Bracketed Localization in Breast-Conserving Surgery: Indications and Success Rates From a Single, High Volume, Academic Breast Cancer Center

BACKGROUND

Bracketed localization is a technique used to help localize lesions for breast-conserving surgery (BCS). To date, there are no guidelines for when bracketed localization should be used in clinical practice. Based on our experience, we aim to provide criteria that should prompt surgeons to consider bracketing.

METHODS

A single-institution retrospective chart review was performed on patients who underwent bracketed localization for BCS between 2015 and 2021. Lesion characteristics were recorded including lesion span, number of lesions, histology type on core needle biopsy and surgical specimen, margin status, and need for additional surgery.

RESULTS

One hundred and thirteen cases were analyzed. Imaging showed an average lesion span of 5.0-cm. Multifocal lesions represented 45% of cases. Ductal carcinoma in situ (DCIS) was a histological component in 64% of core needle biopsies and 76% of surgical specimens. Negative margins were achieved in 82% of patients on the first excision. Additional surgery was performed in 17% of patients. Invasive lobular carcinoma had the highest additional surgery rate at 23%. Negative margins with BCS were achieved in 96% of cases, including those with successful re-excision.

DISCUSSION

This descriptive study shows that bracketed localization was most often employed for patients with large lesion spans, multifocality, and a DCIS or invasive lobular component. While these characteristics are typically associated with higher rates of positive margins, our cohort's rate of additional surgery was comparable to the national average for all BCS operations. These results argue that surgeon utilization of bracketed localization may be beneficial in these clinical scenarios.

A comparison of timely completion of hypofractionated and traditional adjuvant radiation therapy in early-stage breast cancer: Evidence of impact on reducing racial and socioeconomic disparities

BACKGROUND

Timely completion of adjuvant radiation after breast conservation therapy is associated with decreased mortality and increased disease-free survival. Few data exist comparing timely completion between hypofractionated radiation and traditional radiation at a national level or across racial and socioeconomic cohorts.

METHODS

A retrospective review of the National Cancer Database (2012-2016) on patients undergoing breast conservation therapy for early-stage breast cancer, specifically T1 or T2, N0, M0 patients, was performed. Multivariable logistic regression models were used to compare timely completion of hypofractionated radiation (within 5 weeks of initiation) and traditional radiation (within 7 weeks) across patient, tumor, and facility characteristics.

RESULTS

In total, 210,816 patients met criteria, with 59.4% receiving traditional radiation (n = 125,140) and 40.6% receiving hypofractionated radiation (n = 85,676). Overall, 82.8% of patients achieved timely completion of radiation. Among hypofractionated radiation patients, 94.5% of patients achieved timely completion, whereas only 74.8% of traditional radiation patients achieved timely completion (P < .0001). Regarding race/ethnicity, all groups benefited substantially in timely completion of hypofractionated radiation over traditional radiation. However, both treatment cohorts demonstrated that Black (odds ratio (hypofractionated radiation) = 0.842, odds ratio (traditional radiation) = 0.821) and Hispanic (odds ratio (hypofractionated radiation) = 0.917, odds ratio (traditional radiation) = 0.907) patients had lower odds of timely completion compared to White patients (P < .0001). Lower high school graduation rate, median income for patients' ZIP code, and Medicaid were also associated with lower odds of timely completion for both hypofractionated radiation and traditional radiation (both P < .0001).

CONCLUSION

Timely completion of radiation therapy in breast conservation therapy is greater for patients receiving hypofractionated radiation than traditional radiation across racial and socioeconomic cohorts. Disparities in timely completion were substantially reduced with hypofractionated radiation utilization. However, there are treatment disparities across racial and socioeconomic cohorts that persist in both treatment groups.

Evaluation of VIDAS® Immuno-Concentration Salmonella/VIDAS Salmonella Immunoassay Method for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS)/VIDAS Salmonella (SLM) immunoassay method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1266 of the 1440 samples. Of the 174 samples not in agreement, 69 were VIDAS ICS/SLM-positive and BAM/AOAC-negative and 105 were VIDAS ICS/SLM-negative and BAM/AOAC-positive.

