Search

Acute abdominal pain is a common reason for presentation to the emergency department in the United States. This complaint is often ambiguous and requires a broad differential diagnosis and workup to determine the underlying etiology. This article describes one such case that resulted in an atypical diagnosis. In addition to presenting an unusual case representing a common complaint, this submission also illustrates the ability of the nurse practitioner to provide care to patients with complex medical problems, the benefit of postgraduate continued education, and the significant role a nurse practitioner plays on the interdisciplinary team of today’s health care environment.

Postoperative pain managed with opioids has contributed to the opioid crisis through over-prescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board–approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21–94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non–LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an over-prescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.

Lynch syndrome (LS) is a common genetic syndrome characterized by pathogenic mutations of DNA mismatch repair genes resulting in a hereditary predisposition to cancer. While typically associated with colonic and endometrial cancer, LS additionally influences the development of many other malignancies. The Amsterdam II and Revised Bethesda Guidelines are the established clinical criteria for diagnosing LS. These guidelines are based on the most general characteristics of LS and do not address specific characteristics of the less commonly LS-associated malignancies. For individuals that present initially with a non-colon and non-endometrial malignancy, recommendations and guidelines on when to consider screening for LS are limited. Therefore, it is essential that clinicians are familiar with distinct LS-associated patient- and tumor-specific characteristics, especially of the less common LS-associated cancers, so that LS’s diagnosis is not missed. In this review article, we focus on extra-colonic and extra-endometrial LS-associated cancers, paying particular attention to any established or currently investigated cancer features that help raise suspicion for LS and potentially lead to its earlier diagnosis. This review will also discuss current guidelines specific to each LS-associated malignancy.

32 Background: The University of Tennessee Medical Center (UTMCK), Knoxville Tennessee is the region’s sole academic medical center. Annually, 3000 new patients are seen within the Cancer Institute (CI) of UTMCK, and over 13% are breast cancer patients. Under the leadership of our director, Surgical Oncologist Dr. John L. Bell, survivorship care has been offered to these patients for almost twenty years. This combination has created a unique opportunity for us to look at long term results of offering disease-specific survivorship care, and what effect it has made upon detection of recurrence. Methods: Tumor registry data was utilized to examine the influence of survivorship care upon detection of recurrence. All patients treated from 1999 – 2015 with a diagnosis of recurrent breast cancer were selected out of the tumor registry. These patients were then stratified by time to recurrence, and mean, median, and range were calculated in time to recurrence (TR) by month. Results: A total of 223 patients with recurrent breast cancer were identified in our tumor registry out of 4422 total breast cancer patients treated by UTMCK from 1999 – 2015, recurrence rate of 5.04%. The mean TR for this cohort was 43.9 months. The median TR was 33 months, and the range of TR varied from 4 months to 166 months. All patients were followed for a minimum of five years following their diagnosis, and by 60 months, 73.99% of all recurrences were identified. Conclusions: Offering disease specific survivorship care to breast cancer patients is beneficial to both patients and our institution. When recurrence is diagnosed, survivorship care is valuable by helping to identify these cases as early as possible, to get patients back into active treatment sooner in the disease process. We have demonstrated that this is not a recent phenomenon reflective of current practice changes and accreditation requirements, and have validated this with our institution’s long history of providing survivorship care services for breast cancer patients dating back to the last century.

181 Background: The University of Tennessee Medical Center in Knoxville, Tennessee is the regions only academic medical center. This includes the Cancer Institute, where in 2013 a division dedicated to melanoma and soft tissue tumors (MASTT) was created. Since 2013, the number of melanoma cases treated at UTMCK treated has increased in excess of 300%. One critical aspect of the MASTT service was to provide survivorship care to all patients treated. This has given MASTT a unique opportunity to determine how survivorship care has impacted detection of recurrence in melanoma. Methods: Tumor registry data was retrospectively reviewed from a prospectively maintained database. All melanoma patients treated from 2011 to 2015 were identified. This cohort was selected because all of these patients would have been eligible for survivorship care. These patients were then stratified into stage and sub-stage, recurrence status, stage at recurrence, and whether alive or dead. Median and range of time to recurrence were calculated as well. Results: A total of 758 patients were treated for melanoma between 2011 and 2015 at UTMCK by the MASTT service. From this overall sample, a total of 37 patients demonstrated recurrence (4.88% overall). Local recurrence was noted in 9 cases (1.2%), regional recurrence in 4 cases (0.53%) and distant in 15 cases (2.0%). Seven of the recurrent cases were not specified. Median time to recurrence was 12 months (6-40 months). Overall mortality rate for patients with recurrent melanoma was 18/37 (48.6%). Nationally, local recurrence rates are reported between 3 – 5%. Conclusions: A retrospective analysis of tumor registry data for melanoma patients treated at UTMCK CI by the MASTT service line shows that offering survivorship care to this population is beneficial in detecting recurrence. This is key in getting patients evaluated and established for immunotherapy and/or other treatment options at the earliest time of recurrence, which can potentially improve their response to treatment by.

