Prevention of Implant Malposition in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction Using an Acellular Dermal Matrix With Pectoralis Muscle Following Mastectomy for Breast Cancer: A Clinical Review

BACKGROUND

Latissimus dorsi myocutaneous (LDM) pedicled flaps are a well-established method for breast reconstruction in women with inadequate soft tissue coverage following mastectomy for breast cancer. The robust nature of the latissimus blood supply can accommodate immediate implant placement to increase breast volume; however, a known risk factor with this technique is implant malposition. By utilizing an acellular dermal matrix (ADM) in subpectoral implant-based LDM reconstruction, it is hypothesized that patients will experience a lower incidence of implant malposition. This 13-year retrospective review aims to evaluate the effectiveness of breast reconstruction using this technique.

METHODS

A retrospective review was conducted to identify all patients who underwent breast reconstruction following mastectomy with a LDM flap, subpectoral implant, and an ADM from 2007 to 2020 by a single surgeon at a single institution. Demographic and clinical data were collected and analyzed.

RESULTS

A total of 40 patients (LDM flaps, N = 51) were identified. Mean participant age was 50.25 ± 9.67 years and mean body mass index (BMI) was 30.85 ± 6.15 kg/m². Comorbidities included hypertension (40.0%), diabetes mellitus (17.5%), and current smoking (25.0%). Mean follow-up was 31.52 ± 29.51 months. The most common complication was seroma formation (9.8%). No patients experienced implant malposition or flap necrosis.

CONCLUSIONS

The use of a LDM flap and an ADM in implant-based breast reconstruction are each well described in the literature. This 13-year series supports the efficacy of these techniques utilized in combination to provide an aesthetic result while mitigating implant malposition during breast reconstruction of oncologic patients.

Patient demographics, clinicopathologic features, and outcomes in wild-type gastrointestinal stromal tumor: a national cohort analysis

Wild-type KIT and PDGFRA gastrointestinal stromal tumors (GIST) are rare tumors with limited treatment options. We sought to determine the clinicopathologic features of wild-type GIST and identify factors that influence overall survival (OS) using a large national database. Retrospective evaluation of patients with wild-type GIST in the National Cancer Database (NCDB) was performed. Demographic, clinicopathologic, and treatment data were analyzed. Features associated with OS were investigated using Kaplan-Meier analysis and Cox proportional hazards model. 244 patients with median diagnosis age of 59 years (95% CI 57-63) were identified. The stomach was the most common primary site (57%) followed by the small intestine (35%). Surgical resection was performed on 85% of patients and 53% of patients received systemic therapy. Factors associated with decreased OS on multivariable analysis included small intestine primary (HR 2.72, 95% CI 1.13-6.69, P = 0.026) and > 5 mitoses per 50 HPF (HR 4.77, 95% CI 1.86-13.2, P = 0.001). Wild-type GISTs may be identified in older patients, with most arising in the stomach and small bowel. Surgery remains the principal treatment modality. Small intestine primary site and high mitotic count were associated with abbreviated OS.

Perioperative MVT-5873, a fully human monoclonal antibody against a CA 19-9 epitope, for operable CA 19-9 producing pancreatic cancers, cholangiocarcinomas, and metastatic colorectal cancers

