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Surgical treatment of invasive lobular carcinoma (ILC) is challenging due to its diffuse growth pattern, and the positive margin rate after mastectomy is poorly described. We retrospectively determined the positive margin rate in those with stage I-III ILC undergoing mastectomy. We evaluated the relationship between management strategy and recurrence free survival (RFS). In 357 patients, the positive margin rate was 10.6% overall and 18.7% in those with T3 tumors. Having a positive margin was associated with significantly shorter RFS on multivariate analysis (p = 0.01). Undergoing additional local treatment (radiation or re-excision) for a positive margin was significantly associated with improved RFS (p = 0.004). Older women with positive margins were significantly less likely to undergo additional local therapy. Even mastectomy fails to clear margins in a high proportion of patients with large ILC tumors, a finding which may warrant testing neoadjuvant strategies even prior to planned mastectomy. •The positive margin rate after mastectomy for invasive lobular carcinoma is unknown.•In patients undergoing mastectomy for lobular breast cancer, positive margins occurred in 18.7% of those with T3 tumors.•Additional local therapy for positive margins was associated with significantly improved outcomes over only systemic therapy.

Purpose With DCIS incidence on the rise, up to 30% of patients undergo mastectomy for Ductal carcinoma in situ (DCIS) (Nash and Hwang, in: Ann Surg Oncol 30(6):3206–3214, 2023). Local recurrence rates after mastectomy for DCIS are reportedly low, but risk factors for recurrence are not known (Kim et al., in: J Cancer Res Ther 16(6):1197–1202, 2020). We aim to define risk factors associated with ipsilateral breast cancer recurrence in patients undergoing mastectomy for DCIS. Methods We aimed to identify risk factors that may contribute to recurrence of breast cancer following mastectomy for pure DCIS. We hypothesized that close or positive mastectomy margins, age at diagnosis, extent of breast disease and mutation carriers would be associated with increased risk of recurrence. We performed a retrospective chart review of patients who underwent unilateral or bilateral mastectomies for pure DCIS at a single academic tertiary referral center from 2013 to 2023. Results There were 165 patients who met inclusion criteria with an average length of follow-up of 39.9 months. On final surgical pathology, the average span of DCIS was 33.7 mm (± 24.6 mm). Hormone receptor positive disease was identified in 80.6% of the patient cohort. For margin status, 23 patients (14%) had < 1 mm margins on final pathology and of those, 1 received adjuvant radiation therapy and 4 returned to the OR for re-excision. Only 1 (0.6%) patient had ipsilateral disease recurrence during the study period. Conclusion Recurrence after mastectomy for pure DCIS is a rare event and in our study sample, only one recurrence occurred. Risk factors for recurrence appear unrelated to margin status, age, extent of DCIS, or pathogenic mutation (ElSherif et al., in Am J Surg 226(5):646–651, 2023).

Purpose Recent studies have established the safety and efficacy of Superparamagnetic Iron Oxide (SPIO, Magtrace®) for delayed sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) who are undergoing mastectomy. The aim of our study was to measure cost containment with use of Magtrace® in comparison to upfront SLNB with traditional technetium-99 lymphatic tracer. Methods A total of 41 patients at our institution underwent mastectomy with Magtrace® injection for DCIS and were included in our single-institution, retrospective analysis. For comparison, total charges data were obtained for an upfront SLNB at the time of mastectomy. Cost comparison analysis was then performed against charges for intraoperative Magtrace® injection with additional charges incorporated for those patients who required return to the operating room for delayed SLNB. Total cost containment for the cohort with use of Magtrace® was then measured. Results Of the 41 patients who underwent Magtrace® injection, two patients required return to the operating room for a delayed SLNB for invasive disease. Including these charges for a second encounter into our cost analysis, the use of Magtrace® still yielded an overall cost containment of $205,793.55 in our cohort when comparing to patients who underwent upfront SLNB. For patients who underwent Magtrace® injection and did not require return to the operating room, charges were reduced by $6,768.52 per patient. Conclusion The use of Magtrace® for delayed SLNB in patients with DCIS undergoing mastectomy yielded a significant overall cost containment, further supporting its use in this patient population.

