Publications by authors named "Keith A Delman"

122 Publications

Clinical Case-Conference Blogs: Integrating Clinical Librarians to Enhance Resident Education and Enforce ACGME Competencies.

Med Sci Educ 2021 Apr 23;31(2):375-380. Epub 2021 Feb 23.

Department of Medicine, Emory University School of Medicine, Atlanta, GA USA.

Resident conferences are primary educational endeavors for trainees and faculty alike. We describe the development of collaborative clinician-librarian educational blogs within the Internal Medicine (2009), Pediatrics (2012), and General Surgery (2018) residency programs. Clinical librarians attended resident conferences and generated evidence-based blog posts based on learning topics and clinical questions encountered during the conferences. In the decade since introduction of the blogs, this partnership has resulted in over 2000 blog posts and generated over 1800 individual views per month. The development of a clinical librarian-managed blog serves as a relevant resource for promoting evidence-based practices within a case-based learning curriculum, engages interdisciplinary collaboration through existing resources, and is generalizable across various clinical practice disciplines and trainees.
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http://dx.doi.org/10.1007/s40670-021-01229-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368700PMC
April 2021

Increased homeostatic cytokines and stability of HIV-infected memory CD4 T-cells identify individuals with suboptimal CD4 T-cell recovery on-ART.

PLoS Pathog 2021 Aug 27;17(8):e1009825. Epub 2021 Aug 27.

Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Atlanta, Georgia, United States of America.

Clinical outcomes are inferior for individuals with HIV having suboptimal CD4 T-cell recovery during antiretroviral therapy (ART). We investigated if the levels of infection and the response to homeostatic cytokines of CD4 T-cell subsets contributed to divergent CD4 T-cell recovery and HIV reservoir during ART by studying virologically-suppressed immunologic responders (IR, achieving a CD4 cell count >500 cells/μL on or before two years after ART initiation), and virologically-suppressed suboptimal responders (ISR, did not achieve a CD4 cell count >500 cells/μL in the first two years after ART initiation). Compared to IR, ISR demonstrated higher levels of HIV-DNA in naïve, central (CM), transitional (TM), and effector (EM) memory CD4 T-cells in blood, both pre- and on-ART, and specifically in CM CD4 T-cells in LN on-ART. Furthermore, ISR had higher pre-ART plasma levels of IL-7 and IL-15, cytokines regulating T-cell homeostasis. Notably, pre-ART PD-1 and TIGIT expression levels were higher in blood CM and TM CD4 T-cells for ISR; this was associated with a significantly lower fold-changes in HIV-DNA levels between pre- and on-ART time points exclusively on CM and TM T-cell subsets, but not naïve or EM T-cells. Finally, the frequency of CM CD4 T-cells expressing PD-1 or TIGIT pre-ART as well as plasma levels of IL-7 and IL-15 predicted HIV-DNA content on-ART. Our results establish the association between infection, T-cell homeostasis, and expression of PD-1 and TIGIT in long-lived CD4 T-cell subsets prior to ART with CD4 T-cell recovery and HIV persistence on-ART.
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http://dx.doi.org/10.1371/journal.ppat.1009825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8397407PMC
August 2021

Trainee Utilization of the SCORE Curriculum is Associated With Improved ABSITE Performance: A Multi-institutional Study.

J Surg Educ 2021 Aug 9. Epub 2021 Aug 9.

Einstein Healthcare Network, Jefferson Medical College, Philadelphia, Pennsylvania. Electronic address:

Background: The Surgical Council on Resident Education's (SCORE) structured educational curriculum for general surgery residents uses a 2-year repeating cycle of modules and quizzes called "This Week in SCORE" (TWIS) to organize and sequence the curricular content on the SCORE portal. The purpose of this study was to evaluate the impact of using the SCORE content and TWIS curriculum on American Board of Surgery In-Training Examination (ABSITE) performance. To date, no multi-institutional studies have examined this effect.

Methods: Eight residency programs participated, including university and community-based programs. SCORE usage overall, TWIS usage, and ABSITE percentile scores (adjusted for post-graduate year [PGY]) were analyzed for the academic years 2017 to 2020. SCORE usage was defined as number of SCORE logins annually per resident with "low usage" ≤10 times and "high usage" >10 times. TWIS usage was defined as "low usage" (no TWIS quizzes done) or "high usage" (≥1 TWIS quiz per year).

