June 2023

This multicenter cohort study in patients with pathologic T1a cutaneous melanoma demonstrated that patients of younger age, with lymphovascular invasion, with head/neck primary tumor site, and with mitogenicity were at higher risk of having sentinel lymph node positivity (SLN+).

Summary: The majority of newly diagnosed melanoma lesions are T1 lesions (≤1 mm). Previously, the National Comprehensive Cancer Network (NCCN) had routinely recommended T1b lesions (0.80-1.0 mm Breslow’s depth with or without ulceration or <0.8 mm with ulceration) undergo sentinel lymph node biopsy (SLNB), but had not routinely recommended this procedure in those patients with T1a (<0.8 mm without ulceration) lesions. T1 melanoma, in general, has a low risk of SLN+, but younger age, presence of lymphovascular invasion, mitogenicity, and higher Clark level have all been documented in individual series to be associated with a higher risk of SLN+. Unfortunately, the studies demonstrating the lower risk of SLN+ in T1 lesions were primarily weighted towards inclusion of T1b lesions, resulting in a lack of data to support the use of SLNB in T1a melanoma. The Penn institutional cohort examined predictors of SLN+ among these patients and noted a rate of SLN+ as high as 12.8% in patients with T1a melanoma who were <40 years with mitogenicity. Subsequently, this multicenter study aimed to determine the prognostic factors associated with SLN+ among T1a melanoma patients as well as the outcomes associated with SLN+ in this population.

Nine-hundred sixty-five patients with T1a melanoma were examined; the overall SLN+ rate was 4.5%. Factors associated with SLN+ included age ≤42 years (p=0.03, head/neck primary tumor location (p=0.04), presence of lymphovascular invasion (p=0.01), and mitotic count ≥2 mitoses/mm2 (p=0.03). A classification and regression tree with appropriate goodness-of-it was used to risk-stratify patients for SLN+ using these factors. Patients ≤42 years with ≥2 mitoses/mm2 (N = 38) had a SLN+ rate of 18.4%. Among patients of age ≤42 years with lymphovascular invasion, head/neck primary tumor site, and mitotic count ≥2 mitoses/mm2 (N=6), the SLN+ rate was 33%. Median follow-up of the cohort was 73 months, and 5-year disease-specific survival (DSS) was significantly different (90.7% vs 99.5%, p<0.0001) when comparing SLN+ versus SLN- patients.

This study identified high-risk factors for SLN+ in patients with T1a melanoma using a multicenter cohort. Within high-risk subgroups, the rate of SLN+ was as high as 33%, despite previously documented rates of SLN+ in T1 lesions being <5%. Additionally, this study’s survival analysis demonstrated the importance of appropriate staging and prognostication in these patients. While the SLN+ rate for T1a melanomas is low overall, there are subgroups with higher risk of SLN+ for which SLNB should be considered. Following the findings of this study, the 2023 NCCN guidelines were revised to recommend SLNB be offered to patients with T1a cutaneous melanoma in the setting of age ≤42 years, mitogenicity, lymphovascular invasion, or head/neck primary tumor site.

This single-center retrospective study explores risk factors, clinical context, and outcomes of new onset heart failure following liver transplantation. Out of a cohort of 528 patients over five years, six percent of patients developed heart failure, which was associated with increased morbidity and mortality within the first year following liver transplant.

Summary: This study retrospectively investigates the incidence, risk factors, and outcomes of new-onset heart failure (HF) after liver transplantation (LT) in a cohort of adults with normal pre-operative heart function. 528 patients underwent piggyback LT at the University of Miami/Jackson Memorial Hospital over a span of five years. Data from the electronic medical records, including patient demographics, pre-operative clinical variables, pre-transplant cardiac workup, intraoperative anesthesia variables, and post-operative outcomes were gathered. The primary outcome was development of new-onset systolic HF within one year post-transplant, defined as signs/symptoms of HF and echocardiographic evidence of reduced left ventricular (LV) and/or (RV) function.
 
