Leadership in Action: Tales From the Trenches.

Surgeons are natural leaders, but leadership within academic surgery at various levels presents unique challenges. During the 2025 Academic Surgical Congress Hot Topics session on Leadership in Action, we discussed the real challenges faced by leaders in academic surgery across different levels. We review common themes and strategies employed when confronting these difficult situations, focusing on perseverance and creative problem solving.

Evaluating Variation in Lymph Node Sampling During Sentinel Lymph Node Biopsy for Melanoma.

Background: The operative standard for melanoma, implemented by the Commission on Cancer (CoC), addresses margin width and excision depth, but does not collect information on sentinel lymph node biopsy (SLNB). However, SLNB, an implemented technical standard in breast cancer, is also critical in the management of melanoma through its impact on nodal staging. This study aimed to characterize the current facility-level variation in nodal yield and nodal positivity to determine if there is an opportunity for improvement through standardization.

Scaling Smarter Preoperative Testing: A Multisite Evaluation of Adaptations to De-implementation Strategy Using Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies.

Introduction: Unnecessary preoperative testing before low-risk surgery contributes to excess healthcare costs, care cascades, and surgical delays. The Right-Sizing Testing Before Elective Surgery intervention is a multilevel, multicomponent intervention piloted at three hospital sites to reduce low-value testing. To understand how the de-implementation strategies could be tailored across diverse healthcare settings, we applied the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS) to track site-specific modifications.

Perspectives on Commission on Cancer Standard 5.8 on Lung Cancer: A Qualitative Study.

Introduction: In 2021, the Commission on Cancer implemented Standard 5.8, which requires that lymph nodes be sampled from ≥1 hilar and ≥3 different mediastinal lymph node stations for all curative-intent lung cancer resections. While 80% compliance is expected of all Commission on Cancer-accredited hospitals, recent data illustrates only half of sites are currently meeting criteria.

Site Reviewer Perspectives on the Implementation of the Commission on Cancer Operative Standards.

Background: To reduce technical variation in cancer surgery, the Commission on Cancer (CoC) recently implemented six operative standards as part of its national cancer center accreditation process. CoC sites are evaluated for compliance with these standards through scheduled visits conducted by trained site reviewers. We characterized site reviewers' perspectives on the implementation of the operative standards.

Early compliance with lung cancer lymph node standard 5.8: An analysis of 2022 and 2023 Commission on Cancer site reviews.

Objective: To address variability in nodal staging during curative-intent lung cancer resections, the Commission on Cancer implemented Standard 5.8 in 2021, requiring lymph nodes be sampled from ≥3 mediastinal stations and ≥1 hilar station and documented in a synoptic pathology report. We assessed compliance data from recent site reviews to evaluate the early implementation of Standard 5.

National Variation in Implementation of Sentinel Lymph Node Biopsy for Clinically Node-Positive Patients Undergoing Neoadjuvant Therapy.

Background: Sentinel lymph node biopsy (SLNB) is feasible in women with clinically node-positive breast cancer following neoadjuvant chemotherapy and a nodal pathologic complete response. Acceptable false negative rates are achieved through technical considerations such as removing three or more sentinel lymph nodes (SLNs); however, the variation that exists in adherence to this technique is unclear.

Objective: This study aimed to evaluate recent trends in axillary surgery in women with cN1-cN2 disease who received neoadjuvant chemotherapy, adherence to removing three or more SLNs, and variation in SLN yield.

Getting Started in Leadership: Mindsets and Skillsets for Leading in Complex Systems.

As health-care systems grow increasingly complex, surgeons must adapt their leadership skills to different settings. At the 2024 Academic Surgical Congress Hot Topics session on leadership mindset, we discussed discrete strategies for tackling leadership challenges at multiple stages in a surgeon's career. We review strategies for surgeons at any stage in their career, new-career surgeons, surgeons without defined leadership titles, surgeons in executive roles, and surgeons in mentorship positions.

Risk Stratification for Sentinel Lymph Node Positivity in Older Women With Early-Stage Estrogen Receptor-Positive/Human Epidermal Growth Factor Receptor 2 Neu-Negative Invasive Breast Cancer.

Purpose: Guidelines recommend omission of sentinel lymph node biopsy (SLNB) for axillary staging in select patients age 70 years and older with early-stage estrogen receptor-positive (ER+), human epidermal growth factor receptor 2 neu-negative (HER2-) invasive breast cancers (BCs). However, many women meeting criteria for SLNB omission continue to receive this procedure. This study aims to stratify patients into risk cohorts for nodal positivity that can be incorporated into deimplementation strategies to reduce low-value SLNB procedures.

The Effectiveness of Superparamagnetic Iron Oxide Nanoparticles in Reducing Unnecessary Sentinel Lymph Node Biopsies.

Background: Sentinel lymph node biopsy (SLNB) is routinely performed at the time of mastectomy for noninvasive breast disease owing to the potential upgrade on final pathology, resulting in 80% of patients receiving unnecessary SLNB. Superparamagnetic iron oxide nanoparticles (SPIO) are a tracer with extended lymph node marking, facilitating delayed node retrieval in the event of an invasive upgrade. This study assesses the utilization and efficacy of SPIO for potential delayed SLNB for patients undergoing mastectomy.

Trends in Axillary Lymph Node Dissection After Mastectomy Among Patients With Limited Nodal Burden.

Importance: Current practices in axillary treatment for patients with breast cancer who receive a mastectomy for node-positive disease are unknown. For patients who receive postmastectomy radiotherapy (PMRT), the addition of axillary lymph node dissection (ALND) may result in significant overtreatment.

Objectives: To evaluate trends in axillary treatment for patients with limited nodal metastases who receive a mastectomy and identify factors that can be targeted to reduce axillary overtreatment.

Overcoming inertia: Provider perspectives on de-implementation strategies in preoperative testing.

Background: Routine preoperative testing for low-risk surgeries is often unnecessary and may result in preventable harm. While de-implementation strategies have reduced the frequency and proportion of unnecessary preoperative tests, the reach of the strategies and the provider-level adoption remain unclear. Understanding stakeholders' perspective on these strategies is essential for widespread de-implementation.

Multicomponent Deimplementation Strategy to Reduce Low-Value Preoperative Testing.

Importance: Routine preoperative blood tests and electrocardiograms before low-risk surgery do not prevent adverse events or change management but waste resources and can cause patient harm. Given this, multispecialty organizations recommend against routine testing before low-risk surgery.

Objective: To determine whether a multicomponent deimplementation strategy (the intervention) would reduce low-value preoperative testing before low-risk general surgery operations.

American College of Surgeons Operative Standards and Breast Cancer Outcomes.

Importance: The American College of Surgeons (ACS) operative standards were established to detail critical elements of cancer surgery, reduce technical variation, and improve outcomes. Two of the 6 operative standards target adequate axillary surgery for breast cancer. The potential association of the operative standards with short-term oncologic outcomes, such as nodal yield and nodal positivity rates, is currently unknown.