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Objective The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma. Methods The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review. Recommendations "Minimal itm" is defined as lesions in a location with limited spread (generally 1-4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. "Moderate itm" is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. "Maximal itm" is defined as large-volume disease with multiple (>15-20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area. ■ In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered. ■ In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette-Guérin or CO2 laser ablation outside of a research setting. ■ In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference. ■ In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered. [ABSTRACT FROM AUTHOR]

Lipids are involved in a multitude of important cellular functions. They act as signaling molecules and can even provoke apoptosis. In this context we investigated the efficacy of synthetic alkylphosphocholines (APCs) as potential anti-cancer membrane-affecting drugs. Leading to novel therapeutic strategies for cancer treatment, the new agents interact with the cell membrane and do not affect the DNA. The data presented here show a cell death-inducing capacity for 1-O-phosphocholine-2[S]-O-acetyl-octadecane and 1-O-phosphocholin-2[S]-N-acetyl-octadecane in Jurkat T cells as well as in BJAB cells. The activation of caspases is generally required for the induction of apoptosis as shown by experiments with specific caspase inhibitors. The results point on the one hand to the formation of a functional DISC after APC-treatment as indicated by the clustering of receptor molecules and on the other hand to the dependency on the instrinsic apoptotic machinery and the downstream of mitochondria-activated apoptosome. [ABSTRACT FROM AUTHOR]

Abstract Background The incidence of cancer in patients with neurological diseases, who have been treated with LiCl, is below average. LiCl is a well-established inhibitor of Glycogen synthase kinase-3, a kinase that controls several cellular processes, among which is the degradation of the tumour suppressor protein p53. We therefore wondered whether LiCl induces p53-dependent cell death in cancer cell lines and experimental tumours. Results Here we show that LiCl induces apoptosis of tumour cells both in vitro and in vivo. Cell death was accompanied by cleavage of PARP and Caspases-3, -8 and -10. LiCl-induced cell death was not dependent on p53, but was augmented by its presence. Treatment of tumour cells with LiCl strongly increased TNF-α and FasL expression. Inhibition of TNF-α induction using siRNA or inhibition of FasL binding to its receptor by the Nok-1 antibody potently reduced LiCl-dependent cleavage of Caspase-3 and increased cell survival. Treatment of xenografted rats with LiCl strongly reduced tumour growth. Conclusions Induction of cell death by LiCl supports the notion that GSK-3 may represent a promising target for cancer therapy. LiCl-induced cell death is largely independent of p53 and mediated by the release of TNF-α and FasL. Key words: LiCl, TNF-α, FasL, apoptosis, GSK-3, FasL

Context: Spasticity is characterized by muscle hypertonia due to a velocity-dependent increase in tonic stretch reflexes, mostly related to hyperactive spinal reflexes. After spinal cord injury, the impact of noxious stimuli on autonomic dysreflexia is well documented. It is admitted in clinical practice that sublesional noxious stimuli can also increase spasticity. However, this has never been reported in the literature. In this single case study, we describe the impact of a noxious stimulus (bladder stone) on the spasticity of lower limbs in a male with spinal cord injury, using quantitative gait analysis before and after stone removal., Findings: : Clinical evaluation was performed on the subject before and after bladder lithiasis removal, by two physiotherapists using ASIA score and the Modified Ashworth scale. Quantitative gait analyses were compared before and 3 months after lithiasis resection.Regarding gait kinematics, there was a reduction of the right knee recurvatum, and of the successive increases of flexion (double bump) of flexion in the swing phase. In the stance phase, the right ankle maximum dorsiflexion increased. In the swing phase, the double bump of ankle dorsiflexion disappeared. Surface electromyography showed a reduction of the triceps surae hypertonia, especially in the right gastrocnemius muscle at the swing., Conclusion: We propose that lithiasis created a noxious stimulus regarding the S2, S3 and S4 metamers with a diffusion of the spinal reflex to the metamers S1, S2, S3 and S4. This highlights a potential causal link between an intravesical noxious stimulus and an increase in the subject's spasticity, through a disinhibited spinal nociceptive reflex.

