Publications by authors named "Christine Dauphine"

54 Publications

Evaluation of Patterns in Access to Breast Cancer Care and Breast Cancer Presentation in a Safety Net Patient Population.

Am Surg 2021 Mar 11:3134820966288. Epub 2021 Mar 11.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: While prior studies have shown the apparent health disparities in breast cancer diagnosis and treatment, there is a gap in knowledge with respect to access to breast cancer care among minority women.

Methods: We performed a retrospective analysis of patients with newly diagnosed breast cancer from 2014 to 2016 to evaluate how patients presented and accessed cancer care services in our urban safety net hospital. Patient demographics, cancer stage, history of breast cancer screening, and process of referral to cancer care were collected and analyzed.

Results: Of the 202 patients identified, 61 (30%) patients were younger than the age of 50 and 75 (63%) were of racial minority background. Only 39% of patients with a new breast cancer were diagnosed on screening mammogram. Women younger than the age of 50 ( < .001) and minority women ( < .001) were significantly less likely to have had any prior screening mammograms. Furthermore, in patients who met the screening guideline age, more than half did not have prior screening mammograms.

Discussion: Future research should explore how to improve breast cancer screening rates within our county patient population and the potential need for revision of screening guidelines for minority patients.
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http://dx.doi.org/10.1177/0003134820966288DOI Listing
March 2021

A Microcosm of Disparities in Breast Cancer: Comparison Between a Private Hospital and a Safety-Net County Hospital Within Los Angeles County.

Am Surg 2021 Feb 25:3134821998668. Epub 2021 Feb 25.

21640Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: Breast cancer survival is improving due to early detection and treatment advances. However, racial/ethnic differences in tumor biology, stage, and mortality remain. The objective of this study was to analyze presumed disparities at a local level.

Methods: Breast cancer patients at a county hospital and private hospital from 2010 to 2012 were retrospectively reviewed. Demographic, clinical, pathologic, and surgical data were collected. Comparisons were made between hospital cohorts and between racial/ethnic groups from both hospitals combined.

Results: 754 patients were included (322 from county hospital and 432 from private hospital). All patients were female. The median age was 54 years at county hospital and 60 years at private hospital ( < .0001). Racial/ethnic minorities comprised 85% of county hospital patients vs. 12% of private hospital patients ( < .0001). County hospital patients had a higher grade, clinical/pathologic stage, HER2-positive rate, and mastectomy rate. Compared to other racial/ethnic groups, non-Hispanic white women were more likely to have lower grade and ER-positive tumors. Hispanic/Latina women were younger and were more likely to have HER2-positive tumors. Both Hispanic/Latina and non-Hispanic black women presented at higher clinical stages and were more likely to undergo neoadjuvant chemotherapy and mastectomy.

Discussion: At county hospital compared to private hospital, the proportion of racial/ethnic minorities was higher, and patients presented at younger ages with more aggressive tumors and more advanced disease. The racial/ethnic disparities that were identified locally are largely consistent with those identified in national database studies. These marked differences at hospitals within a diverse city highlight the need for further research into the disparities.
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http://dx.doi.org/10.1177/0003134821998668DOI Listing
February 2021

Does diagnostic mammography need to be a routine component of the initial evaluation of a breast symptom in women 30-39 years of age?

Breast J 2021 Apr 12;27(4):330-334. Epub 2021 Feb 12.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Diagnostic mammography is routinely ordered, along with targeted breast ultrasound, to evaluate breast symptoms in women 30-39 years of age. However, in this age group, mammography is often limited by breast density and the probability of detecting an occult malignancy is low. We sought to evaluate whether diagnostic mammography detected any new incidental malignancies in women aged 30-39 years presenting with focal breast symptoms. This retrospective study included women 30-39 years of age who had a diagnostic mammogram performed for focal breast symptoms at a single institution from 2002 to 2017. Descriptive analyses were performed to determine the rate of incidental mammographic findings outside of the region of the presenting symptom that 1) led to additional imaging and/or biopsies and 2) were found to be malignant. During the 16-year study period, 1770 evaluations were performed, of which 249 (14.1%) were found to have an additional incidental mammographic abnormality. Further diagnostic imaging was required in 211 (11.3%), core biopsy in 67 (3.8%), and excisional biopsy in 8 (0.5%). None of the mammographically detected incidental findings resulted in a new diagnosis of breast cancer. In the evaluation of focal benign breast symptoms in women 30-39 years of age, diagnostic mammography did not detect any new incidental malignancies outside of the area of interest, but instead led to additional unavailing imaging and biopsy procedures. The mammography component of the diagnostic evaluation of younger average-risk women may potentially be omitted if the presenting symptom is determined to be benign with ultrasound alone.
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http://dx.doi.org/10.1111/tbj.14199DOI Listing
April 2021

Current status of robotic surgery in colorectal residency training programs.

Surg Endosc 2021 Feb 1. Epub 2021 Feb 1.

Department of Surgery, Harbor-UCLA Medical Center, 1000 W Carson St. Box 25, Torrance, CA, 90509, USA.

Background: Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described.

Methods: A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components.

Results: Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05).