Of the cohort, 6% developed new-onset HF within the first year, with 77% being non-ischemic. The primary causes of non-ischemic HF were takotsubo cardiomyopathy (median onset: 4 days) and sepsis (31 days). Non-ischemic HF exhibited worse LV dysfunction compared to ischemic HF (LVEF reduction of 25% vs. 15%), with 83% of these patients showing partial or complete function recovery. Two out of seven ischemic HF cases occurred in patients with new coronary artery disease (CAD). Among patients with documented pre-transplant CAD, 6% developed ischemic HF after LT, at a median of 5 post-operative days. Overall, those with new-onset HF post-LT had higher rates of cardiovascular events including myocardial infarction, atrial fibrillation, stroke, and DVT/PE, within the first year. These patients also exhibited longer intubation times, higher incidence of tracheostomy, extended ICU and hospital stays, and lower survival rates compared with the non-HF group (65% vs 94%).

Several preoperative risk factors associated with new-onset HF post-LT were identified, including higher MELD scores, pre-transplant renal replacement therapy (RRT), lower baseline hemoglobin levels, diastolic dysfunction, and a history of pre-transplant hospitalization or mechanical ventilation. Intraoperative factors such as the use of vasopressors (specifically epinephrine and norepinephrine) and the volume of crystalloid administration, also impacted the risk of new-onset HF. To further explore these variables and their potential relationship with HF occurrence, the authors employed recursive partitioning. The classification tree generated identified three key risk subgroups: vasopressor use, baseline hemoglobin, and crystalloid administration.

This research highlights the necessity for adept perioperative care to minimize post-LT HF risk and its wide-ranging impact within the first year. Notably, only 6% of patients with pre-transplant CAD in this cohort developed ischemic HF, reaffirming rigorous pre-transplant cardiac workup. The study aligns with others showing non-ischemic HF as most common post-LT, primarily due to stress-induced cardiomyopathy. The significance of intraoperative vasopressor use, preoperative anemia, and high-volume crystalloid resuscitation suggests volume overload and elevated catecholamines are critical factors in development of non-ischemic HF. The study also quantifies severe outcomes of post-LT HF, including cardiovascular events, in-hospital complications, and one-year mortality. Despite inherent limitations in study design and potential selection bias, this research underscores the clinical intricacies of HF post-LT, calling for further research to enhance perioperative care and outcomes for LT recipients.

This cross-sectional study used the Nationwide Emergency Department Sample (NEDS) to evaluate the association between race/ethnicity and interhospital transfer for complex emergency surgical disease.

Summary: Studies have shown that transfer to high-volume tertiary care centers with more advanced clinical resources is associated with improved outcomes for life threatening emergency general surgery conditions. Standardized protocols to guide initiation of such transfers, however, are often lacking. The present study sought to identify and better quantify racial/ethnic disparities in interhospital transfers (IHT), in order to help address barriers to quality surgical care and improved outcomes for complex emergency surgical disease.

This was a cross-sectional analysis of adult patients over 18 years of age, who presented to an emergency department in the United States with 1 of 13 complex surgical conditions. Data was pooled from the 2019 Nationwide Emergency Department Sample—the largest all-payor ED database in the United States, that included geographic, clinical, hospital and patient information. Patients were dichotomized using a previously described schema into “less complex” and “more complex,” and only included “more complex” patients in the present study. Ultimately, a weighted population of 387, 610 patients from nearly 90,000 patient encounters across 989 emergency departments, were included in their final analyses.

Not surprisingly, in unadjusted models, non-Hispanic white patients had significantly higher rates of interhospital transfer, compared to patients identified as non-Hispanic Black, Asian/Pacific islander or Hispanic/Latino.  Interestingly, after multivariate regression modeling, this difference went away for non-Hispanic Black patients, but persisted for the other minoritized groups included in this study, with significantly lower rates of interhospital transfer for Hispanic/Latino and Asian/Pacific Islander identified patients compared to non-Hispanic white patients.

This study does offer an interesting starting point for further investigation, but it limited. The article suggests factors beyond geography, age, comorbidity, socioeconomic and insurance status drive racial/ethnic differences in IHT, but does not offer insight into these factors. The two patient groups with persistent IHT differences, compared to the non-Hispanic white group, represent incredibly heterogenous groups of people with significant cultural, language, and social differences, not captured in these groupings. This heterogeneity makes interpretation of this data difficult, a point the authors acknowledge.

While this study has many limitations, it does identify a potential target for further investigation by regional policy makers and hospital systems, so as to improve quality and equity of surgical care.