Background Gene expression profiling (GEP) has been integrated into cancer treatment decision‐making in multiple neoplasms. We prospectively evaluated the prognostic utility of the 31‐GEP test (DecisionDx‐Melanoma, Castle Biosciences, Inc) in cutaneous melanoma (CM) patients undergoing sentinel node biopsy (SNB). Methods One hundred fifty‐nine patients (age 26‐88) diagnosed with melanoma between 01/2013 and 8/2015 underwent SNB and concurrent GEP testing. GEP results were reported as low‐risk Class 1 (subclasses 1A and 1B) or high‐risk Class 2 (subclasses 2A and 2B). Statistical analyses were performed with chi‐square analysis, t tests, log‐rank tests, and Cox proportional hazard models. Recurrence‐free survival (RFS) and distant metastasis‐free survival (DMFS) were estimated using Kaplan‐Meier method. Results Median follow‐up was 44.9 months for event‐free cases. Median Breslow thickness was 1.4 mm (0.2‐15.0 mm). There were 117 Class 1 and 42 Class 2 patients. Gender, age, Breslow thickness, ulceration, SNB positivity, and AJCC stage were significantly associated with GEP classification ( P < 0.05 for all). Recurrence and distant metastasis rates were 5% and 1% for Class 1 patients compared with 55% and 36% for Class 2 patients. Sensitivities of Class 2 and SNB for recurrence were 79% and 34%, respectively. Of 10 SNB‐positive/Class 2 patients, 9 recurred. By multivariate analysis, only SNB result and GEP class were statistically associated with both RFS ( P = 0.008 and 0.0001) and DMFS ( P = 0.019 and 0.001). Conclusions Gene expression profiling Class 2 result and SNB positivity were independently associated with recurrence and distant metastasis in primary CM patients. GEP testing may have additive prognostic utility in initial staging work‐up of these patients.

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Operative exposure is key to ensuring surgical efficiency and patient safety in cardiac surgery. As the population ages and the prevalence of obesity increases, cardiac surgeons will be challenged to consider obese patient physiology and body habitus, surgical exposure and sternotomy closure techniques, and postoperative medical management to ensure optimal outcomes. In this article, we describe techniques to improve operative exposure in both obese and non-obese patients undergoing basic cardiac surgery and highlight the roles of surgical team members to ensure patient safety and provide optimal anesthetic management. We describe pre-operative techniques regarding incision-site marking and alternative positioning techniques on the operating table to improve visualization and decrease risk of upper extremity injury. We summarized the roles of surgical team members regarding patient positioning, especially in those that are obese, and the challenges associated for anesthesia staff pre- and intraoperatively. Procedural techniques regarding sternotomy management and closure, cannulation, internal mammary harvest, and mitral valve exposure are discussed. Cardiac surgical teams must consider the risks associated with the obese patient population undergoing cardiac surgery procedures and employ techniques pre-, intra-, and postoperatively in a multidisciplinary fashion. Safe and efficacious techniques are paramount to optimal patient outcomes.

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