Conclusions: This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.
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http://dx.doi.org/10.1007/s00464-020-08276-yDOI Listing
February 2021

Intraductal papilloma: An unusual presentation.

Breast J 2021 Mar 29;27(3):278-279. Epub 2020 Dec 29.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

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http://dx.doi.org/10.1111/tbj.14147DOI Listing
March 2021

Initiation of an Intraoperative Radiotherapy Program at a Safety net Hospital: What Is the Impact of an Intraoperative Radiotherapy Program in Underserved Patients With Early Breast Cancer?

Am Surg 2020 Nov 24:3134820956351. Epub 2020 Nov 24.

Department of Surgery, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: Intraoperative radiotherapy (IORT) can allow for single-dose radiation treatment following breast conservation therapy in low-risk patients with early breast cancer, in lieu of a traditional 6-week course of whole breast radiotherapy (WBRT). The objective of this study was to analyze the uptake and utilization of an IORT program in a safety-net hospital.

Materials And Methods: A retrospective review was conducted for all patients who underwent IORT from September 2014 to June 2018. Patient demographics, tumor characteristics, and IORT outcomes were analyzed. The proportion of patients undergoing IORT were determined to assess utilization and uptake.

Results: There were 27 female patients that received IORT, 23 (85.2%) of which required no further radiotherapy. Three (7.4%) patients had positive axillary lymph nodes and/or positive margins requiring subsequent WBRT. One patient (3.7%) developed an in-breast recurrence distant from the lumpectomy site 23 months after IORT. Ten patients (37.0%) developed a postoperative complication, including 5 seromas and 6 wound complications (superficial infections and/or wound necrosis). Overall, in the 46-month study period, IORT accounted for only 6.4% of 423 operations. Still, 27 of 29 (93.1%) patients who met eligibility criteria for IORT underwent the procedure.

Discussion: Although IORT comprised only 6.4% of all cases due to higher rates of mastectomy rates and advanced disease in our population, there was a high uptake of IORT among patients who met eligibility criteria for the procedure. Major complication rates of IORT were low, and most patients successfully completed radiotherapy in 1 intraoperative dose.
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http://dx.doi.org/10.1177/0003134820956351DOI Listing
November 2020

Are Nomograms Useful in Predicting Upstage From Ductal Carcinoma In Situ to Invasive Carcinoma Requiring Sentinel Lymph Node Biopsy?

Am Surg 2020 Oct 2;86(10):1238-1242. Epub 2020 Nov 2.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

The upstage rate from ductal carcinoma in situ (DCIS) on core biopsy to invasive carcinoma at definitive excision ranges from 20 to 30%. Nomograms have been developed to aid in the prediction of upstaging so as to guide surgical planning with respect to performance of sentinel lymph node biopsy (SLNB). The aim of this study was to evaluate the ability of these nomograms to predict upstaging within our public hospital population. A retrospective review of patients with DCIS from 2013 to 2018 at a single institution was performed. Individualized probability of upstage was calculated using the Samsung Medical Center (SMC) and (ASO) nomograms. Areas under the receiver operating characteristic curves were calculated to assess the discriminative power of each. Of 105 patients with DCIS, 31 (29.5%) were upstaged to invasive disease. The SMC and ASO nomograms demonstrated area under the curves (AUCs) of .65 (OR = 1.023, 95% CI 1.004-1.042, = .02) and .60 (OR = 1.035, 95% CI 1.003-1.068, = .03), respectively. While SMC provided greater discrimination in our cohort, the performance of these nomograms as reliable clinical adjuncts to guide SLNB decision-making in this cohort was less than optimal and thus should not be the sole factor in determining individual upstage risk.
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http://dx.doi.org/10.1177/0003134820964192DOI Listing
October 2020

Can Oncotype DX testing be omitted in invasive breast cancer patients with clinicopathologic factors predicting very high pretest probability of a concordant result?

Breast J 2020 11 1;26(11):2199-2202. Epub 2020 Oct 1.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Objective: To determine if clinicopathologic (CP) factors could identify patients at "very low" and/or "very high" pretest probability of a high Oncotype DX (ODX) score.

Methods: A retrospective analysis of all patients that had ODX testing 2008-2018 at a single institution.

Results: Of 215 patients, all 16 (7.4%) with "all high" risk CP factors had high ODX scores, and all 45 (20.9%) over age 50 with "all low" risk CP factors had ODX recommendations for no chemotherapy.

Conclusions: Oncotype DX results did not change chemotherapy recommendations in those with "very low" or "very high" pretest probability of high ODX scores.
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http://dx.doi.org/10.1111/tbj.14068DOI Listing
November 2020

A Randomized Prospective Blinded Study Evaluating the Effect of Music on Novice Surgical Trainees' Ability to Perform a Simulated Surgical Task.

J Surg Educ 2021 Mar-Apr;78(2):638-648. Epub 2020 Sep 8.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, California; The Lundquist Institute, Torrance, California. Electronic address:

Objective: To determine if playing music would affect novice surgical trainees' ability to perform a complex surgical task.

Background: The effect of music in the operating room (OR) is controversial. Some studies from the anesthesiology literature suggest that OR music is distracting and should be banned. Other nonblinded studies have indicated that music improves surgeons' efficiency with simple tasks.