Purpose: This qualitative study explored First Nations (FN) women's perceptions about breast reconstruction (BR) after breast cancer surgery. Method: Participants were recruited through purposive and snowball sampling via Aboriginal health and community organizations, breast and plastic surgeons, an Aboriginal health liaison and an FN elder. Semistructured one-on-one interviews and an FN sharing circle were conducted, transcribed, and analyzed using thematic content analysis. Results: Nine women participated in the interviews. Three (33%) had been offered and had pursued BR, while 6 (67%) were either not offered or had not pursued breast reconstruction. Two of these 6 stated that they were not interested in BR. Four women participated in the sharing circle; 2 had been interviewed prior and 2 were new participants who shared similar themes and experiences to other participants also interviewed. Four key themes were identified: identity, information gaps, financial and transportation barriers, and consequences of colonization. Reasons cited to pursue BR were consistent with non-FN women such as improving self-image, concepts of femininity, and sense of normalcy. All participants reported that accessible, appropriate, and timely and culturally sensitive BR information was lacking. Living on reserve and the attendant expenses related to attending medical appointments was another barrier experienced by women in our study. The devastating impacts of colonization also deeply impacted several women in our study. Conclusion: When offered, FN women were receptive to pursuing BR. FN women have a particular set of obstacles related to consequences of colonization. Culturally sensitive and relevant oral communications grounded in first-hand experiences are desired. The 4 themes identified did influence the rate of BR uptake in the FN women who participated in our study and provided significant and unique obstacles to FN women., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: HD received Alberta Cancer Foundation Richard R. Singleton Summer Studentship to fund this research. HS, CW, and CT have nothing to disclose., (© 2023 The Author(s).)

Background: Four externally validated sentinel node biopsy (SNB) prediction nomograms exist for malignant melanoma that each incorporate different clinical and histopathologic variables, which can result in substantially different risk estimations for the same patient. We demonstrate this variability by using hypothetical melanoma cases., Methods: We compared the MSKCC and MIA calculators. Using a random number generator, 300 hypothetical thin melanoma "patients" were created with varying age, tumor thickness, Clark level, location on the body, ulceration, melanoma subtype, mitosis, and lymphovascular invasion (LVI). The chi-square test was used to detect statistically significant differences in risk estimations between nomograms. Multivariate linear regression was used to determine the most relevant contributing pathologic features in cases where the predictions diverged by > 10%., Results: Of 300 randomly generated cases, 164 were deleted as their clinical scenarios were unlikely. The MSKCC nomogram generally calculated a lower risk than the MIA (p < 0.001). The highest risk score attained for any "patient" using MSKCC calculator was 15% achieved in one of 136 patients (0.7%), whereas using the MIA nomogram, 58 of 136 patients (43%, p < 0.001) had predicted risk >15%. Regression analysis on patients with >10% difference between nomograms revealed LVI (26, p < 0.001), mitosis (14, p < 0.001), and melanoma subtype (8, p < 0.001) were the factors with high coefficients within MIA that were not present in MSKCC., Conclusions: Nomograms are useful tools when predicting SNB risk but provide risk outputs that are quite sensitive to included predictors., (© 2024. Society of Surgical Oncology.)

Competing Interests: Conflict of Interest The authors state no conflict of interest.

Aims: Plaque-type blue naevi are rare melanocytic tumours presenting as large, pigmented plaques at birth or during childhood. There is a risk for malignant transformation, but no larger comprehensive studies exist and the diagnosis is challenging, especially on limited biopsy material. The aim is to describe the clinicopathological features and behaviour of the disease more comprehensively., Methods and Results: We retrieved eight plaque-type blue naevi, presenting as large, pigmented plaques (median = 7 cm; range = 3-26) most frequently affecting the scalp (four) followed by the cheek, arm, abdominal wall and gluteal cleft (one each), with a slight female predilection. Median age at time of biopsy was 39.5 years (range = 15-90), but three tumours had been present at birth and one since childhood. Histopathologically, the tumours were poorly circumscribed and composed of cellular fascicles of uniform spindle cells in a background of variably prominent pigmented dendritic cells affecting dermis and subcutaneous tissues. The majority had mutations in GNAQ. One tumour showed malignant transformation, characterised by an expansile nodule of pleomorphic epithelioid melanocytes with rhabdoid morphology, high mitotic activity and areas of necrosis. This patient developed metastatic melanoma to lymph nodes. All patients are alive with a median follow-up of 60 months., Conclusion: Plaque-type blue naevi are diagnostically challenging tumours with risk for malignant transformation. Awareness and familiarity with the salient clinicopathological features are necessary for reliable diagnosis, and long-term clinical follow-up is required to monitor for malignant transformation., (© 2024 John Wiley & Sons Ltd.)

