Additional Excision Research Articles

Sclerosing Dermatofibrosarcoma Protuberans Shows Significant Overlap With Sclerotic Fibroma in Both Routine and Immunohistochemical Analysis: A Potential Diagnostic Pitfall.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, low-to-intermediate grade sarcoma with several histologic variants, including pigmented (Bednar tumor), sclerosing, myxoid, atrophic, and DFSP with fibrosarcomatous changes. Two patterns of sclerosis in DFSP can be observed, a sclerotic fibroma-like pattern and a morphea/lichen sclerosus-like pattern. Partial biopsies of sclerosing DFSPs with the sclerotic fibroma pattern can be misdiagnosed as sclerotic fibroma or other benign sclerosing tumors (eg, perineurioma, dermatofibroma). DFSPs from our tissue archives were screened for tumors with a sclerosing pattern, and then studied with epithelial membrane antigen (EMA), CD34, and elastic tissue staining to investigate whether such stains can differentiate sclerosing DFSP from sclerotic fibroma. Ten cases of sclerotic fibroma were similarly studied. Two of the 27 DFSPs were predominantly sclerosing and 5 additional DFSPs had a mixed histopathologic pattern including a sclerosing component. Immunohistochemically, all DFSPs with sclerosing (predominant or mixed) pattern were positive for CD34, and 5/7 were at least focally positive for EMA. Elastic tissue staining was reduced or absent in the sclerotic areas. All cases of sclerotic fibroma were either positive or focally positive for CD34, whereas EMA was focally positive in 5/10. Elastic tissue staining ranged from reduced to totally absent in the sclerotic fibromas. In conclusion, the similar histopathologic and immunophenotypic characteristics in sclerotic fibroma and sclerosing DFSP found in this analysis highlight the importance of obtaining clinical information and potentially additional excision for partial biopsies showing a sclerotic fibroma-like pattern.

The Usefulness of Intraoperative Circumferential Frozen-Section Analysis of Lumpectomy Margins in Breast-Conserving Surgery.

PurposeIntraoperative frozen-section analysis of the lumpect-omy margin during breast-conserving surgery (BCS) is an excellent method in obtaining a clear resection margin. This study aimed to investigate the usefulness of intraoperative circumferential frozen-section analysis (IOCFS) of lumpectomy margin during BCS for breast cancer, and to find factors that increase the conversion into mastectomy.MethodsFrom 2007 to 2011, 509 patients with breast cancer underwent IOCFS during BCS. The outer surfaces of the shaved lumpectomy margins were evaluated. A negative margin was defined as no ink on the tumor. All margins were evaluated using the permanent section analysis.ResultsAmong the 509 patients, 437 (85.9%) underwent BCS and 72 (14.1%) finally underwent mastectomy. Of the 483 pathologically confirmed patients, 338 (70.0%) were true-negative, 24 (5.0%) false-negative, 120 (24.8%) true-positive, and 1 (0.2%) false-positive. Twenty-four patients (4.7%) among total 509 patients had undetermined margins as either atypical ductal hyperplasia or ductal carcinoma in situ in the first IOCFS. The IOCFS has an accuracy of 94.8% with 83% sensitivity, 99.7% specificity, 93.4% negative predictive value, and 99.2% positive predictive value. Sixty-three cases (12.4%) were converted to mastectomy, the first intraoperatively. Of the 446 (87.6%) patients who successfully underwent BCS, 64 patients received additional excisions and 32 were reoperated to achieve clear margin (reoperation rate, 6.3%). Twenty-three of the reoperated patients underwent re-excisions using the second intraoperative frozen section analysis, and achieved BCS. Nine cases were additionally converted to mastectomy. No significant differences in age, stage, and biological factors were found between the BCS and mastectomy cases. Factors such as invasive lobular carcinoma, multiple tumors, large tumor, and multiple excisions increased the conversion to mastectomy.ConclusionThe IOCFS analysis during BCS is useful in evaluating lumpectomy margins and preventing reoperation.

Role of frozen section in the intra-operative margin assessment during breast conserving surgery.