Results: Four hundred and twenty-eight trainees were evaluated. Trainees with high SCORE and TWIS usage consistently achieved a higher ABSITE percentile score. This difference was maintained in subgroup analysis by PGY with the greatest impact in PGY-1 and PGY-2 levels.

Conclusions: Utilization of multiple aspects of SCORE content appears to have a significant positive impact on ABSITE performance across all levels of postgraduate training. This multi-institutional study of a large number of users is the first to demonstrate that increased usage of SCORE content appears to be a predictor of ABSITE performance success.
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http://dx.doi.org/10.1016/j.jsurg.2021.06.022DOI Listing
August 2021

Relationship between burnout and mistreatment: Who plays a role?

Am J Surg 2021 Jul 22. Epub 2021 Jul 22.

Department of Surgery, University of Alabama Birmingham, Birmingham, AL, USA.

Introduction: Surgery residents have high burnout rates and mistreatment occurs during training. We hypothesized that residents who reported mistreatment would be more likely to experience burnout.

Methods: A multi-institutional observational study asked residents to complete the Maslach Burnout Inventory and to rate how often they experienced mistreatment. Scores in the high-risk range for emotional exhaustion or depersonalization were classified as burnout. Associations between mistreatment behaviors, program, sex, post graduate year(PGY), and clinical status were measured by Spearman's correlation, linear regression, and logistic regression.

Results: We invited 398 residents to participate; 180 responded(45%). 52%(n = 93) were female, there was an even distribution among PGY, and seven programs were represented. Almost half of the cohort (48%) reported high risk for burnout and 68% reported experiencing mistreatment. Mistreatment by senior physician team members were correlated with EE(rho = 0.184,p = 0.016) and DP(rho = 0.181,p = 0.016).

Conclusion: While overall burnout was not significantly associated with mistreatment behaviors, both burnout and mistreatment were commonly reported.
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http://dx.doi.org/10.1016/j.amjsurg.2021.06.009DOI Listing
July 2021

Non-technical skill assessments across levels of US surgical training.

Surgery 2021 Sep 2;170(3):713-718. Epub 2021 Apr 2.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland. Electronic address:

Background: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool.

Methods: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression.

Results: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories.

Conclusion: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.
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http://dx.doi.org/10.1016/j.surg.2021.02.058DOI Listing
September 2021

Invited Commentary.

Authors:
Keith A Delman

J Am Coll Surg 2021 04;232(4):524-525

Atlanta GA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.028DOI Listing
April 2021

Invited Commentary.

Authors:
Keith A Delman

J Am Coll Surg 2021 04;232(4):431-432

Atlanta, GA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.049DOI Listing
April 2021

The Impact of Obesity on Surgically Treated Locoregional Melanoma.

Ann Surg Oncol 2021 Mar 14. Epub 2021 Mar 14.

Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.

Background: The impact of obesity on early-stage melanoma is poorly understood. We examined the impact of overweight and obesity on clinical outcomes in locoregional melanoma.

Methods: Adults who underwent surgery at Emory University Healthcare between 2010 and 2017 for clinically stage I-II cutaneous melanoma, with known stage, height, and weight at the time of presentation, were identified. The relationship between body mass index (BMI) and clinicopathologic characteristics was assessed.

Results: Of 1756 patients, 584 were obese (33.2%; BMI ≥ 30), 658 were overweight (37.5%; BMI ≥ 25 and < 30), and 514 were normal weight (29.3%; BMI < 25). Demographics associated with obesity included male sex (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.1-3.3; p < 0.001) and lower income (OR 1.5, 95% CI 1.2-1.9; p = 0.003). Melanomas in obese patients were thicker (2.0 ± 0.2 mm) than in overweight (1.7 ± 0.1 mm) or normal-weight patients (1.4 ± 0.1 mm; p = 0.002). Ulceration, mitoses, BRAF status, and sentinel lymph node (SLN) status were not affected by obesity. In multivariable analysis, obesity independently predicted increased odds of pathologic stage II melanoma (vs. stage 0 or I; OR 1.9, 95% CI 1.4-2.7, p = 0.001), but not pathologic stage III melanoma (p > 0.05). At 33 months' median follow-up, obesity was not an independent predictor of stage-specific overall survival (p > 0.05).

