The NCCN considers “baseline staging” (whole body CT or PET scan +/- brain MRI) for all asymptomatic melanoma patients with a positive sentinel lymph node biopsy. The true yield of these workups is unknown. We created cohorts of adult malignant melanoma patients, using the National Cancer Database (2012-2020) to mimic three common scenarios: (1) clinically node negative, with positive sentinel lymph node(s) (SLNB[+]); (2) clinically node negative, with negative sentinel lymph node(s) (SLNB[-]); (3) clinically node positive with confirmed lymph node metastases (cN[+] and pN[+]). Multivariable regression, supervised decision trees, and nomograms were constructed to assess the risk of metastases based on key features. 10,371 patients were SLNB[+], 55,172 were SLNB[-], and 4,012 were cN[+] and pN[+]. The proportion of patients with any metastatic disease (brain metastases) were as follows: SLNB[+]: 1.4% (0.3%); SLNB[-] 0.3% ( 4, ulceration, and lymphovascular invasion were associated with greater risk of metastatic disease. A supervised decision tree for SLNB[+] and SLNB[-] patients found the only groups with >2% risk of metastases were T4 tumors or T2/T3 tumors with ulceration and LVI. Most groups had a negligible risk (<0.1%) of brain metastases. This is the first large analysis to guide the use of imaging for cutaneous melanoma. Among clinically node negative patients, metastatic disease is uncommon and brain metastases are exceedingly rare. Further investigation could promote a tailored approach to metastatic workups guided by individual risk factors.

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BACKGROUND: The growing usage of direct oral anticoagulants (DOACs) has brought into question the need for pharmacologic reversal in patients who develop traumatic brain injuries (TBIs). While there are specific benefits in reversal for TBI patients on warfarin, the impact has not been clearly shown in DOAC populations. This study evaluated radiographic and clinical outcomes among patients with isolated mild TBIs to determine whether DOAC usage or its reversal confers measurable differences in early outcomes. METHODS: We conducted a retrospective review of adults (18 to 99 y) with isolated mild TBI (Glasgow Coma Scale: 13 to 15) after ground-level falls at a Level I trauma center from 2016 to 2024. The primary outcome was radiographic hemorrhage progression, defined as >2-mm increase in hemorrhage or need for >2 head computed tomographies within 24 hours. Secondary outcomes included Glasgow Coma Scale decline, intensive care unit length of stay, neurosurgical intervention, thromboembolic events, disposition, and inpatient mortality. Multivariable logistic regression and propensity score matching were used to evaluate associations between DOAC usage, reversal therapy, and outcomes. RESULTS: Among 273 patients, 96 (35%) were taking a DOAC, and of these, 41 received four-factor prothrombin complex concentrate and 18 received andexanet alfa. DOAC patients demonstrated similar rates of radiographic progression, intensive care unit length of stay, and discharge disposition compared with non-DOAC patients. In multivariate analysis, DOAC usage was not associated with increased radiographic progression, measured by subdural hemorrhage growth (47.5% vs. 44.8%; p = 0.70) or increased need for >2 computed tomography scans (49.1% vs. 48.9%, p = 1.00). Among DOAC users, reversal was also not associated with improved radiographic progression or secondary outcomes. No significant outcome differences were observed between reversal with four-factor prothrombin complex concentrate and andexanet alfa. CONCLUSIONS: In isolated mild TBI after ground-level falls, DOAC usage was not associated with worsened clinical outcomes or increased radiographic progression. Pharmacologic reversal offered no measurable benefit. These findings support selective reversal in stable mild TBI. ( J Trauma Acute Care Surg . 2026;00: 000–000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Background: Circulating tumor DNA is a promising biomarker for molecular residual disease and recurrence surveillance in biliary tract cancers. We evaluated the association between postoperative tumor-informed ctDNA and recurrence-free survival (RFS) and assessed the performance of initial and longitudinal ctDNA surveillance. Methods: We performed a single-institution retrospective cohort study of 51 patients with resected non-metastatic biliary tract cancers who underwent postoperative ctDNA testing. Kaplan–Meier, log-rank, univariable Cox regression, and limited multivariable Cox regression analyses were used to evaluate associations between ctDNA status and RFS. A 3-month landmark sensitivity analysis was performed to address time-related bias. Results: Twenty-five patients (49.0%) developed recurrence. Recurrence occurred in 18 of 20 patients (90.0%) with postoperative ctDNA positivity compared with 7 of 31 patients (22.6%) without ctDNA positivity. Median RFS was 10.8 versus 47.4 months, respectively. Postoperative ctDNA positivity was associated with shorter RFS (HR, 7.85; 95% CI, 3.03–20.29; p < 0.001). In a pre-specified multivariable Cox model adjusting for stage III/IV disease and CA 19-9 > 37 U/mL, postoperative ctDNA positivity remained associated with shorter RFS (adjusted HR, 5.09; 95% CI, 1.82–14.26; p = 0.002). Longitudinal ctDNA surveillance demonstrated a sensitivity of 72.0%, specificity of 92.3%, PPV of 90.0%, and NPV of 77.4% for recurrence. Median lead time to recurrence was 69.5 days. In a 3-month landmark cohort of 37 evaluable patients, postoperative ctDNA positivity was associated with shorter subsequent RFS after exploratory adjustment for stage and CA 19-9 (adjusted HR, 6.45; 95% CI, 1.47–28.34; p = 0.014). Conclusions: Postoperative ctDNA positivity was associated with recurrence and shorter RFS. Longitudinal ctDNA surveillance improved recurrence detection and frequently preceded clinically documented recurrence.