Evaluation of VIDAS® Immuno-Concentration Salmonella Assay Plus Selective Plate Method (Hektoen Enteric, Bismuth Sulfite, Salmonella Identification) for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, bismuth sulfite, Salmonella identification) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1283 of the 1440 test samples. Of the 157 test samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 75 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Salmonella in Selected Foods by VIDAS® Immuno-Concentration Salmonella Plus Selective Plate Method (Hektoen Enteric, Xylose Lysine Desoxycholate, Bismuth Sulfite): Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, xylose lysine desoxycholate, bismuth sulfite) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1297 of the 1455 samples. Of the 158 samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 76 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Conservative management of a traumatic common iliac venous pseudoaneurysm: a case report

Limited evidence-based protocols exist regarding the management of venous pseudoaneurysms. Cases reports have documented surgical treatments including endovascular coil embolization or suture ligation in the setting of hemodynamic stability. Depending on the location of the venous injury, a more conservative approach to a stable pseudoaneurysm may be advantageous. This report describes a case of a patient who sustained a blunt traumatic common iliac vein pseudoaneurysm who was successfully managed non-operatively.

Managed care and Medicaid reform in Tennessee: the impact of TennCare on access and health-seeking behavior

Tennessee's TennCare program, established in 1994, uses a managed care system to address the problem of escalating Medicaid costs while expanding coverage to the chronically uninsured. This paper examined TennCare based on results of survey research commissioned by the state and conducted by the authors. Findings indicated that respondents formerly on Medicaid who had previously indicated a preference for Medicaid were now much more likely to prefer TennCare and were now as satisfied with TennCare as they had been with Medicaid in 1993. TennCare has had some impact on health care behavior, with fewer recipients seeking care at a hospital and more seeking care at a doctor's office or a clinic. At this point, Tennessee's experience with TennCare seems to be successful. Tennessee has been able to fund a fairly significant increase in coverage of the uninsured population while staying within the projected cost parameters of the Medicaid system.

Cadaver validation of skeletal muscle measurement by magnetic resonance imaging and computerized tomography

Magnetic resonance imaging (MRI) and computerized tomography (CT) are promising reference methods for quantifying whole body and regional skeletal muscle mass. Earlier MRI and CT validation studies used data-acquisition techniques and data-analysis procedures now outdated, evaluated anatomic rather than adipose tissue-free skeletal muscle (ATFSM), studied only the relatively large thigh, or found unduly large estimation errors. The aim of the present study was to compare arm and leg ATFSM cross-sectional area estimates (cm2) by using standard MRI and CT acquisition and image-analysis methods with corresponding cadaver estimates. A second objective was to validate MRI and CT measurements of adipose tissue embedded within muscle (interstitial adipose tissue) and surrounding muscle (subcutaneous adipose tissue). ATFSM area (n = 119) by MRI [38.9 +/- 22.3 (SD) cm2], CT (39.7 +/- 22.8 cm2), and cadaver (39.5 +/- 23.0 cm2) were not different (P > 0.001), and both MRI and CT estimates of ATFSM were highly correlated with corresponding cadaver values [MRI: r = 0.99, SE of estimate (SEE) 3.9 cm2, P < 0.001; and CT: r = 0.99, SEE = 3.8 cm2, P < 0.001]. Similarly good results were observed between MRI- and CT-measured vs. cadaver-measured interstitial and subcutaneous adipose tissue. For MRI-ATFSM the intraobserver correlation for duplicate measurements in vivo was 0. 99 [SEE = 8.7 cm2 (2.9%), P < 0.001]. These findings strongly support the use of MRI and CT as reference methods for appendicular skeletal muscle, interstitial and subcutaneous adipose tissue measurement in vivo.