Design/methods: A prospective, blinded, randomized trial of 19 novice surgical trainees was conducted using an in vitro model. Each trainee performed a baseline vascular anastomosis (VA) without music. Subsequently, they performed one VA with music (song validated to reduce anxiety) and one without, in random order and without prior knowledge of the study's purpose. The primary endpoint was a difference in differences from baseline with and without music with respect to time to completion, acceleration/deceleration (using a previously validated hand-tracking motion device), and video performance scoring (3 blinded experts using a validated scale). The participants completed a poststudy survey to gauge their opinions regarding music during tasks.

Results: Overall, 57 VAs by 19 trainees were evaluated. Average time to completion was 11.6 minutes. When compared to baseline, time to completion improved for both the music group (p = 0.01) and no-music group (p = 0.001). When comparing music to no music, there was no difference in time to completion (p = 0.7), acceleration/deceleration (p = 0.3), or video performance scorings (p = NS). Among participants, 89% responded that they enjoy listening to music while performing tasks.

Conclusions: Using three outcome measures, relaxing music did not improve the performance of novice surgical trainees performing a complex surgical task, and the music did not make their performance worse. However, nearly all trainees reported enjoying listening to music while performing tasks.
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http://dx.doi.org/10.1016/j.jsurg.2020.08.020DOI Listing
September 2020

Squamous Cell Carcinoma Arising in Breast Implant Capsules.

Ann Plast Surg 2021 03;86(3):268-272

Department of Radiology, Harbor-UCLA Medical Center, Torrance, CA.

Abstract: Breast augmentation and reconstruction utilizing implants are among the most common plastic surgery procedures performed in the United States. A small proportion of these implants are removed each year. We report 2 cases where routine pathologic evaluation of capsulectomy specimens revealed squamous cell carcinoma associated with the breast implant capsule and discuss the possible pathogenesis of this unusual entity. Both patients had long-standing implants (>10 years) and presented with acute unilateral breast erythema and swelling. Intraoperatively, the capsules for both cases appeared thickened and calcified, containing extensive granulomatosis and keratinaceous debris invading into the chest wall. Extensive workup failed to find an occult primary. One patient died from a malignant pleural effusion secondary to tumor invasion during chemotherapy, and the second patient obtained stabilization of the mass after 5 weeks of chemotherapy but subsequently declined further surgical intervention. A thorough literature review was performed, and 5 similar reports were identified, involving 6 patients. All patients presented with similar clinical presentations as ours and had poor outcomes. The mean reporting age at diagnosis was 60 years, and the average time from initial implant to diagnosis was 25 years. Due to the small numbers of squamous cell carcinomas associated with breast implant capsules, the true association between the 2 is unknown. It is postulated that chronic inflammation/irritation from the breast implant and epithelialization of the capsule play a significant role in the disease process. This may represent a new entity of "chronic inflammatory capsular malignancies." Increased awareness of this entity may allow for earlier suspicion, diagnosis, and management.
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http://dx.doi.org/10.1097/SAP.0000000000002524DOI Listing
March 2021

Should Robotic Surgery Training Be Prioritized in General Surgery Residency? A Survey of Fellowship Program Director Perspectives.

J Surg Educ 2020 Nov - Dec;77(6):e245-e250. Epub 2020 Aug 1.

Department of Surgery, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California. Electronic address:

Objective: Robotic surgery has been increasingly incorporated into the subspecialties of colorectal (CRS), minimally invasive/bariatric (MIS/Bar), and surgical oncology/hepatobiliary (SO/HPB) surgery, yet its impact on fellowship applicant evaluation and contribution to postresidency training remains undefined. The aim of our study was to evaluate how robotic training during General Surgery (GS) residency affects an applicant's competitiveness from the perspective of fellowship programs.

Design: A web-based survey was sent to all 235 accredited fellowship programs in CRS (n = 66), MIS/Bar (n = 122), and SO/HPB (n = 47) within the United States and Canada. Fellowship programs were queried on the import of robotic surgery training during GS residency and its impact on an applicant's match potential.

Results: Of 235 programs, 155 (66%) responded to the survey - 42 (63.6%) CRS, 87 (71.3%) MIS/Bar, and 26 (55.3%) SO/HPB. Of responding programs, 147 (94.8%) have a surgical robot at their institution, and 131 (84.5%) have fellows actively operating at the console. Overall, 107 (69%) fellowship program directors rated robotic training during surgery residency as "somewhat" or "very" important for residents seeking fellowship. While 95 (61.3%) programs said GS residents should not prioritize robotic training, 60 (38.7%) felt they should, and 38 (24.5%) were more likely to rank an applicant higher if they had some console exposure. Still, 69.7% (n = 108) of programs expect no robotic experience for incoming fellows.

Conclusions: This study demonstrates that most fellowship programs have low expectations of robotic experience for incoming fellows. Still, it is notable that nearly a quarter of programs would rank an applicant more highly if they had robotic console exposure. While these findings appear reassuring to residents with limited access to robotic training, residency programs should be alerted to the growing importance of robotic exposure.
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http://dx.doi.org/10.1016/j.jsurg.2020.07.025DOI Listing
August 2020

Single Hormone Receptor-Positive Breast Cancers Have Distinct Characteristics and Survival.