Conclusion: Obese patients are nearly twice as likely as their normal-weight peers to present with thicker melanomas, but they have similar stage-specific overall survival and SLN positivity. Obesity may promote more aggressive growth of the primary tumor, and barriers to preventive care in obese patients may exacerbate later-stage presentation.
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http://dx.doi.org/10.1245/s10434-021-09773-7DOI Listing
March 2021

A longitudinal cadaver-based simulation curriculum creates sustainable increases in resident confidence and exposure to fundamental techniques: Results of a 5-year program evaluation.

Am J Surg 2021 07 2;222(1):104-110. Epub 2020 Nov 2.

Department of Surgery, Emory University, Atlanta, GA, USA. Electronic address:

Introduction: For the past five years, our surgical residency program has led a cadaver-based simulation course focused on fundamental surgical maneuvers. This study aimed to quantify the impact of this course on resident exposure to surgical skills and longitudinal impact on resident education.

Methods: General surgery residents participated in an annual cadaver-based simulation curriculum. Participants completed surveys regarding improvements in knowledge and confidence; these results were stratified between course iterations (P1: 2 years, 2014-15; P2: 3 years, 2016-2018).

Results: Residents reported a sustained increase in knowledge of anatomy and technical dissection, confidence in performing operative skills independently, and exposure to operative skills that were otherwise not encountered in clinical rotations. Junior residents demonstrated an increase in gaining skills they would otherwise not achieve (87% vs. 98%, p = 0.028) and confidence to safely perform these procedures in the clinical setting (94% vs. 100%, p = 0.077).

Conclusion: This annual, longitudinal cadaver-based skills course focused on fundamental maneuvers demonstrates a sustained impact in resident and faculty surgical confidence in resident's operative skills as a component of a longitudinal simulation curriculum to enhance competency-based promotion.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.036DOI Listing
July 2021

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study.

J Surg Educ 2020 Nov - Dec;77(6):e86-e93. Epub 2020 Oct 17.

Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama. Electronic address:

Introduction: Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout.

Methods: General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site.

Results: Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication."

Conclusions: A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.
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http://dx.doi.org/10.1016/j.jsurg.2020.09.024DOI Listing
June 2021

Oncologic Outcomes After Isolated Limb Infusion for Advanced Melanoma: An International Comparison of the Procedure and Outcomes Between the United States and Australia.

Ann Surg Oncol 2020 Dec 11;27(13):5107-5118. Epub 2020 Sep 11.

Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.

Background: Isolated limb infusion (ILI) is a minimally invasive procedure for delivering high-dose chemotherapy to extremities affected by locally advanced or in-transit melanoma. This study compared the outcomes of melanoma patients treated with ILI in the United States of America (USA) and Australia (AUS).

Methods: Patients with locally recurrent in-transit melanoma treated with ILI at USA or AUS centers between 1992 and 2018 were identified. Demographic and clinicopathologic characteristics were collected. Primary outcomes of treatment response, in-field progression-free survival (IPFS), distant progression-free survival (DPFS), and overall survival (OS) were evaluated by the Kaplan-Meier method. Multivariable analysis evaluated whether availability of new systemic therapies affected outcomes.

Results: More ILIs were performed in AUS (n = 411, 60 %) than in the USA (n = 276, 40 %). In AUS, more ILIs were performed for stage 3B disease than in the USA (62 % vs 46 %; p < 0.001). The reported complete response rates were similar (AUS 30 % vs USA 29 %). Among the stage 3B patients, AUS patients had better IPFS (p = 0.001), whereas DPFS and OS were similar between the two countries. Among the stage 3C patients, the USA patients had better OS (p < 0.001), whereas IPFS and DPFS were similar. Availability of new systemic therapies did not affect IPFS or DPFS in either country. However, the USA patients who received ILI after ipilimumab approval in 2011 had significantly improved OS (hazard ratio, 0.62; p = 0.013).

Conclusions: AUS patients were treated at an earlier disease stage than the USA patients with better IPFS for stage 3B disease. The USA patients treated after the availability of new systemic therapies had a better OS.
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http://dx.doi.org/10.1245/s10434-020-09051-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674259PMC
December 2020

Factors predicting toxicity and response following isolated limb infusion for melanoma: An international multi-centre study.

Eur J Surg Oncol 2020 11 13;46(11):2140-2146. Epub 2020 Jul 13.

Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

Introduction: Isolated limb infusion (ILI) is a minimally-invasive procedure for delivering high-dose regional chemotherapy to treat melanoma in-transit metastases confined to a limb. The aim of this international multi-centre study was to identify predictive factors for toxicity and response.

Methods: Data of 687 patients who underwent a first ILI for melanoma in-transit metastases confined to the limb between 1992 and 2018 were collected at five Australian and four US tertiary referral centres.

Results: After ILI, predictive factors for increased limb toxicity (Wieberdink grade III/IV limb toxicity, n = 192, 27.9%) were: female gender, younger age, procedures performed before 2005, lower limb procedures, higher melphalan dose, longer drug circulation and ischemia times, and increased tissue hypoxia. No patient experienced grade V toxicity (necessitating amputation). A complete response (n = 199, 28.9%) was associated with a lower stage of disease, lower burden of disease (BOD) and thinner Breslow thickness of the primary melanoma. Additionally, an overall response (combined complete and partial response, n = 441, 64.1%) was associated with female gender, Australian centres, procedures performed before 2005, lower limb procedures and lower actinomycin-D doses. On multivariate analysis, higher melphalan dose remained a predictive factor for toxicity, while lower stage of disease and lower BOD remained predictive factors for overall response.

Conclusion: ILI is safe and effective to treat melanoma in-transit metastases. Predictive factors for toxicity and response identified in this study will allow improved patient selection and optimization of intra-operative parameters to increase response rates, while keeping toxicity low.
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http://dx.doi.org/10.1016/j.ejso.2020.06.040DOI Listing
November 2020

APDS Consensus Statement: Ideal Senior Medical Student Experiences for Preparedness for General Surgery Internship.

J Surg Educ 2021 Jan-Feb;78(1):69-75. Epub 2020 Jul 28.

Department of Surgery, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.

Objective: Guide optimal standards on ideal senior medical student experiences for preparedness for general surgery internship DESIGN: Work product of task force, approved by the Association of Program Directors in Surgery CONCLUSION: General surgery rotations should mirror the learning and working environment of a surgical intern. Opportunities should mimic the next phase of learning to help guide informed decisions regarding entrustability for entry into residency training. These opportunities will also help identify students who may have an aptitude for pursuing a general surgery internship. Students should achieve entrustability in Association of American Medical Colleges Core Entrustable Professional Activities (EPAs); curricula should align Core EPAs and modified American Board of Surgery EPAs to guide essential general surgery components. Experiences should include required night, holiday, and/or weekend shifts, a dedicated critical care experience, and a resident preparatory curriculum focusing on nontechnical and essential technical skills. We encourage the opportunity for additional surgical mentorship and subspecialty experience through Surgical Interest Groups or Surgical Honors or Specialty Tracks.
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http://dx.doi.org/10.1016/j.jsurg.2020.07.015DOI Listing
June 2021

Management of Melanoma Patients with Positive Nodes.

Adv Surg 2020 09 13;54:191-204. Epub 2020 May 13.

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365 Clifton Road, Building B, 4th Floor, Atlanta, GA 30322, USA. Electronic address:

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http://dx.doi.org/10.1016/j.yasu.2020.03.001DOI Listing
September 2020

"What Is Old Is New Again" Commentary on "Ensuring That Step 1 Isn't the Next 'Back in My Day"'.

Ann Surg 2020 08;272(2):240

Department of Surgery, Emory University School of Medicine, Atlanta, GA.

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http://dx.doi.org/10.1097/SLA.0000000000004046DOI Listing
August 2020

Development of a Surgical Evidence Blog at Morbidity and Mortality Conferences: Integrating Clinical Librarians to Enhance Resident Education.

J Surg Educ 2020 Sep - Oct;77(5):1069-1075. Epub 2020 Jun 15.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Introduction: Surgical morbidity and mortality (M&M) conference is a primary educational endeavor for trainees and faculty alike. Case presentations are enhanced by inclusion of clinical evidence; however, trainees are frequently limited in their ability to collect and share this type of material.

Methods: A surgical evidence web log ("blog") was created in partnership between the Clinical Librarian Service and the Department of Surgery. A clinical librarian attended weekly departmental M&M conferences and reviewed evidence in collaboration with a surgical resident. For each case presented, the clinical librarian created an evidence-based blog post based on specific learning topics encountered in the routine discussion of the M&M conference. The goal of this surgeon-librarian partnership was to enhance M&M's educational value by reinforcing learning topics, serving as a repository of case-based evidence, and involving trainees in evidence-based surgical practice.

