedure choice, women choose to complete pre‐ and post‐operative Breast‐Q© Breast‐ conserving Surgery (BCS), Mastectomy (M), or Reconstruction ® modules and demographic surveys. Individual effects of pre‐operative factors on procedure choice were assessed using ANOVA for continuous variables and chi‐squared for categorical. Significant factors (p≤0.05) were added to a multinomial logistic regression model. Results: A total of 375 women completed pre‐operative surveys (BCS=244, M=39, BR=92). Compared to BR, those chose BCS were older (RRR=1.094, p\u3c0.001) with larger BMIs (RRR=1.094, p=0.001), without a history of breast cancer (RRR=0.130 (yes vs. no), p=0.016), and Stage I disease (RRR=4.920, p\u3c0.001). Women making more than $200K (RRR=4.56x105 (vs. 35K), p\u3c0.0001) were also more likely to undergo BR. Compared to BCS, women undergoing neoadjuvant chemotherapy (RRR=3.591, p=0.047) and Stage II disease (RRR=4.238, p=0.040) were more likely to undergo mastectomy alone, whereas race, education, employment, and most incomes did not correlate with procedure choice. Conclusions: Our data suggest that racial and socioeconomic disparities in procedure type can be addressed by presenting equally effective surgical strategies to all patients in a multidisciplinary model that allows patients to interact with plastic surgeons, radiation oncologists, and surgical and medical oncologists

Patient factors that affect pre-operative patient-reported outcomes in women undergoing breast cancer surgery

Background/Objective: Understanding the impact of patient, disease, and treatment factors on pre‐ operative patient reported outcomes (PROs) is important to guide surgical decision‐making with breast cancer. Methods: This prospective cohort study evaluates PROs in women undergoing breast cancer treatment at a metropolitan health care system. New cases undergo tumor board discussion and same‐day consultations with various specialties. Women choose to complete pre‐ and post‐operative Breast‐Q© Breast‐conserving surgery (BCS), mastectomy (M), or reconstruction ® modules and demographic surveys. Individual associations to pre‐operative Breast‐Q survey scores were assessed using linear regression models (1 for each Breast‐Q survey type). Variables significant for at least 1 survey were included in multiple linear regression models. Results: A total of 375 women completed the pre‐operative surveys (BCS=244, M=39, BR=92). Procedure choice, laterality, race, marital status, employment, prior breast cancer, neoadjuvant chemotherapy, or history of radiation or chemotherapy did not impact PROs. Breast satisfaction decreased with higher BMI (est=‐0.367, p=0.045) and Stage II disease (est=‐11.011 (vs. Stage 0), p=0.008). Lower psychosocial score was associated with younger age (est=0.271, p=0.002), higher BMI (est=‐0.367, p=0.014), and income \u3c$35k (est=0.172 (vs. 35k+), p=0.016). Similarly, lower physical well‐being of the chest was associated with younger age (est=0.207, p=0.011), higher BMI (est=‐0.285, p=0.039), and income \u3c$35k (est=0.218 (vs. 35k+, p=0.039). Sexual well‐being decreased with higher BMI (est=‐0.545, p=0.004) and income \u3c$35k (est=0.135 (vs. 35k+), p=0.016). Conclusions: While factors such as age, BMI, and stage of disease are difficult to change prior to surgery, patients with lower income may need special interventions to assist them through the treatment process

The effect of lymphatic microsurgical preventive healing approach (LYMPHA) on the development of upper-extremity lymphedema following axillary lymph node dissection in breast cancer patients