Ann Surg Oncol 2020 Nov 28;27(12):4687-4694. Epub 2020 Jul 28.

Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: Estrogen receptor (ER) and progesterone receptor (PR) status is pivotal to determining the prognosis and treatment of human epidermal growth factor 2 (HER2) receptor-negative invasive breast cancer. Frequently ER-positive (ER+) and/or PR-positive (PR+) cancers are labeled nonspecifically as "hormone receptor-positive" although only one is positive. This study aimed to evaluate and characterize the ER+PR- and ER-PR+ breast cancer phenotypes in reference to ER+PR+ cancers.

Methods: A retrospective cohort study of female patients with HER2-negative (HER2-) invasive breast cancer diagnosed in 2010-2015 was performed using the National Cancer Database. Cases were grouped into ER+PR+, ER-PR+, ER+PR-, and ER-PR- phenotypes to determine differences in patient demographics, tumor characteristics, and overall survival.

Results: Of 823,969 cases, 619,050 (75.1%) were ER+PR+, 79,777 (9.7%) were ER+PR-, 7006 (0.9%) were ER-PR+, and 118,136 (14.3%) were ER-PR-. Compared with the ER+PR+ group, the ER+PR- and ER-PR+ groups were more likely to be high-grade cancer (16.0% vs. 34.2% and 80.0%, respectively; p < 0.001), to have lymphovascular invasion (17.9% vs. 19.6% and 23.0%; p < 0.001), to be node-positive (13.5% vs. 19.7% and 26.3%; p < 0.001), to be stage 4 cancer (3.6% vs. 5.9% and 6.7%; p < 0.001), to have a higher multigene assay score (mean, 16.0 vs. 27.8 and 38.1; p < 0.001), and to have a worse survival (90.6% vs. 83.8% and 78.1%; p < 0.001).

Conclusion: Single hormone receptor-positive breast cancer subtypes (ER+PR- and ER-PR+) are more likely to have unfavorable characteristics and worse survival than the ER+PR+ subtype, with the ER-PR+ subtype having outcomes similar to those for ER-PR- cancers. The single hormone receptor-positive subtypes, representing 10% of HER2- cancers, should be considered clinically distinct from ER+PR+ disease.
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http://dx.doi.org/10.1245/s10434-020-08898-5DOI Listing
November 2020

ASO Author Reflections: Time for a Paradigm Shift in "Hormone Receptor Positive" Invasive Breast Cancer?

Ann Surg Oncol 2020 Dec 28;27(Suppl 3):692. Epub 2020 Jul 28.

Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

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http://dx.doi.org/10.1245/s10434-020-08950-4DOI Listing
December 2020

Assessing Surgical Coaching, a Sport in Its Infancy: The Wisconsin Surgical Coaching Rubric.

JAMA Surg 2020 06;155(6):492

Harbor-UCLA Medical Center, Department of Surgery, Torrance, California.

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http://dx.doi.org/10.1001/jamasurg.2020.0425DOI Listing
June 2020

Evaluation of the predictive ability of ultrasound-based assessment of breast cancer using BI-RADS natural language reporting against commercial transcriptome-based tests.

PLoS One 2020 10;15(1):e0226634. Epub 2020 Jan 10.

Department of Radiology, The University of Hong Kong, Hong Kong, China.

Purpose: The objective of this study was to assess the classification capability of Breast Imaging Reporting and Data System (BI-RADS) ultrasound feature descriptors targeting established commercial transcriptomic gene signatures that guide management of breast cancer.

Materials And Methods: This retrospective, single-institution analysis of 219 patients involved two cohorts using one of two FDA approved transcriptome-based tests that were performed as part of the clinical care of breast cancer patients at Harbor-UCLA Medical Center between April 2008 and January 2013. BI-RADS descriptive terminology was collected from the corresponding ultrasound reports for each patient in conjunction with transcriptomic test results. Recursive partitioning and regression trees were used to test and validate classification of the two cohorts.

Results: The area under the curve (AUC) of the receiver operator curves (ROC) for the regression classifier between the two FDA approved tests and ultrasound features were 0.77 and 0.65, respectively; they employed the 'margins', 'retrotumoral', and 'internal echoes' feature descriptors. Notably, the 'retrotumoral' and mass 'margins' features were used in both classification trees. The identification of sonographic correlates of gene tests provides added value to the ultrasound exam without incurring additional procedures or testing.

Conclusions: The predictive capability using structured language from diagnostic ultrasound reports (BI-RADS) was moderate for the two tests, and provides added value from ultrasound imaging without incurring any additional costs. Incorporation of additional measures, such as ultrasound contrast enhancement, with validation in larger, prospective studies may further substantiate these results and potentially demonstrate even greater predictive utility.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226634PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953781PMC
April 2020

Lipomatous Soft Tissue Masses: Challenging the Paradigm of Routine Preoperative Biopsy.

J Surg Res 2020 03 23;247:103-107. Epub 2019 Nov 23.

Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California. Electronic address:

Background: Lipomatous masses are the most common soft tissue tumors. While the majority are benign lipomas, it is important to identify those masses that are malignant prior to excision. Current guidelines recommend core needle biopsy (CNB) for all lipomatous masses larger than 3-5 cm. The objective of this study was to determine if routine preoperative CNB based on mass size is necessary, or if radiographic features can guide the need for CNB.

Materials And Methods: Patients who underwent excision of extremity or truncal lipomatous masses at a single institution from October 2014 to July 2017 were retrospectively reviewed. By protocol, preoperative imaging was routinely obtained for all masses larger than 5 cm. High-risk radiographic features (intramuscular location, septations, nonfat nodules, heterogeneity, and ill-defined margins) and surgical pathology were evaluated to determine patients most likely to benefit from preoperative CNB.

Results: Of 178 patients, 2 (1.1%) had malignant tumors on surgical pathology. All masses smaller than 5 cm were benign and, if imaging was obtained, had two or fewer high-risk radiographic features. Both of the patients with malignant tumors had masses larger than 5 cm, preoperative imaging that showed at least four high-risk radiographic features, and underwent CNB prior to excision.

Conclusions: The overall rate of malignancy is very low. The results of this study suggest that lipomatous masses smaller than 5 cm without concerning clinical characteristics do not require preoperative imaging or CNB. Conversely, lipomatous masses larger than 5 cm should undergo routine MRI with subsequent CNB if multiple high-risk radiographic features are present.
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http://dx.doi.org/10.1016/j.jss.2019.10.037DOI Listing
March 2020

Investigating Gender Differences in Faculty Evaluations by Trainees in a Gender-Balanced General Surgery Program.

J Surg Educ 2019 Nov - Dec;76(6):e132-e137. Epub 2019 Sep 26.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, California; The Los Angeles Biomedical Research Institute, Los Angeles, California. Electronic address:

Purpose: Women account for 21% of faculty positions in general surgery. In fields with lower female representation, female faculty receive lower evaluation scores by trainees compared to male faculty. At 42%, the female faculty representation in our general surgery department doubles the national average. We sought to determine if variations in faculty evaluations would be observed in a more gender-balanced general surgery program.

Methods: Two years of faculty teaching evaluations by residents in a general surgery residency program were collected from the MedHub system. Total 3277 resident evaluations of 26 faculty members (11 female, 15 male) were analyzed. Seven areas (scored 1-7, with 1 = needs improvement and 7 = outstanding) were examined. Chi-square test was used to compare the percentage of male and female faculty members who scored a 6 or 7 in each category, and multivariate logistic regression analysis was used to determine the association of gender with the evaluation score, while adjusting for the number of encounters between the trainee and the faculty member.

Results: There were no significant differences between male and female faculty in the "overall" evaluation score, nor in the "practice-based learning" and the "interpersonal and communication skills" categories. Female faculty had statistically significantly higher scores in "patient care", "professionalism," and "systems-based care" categories, whereas male faculty had higher evaluations in the "medical knowledge" category.

Conclusion: In a general surgery residency program with a relatively gender-balanced faculty, there was no gender difference in the "overall" evaluation of faculty by residents. However, there were gender differences in specific domains. These findings suggest that gender balance in teaching faculty may help eliminate previously observed teaching evaluation bias in the traditionally male dominated fields.
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http://dx.doi.org/10.1016/j.jsurg.2019.06.007DOI Listing
December 2020

Can Selective Image-Guided Intraoperative Margin Resection Improve Re-Excision Rates after Lumpectomy in Ductal Carcinoma of the Breast?

Am Surg 2018 Oct;84(10):1580-1583

Department of Surgery and †Division of Surgical Oncology, Harbor-UCLA Medical Center, Torrance, California, USA.

The rate of positive margins after breast conserving surgery (BCS) can be as high as 50 per cent, and optimal techniques for reducing rates of positive margins are presently debated. Our institution has previously demonstrated low rates of margin re-excision using a standardized approach to intraoperative selective margin excision for patients undergoing BCS. We hypothesized that this approach can be used for patients with ductal carcinoma (DCIS) and can yield similar rates when compared with invasive cancer. We performed a retrospective analysis of women with breast cancer who underwent BCS from January 2012 through July 2016 using our institution's standardized approach to selective margin resection. Of the 152 patients who underwent BCS, there were 30 (20%) with DCIS and 122 (80%) with invasive cancer. There was no statistically significant difference in re-excision rates for DCIS (13.3%) and invasive cancer (13.1%). Notably, the DCIS group had a larger mean lesion size ( = 0.00009); however, the lesion was visible on ultrasound more often in the invasive cancer group ( = 0.007). This standardized approach to intraoperative selective margin excision can produce similar rates of margin re-excision for DCIS and invasive cancer and may be a viable option for lowering re-excision rates for patients with DCIS.
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October 2018

Effect of the Affordable Care Act on breast cancer presentation at a safety net hospital.

Am J Surg 2019 04 17;217(4):764-766. Epub 2019 Jan 17.

Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA. Electronic address:

Introduction: The Affordable Care Act (ACA) mandated the expansion of Medicaid in order to increase access to health care services. We examined the effect of the ACA on breast cancer screening and diagnosis at a Los Angeles safety net hospital.