Breast cancer-related lymphedema (BCRL) following axillary lymph node dissection (ALND) is a life-altering sequela for patients and a challenging problem for their surgeons. In order to prevent BCRL, immediate lymphatic reconstruction (ILR) is a surgical technique that has been devised to restore lymphatic drainage to the operative limb. Although ILR is becoming popular in the literature, we have identified several challenges within our own ILR research, including a lack of a clear definition of lymphedema, a lack of common outcome measures and possible alteration of the natural history of lymphedema through early compression therapy. Given these challenges, we must move forward with caution, while striving to develop clear and universally agreed upon definitions and outcomes, so that we can advance the body of evidence in support of ILR., Competing Interests: Declaration of competing interest The authors declare no personal or financial conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018-March 2020) and during the pandemic (DP; April 2020-March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: There has been an increase in health care-focused smartphone apps, including those for encouraging healthy behaviors and managing chronic conditions, but app-assisted postsurgical care has yet to be fully explored., Objective: To compare quality of recovery and patient satisfaction between conventional in-person follow-up and smartphone app-assisted follow-up for patients following Enhanced Recovery After Surgery Society (ERAS) protocols., Design, Setting, and Participants: This randomized clinical trial, conducted from June 2019 to April 2021, included women older than 18 years undergoing oncologic breast reconstruction or major gynecologic oncology surgery following ERAS protocols with the care of 2 surgeons at an academic tertiary care center., Interventions: Patients were randomized 1:1 to receive smartphone app-assisted follow-up or conventional in-person follow-up. The smartphone group used a surgeon-monitored app to record Quality of Recovery 15 (QoR15) scores, European Organisation for Research and Treatment of Cancer-selected adverse events, drain outputs, and surgical site photographs over 6 weeks. Patient satisfaction scores were assessed using validated Patient Satisfaction Questionnaire III (PSQ-III) subscales at 2 and 6 weeks postoperatively. The conventional follow-up group also completed the QoR15 and PSQ-III questionnaires at these intervals., Main Outcomes and Measures: The primary outcomes were quality of recovery and patient satisfaction, as measured by the QoR15 and PSQ-III, respectively. Secondary outcomes were costs of follow-up; the number of contacts with the medical system, complications, and surgeons' contacts with patients; and surgeons' perceptions of app-assisted care., Results: Of 72 patients included in the trial, 36 underwent breast reconstruction (mean [SD] age, 45.30 [9.13] years) and 36 underwent gynecologic oncology surgery (mean [SD] age, 54.90 [11.18] years). Three patients dropped out (2 who underwent breast reconstruction [1 in the app group, 1 in the control group], 1 who underwent gynecologic oncology surgery [control group]). The app group had significantly higher mean (SD) QoR15 scores than the control group (2 weeks: 127.58 [22.03] vs 117.68 [17.52], P = .02; 6 weeks: 136.64 [17.53] vs 129.76 [16.42], P = .03). Patients were equally satisfied between groups in all subsets of the PSQ-III at these intervals. The mean (SD) number of complications was similar in both groups, and a similar number of surgeon contacts per patient occurred (1.6 [1.2] vs 2.1 [2.0], P = .16). Surgeons appreciated early identification of complications with the app., Conclusions and Relevance: In this randomized clinical trial, postoperative follow-up for patients undergoing breast reconstruction and gynecologic oncology surgery using smartphone app-assisted monitoring led to improved quality of recovery and equal satisfaction with care compared with conventional in-person follow-up., Trial Registration: ClinicalTrials.gov Identifier: NCT03456167.