Results: Blog posts included summaries of available evidence, critical reviews of seminal studies, and reviews of evidence-based guidelines framed in the context of the case. New blog posts were promoted via direct links in an existing weekly newsletter sent to all trainees and faculty in the department. Within the first year, surgical residents reported increased interaction with the literature, and 100% reported gaining knowledge that they would otherwise not receive through their standard readings, with 73% of residents using this to influence clinical practice and 87% applying knowledge in test preparation. This surgeon-librarian partnership enforces interdisciplinary collaboration through existing resources, and is highly generalizable to both surgical and medical training programs.

Conclusions: In this study, the development of a surgical evidence blog represents an effective resource for promoting evidence-based practices within a case-based learning curriculum. This intervention is the first report in the literature to integrate the expertise and resources of a Clinical Librarian Service with an evidence-based resident educational curriculum in a surgical residency program.
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http://dx.doi.org/10.1016/j.jsurg.2020.03.024DOI Listing
June 2021

Residents Behaving Badly: Pioneering Operations and the Surgical Trainees Who Performed Them.

J Surg Educ 2020 Nov - Dec;77(6):1392-1395. Epub 2020 Jun 15.

Department of Surgery, Emory University, Atlanta, Georgia. Electronic address:

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http://dx.doi.org/10.1016/j.jsurg.2020.05.021DOI Listing
June 2021

The (R)evolution of Melanoma Care.

Surg Oncol Clin N Am 2020 Jul;29(3):xv-xvi

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute of Emory University School of Medicine, 1365 Clifton Road NE, Atlanta, GA 30322, USA. Electronic address:

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http://dx.doi.org/10.1016/j.soc.2020.03.002DOI Listing
July 2020

Development of a surgical oncology training curriculum for accreditation.

J Surg Oncol 2020 Jul 18;122(1):15-20. Epub 2020 May 18.

Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York City, New York.

In 2011, the American Board of Surgery announced a new specialty board certification for Complex General Surgical Oncology. The development of a 2-year fellowship training curriculum was based on the core values of multidisciplinary care, surgical management of oncologic disease, education in basic research and clinical trial design, community outreach, patient counseling, and leadership in oncology. This article highlights the elements necessary for developing a fellowship training program in the context of these core values.
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http://dx.doi.org/10.1002/jso.25933DOI Listing
July 2020

Minimally invasive inguinal lymphadenectomy.

Authors:
Keith A Delman

J Surg Oncol 2020 Jul 22;122(1):96-98. Epub 2020 Mar 22.

Department of Surgery, Division of Surgical Oncoligy, Emory University, Atlanta, Georgia.

The focus of this article is not purely on the technical aspects of a novel procedure, but also the considerations a team might pursue in adopting, modifying, or developing a new procedure of any type. Performing a minimally invasive inguinal lymphadenectomy is challenging even to individuals experience in laparoscopic techniques and with open lymphadenectomy. This article summarizes the approach to adopting any new technique and specifically addresses the learning curve for minimally invasive lymphadenectomy. In addition, specific technical aspects of the procedure are enumerated.
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http://dx.doi.org/10.1002/jso.25876DOI Listing
July 2020

International Multicenter Experience of Isolated Limb Infusion for In-Transit Melanoma Metastases in Octogenarian and Nonagenarian Patients.

Ann Surg Oncol 2020 May 9;27(5):1420-1429. Epub 2020 Mar 9.

Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.

Background: Isolated limb infusion (ILI) is used to treat in-transit melanoma metastases confined to an extremity. However, little is known about its safety and efficacy in octogenarians and nonagenarians (ON).

Patients And Methods: ON patients (≥ 80 years) who underwent a first ILI for American Joint Committee on Cancer seventh edition stage IIIB/IIIC melanoma between 1992 and 2018 at nine international centers were included and compared with younger patients (< 80 years). A cytotoxic drug combination of melphalan and actinomycin-D was used.