Methods: We performed a retrospective review of breast cancer patients treated at our institution. We compared two cohorts: patients diagnosed with breast cancer in the years 2011-2012 (pre-ACA) vs. 2015-2016 (post-ACA).

Results: There were no differences in number of screening mammograms performed, age at diagnosis, mammography-detected cancers, or clinical stage at diagnosis. There was a significant decrease in the number of patients who reported as self-pay (34% vs. 6%, p < 0.0001).

Conclusion: In the 2-year period following ACA implementation, there was limited impact on breast cancer presentation at a safety-net hospital. Long-term follow-up across different healthcare systems is necessary to fully evaluate the global impact of the ACA on breast cancer care.
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http://dx.doi.org/10.1016/j.amjsurg.2019.01.009DOI Listing
April 2019

A survey of robotic surgery training curricula in general surgery residency programs: How close are we to a standardized curriculum?

Am J Surg 2019 02 22;217(2):256-260. Epub 2018 Nov 22.

Department of Surgery, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1000 West Carson Street, Torrance, CA, 90502, United States; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, United States. Electronic address:

Background: Robotic surgery is increasingly adopted into surgical practice, but it remains unclear what level of robotic training general surgery residents receive. The purpose of our study was to assess the variation in robotic surgery training amongst general surgery residency programs in the United States.

Methods: A web-based survey was sent to 277 general surgery residency programs to determine characteristics of resident experience and training in robotic surgery.

Results: A total of 114 (41%) programs responded. 92% (n = 105) have residents participating in robotic surgeries; 68%(n = 71) of which have a robotics curriculum, 44%(n = 46) track residents' robotic experience, and 55%(n = 58) offer formal recognition of training completion. Responses from university-affiliated (n = 83) and independent (n = 31) programs were not significantly different.

Conclusions: Many general surgery residencies offer robotic surgery experience, but vary widely in requisite components, formal credentialing, and case tracking. There is a need to adopt a standardized training curriculum and document resident competency.
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http://dx.doi.org/10.1016/j.amjsurg.2018.11.006DOI Listing
February 2019

A new era of neoadjuvant treatment with Pertuzumab: Should the 10-lymph node guideline for axillary lymph node dissection in breast cancer be revised?

Cancer Rep (Hoboken) 2018 12 16;1(4):e1132. Epub 2018 Sep 16.

Department of Surgery, Division of Surgical Oncology, Harbor UCLA Medical Center, Torrance, CA, USA.

Background: Pertuzumab has improved pathologic complete response rates when compared with other chemotherapeutics in the treatment of HER-2 positive breast cancer patients.

Aims: We sought to determine if axillary lymph node dissections (ALNDs) yielding at least the national standard of 10 lymph nodes is lower in patients who received neoadjuvant pertuzumab.

Methods And Results: A retrospective database identified patients who underwent ALND for breast cancer. We compared the axillary lymph node retrieval rates in those who received or did not receive neoadjuvant pertuzumab. Of 139 breast cancer patients who underwent ALND, fewer than 10 axillary lymph nodes were found in 41.7% of patients who received neoadjuvant pertuzumab (P < 0.01) and 18.6% of patients who received neoadjuvant therapy without pertuzumab (P = 0.01).

Conclusion: Neoadjuvant chemotherapy was associated with a significantly lower rate of "adequate" ALNDs as defined by current guidelines. The patient subset that received neoadjuvant pertuzumab was more likely to have fewer than 10 axillary lymph nodes retrieved.
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http://dx.doi.org/10.1002/cnr2.1132DOI Listing
December 2018

Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result.

Breast 2018 Dec 23;42:50-53. Epub 2018 Aug 23.

Department of Surgery, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, 1000 West Carson St, Torrance, CA, 90502, United States; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, United States. Electronic address:

Background: There is currently no clear consensus recommendation for the use of short-interval follow-up mammography after a benign-concordant breast biopsy (BCBB), and practice patterns vary widely. The objectives of this study were to evaluate whether a short-interval follow-up mammogram provided clinical utility after stereotactic BCBB and to examine the costs associated with this surveillance strategy.

Methods: A retrospective review of women who underwent a stereotactic breast biopsy yielding benign-concordant results between January 2005 and October 2014 was performed to evaluate findings on subsequent imaging, to calculate compliance with recommended short-interval imaging, and to examine whether subsequent imaging revealed an abnormality at the site of the initial stereotactic BCBB. A cost analysis was performed utilizing Medicare reimbursement rates to calculate projected and actual costs of short-interval follow-up imaging after stereotactic BCBB.

Results: Of the 470 stereotactic BCBB performed, a short-interval mammogram was completed in 207 (44.0%), 9 (4.3%) of which had suspicious mammographic findings at the initial biopsy site, and 6 subsequently underwent biopsy, with none resulting in malignant or high-risk pathology. The cost of short-interval mammographic follow-up (n = 207) was calculated at $28,541.16.

Conclusions: This study provides evidence that 6-month follow-up mammography has low clinical utility and unnecessarily increases costs after stereotactic BCBB. A safe and more cost-effective strategy may be resumption of routine mammography at 12 months post-biopsy.
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http://dx.doi.org/10.1016/j.breast.2018.08.101DOI Listing
December 2018

Can Deficiencies in Performance Be Identified Earlier in Surgical Residency? An Initial Report of a Surgical Trainee Assessment of Readiness Exam.