Breast conserving surgery (BCS) is increasingly done for early breast cancers in many countries since it has been demonstrated by randomized trials that survival rates after BCS followed by adjuvant therapy are equivalent to those obtained after mastectomy. Frozen section analyses (FSA) is a technique used for intra-operative assessment of margin status in BCS. The aim of this study was to assess the concordance of margin status assessment by FSA and permanent sections and to assess correlation with local recurrence. A total of 162 patients underwent BCS for in situ or invasive carcinoma with FSA of margins during the year 2008 at our center. The inclusion criteria in this study were patients with intact tumor at the time of surgery. After application of the inclusion criteria, 60 patients could be included in this study. After frozen section, 20 patients had an initial negative margin. 40 subjects underwent additional excisions at the time of initial surgery because of close or positive margins. Of these 40 patients, in 32 patients a negative margin could be achieved with re-excisions. Pathological analyses of frozen section showed concordance to permanent sections in all cases. At a median follow-up of 40 months, there were no local recurrences. Intra-operative FSA allows resection of suspicious margins at the time of primary conservative surgery and results in low rates of local recurrence and second surgeries. There is good concordance between results of FSA and the final paraffin section in assessing margin status.

The Efficacy of Intraoperative Frozen Section Analysis During Breast-Conserving Surgery for Patients with Ductal Carcinoma In Situ.

INTRODUCTIONRecently, the incidence of ductal carcinoma in situ (DCIS), a noninvasive breast malignancy, has increased. This has resulted in an increase in the incidence of breast-conserving surgery (BCS). Numerous studies have suggested that intraoperative frozen section analysis (IFSA) could reduce the rate of additional excisions required to obtain adequate resection margins. However, DCIS is a known risk factor for positive margin status during BCS. Furthermore, some authors have concluded that IFSA may not be reliable for the detection of DCIS.AIMThe aim of this study was to evaluate the safety and efficacy of IFSA in patients with DCIS.METHODSThe operative and pathological reports of patients with DCIS, who underwent BCS at our institute between 2006 and 2015, were retrospectively reviewed. The results of IFSA and the pathological findings of final reanalyzed frozen tissue specimens were analyzed.RESULTSIn total, 25 patients were included in our analysis. None of the patients required additional operations. The correct diagnosis rate for IFSA was 89.6%, with a sensitivity and specificity of 60.0% and 95.8%, respectively.CONCLUSIONIFSA could be beneficial for determining safety resection margins in patients with DCIS.

Proximal nail fold flap for digital mucous cyst excision.

The skin covering a digital mucous cyst is often very thin and is often excised with the cyst. Thus, transfer of a skin flap is needed for the defect. We have developed a proximal nail fold flap technique by which the thin skin covering the cyst can be preserved. We conducted a retrospective study to assess the effectiveness and reliability of this technique for digital mucous cyst excision. The study group comprised 26 patients treated for 28 digital mucous cysts. The flap was elevated on the nail matrix to expose the distal interphalangeal joint capsule. To preserve the skin in cases in which the skin covering the cyst was exceptionally thin, we did not excise the upper part of the cyst wall. Excision of the cyst and stalk was successful in all cases. Additional excision of the joint capsule or osteophyte(s) was achieved in 20 cases and 5 cases, respectively. No flap necrosis, skin defect or nail deformity resulted. Three of the cysts recurred and were treated successfully by reoperation involving the same flap elevation technique. We conclude that the proximal nail fold flap is useful for excision and reliable for wound coverage after digital mucous cyst excision. J. Med. Invest. 63: 278-280, August, 2016.

Serial full-thickness excision of dysplastic vocal fold leukoplakia: Diagnostic or therapeutic?