Results: Of the 687 patients undergoing a first ILI, 160 were ON patients (median age 84 years; range 80-100 years). Compared with the younger cohort (n = 527; median age 67 years; range 29-79 years), ON patients were more frequently female (70.0% vs. 56.9%; p = 0.003), had more stage IIIB disease (63.8 vs. 53.3%; p = 0.02), and underwent more upper limb ILIs (16.9% vs. 9.5%; p = 0.009). ON patients experienced similar Wieberdink limb toxicity grades III/IV (25.0% vs. 29.2%; p = 0.45). No toxicity-related limb amputations were performed. Overall response for ON patients was 67.3%, versus 64.6% for younger patients (p = 0.53). Median in-field progression-free survival was 9 months for both groups (p = 0.88). Median distant progression-free survival was 36 versus 23 months (p = 0.16), overall survival was 29 versus 40 months (p < 0.0001), and melanoma-specific survival was 46 versus 78 months (p = 0.0007) for ON patients compared with younger patients, respectively.

Conclusions: ILI in ON patients is safe and effective with similar response and regional control rates compared with younger patients. However, overall and melanoma-specific survival are shorter.
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http://dx.doi.org/10.1245/s10434-020-08312-0DOI Listing
May 2020

Introducing the "Virtual Tumor Board" series in CA: A Cancer Journal for Clinicians.

Authors:
Keith A Delman

CA Cancer J Clin 2020 03 26;70(2):77. Epub 2020 Feb 26.

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http://dx.doi.org/10.3322/caac.21598DOI Listing
March 2020

Surgical Considerations and Systemic Therapy of Melanoma.

Surg Clin North Am 2020 Feb 1;100(1):141-159. Epub 2019 Nov 1.

Division of Surgical Oncology, Emory University School of Medicine, 1365B Clifton Road Northeast, Suite B4000, Atlanta, GA 30322, USA. Electronic address:

Recent advances in effective medical therapies have markedly improved the prognosis for patients with advanced melanoma. This article aims to highlight the current era of integrated multidisciplinary care of patients with advanced melanoma by outlining current approved therapies, including immunotherapy, targeted therapy, radiation therapy, and other strategies used in both the adjuvant and the neoadjuvant setting as well as the evolving role of surgical intervention in the changing landscape of advanced melanoma.
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http://dx.doi.org/10.1016/j.suc.2019.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914258PMC
February 2020

Can a Structured, Video-Based Cadaver Curriculum Demonstrating Proficiency Enhance Resident Operative Autonomy?

J Surg Educ 2019 Nov - Dec;76(6):e152-e160. Epub 2019 Sep 20.

Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia. Electronic address:

Introduction: Autonomy is of foremost concern in the current era of surgical residency, and it is especially important to trainees when considering their surgical education. Factors impacting trainee independence include the restriction of clinical work hours and the development of advanced minimally invasive techniques such as robotics, which requires separate technical education outside of conventional surgical education. Moreover, when residents are left to learn fundamental exposures via their clinical experience alone, they run the risk of not being exposed to some fundamental skills based on case volume and type. The Department of Surgery at Emory University developed a cadaver-based simulation curriculum to standardize exposure to fundamental operative skills and enhance proficiency outside the operating room, with the larger aim of improving resident autonomy.

Methods: Residents were assigned to small groups led by a chief resident with an even distribution of postgraduate year (PGY) levels. Each group participated in core surgical exposures and fundamental maneuvers on a cadaver over a 6-hour session. Residents were tested on skills according to their PGY level about 1 month after the course. Testing included recitation of the skill in an oral boards format, highlighting major steps, followed by performance of the skill. All steps were video-recorded with no resident identifiers. These were reviewed by 2 independent, blinded faculty examiners who assigned proficiency grades to each resident video.

Results: Three hundred and thirty-three individual procedure evaluations were done over the 5-year period. Senior residents (PGY3-5) had 86% pass rate while junior residents (PGY1-2) had 70% pass rate. Overall, 21% of residents failed to achieve competence in their assigned skills. Junior residents were less likely to achieve competence compared to senior residents. Faculty graders had improved congruence in grading as the course progressed through the 5 years. The most recent 2 years had >80% congruence in faculty grading compared to less than 50% congruence in the first 2 years. 81% of attendings agreed this course positively influenced the granting of autonomy in the operating room.

Conclusions: A cadaveric skills course focused on fundamental maneuvers with objective confirmation of achieving competency is a viable adjunct to clinical operative experience. Video-recorded evaluation, of these fundamental skills improved both resident and attending confidence in trainee operative skill.
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http://dx.doi.org/10.1016/j.jsurg.2019.08.004DOI Listing
December 2020

The Prognostic Value of Lymphovascular Invasion in Truncal and Extremity Soft Tissue Sarcomas: An Analysis from the National Cancer Database.