J Surg Educ 2018 Nov 19;75(6):e91-e96. Epub 2018 Aug 19.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, California; Los Angeles Biomedical Research Institute, Torrance, California.

Objective: Identifying gaps in medical knowledge, patient management, and procedural competence is difficult early in surgical residency. We designed and implemented an end-of-year examination for our postgraduate year 1 residents, entitled Surgical Trainee Assessment of Readiness (STAR). Our objective in this study was to determine whether STAR scores correlated with other available indicators of resident performance, such as the American Board of Surgery in-training exam (ABSITE) and Milestone scores, and if they provided evidence of additional discriminatory value.

Study Design: Overall and component scores of the STAR exam were compared to the ABSITE and Milestone assessment scores for the 17 categorical residents that took the exam in 2016 and 2017.

Setting: Harbor-UCLA Medical Center, a university-affiliated academic medical center.

Participants: Seventeen categorical general surgery residents.

Results: The STAR Total Test Score (β = 2.77, p = 0.006) was an independent predictor of the ABSITE taken the same year, and components of the STAR were independent predictors of ABSITE taken the following year. The STAR Total Test Score was lowest in the 3 residents who had at least 1 low Milestone score assessed in the same year; and 2 of these 3 residents had at least 1 low Milestone score assigned the next year after STAR. Lastly, the Patient Care 1 and 2 Milestones assessed in the same year as STAR were uniformly scored as appropriate for level of training, yet the corresponding STAR component for those milestones demonstrated 3 residents as having deficiencies.

Conclusions: We have created a multifaceted standardized STAR exam, which correlates with performance on the ABSITE and early milestone scores. It also appears to discriminate resident performance where milestone assessments do not. Further evaluation of the STAR exam with longer term follow-up is needed to confirm these initial findings.
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http://dx.doi.org/10.1016/j.jsurg.2018.07.030DOI Listing
November 2018

Intraoperative Injection of 99m-Tc Sulfur Colloid for Sentinel Lymph Node Biopsy: Can the Preoperative Injection Procedure be Eliminated?

Ann Surg Oncol 2018 Oct 28;25(10):2975-2978. Epub 2018 Jun 28.

Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: Sentinel lymph node biopsy (SLNB) historically involves a separate appointment in the Radiology Department to undergo injection of the radiocolloid tracer (RT) the day of, or prior to, surgery, which can lead to disruptions in scheduling. Furthermore, the patient must endure an additional procedure. In a pilot study, intraoperative injection of the RT was previously shown to be equally as effective as preoperative injection. This study evaluates the efficacy of this method in a large cohort and examines factors associated with failure of the RT to reach the axilla.

Methods: A retrospective review of patients who underwent SLNB between June 2010 and June 2017 was performed. All patients were injected immediately following intubation with sulfur colloid and blue dye, unless contraindicated. Operative records were reviewed to determine whether sentinel nodes were identified and if gamma counts were detected. Patient and tumor characteristics were examined to identify factors related to failed RT uptake in the axilla.

Results: In 7 years, 453 SLNBs were performed, with sentinel nodes being detected in 447 (98.7%) of these SLNBs. In the six cases where no nodes were detected, all had a prior ipsilateral axillary procedure. Sentinel nodes were undetectable with the gamma probe in 16 (3.5%) cases; a prior axillary procedure was the only statistically significant independent variable associated with this failure.

Conclusion: Intraoperative injection of the RT is highly effective in the detection of sentinel nodes in clinically node-negative breast cancer patients. Eliminating the need for a preoperative injection of RT can avoid scheduling conflicts and decrease patient morbidity.
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http://dx.doi.org/10.1245/s10434-018-6594-3DOI Listing
October 2018

Building a Single-Site Robotic Cholecystectomy Program in a Public Teaching Hospital: Is It Safe for Patients and Feasible for Residents to Participate?

Am Surg 2018 Feb;84(2):188-191

Department of Surgery, Division of Surgical Oncology, Harbor UCLA, Medical Center, Torrance, California, USA.

Single-site robotic cholecystectomy (SSRC) accounts for most of the robotic surgery cases performed by general surgeons at our institution since acquiring the da Vinci Si Surgical SystemTM (Intuitive Surgical, Inc., Sunnyvale, CA) in 2014. We sought to determine whether a SSRC program is safe to start in a public teaching hospital and to determine whether resident participation in this procedure is feasible. Data on age, gender, race, BMI, total operative time, length of stay, comorbidities, and conversion from laparoscopic to open surgery were examined for elective SSRC and laparoscopic cholecystectomies (LCs) performed by two faculty surgeons between February 2015 and August 2015. Thirty-eight patients underwent elective SSRC, whereas 27 patients underwent LC. Residents participated as operating surgeons for some portion of the case in 15 SSRC cases and in all LC cases. There were no significant differences in operative time, length of stay, or 30-day readmission rates, regardless of resident involvement. Patients in the SSRC group had a significantly lower BMI (25.8 vs 33.7, P = 0.008). This study suggests that resident participation does not increase complications or total operative time and that SSRC is a safe procedure to start in a public teaching hospital after proper faculty and resident training.
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February 2018

Single-site robotic cholecystectomy and robotics training: should we start in the junior years?