Purpose Unnecessary axillary surgery can potentially be avoided in patients with DCIS undergoing mastectomy. Current guidelines recommend upfront sentinel lymph node biopsy during the index operation due to the potential of upstaging to invasive cancer. This study reviews a single institution’s experience with de-escalating axillary surgery using superparamagnetic iron oxide dye for axillary mapping in patients undergoing mastectomy for DCIS. Methods This is a retrospective single-institution cross-sectional study. All medical records of patients who underwent mastectomy for a diagnosis of DCIS from August 2021 to January 2023 were reviewed and patients who had SPIO injected at the time of the index mastectomy were included in the study. Descriptive statistics of demographics, clinical information, pathology results, and interval sentinel lymph node biopsy were performed. Results A total of 41 participants underwent 45 mastectomies for DCIS. The median age of the participants was 58 years (IQR = 17; range 25 to 76 years), and the majority of participants were female (97.8%). The most common indication for mastectomy was diffuse extent of disease (31.7%). On final pathology, 75.6% (34/45) of mastectomy specimens had DCIS without any type of invasion and 15.6% (7/45) had invasive cancer. Of the 7 cases with upgrade to invasive disease, 2 (28.6%) of them underwent interval sentinel lymph node biopsy. All sentinel lymph nodes biopsied were negative for cancer. Conclusion The use of superparamagnetic iron oxide dye can prevent unnecessary axillary surgery in patients with DCIS undergoing mastectomy.

Hospitality industry members have an expectation of graduates that are entering the industry to meet knowledge and skills requirements. These individuals start their qualification with a certain level of expectation about the industry. The hospitality industry faces many challenges; one of these is the early career departure of hospitality graduates. For the purpose of this study, graduate preparedness was assessed by identifying how the curriculum at various hospitality institutions has contributed to the students’ preparation and confidence in pursuing a career in the hospitality industry. The expectations of a graduate were identified by various industry members, who highlighted the necessary requirements that prove to be essential in a potential employee. The study applied a mixed method research approach. Quantitative data was collected from third and fourth-year hospitality students, from various South African hospitality institutions, with the use of an online questionnaire to identify their preparedness to enter the industry, post the COVID-19 year, 2020. Qualitative data were collected from hospitality industry managers, each representing a different hotel group within South Africa. Data were collected using semi-structured interviews to identify their expectations of a graduate, if their expectations had changed due to COVID-19, as well as identifying strategies to reduce the gap between graduate preparedness and industry expectations. Both groups of respondents emphasised the importance of work experience before and during the training of the students to ensure that their expectation management is rationalised.

Although neurobiological mechanisms underlying alcohol use and dependence have been extensively researched, mechanisms explaining sex differences in alcohol drinking are poorly understood. The cortical-striatal circuit plays a key role in the development of alcohol dependence, and it has previously been shown that oscillations from these regions predict drinking in non-dependent male rats, but not in female rats. Since women are more likely to report using alcohol for negative reinforcement reasons and are more sensitive to stress-induced relapse, we hypothesized that stress-related neural circuits may contain more information predictive of female drinking. To test this, we determined whether cortical, striatal, and/or limbic oscillations during alcohol self-administration would distinguish between dependent and non-dependent rats in a sex-specific manner. Male and female Sprague-Dawley rats were trained to self-administer 10% alcohol before implanting bilateral electrodes targeting the infralimbic medial prefrontal cortex (mPFC), nucleus accumbens shell (NAcSh), and central nucleus of the amygdala (CeA). Then, half of the rats were exposed to four weeks of chronic intermittent alcohol (CIA) vapor (14 hours on/10 hours off) to induce dependence. After dependence was established and during acute withdrawal (approximately 7 hours after the vapor turns off), local field potentials (LFPs) were recorded from the mPFC, NAcSh, and CeA during another round of self-administration sessions. Using an unbiased machine learning approach, we built predictive models to determine whether oscillations could distinguish CIA-exposed from control rats in both sexes. Overall, female rats self-administered more alcohol than males. CIA exposure increased alcohol self-administration in both sexes, but to a larger extent in males. Preliminary analysis revealed that NAcSh and mPFC LFPs best predict CIA exposure in males, while CeA and mPFC oscillations best predict CIA exposure in females. These data provide support for sex-specific neurobiological correlates of dependence, which contributes to our understanding of sex differences in alcohol misuse.

BackgroundAxillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial.MethodsWe examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time.ResultsOf 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR−/HER2−, HR+/HER2−, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001).ConclusionsUse of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.

Background Internal mammary lymphadenopathy (IML) plays a role in breast cancer stage and prognosis. We aimed to evaluate method of IML detection, how IML impacts response to neoadjuvant chemotherapy (NAC), and oncologic outcomes. Methods We evaluated patients enrolled in the I-SPY-2 clinical trial from 2010 to 2022. We captured the radiographic method of IML detection (magnetic resonance imaging [MRI], positron emission tomography/computed tomography [PET/CT], or both) and compared patients with IML with those without. Rates of locoregional recurrence (LRR), distant recurrence (DR) and event-free survival (EFS) were compared by bivariate analysis. Results Of 2095 patients, 198 (9.5%) had IML reported on pretreatment imaging. The method of IML detection was 154 (77.8%) MRI only, 11 (5.6%) PET/CT only, and 33 (16.7%) both. Factors associated with IML were younger age ( p  = 0.001), larger tumors ( p  < 0.001), and higher tumor grade ( p  = 0.027). Pathologic complete response (pCR) was slightly higher in the IML group (41.4% vs. 34.0%; p  = 0.03). There was no difference in breast or axillary surgery ( p  = 0.41 and p  = 0.16), however IML patients were more likely to undergo radiation (68.2% vs. 54.1%; p  < 0.001). With a median follow up of 3.72 years (range 0.4–10.2), there was no difference between IM+ versus IM− in LRR (5.6% vs. 3.8%; p  = 0.25), DR (9.1% vs. 7.9%; p  = 0.58), or EFS (61.6% vs. 57.2%; p  = 0.48). This was true for patients with and without pCR. Conclusions In this large cohort of patients treated with NAC, outcomes were not negatively impacted by IML. We demonstrated that IML influences treatment selection but is not a poor prognostic indicator when treated with modern NAC and multidisciplinary disease management.

BackgroundAlthough rates of total skin-sparing (nipple-sparing) mastectomies are increasing, the oncologic safety of this procedure has not been evaluated in invasive lobular carcinoma (ILC). ILC is the second most common type of breast cancer, and its diffuse growth pattern and high positive margin rates potentially increase the risk of poor outcomes from less extensive surgical resection.MethodsWe compared time to local recurrence and positive margin rates in a cohort of 300 patients with ILC undergoing either total skin-sparing mastectomy (TSSM), skin-sparing mastectomy, or simple mastectomy between the years 2000–2020. Data were obtained from a prospectively maintained institutional database and were analyzed by using univariate statistics, the log-rank test, and multivariate Cox proportional hazards models.ResultsOf 300 cases, mastectomy type was TSSM in 119 (39.7%), skin-sparing mastectomy in 52 (17.3%), and simple mastectomy in 129 (43%). The rate of TSSM increased significantly with time (p < 0.001) and was associated with younger age at diagnosis (p = 0.0007). There was no difference in time to local recurrence on univariate and multivariate analysis, nor difference in positive margin rates by mastectomy type. Factors significantly associated with shorter local recurrence-free survival were higher tumor stage and tumor grade.ConclusionsTSSM can be safely offered to patients with ILC, despite the diffuse growth pattern seen in this tumor type.