Ann Surg Oncol 2019 Dec 9;26(13):4723-4729. Epub 2019 Sep 9.

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.

Objective: The aim of this study was to determine the association between lymphovascular invasion (LVI) and overall survival (OS) in truncal/extremity soft tissue sarcomas (STS).

Methods: The National Cancer Database (NCDB) was queried for all patients, ages 18-85 years, who underwent resection of primary, truncal/extremity STS between 2010 and 2012, and had LVI data. The primary endpoint was OS.

Results: Among 6169 patients identified, the most common histology groups were (1) liposarcoma (LPS, 24%), (2) undifferentiated pleiomorphic sarcoma (UPS, 19%), and (3) leiomyosarcoma (LMS, 15%); 449 patients (7%) were LVI-positive. There were no differences in demographics or comorbidities between the LVI groups. Compared with LVI-negative patients, LVI-positive patients were more likely to have larger (> 5 cm: 80% vs. 66%), deep (80% vs. 68%), and high-grade tumors (82% vs. 57%). They were also more likely to have positive margins (27% vs. 17%), nodal (16% vs. 2%) and metastatic disease (21% vs. 4%), and receive chemotherapy (37% vs. 18%; all p < 0.001). LVI was associated with worse median OS (39 months vs. MNR; p < 0.001), which persisted on stratum-specific analyses for all tumor grades, size categories, and stages I-III, but not stage IV. On multivariable Cox regression, LVI was associated with worse OS (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.39-2.44), while accounting for other significant prognostic factors. Among non-metastatic, curative-intent resections (n = 5696), LVI was still associated with worse OS (HR 1.79, 95% CI 1.28-2.49).

Conclusions: LVI appears to be an important adverse pathologic factor in truncal and extremity STS. Even when taking into account other established prognostic factors, LVI was predictive of worse OS. Knowledge of LVI status may help to better risk-stratify patients and guide management strategies, and should be considered in future prognostic classification schemes and nomograms.
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http://dx.doi.org/10.1245/s10434-019-07805-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958703PMC
December 2019

A Call to Arms: Surgeons Must Play an Important and Early Role in the Management of Patients with Advanced Melanoma.

Ann Surg Oncol 2019 Dec 29;26(13):4180-4181. Epub 2019 Aug 29.

Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.

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http://dx.doi.org/10.1245/s10434-019-07648-6DOI Listing
December 2019

Neoadjuvant therapy of locally/regionally advanced melanoma.

Ther Adv Med Oncol 2019 31;11:1758835919866959. Epub 2019 Jul 31.

Department of Hematology and Medical Oncology, Emory University School of Medicine, Winship Comprehensive Cancer Center, 1365 Clifton Rd Atlanta, GA 30322, USA.

Locally/regionally advanced melanoma confers a major challenge in terms of surgical and medical management. Surgical treatment carries the risks of surgical morbidities and potential complications that could be lasting. In addition, these patients continue to have a high risk of relapse and death despite the use of standard adjuvant therapy. Neoadjuvant therapy has the potential to significantly improve the clinical outcome of these patients, particularly in this era of newer and effective targeted and immunotherapeutic agents. Previous neoadjuvant studies tested chemotherapy with temozolomide where the clinical activity was limited. Biochemotherapy (BCT) was tested in two studies in the neoadjuvant setting and showed high tumor response rates; however, BCT was ultimately abandoned following its failure to demonstrate survival benefits in randomized trials of metastatic disease. Success of immunotherapy and targeted therapy in prolonging the lives of patients with metastatic melanoma generated considerable interest to investigate these novel strategies in the adjuvant and neoadjuvant settings. A number of neoadjuvant targeted and immunotherapy studies have been completed in melanoma to date and have yielded promising clinical activity. Given these encouraging results, a number of studies with other molecularly targeted and immunotherapeutic agents and their combinations are ongoing in the neoadjuvant setting; long-term outcome data are eagerly awaited. Such studies also provide access to biospecimens before and during therapy, allowing for the conduct of biomarker and mechanistic studies that may have a significant impact in guiding adjuvant therapy choices and drug development.
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http://dx.doi.org/10.1177/1758835919866959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669845PMC
July 2019

Lung Surveillance Strategy for High-Grade Soft Tissue Sarcomas: Chest X-Ray or CT Scan?