80 Background: Developing a Survivorship program goes beyond providing survivorship care plans to patients upon completion of cancer treatment. Programs can take many forms; ranging from very robust with long-term follow-up to minimal, with patients returning to the primary care provider when cancer-specific treatment is complete. To develop our program at an academic medical center with 2900 annual new cancer patients, we chose to enlist a SSC of survivors to help shape our program. Methods: In addition to fulfilling the American College of Surgeons Commission on Cancer Standard 3.3 requirements, we also desire to meet the needs of the patient. Thus, the survivorship program coordinator requested that providers within the Cancer Institute (CI) identify patients to form a SSC. 13 physicians contributed a total of 14 patients as candidates. Each patient was invited to participate and 7 accepted. The initial SSC meeting was held 6 months after initiation of our survivorship program. Results: SSC members represented 5 different primary malignancies and had varying degrees of experience within the treatment continuum. The initial meeting began with an overview of the current services available in the CI. Members were also given the opportunity to share treatment & survivorship experiences. Some of the SSC members utilized patient navigation during CI initial intake; others had experience with CI support groups. Some used ancillary services such as physical therapy, integrative health, financial counselors, and social services; others were not aware these services were available. A list of 4 categories of goals for program development was suggested with a meeting planned again in one year to review progress. Meeting one year later, the group determined progress was made in 3/4 (75%) of the goals. Conclusions: When creating a Survivorship program, patient goals should be considered and aligned with institutional and accreditation goals. One way to ensure that this is accomplished is to enlist front-end input from a SSC that represents a wide variety of treatment experiences and providers. In our experience, this strategy leads to alignment of patient and programmatic goals resulting in increased patient satisfaction and program quality.

35 Background: In 2014, the American College of Surgeons Commission on Cancer mandated in Standard 3.3 that SCP be provided for all patients at the completion of active treatment. Minimum requirements for what SCP should include were provided; however, no standardized model was proposed. We outline how a large academic medical center approached this as an opportunity instead of an obstacle. Methods: A pilot for developing SCP for the University of Tennessee Medical Center Cancer Institute (UTMC, CI), where 2700 new cancer cases per year are seen, was created. Initially approached by the Division of Surgical Oncology, SCPs were established for all patients. This approach allowed the UTMC, CI to determine all best practices for meeting Standard 3.3. This pilot identified all major stake holders including mid-level providers who see follow-up patients, a physician champion, and the survivorship care plan that best fit our organizational challenges and work flow. Results: The described approach allowed us to exceed our goal of providing SCP for 10% of patients seen in 2015 prior to the conclusion of the third-quarter. By keeping the pilot small, we were able to pinpoint the “best practice” for identifying patients, completing the SCP, delivery of the SCP, and providing care in an efficient way. By creating SCP that can be adapted by the entire UTMC, CI, we were able to ensure that we are meeting all of our stakeholder’s needs. Conclusions: Compliance with Standard 3.3 for SCP does not have to be a daunting task. The process can be adapted to be efficient while utilizing already stressed financial and personnel resources. A successful survivorship program can be developed as a pilot prior to being adapted by an entire organization. We recommend identifying the appropriate stake holders, defining a physician champion, and identifying SCP that best serve the mission of each organization while meeting all regulatory requirements.

Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board–approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ADM was indicated in patients with preclusive factors for general anesthesia, protracted procedure time, reluctance for additional donor site wound, and personal choice. We reviewed defect characteristics, healing time, postoperative outcomes, and patient demographics. The 228 participants (151 males, 77 females) had a median age of 72 years (range, 29–95 years), with melanoma diagnosed in 113 (49.6%), squamous cell carcinoma in 61 (26.8%), and basal cell carcinoma in 28 (12.2%) patients. The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.