J Surg Res 2018 04 22;224:1-4. Epub 2017 Dec 22.

Division of Surgical Oncology, Department of Surgery, Harbor UCLA Medical Center, Torrance, California.

Background: It has become increasingly important to expose surgical residents to robotic surgery as its applications continue to expand. Single-site robotic cholecystectomy (SSRC) is an excellent introductory case to robotics. Resident involvement in SSRC is known to be feasible. Here, we sought to determine whether it is safe to introduce SSRC to junior residents.

Materials And Methods: A total of 98 SSRC cases were performed by general surgery residents between August 2015 and August 2016. Cases were divided into groups based on resident level: second- and third-years (juniors) versus fourth- and fifth-years (seniors). Patient age, gender, race, body mass index, and comorbidities were recorded. The number of prior laparoscopic cholecystectomies completed by participating residents was noted. Outcomes including operative time, console time, rate of conversion to open cholecystectomy, and complication rate were compared between groups.

Results: Juniors performed 54 SSRC cases, whereas seniors performed 44. There were no significant differences in patient age, gender, race, body mass index, or comorbidities between the two groups. Juniors had less experience with laparoscopic cholecystectomy. There was no significant difference in mean operative time (92.7 min versus 98.0 min, P = 0.254), console time (48.7 min versus 50.8 min, P = 0.639), or complication rate (3.7% versus 2.3%, P = 0.68) between juniors and seniors.

Conclusions: SSRC is an excellent way to introduce general surgery residents to robotics. This study shows that with attending supervision, SSRC is feasible and safe for both junior and senior residents with very low complication rates and no adverse effect on operative time.
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http://dx.doi.org/10.1016/j.jss.2017.07.015DOI Listing
April 2018

A prospective clinical study to evaluate the safety and performance of wireless localization of nonpalpable breast lesions using radiofrequency identification technology.

AJR Am J Roentgenol 2015 Jun;204(6):W720-3

1 Department of Surgery, Los Angeles Biomeical Research Institute at Harbor-UCLA Medical Center, 1000 West Carson, Box 25, Torrance, CA 90502.

Objective: The purpose of this study was to evaluate the safety and performance of localizing nonpalpable breast lesions using radiofrequency identification technology.

Subjects And Methods: Twenty consecutive women requiring preoperative localization of a breast lesion were recruited. Subjects underwent placement of both a hook wire and a radiofrequency identification tag immediately before surgery. The radiofrequency identification tag was the primary method used by the operating surgeon to localize each lesion during excision, with the hook wire serving as backup in case of tag migration or failed localization. Successful localization with removal of the intended lesion was the primary outcome measured. Tag migration and postoperative infection were also noted to assess safety.

Results: Twenty patients underwent placement of a radiofrequency identification tag, 12 under ultrasound guidance and eight with stereotactic guidance. In all cases, the radiofrequency identification tag was successfully localized by the reader at the level of the skin before incision, and the intended lesion was removed along with the radiofrequency identification tag. There were no localization failures and no postoperative infections. Tag migration did not occur before incision, but in three cases, occurred as the lesion was being retracted with fingers to make the final cut along the deep surface of the specimen.

Conclusion: In this initial clinical study, radiofrequency tags were safe and able to successfully localize nonpalpable breast lesions. Radiofrequency identification technology may represent an alternative method to hook wire localization.
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http://dx.doi.org/10.2214/AJR.14.13201DOI Listing
June 2015

Examining the role of screening mammography in men at moderate risk for breast cancer: two illustrative cases.

Breast J 2015 May-Jun;21(3):316-7. Epub 2015 Apr 16.

Department of Radiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California.

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http://dx.doi.org/10.1111/tbj.12411DOI Listing
May 2016

Core needle biopsy is a safe and accurate initial diagnostic procedure for suspected lymphoma.

Am J Surg 2014 Dec 20;208(6):1003-8; discussion 1007-8. Epub 2014 Sep 20.

Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Box 25, Torrance, CA 90502, USA. Electronic address:

Background: Excisional biopsy is currently recommended for the analysis of lymphadenopathy suspicious for lymphoma. This study aims to evaluate the efficacy and safety of image-guided core needle biopsy (IGCNB) for the diagnosis of lymphoma using a standard protocol for tissue acquisition and analysis.

Methods: All IGCNBs from 2008 to 2014 performed under the study protocol were included in analysis. Demographics, pathology results, additional studies, and follow-up information were recorded.

Results: Seventy-three IGCNBs were performed in 71 consecutive patients. Lymphoma was diagnosed in 37 patients (51%). All 37 patients (100%) were subtyped and treated based on IGCNB results. The remaining 36 IGCNBs in 34 patients did not have subsequent diagnosis of lymphoma in a mean follow-up of 15 months (range, 0 to 54 months). There were no complications.

Conclusions: IGCNB performed under a standard protocol is effective and safe and should be considered as an initial diagnostic tool for the evaluation of lymphadenopathy suspicious for lymphoma.
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http://dx.doi.org/10.1016/j.amjsurg.2014.09.001DOI Listing
December 2014