Background: The primary purpose of this study was to investigate the relationships between career burnout and the barriers to gender equity identified by Canadian female orthopaedic surgeons. A secondary purpose was to assess relationships between the demographic characteristics of the female surgeons and career burnout and job satisfaction., Methods: An electronic survey was distributed to 330 Canadian female orthopaedic surgeons. Demographic variables including age, stage and years in practice, practice setting, and marital status were collated. The survey included the Gender Bias Scale (GBS) questionnaire and 2 questions each about career burnout and job satisfaction. The Pearson r correlation coefficient evaluated the relationships among the higher- and lower-order factors of the GBS, burnout, and job satisfaction. Spearman rank correlation coefficient assessed relationships among burnout, job satisfaction, and demographic variables., Results: Survey responses were received from 218 (66.1%) of the 330 surgeons. A total of 110 surgeons (50.5%) agreed or strongly agreed that they felt career burnout (median score = 4). Burnout was positively correlated with the GBS higher-order factors of Male Privilege (r = 0.215, p < 0.01), Devaluation (r = 0.166, p < 0.05), and Disproportionate Constraints (r = 0.152, p < 0.05). Job satisfaction (median = 4) was reported by 168 surgeons (77.1%), and 66.1% were also satisfied or very satisfied with their role in the workplace (median = 4). Burnout was significantly negatively correlated with surgeon age and job satisfaction., Conclusions: Half of the female orthopaedic surgeons reported symptoms of career burnout. Significant relationships were evident between burnout and barriers to gender equity. Identification of the relationships between gender-equity barriers and burnout presents an opportunity to modify organizational systems to dismantle barriers and reduce this occupational syndrome., Clinical Relevance: Given the relationships between gender inequity and career burnout in this study of female orthopaedic surgeons, actions to dismantle gender barriers and address systemic biases are necessary at all career stages to reduce burnout., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H499)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Lymphedema remains a risk for 13-34% of breast cancer patients who require an axillary dissection (ALND) and radiation. Immediate lymphovenous anastomosis (LVA) may mitigate lymphedema by up to 30% by restoring the physiologic lymphatic drainage immediately after ALND. Currently, completion of ALND (cALND) versus radiation after neoadjuvant therapy (NAC) is being addressed by the Alliance A11202 trial, leaving a paucity of data to guide practice. Our study describes the implementation process of LVA into clinical practice after NAC for node-positive breast cancer in the current clinical context., Methods: We reviewed a prospective database of LVA in node-positive patients (cT1-4,Nany) who received NAC followed by axillary surgery ± immediate LVA from October 2021 to 2022. The evolution of the surgical approach is described. Specifically, patients who downstaged to clinically negative nodes post-NAC were offered targeted SLNB with dual-tracer and intraoperative frozen section (FS). Patients were reminded that the standard of care for any node positive is cALND. Immediate cALND with LVA was performed for grossly positive nodes or all positive SLNs; cALND was omitted for those with negative SLNs. For a microscopic disease on a frozen section, a shared decision was made pre-operatively, given each patient's differing valuations of the benefit and risks of cALND ± LVA versus no cALND with planned regional radiation postoperatively. LVA was offered as an option as part of our institutional evaluation of the procedure., Results: A total of 15 patients were included; the mean age was 49.9 (range 32-75) with stage IIA to IIIB breast cancer. Of these, 6 (40%) were triple negative, 5 (33.3%) HER-2 positive, and 4 (26.7%) ER/PR+ HER-2 negative. There were 13 women (86.7%) who had persistent axillary adenopathy based on clinical and/or ultrasound assessment, with 8 patients proceeding directly to ALND with LVA. Among these patients, 3 (37.5%) had pathologic nodal disease, and 5 (62.5%) were node negative, confirming the limitations of pre-operative imaging. As a result, the subsequent 7 (46.7%) underwent targeted SLNB with FS, with 3 patients (42.9%) avoiding an ALND as a result of a negative FS. A total of 4 patients (57.1%) had 1 or more positive lymph nodes on FS: 3 proceeded with a cALND and LVA, and 1 patient (14.2%) opted for no cALND based on a pre-operative discussion and received adjuvant radiation and chemotherapy. Of the 11 patients who underwent ALND and LVA, 1 patient (9.1%) developed lymphedema at 6.9 months following their surgery. The accuracy, sensitivity, and specificity of pre-operative US were 46.7%, 85.7%, and 12.5% and intraoperative FS were 88.0%, 72.7%, and 100%, respectively., Conclusions: As adjuvant nodal radiation and systemic therapy continue to improve, the benefit of a cALND in patients with the limited residual disease remains unclear as we await the outcomes from clinical trials. In the era of clinical uncertainty, we propose a nuanced approach to the axilla by utilizing a shared decision model with patients, incorporating targeted SLNB with FS and completion node dissection when required and desired by the patient, coupled with LVA in a simple stepwise treatment pathway.

Learning Objectives: After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management., Summary: Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret., Methods: This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction., Results: Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05)., Conclusions: Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision., Clinical Question/level of Evidence: Therapeutic, I., Competing Interests: Disclosure: The authors do not have a financial interest in any of the products, devices, or drugs mentioned in this article. Dr. Sherman developed the BRECONDA and her institution collects user fees for its use. Professor Kerry Sherman has no conflict of interest to disclose for this research., (Copyright © 2022 by the American Society of Plastic Surgeons.)

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses.