Background/Objective: Lymphedema following axillary lymph node dissection (ALND) is a common complication that can negatively impact quality of life as it reduces the functional capacity of the affected arm. It can also predispose patients to serious infectious complications such as limb cellulitis and development of malignancy. The lymphatic microsurgical preventive healing approach (LYMPHA procedure) involves the creation of a lymphatic‐to‐venous bypass at the time of axillary lymph node dissection (ALND) as a means of preventing lymphedema. The goal of our study is to assess the effect of LYMPHA on the development of clinical and subjective post‐operative lymphedema. Methods: This is a prospective longitudinal study in patients with breast cancer who underwent ALND with or without LYMPHA. The incidence of lymphedema was compared between ALND alone and ALND with LYMPHA using descriptive statistics. Limb circumference of both affected and unaffected limbs were measured and used to calculate limb volume by using an equation that converts limb circumference (cm) to volume (cc). Lymphedema was defined as a volume difference of ≥10% between the affected and unaffected limb. Patient symptoms were also assessed and compared between the 2 groups. Patient demographics including age, preoperative body mass index (BMI), smoking history, comorbidities, receipt of neoadjuvant or adjuvant chemotherapy, and receipt of adjuvant radiation were compared between the groups. Results: In our cohort of 139 patients, 104 underwent ALND with LYMPHA, while 35 underwent ALND alone. Of these, 52.5% of patients had documented interlimb circumference measurements. The mean age was 52.6 years old, mean BMI was 30.16 kg/m2, 4 patients (2.9%) had pre‐operative radiation, 102 patients (73.4 %) had post‐operative radiation, 86 patients (61.9 %) had neoadjuvant chemotherapy, 41 and 58 patients (41.7 %) had adjuvant chemotherapy. There were no significant differences between the 2 groups in the above demographics and treatment variables, except those who underwent ALND alone had a significantly higher incidence of diabetes mellitus (25.7% patients with ALND alone vs 11.5% LYMPHA patients (p=0.043)). Based on patient reported symptoms and the need to initiate complete decongestive therapy, 57.1% (n=20) of patients who underwent ALND alone developed lymphedema compared to 26.9% (n=28 patients) of those who had ALND with LYMPHA (p=0.0011). When comparing the relative volume difference, 57.1% (n=8) of ALND alone patients developed lymphedema versus 20.3% (n=12) of LYMPHA patients (p=0.0055). Conclusions: Our data support the universal use of LYMPHA at the time of ALND as a means of preventing upper extremity lymphedema. Further studies are needed to evaluate quality of life and functional differences between those who had LYMPHA and those who did not

Factors Affecting Healing in Patients Participating in a Hidradenitis Suppurativa Multidisciplinary Clinic

Introduction: Hidradenitis suppurativa (HS) is a debilitating condition with treatment that varies with patients’ circumstances and symptoms. We present our experience with surgical treatment for HS patients who follow in our Hidradenitis Suppurativa Multidisciplinary Program (HSMP). Methods: We retrospectively reviewed outcomes of 248 HSMP patients who underwent surgical treatment at a single institution from January 2013 to December 2015. Inclusion criteria included adults with HS and exclusion criteria included patients with \u3c2 years follow-up. Demographic data, type of operation, healing rates, and potential factors contributing to wound healing were analyzed. Results: Mean follow-up was 28 months. An overall healing rate of 76% was seen, with ablative procedures healing better than primary repairs (78.5% vs 68%; p = 0.011). Hurley stage (p = 0.09) or number of sites involved (p = 0.959) were not significant predictors of healing. Postoperative compliance with the HSMP was the strongest predictor of healing (78% vs 45%; p = 0.004). Multivariate analysis showed sex, age, BMI, tobacco use, diabetes, preoperation hemoglobin, and family history of HS did not significantly affect healing. Immune modulating therapy use within 2 weeks of operation was a negative predictor for healing (odds ratio 0.23; p = 0.004). Conclusions: Postoperative compliance with our HSMP was a strong predictor of achieving long-term healing. Hurley stage and number of involved sites did not correlate with successful healing. Ablative procedures healed better than primary repairs. Use of biologics within 2 weeks of surgical intervention negatively affected long-term healing

The economics of converting red alder to Douglas-fir /

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