TPS4655

Background: Operable hepatopancreatobiliary (HPB) cancers continue to pose significant challenges. Radical resections are rarely curative, and chemotherapy is able to reduce tumor recurrence for only a fraction of patients. Despite the obvious advantages of extirpation of the identifiable tumor(s), the inflammatory milieu that accompanies surgery and the obligate time off cytotoxic agents allows for activation of remote quiescent disseminated tumor cells, leading to metastatic recurrence. We are conducting a study to determine the safety and efficacy of immediate peri-operative MVT-5873, a cytotoxic monoclonal antibody targeting Carbohydrate Antigen 19-9 (CA 19-9), in patients undergoing resections pancreatic cancer, cholangiocarcinoma or metastatic colorectal cancer to the liver. MVT-5873 is a human IgG1 antibody isolated from a patient following immunization with a sLea-KLH vaccine. MVT-5873 has demonstrated cell surface binding in sLea positive human tumor lines and has been shown to be potent in complement-dependent cytotoxicity assays and antibody-dependent cell mediated cytotoxicity assays. In patients with CA 19-9-producing cancers, MVT-5873 treatment has been shown to decrease serum CA 19-9 levels and prevent tumor progression. This trial may open the door for investigation of additional and/or synergistic agents in the immediate peri-operative period and usher in a new paradigm in the management of surgically treated cancers. Methods: This is a prospective, Phase II trial designed to determine the efficacy (increase in 1-yr DFS) and safety of peri-operative MVT-5873 for subjects with operable pancreatic, liver and bile duct cancers with elevated CA 19-9 levels. Patients may receive any standard neoadjuvant regimen prior to enrollment at the NIH Clinical Center in Bethesda, Maryland. Eligible patients will receive a pre-operative dose of MVT-5873 three days prior to the planned operation to remove all demonstrable disease. Following the operation, patients will receive a total of four doses of MVT-5873; the first two doses on postoperative days four and ten. The third dose will be administered on the normally scheduled postoperative clinic visit, followed by a final dose one month after discharge from the hospital and prior to the start of adjuvant treatment. Clinical trial information: NCT03801915 .

Telesurgical Assessment: Using Smartphone Messaging to Efficiently Manage Postoperative Wounds

Background: Telemedicine is an evolving field of interactions between physicians and patients remotely. Health care delivery, patient satisfaction, adherence, earlier diagnosis, increased access, and cost reduction are all areas that telemedicine has potential influence. One focus involves the use of photos in wound assessment. Today, many patients' smartphones can capture high-quality digital photographs, which can easily be transmitted. Postoperative patients are an ideal population for this, as they have a certain level of uncertainty with regard to the healing course, which can often lead to patients seeking out care in unnecessarily costly settings. These visits can lead to inefficient use of health care resources, especially when a telesurgical assessment (TSA) could provide appropriate care more efficiently. Objective: We present data collected from a series of patients who received a TSA to demonstrate the potential benefits of incorporating TSA into postoperative wound care. Methods/Clinical Presentation: Patients who underwent a procedure and contacted their surgeon within 2 weeks with concerns received a TSA, which included a discussion as well as photographs through smartphone. Their surgeon then determined further treatment steps, if any. Results: We experienced that 85% of patients did not require emergent treatment for their concerns, 46% were prescribed medications, whereas 39% of patients did not require any intervention. Conclusion: Our results show that TSAs alleviated patient concerns and provide resolutions, while saving resources and increasing satisfaction. Incorporating aspects of telemedicine into outpatient practice could be valuable, especially with postoperative wound checks.

Thoracic spinal stenosis associated with renal osteodystrophy. Diagnosis based on magnetic resonance imaging and computed tomography

We describe a case of thoracic myelopathy in a patient with renal osteodystrophy. The patient had chronic renal failure for longer than 20 years and had skeletal changes indicative of renal osteodystrophy, before the onset of myelopathy. Association between spinal stenosis and this entity has been documented only once before in the lumbar region. This is therefore the first case of thoracic myelopathy due to severe stenosis in just one vertebra in a patient with renal osteodystrophy, which was documented by computed tomography as well as magnetic resonance imaging and proven by histopathology.

The pharmacological treatment of delusional depression

The authors investigated the pharmacological treatment of delusional depression by assigning patients on a random double-blind basis to amitriptyline alone, perphenazine alone, or a combination of the two. Fourteen (78%) of the 18 patients assigned to amitriptyline plus perphenazine were responders, compared with seven (41%) of 17 patients treated with amitriptyline alone and three (19%) of the 16 patients treated with perphenazine alone. The combination of amitriptyline and perphenazine was clearly superior (p less than .01).