J Am Coll Surg 2019 11 1;229(5):449-457. Epub 2019 Aug 1.

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Atlanta, GA. Electronic address:

Background: Given the propensity for lung metastases, National Comprehensive Cancer Network guidelines recommend lung surveillance with either chest x-ray (CXR) or CT in high-grade soft tissue sarcoma. Considering survival, diagnostic sensitivity, and cost, the optimal modality is unknown.

Methods: The US Sarcoma Collaborative database (2000 to 2016) was reviewed for patients who underwent resection of a primary high-grade soft tissue sarcoma. Primary end point was overall survival (OS). Cost analysis was performed.

Results: Among 909 patients, 83% had truncal/extremity and 17% had retroperitoneal tumors. Recurrence occurred in 48%, of which 54% were lung metastases. Lung surveillance was performed with CT in 80% and CXR in 20%. Both groups were clinically similar, although CT patients had more retroperitoneal tumors and recurrences. Regardless of modality, 85% to 90% of lung metastases were detected within the first 2 years with a similar re-intervention rate. When considering age, tumor size, location, margin status, and receipt of radiation, lung metastasis was independently associated with worse OS (hazard ratio 4.26; p < 0.01) and imaging modality was not (hazard ratio 1.01; p = 0.97). Chest x-ray patients did not have an inferior 5-year OS rate compared with CT (71% vs 60%; p < 0.01). When analyzing patients in whom no lung metastases were detected, both cohorts had a similar 5-year OS rate (73% vs 74%; p = 0.42), suggesting CXR was not missing clinically relevant lung nodules. When adhering to a guideline-specified protocol for 2018 projected 4,406 cases, surveillance with CXR for 5 years results in savings of $5 million to $8 million/year to the US healthcare system.

Conclusions: In this large multicenter study, lung surveillance with CXR did not result in worse overall survival compared with CT. With considerable savings, a CXR-based protocol can optimize resource use for lung surveillance in high-grade soft tissue sarcoma; prospective trials are needed.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815708PMC
November 2019

Long-Term Oncologic Outcomes After Isolated Limb Infusion for Locoregionally Metastatic Melanoma: An International Multicenter Analysis.

Ann Surg Oncol 2019 Aug 25;26(8):2486-2494. Epub 2019 Mar 25.

Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.

Background: Isolated limb infusion (ILI) is a minimally invasive procedure for delivering high-dose regional chemotherapy to patients with locally advanced or in-transit melanoma located on a limb. The current international multicenter study evaluated the perioperative and long-term oncologic outcomes for patients who underwent ILI for stage 3B or 3C melanoma.

Methods: Patients undergoing a first-time ILI for stage 3B or 3C melanoma (American Joint Committee on Cancer [AJCC] 7th ed) between 1992 and 2018 at five Australian and four United States of America (USA) tertiary referral centers were identified. The primary outcome measures included treatment response, in-field (IPFS) and distant progression-free survival (DPFS), and overall survival (OS).

Results: A total of 687 first-time ILIs were performed (stage 3B: n = 383, 56%; stage 3C; n = 304, 44%). Significant limb toxicity (Wieberdink grade 4) developed in 27 patients (3.9%). No amputations (grade 5) were performed. The overall response rate was 64.1% (complete response [CR], 28.9%; partial response [PR], 35.2%). Stable disease (SD) occurred in 14.5% and progressive disease (PD) in 19.8% of the patients. The median follow-up period was 47 months, with a median OS of 38.2 months. When stratified by response, the patients with a CR or PR had a significantly longer median IPFS (21.9 vs 3.0 months; p < 0.0001), DPFS (53.6 vs 12.7 months; p < 0.0001), and OS (46.5 vs 24.4 months; p < 0.0001) than the nonresponders (SD + PD).

Conclusion: This study is the largest to date reporting long-term outcomes of ILI for locoregionally metastatic melanoma. The findings demonstrate that ILI is effective and safe for patients with stage 3B or 3C melanoma confined to a limb. A favorable response to ILI is associated with significantly longer IFPS, DPFS, and OS.
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http://dx.doi.org/10.1245/s10434-019-07288-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771312PMC
August 2019
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