Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

What is the best imaging modality to determine imaging response to neoadjuvant therapy in breast cancer?

February 12, 2020 Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Breast MRI is the most sensitive and specific imaging modality to determine imaging response to neoadjuvant therapy and has the highest correlation coefficient when comparing imaging size to pathologic tumor size when compared to any combination of physical examination, mammography, and ultrasonography.

👉Nevertheless, it is not necessary to routinely perform post-treatment MRI, especially when a well-circumscribed sonographically visible cancer has been followed with ultrasound during treatment.

👉Researchers are studying breast specific gama imaging (BSGI) as an enhanced screening modality but its accuracy in determining tumor detection and response after neoadjuvant therapy is unproven. The high dose of radiation with BSGI has been a concern.

👉REFERENCES

De Los Santos JF, Cantor A, Amos KD, et al. Magnetic resonance imaging as a predictor of pathologic response in patients treated with neoadjuvant systemic treatment for operable breast cancer (TBCRC 017). Cancer. 2013;199:1776-1783.
Lee HS, Ko BS, Ahn SH, et al. Diagnostic performance of breast-specific gamma imaging in the assessment of residual tumor after neoadjuvant therapy in breast cancer patients. Breast Cancer Res Treat. 2014;145:91-100.
Marinovich ML, Macaskill P, Irwig L, et al. Meta-analysis of agreement between MRI and pathologic breast tumour size after neoadjuvant chemotherapy. Br J Cancer. 2013; 109:1528-1536.
McLaughlin S, Mittendorf EA, Bleicher RJ, et al. The 2013 Society of Surgical Oncology Susan G. Komen for the Cure Symposium: MRI in breast cancer: where are we now? Ann Surg Oncol. 2014;21:28-36.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y cirujano de mamá de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

Es experto en el manejo del cáncer de mama.

👉Es miembro de la American Society of Breast Surgeons:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

Cost Savings Utilizing Molecular Studies for Indetermined Thyroid Nodules

February 12, 2020 Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Cost savings from incorporating ThyroSeq testing into the management of patients with thyroid nodules with indeterminate cytology is based on:

The avoidance of unnecessary surgeries
Selection of the optimal extent for the initial surgery thereby minimizing the two-step surgeries, i.e. lobectomy followed by completion of thyroidectomy.

👉The results of a prospective, double-blind, multicenter study of ThyroSeq v3 (Steward DL et al. JAMA Oncol. 2018.) allow to estimate the impact of ThyroSeq on avoiding unneeded diagnostic thyroid surgeries, as show on the figure below.

👉In a series of 100 patients with Bethesda III and Bethesda IV thyroid nodules and with the expected cancer/NIFTP prevalence of 28%:

61 tests will be reported as Negative and 39 as Positive.

👉Among test-negative nodules only two cancers will be missed (those are expected to be low-risk, intrathyroidal cancers).

👉Among the test-positive nodules:

23 (67%) will be diagnosed as cancer or NIFTP on surgery
The majority of remaining nodules are expected to be neoplasms, likely with some malignant potential.

👉Overall, 61% of thyroid surgeries will be avoided, with their costs and complications.

👉Nicholson KJ, et al. Molecular Testing of Bethesda III/IV Thyroid Nodules: A Cost-Effectiveness Analysis. Thyroid. 2019. doi.org/10.1089/thy.2018.0779

👉This study modeled a decision tree from the payor perspective, comparing the cost-effectiveness of diagnostic lobectomy, ThyroSeq v3, and Afirma GSC for indeterminate (Bethesda III/IV) thyroid nodules.

👉Based on the model, the cost per correct diagnosis was $14,277 for ThyroSeq v3, $17,873 for Afirma GSC, and $38,408 for diagnostic lobectomy.

👉One-way sensitivity analysis found that ThyroSeq v3 had robustly lower cost per correct diagnosis than Afirma GSC.

👉Two-way sensitivity analysis varying costs of ThyroSeq v3 and Afirma GSC demonstrated that ThyroSeq was still the preferred strategy.

👉The study stated that in no range of tested cost variations was diagnostic lobectomy the preferred strategy over molecular testing.

👉The study concluded that either Afirma GSC or ThyroSeq v3 was considerably more cost-effective than diagnostic lobectomy and that ThyroSeq v3 was more likely to be cost-effective than Afirma GSC.