Background: Only 13.6% of orthopaedic surgeons in Canada are women, even though there is nothing inherent to the practice of orthopaedic surgery that favors men over women. Clearly, there is a need to identify, define, and measure the barriers faced by women in orthopaedic surgery., Methods: An electronic survey was distributed to 330 female-identifying Canadian orthopaedic surgeons and trainees and included the validated Gender Bias Scale (GBS) and questions about career burnout. The barriers for women in Canadian orthopaedics were identified using the GBS. The relationships between the GBS and burnout were investigated. Open-text questions explored the barriers perceived by female orthopaedic surgeons., Results: The survey was completed by 220 female orthopaedic surgeons and trainees (66.7%). Five barriers to gender equity were identified from the GBS: Constrained Communication, Unequal Standards, Male Culture, Lack of Mentoring, and Workplace Harassment. Career burnout correlated with the GBS domains of Male Privilege (r = 0.215; p < 0.01), Disproportionate Constraints (r = 0.152; p < 0.05), and Devaluation (r = 0.166; p < 0.05). Five main themes emerged from the open-text responses, of which 4 linked closely to the barriers identified in the GBS. Work-life integration was also identified qualitatively as a theme, most notably the difficulty of balancing disproportionate parental and childcare responsibilities alongside career aspirations., Conclusions: In this study, 5 barriers to workplace equity for Canadian female orthopaedic surgeons were identified using the validated GBS and substantiated with qualitative assessment using a mixed-methods approach. Awareness of these barriers is a necessary step toward dismantling them and changing the prevailing culture to be fair and equitable for all., Clinical Relevance: A just and equitable orthopaedic profession is imperative to have healthy and thriving surgeons who are able to provide optimal patient care., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H71 )., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR)., Methods: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment., Results: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% ( n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% ( n = 16) of ILND ( p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% ( n = 4) and 37.5% ( n = 12) respectively ( p = 0.016, NS). The rate of transient lymphedema was 2.9% ( n = 1) for ALND and 12.5% ( n = 4) for ILND ( p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema., Conclusion: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.

Introduction: Factors influencing breast reconstruction rates in Canada are complex and multi-factorial, ranging from patient-related to systemic considerations. For plastic surgeons, rates of immediate breast reconstruction (IBR) hinge on referral patterns from general surgeons performing breast cancer surgery and informed discussions with patients about their goals and risk tolerance. We seek to understand the reasons Alberta patients are not receiving IBR as reported by general surgeons., Methods: The Synoptec™ database is a synoptic operative report designed by Cancer Surgery Alberta™ and utilized by 95% of Alberta breast cancer surgeons. Within this report are mandatory questions regarding if a patient is receiving IBR and, if not, why. A retrospective review of this database was performed for all patients undergoing surgical treatment of breast cancer over two years. All statistical comparisons were made using chi-squared test for categorical variables with a p-value of 0.05 considered significant., Results: Of 6253 patients undergoing breast cancer surgery, 2649 underwent mastectomy and 615 mastectomy patients received IBR. The most commonly reported reasons patients did not undergo IBR were patient preference (55%), high likelihood of postoperative radiation therapy (20%), and high risk due to patient co-morbidities (12%). Resource limitations (2%) and a lack of an IBR discussion (3%) was rarely cited as reasons for no IBR., Conclusions: There are many reconstructive options following mastectomy in breast cancer survivors. This study provides a unique look into general surgeon reported reasons patients are not receiving IBR and demonstrates the need for further probing into the thought-process behind these reported reasons from both a surgeon and patient perspective., (Copyright © 2022. Published by Elsevier Ltd.)

The objective of this study is to summarize the current body of evidence detailing the impact of immediate lymphatic reconstruction (ILR) on the incidence of breast cancer-related lymphedema (BCRL) following axillary node dissection (ALND)., Methods: Medline and Embase databases were queried for publications, where ILR was performed at the time of ALND for breast cancer. Exclusion criteria included lymphaticovenous anastomosis for established BCRL, animal studies, non-breast cancer patient population studies, and descriptive studies detailing surgical technique. Meta-analysis was performed with a forest plot generated using a Mantel -Haenszel statistical method, with a random-effect analysis model. Effect measure was reported as risk ratios with associated 95% confidence intervals. The risk of bias within studies was assessed by the Cochrane Collaboration tool., Results: This systematic review yielded data from 11 studies and 417 breast cancer patients who underwent ILR surgery at the time of ALND. There were 24 of 417 (5.7%) patients who developed BCRL following ILR. Meta-analysis revealed that in the ILR group, 6 of 90 patients (6.7%) developed lymphedema, whereas in the control group, 17 of 50 patients (34%) developed lymphedema. Patients in the ILR group had a risk ratio of 0.22 (CI, 0.09 -0.52) of lymphedema with a number needed to treat of four., Conclusions: There is a clear signal indicating the benefit of ILR in preventing BCRL. Randomized control trials are underway to validate these findings. ILR may prove to be a beneficial intervention for improving the quality of life of breast cancer survivors., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity., Methods: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services., Results: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services., Conclusions: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)