Cardiac dysrhythmia during sleep in the critically ill: a pilot study

BACKGROUND: Few investigators have examined the hemodynamic status related to circadian and sleep-related cardiovascular events in critically ill patients. OBJECTIVE: To describe the relationships among nocturnal angina, myocardial infarction, and sleep, and to describe the cardiac rhythm, heart rate, and frequency of premature supraventricular and ventricular contractions during the sleep of critical care patients with cardiovascular disease. METHODS: A descriptive survey was done on nine patients in the medical intensive care unit of a large medical center. All subjects had cardiovascular disease and were studied during one night of sleep. RESULTS: There were no incidences of chest pain during the study and no changes in baseline cardiac rhythm associated with sleep staging. There was a significant statistical difference in mean heart rate among waking, stage 1 nonrapid-eye-movement sleep, and stage 2 nonrapid-eye-movement sleep; a lower heart rate was observed in stage 2 nonrapid-eye-movement sleep. The mean heart rate decreased by 3% to 4% from the waking state to sleep. No clinical or statistically significant differences in the frequency of premature supraventricular and ventricular contractions between sleep stages or sleeping and waking were found. CONCLUSIONS: The results of this pilot investigation do not suggest that dysrhythmia occurs more frequently during certain sleep stages or during the sleep state in critical care unit patients with cardiovascular disease. The mean heart rate slowed by 3% to 4% during rapid-eye-movement and nonrapid-eye-movement sleep, but decreases in heart rate were not as great as those noted in normal, healthy subjects.

Cardiac dysrhythmia during sleep in the critically ill: a pilot study

BACKGROUND

Few investigators have examined the hemodynamic status related to circadian and sleep-related cardiovascular events in critically ill patients.

OBJECTIVE

To describe the relationships among nocturnal angina, myocardial infarction, and sleep, and to describe the cardiac rhythm, heart rate, and frequency of premature supraventricular and ventricular contractions during the sleep of critical care patients with cardiovascular disease.

METHODS

A descriptive survey was done on nine patients in the medical intensive care unit of a large medical center. All subjects had cardiovascular disease and were studied during one night of sleep.

RESULTS

There were no incidences of chest pain during the study and no changes in baseline cardiac rhythm associated with sleep staging. There was a significant statistical difference in mean heart rate among waking, stage 1 nonrapid-eye-movement sleep, and stage 2 nonrapid-eye-movement sleep; a lower heart rate was observed in stage 2 nonrapid-eye-movement sleep. The mean heart rate decreased by 3% to 4% from the waking state to sleep. No clinical or statistically significant differences in the frequency of premature supraventricular and ventricular contractions between sleep stages or sleeping and waking were found.

CONCLUSIONS

The results of this pilot investigation do not suggest that dysrhythmia occurs more frequently during certain sleep stages or during the sleep state in critical care unit patients with cardiovascular disease. The mean heart rate slowed by 3% to 4% during rapid-eye-movement and nonrapid-eye-movement sleep, but decreases in heart rate were not as great as those noted in normal, healthy subjects.

A peer review of a peer review organization

Under Medicare, one of the federally required objectives of peer review organizations is to reduce inappropriate and unnecessary admissions. We reevaluated 32 admissions approved and 32 denied by the Arizona peer review organization, Health Services Advisory Group (HSAG), in a "blind" manner to determine whether practicing physicians in the community agree with the local peer review organization. Overall, physicians at the Scottsdale Memorial Hospital (SMH) approved 72% of HSAG-approved and denied 61% of HSAG-denied admissions. Of the 64 admissions, 3 or 4 of 4 reviewers (2 physicians and 2 nurses) agreed with the HSAG decision in 38 (59%), but 2 or more reviewers disagreed in the other 26 (41%). Disagreement between the 2 physicians occurred in 48% of the cases and disagreement between the 2 nurses in 33%. Even among admissions denied by SMH physician reviewers, the physicians would have admitted 23% of those patients under similar circumstances. In 28% of the HSAG-denied admissions, the reviewing physicians thought that the patients' health care would have been compromised if the admissions had not taken place. Despite well-defined criteria for the appropriateness of hospital admissions, the review process remains subjective, with much disagreement between peer review organizations and practicing physicians.