👉Rivas AM, et al. ThyroSeq V2.0 Molecular Testing: A Cost-Effective Approach for the Evaluation of Indeterminate Thyroid Nodules. Endocr Pract. 2018 Sept; 24(9):780-788

👉This study evaluated cost effectiveness of ThyroSeq utilized for managing patients with Bethesda III-IV cytology nodules at Mayo Clinic Florida, where the test is used in routine clinical practice since January 2015.

👉The study showed that the cost of treatment per patient with Bethesda III category nodules was $54,000 when no molecular testing was used and $44,570 after ThyroSeq introduction.

👉Three patients with negative ThyroSeq results were able to avoid surgery resulting in cost saving of $67,500 per patient.

👉For patients with Bethesda IV category nodules, the cost of treatment was $29,000 and $43,200 using and not using ThyroSeq, respectively.

👉Twelve patients with Bethesda IV nodules were negative by ThyroSeq, of which 11 did not have surgery, resulting in cost saving of $84,000 per patient.

👉The authors of this independent study performed at a high volume thyroid medical center concluded that ThyroSeq is a cost effective tool to diagnose thyroid cancer compared to thyroidectomy without molecular testing in patients with nodules categorized as Bethesda III and IV.

👉Yip L, et al. Comprehensive cost analysis of available molecular tests for thyroid nodules with follicular neoplasm cytology 2015 15th International Thyroid Congress, A-381

👉This study evaluated the costs associates with management of patients with Bethesda IV cytology nodule using ThyroSeq as compared to standard of care (SC) patient management without molecular testing, using Afirma®GEC, and using 7-gene mutational panel.

👉The study demonstrated that the ThyroSeq-guided care was associated with a substantially lower cost (average per patient $7,683, range $7,174-$8,333) as compared to the average per patient cost of standard of care ($11,505, range $10,676-$12,347) and of care utilizing Afirma®GEC ($13,027, range $12,373-$13,666) or 7-gene mutational panel ($12,029, range $11,254-$12,823).

👉The study estimated that due to high test sensitivity (90%) and specificity (93%), ThyroSeq GC-guided algorithm for Bethesda IV nodules should result in 30% reduction in the cost of management of patients with these nodules.

👉Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon / endocrine surgeon / surgical oncologist and is a member of Sociedad Quirúrgica S.C at the America British Cowdray Medical Center in Mexico City:

prof_739_20190417135234

Rodrigo Arrangoiz MS, MD, FACS:
- Is a member of the American Head and Neck Society

- He is a member of the American Thyroid Association:

Unknown

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Teacher

#Surgeon

#Cirujano

#ThyroidExpert

#ThyroidSurgeon

#CirujanodeTiroides

#ExpertoenTiroides

#ExpertoenParatiroides

#Paratiroides

#Hiperparatiroidismo

#CancerdeTiroides

#ThyroidCancer

#PapillaryThyroidCancer

#SurgicalOncologist

#CirujanoOncologo

#CancerSurgeon

#CirujanodeCancer

#HeadandNeckSurgeon

#CirugiaEndocrina

#CirujanodeTumoresdeCabezayCuello

#OralCavityCancer

#Melanoma

Nipple Sparing Mastectomy (NSM)

February 9, 2020 Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉NSM is an oncologically sound option for selected breast cancer patients (as it is for prophylaxis) but there is no clear consensus as to the selection criteria.

👉Based on careful anatomic studies and recent comprehensive reviews, nipple involvement was present in 11.5% of reported NSM procedures, and was associated with:

Tumor-to-nipple distance of less than 2 cm
Positive nodes
Lymphovascular invasion
ER/PR-negative
HER2-positive
Locally advanced
Retroareolar tumors
Multicentric tumors

👉Local recurrence occurred more frequently in the skin flaps (4.2%) than in the nipple (0.9%).

👉Nipple necrosis was partial thickness in 6.3% and full thickness in 2.9% of patients.

👉A negative nipple margin is necessary for NSM but is not sufficient for patients whose tumors are otherwise unsuitable.

👉NSM is also not suitable for patients whose breasts are very large and/or ptotic, who are elderly, or who have significant comorbidities.

REFERENCES

Mallon P, Feron JG, Couturaud B, et al. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg. 2013;131:969-984.
Rusby JE, Brachtel EF, Michaelson JS, et al. Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications. Breast Cancer Res Treat. 2007;106:171-179.
Rusby JE, Brachtel EF, Othus M, et al. Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy. Br J Surg. 2008;95:1356-1361.
Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg. 2010;97:305-316.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y cirujano de mamá de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

Es experto en el manejo del cáncer de mama.

👉Es miembro de la American Society of Breast Surgeons:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

Nerve damage during a modified radical mastectomy.

February 9, 2020 Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Nerve damage during a modified radical mastectomy includes transection of sensory nerves to the breast and breast skin and possible transection of motor nerves to the pectoralis major muscle (medial pectoral neurovascular bundle), serratus anterior muscle (long thoracic nerve), and latissimus dorsi muscle (thoracodorsal nerve).

👉Transection of sensory nerves to the breast skin is unavoidable as most of these sensory nerves traverse the breast.

👉The most common complaint after a mastectomy is numbness of the mastectomy skin flaps as well as of the nipple/areolar complex if preserved.

👉Only 10% to 15% of patients report preserved sensation in the nipple areolar complex after nipple-sparing mastectomy.

👉Phantom breast pain is a possible outcome after mastectomy and occurs in 14% to 17% of patients at one-year after surgery.

👉Damage to motor nerves is associated with axillary dissection rather than mastectomy.

👉The medial pectoral neurovascular bundle pierces the pectoralis minor muscle then wraps around the lateral border of the pectoralis major muscle.

👉Transection of this nerve can result in atrophy of the lateral portion of the muscle.

👉Functional deficit associated with this injury is typically minor.

👉Transection of the long thoracic nerve during an axillary dissection will result in a winged scapula.

👉The winged scapula is most visible when a patient is standing straight and pushing against a wall with both arms.

👉The affected scapula will visibly protrude while the normally innervated scapula will remain flush with the back.

👉Injury to the thoracodorsal nerve can impact several activities such as rock climbing, rowing, and standing from a seated position.

👉This latter function is especially significant as an individual ages because the upper body is relied on more often for strength compared with the legs.

👉Injury to the thoracodorsal nerve may also have implications if other components of the thoracodorsal neurovascular bundle are damaged as this may limit use of the latissimus dorsi flap for subsequent breast reconstruction.

👉The relative likelihood of these injuries is low.

👉Injury to the long thoracic nerve is most commonly reported.

👉Damage to the brachial plexus would be very unlikely during a modified radical mastectomy, however, brachial plexopathies can occur as a result of postmastectomy radiation.

👉REFERENCES

Ahmed A, Bhatnagar S, Rana SP, et al. Prevalence of phantom breast pain and sensation among postmastectomy patients suffering from breast cancer: a prospective study. Pain Pract. 2014;14:E17-28.
Porzionato A, Macchi V, Stecco C et al. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat. 2012; 25(5):559-575.
Freeman SR, Washington SJ, Pritchard T et al. Long term results of a randomized prospective study of preservation of the intercostobrachial nerve. Eur J Surg Oncol. 2003;29(3):213-215.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y cirujano de mamá de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

Es experto en el manejo del cáncer de mama.

👉Es miembro de la American Society of Breast Surgeons:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

How diagnostic performance of ThyroSeq compares with other tests?

February 9, 2020 Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉According to the ThyroSeq clinical validation study supplemental table, reported in JAMA Oncology, ThyroSeq GC has a benign call rate of 61%, as compared to the Afirma GSC rate of 54%, which indicates that ThyroSeq allows more patients to safely avoid diagnostic surgeries.

👉Additionally, ThyroSeq GC has a higher negative call rate for histologically benign nodules with indeterminate cytology (82%) than Afirma GSC (68%).

👉This means that patients with nodules that have indeterminate cytology but are histologically benign would avoid diagnostic surgery with ThyroSeq GC more often than with Afirma GSC.

Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon / endocrine surgeon / surgical oncologist and is a member of Sociedad Quirúrgica S.C at the America British Cowdray Medical Center in Mexico City:

prof_739_20190417135234

Rodrigo Arrangoiz MS, MD, FACS:
- Is a member of the American Head and Neck Society

- He is a member of the American Thyroid Association:

Unknown