A previous study proposed that serial full-thickness excisional biopsies of vocal fold leukoplakia therapeutically decreased dysplasia grade. The current investigation aimed to 1) analyze the pathological evolution and natural history of these lesions and 2) re-examine the role of serial excisions in dysplasia grade regression in long-term follow-up. Retrospective case series. Patients treated for vocal fold dysplasia (1994-2013) with serial full-thickness microflap-type excisions were identified and followed longitudinally. Excluded were those with one excision, invasive cancer at initial excision, or history of laryngeal cancer or radiation. Data from surgical procedures, associated pathology, and patient characteristics were recorded. Weighted repeated measures ordinal logistic regression measured associations with pathology findings. Of 55 patients (median age = 65 years, interquartile range = 54-73 years, 89% male, 63% ever smokers, 27% alcohol users), 31 met inclusion criteria. During the study period, patients had two to 44 excisions, with a median time between excisions of 4.0 months. Each additional excision increased odds of higher-grade pathology by 4% (odds ratio = 1.04, 95% confidence interval = 1.01-1.06; P = .007). A transition model demonstrated that patients with moderate dysplasia, severe dysplasia, or carcinoma in situ on a prior biopsy had 2.64-, 5.64-, and 8.73-times increased odds of the same or higher pathology grade at the next excision, respectively. Data do not support the hypothesis that serial full-thickness excisions decrease dysplasia grade. Progression of dysplasia appears to be nonlinear, but higher-grade dysplasia is more likely to progress to malignancy. 4.

Hormonal Receptor Positivity and Clinical Multifocality Are Independent Predisposing Factors for Positive Margin Events in Breast-Conserving Surgery after Neoadjuvant Chemotherapy

Purpose: Neoadjuvant chemotherapy (NAC) frequently results in shrinkage of the primary tumor. It is not easy to perform breast-conserving surgery (BCS) after NAC, based on tumor extent alone. We identified the clinicopathological factors associated with positive margins on frozen or permanent sections in patients undergoing BCS after NAC. Methods: The records of 151 patients who had BCS after NAC between 2005 and 2010 were reviewed. All patients underwent subsequent imaging work-up including breast magnetic resonance imaging, ultrasound, and breast mammography at the midpoint and/or the end of NAC. Positive resection margins on frozen or permanent sections were considered to be due to the presence of either invasive carcinoma or in situ carcinoma. The relationship between the microscopic margin status and clinicopathological factors was analyzed when positive margins were detected. Results: Of 151 patients, 39 (25.8%) were diagnosed with a pathological complete response, while 135 patients (89.4%) had a negative margin on both frozen and permanent sections and 16 (10.6%) had a positive margin on frozen or permanent sections. Of the 16 patients, 14 finally obtained negative margins after additional excision and two (1.3%) had positive margins due to in situ carcinoma. Multivariate analysis revealed that clinical multifocality after NAC (p= 0.006), and hormonal receptor (HR) positivity (p= 0.028) were significantly associated with positive margins on frozen or permanent sections, but were not associated with tumor size after NAC, specimen volume, or human epidermal growth factor receptor 2 positivity. Conclusion: We propose that HR positivity and clinical multifocality after NAC are predisposing factors for positive margins in patients undergoing BCS after NAC. It is necessary to obtain safe resection margins to avoid positive margins in these patients.

Dual outline of navigating utensil in thoracoscopic segmentectomy: a new method.

Thoracoscopic segmentectomy requires an adequate surgical margin; however, only a few reports have described the procedure of how to maintain a constant distance from the tumour. We here suggest a novel simple method to secure an adequate surgical margin: the dual outline of navigating utensil in thoracoscopic segmentectomy (DONUTS) method. We used a DONUTS indicator sheet produced from a 1.5-mm thick absorbed sheet with a proper diameter to secure an adequate surgical margin. The indicator sheet, which was affixed to the pleura, indicated a new resection line. With this new line, an additional excision was performed in addition to conventional segmentectomy. The clinical records of 9 patients who underwent treatment with the DONUTS method between August 2011 and December 2013 were retrospectively reviewed. No postoperative complications of loco-regional recurrence were observed over a mean period of 20.3 months.

PD17-03 “TUMOR BUDDING”, A NOVEL PROGNOSTIC INDICATOR FOR PREDICTING STAGE PROGRESSION IN T1 BLADDER TUMORS

You have accessJournal of UrologyBladder Cancer: Non-invasive II1 Apr 2015PD17-03 “TUMOR BUDDING”, A NOVEL PROGNOSTIC INDICATOR FOR PREDICTING STAGE PROGRESSION IN T1 BLADDER TUMORS Keishiro Fukumoto, Eiji Kikuchi, Shuji Mikami, Kazuyuki Yuge, Ogihara Koichiro, Kazuhiro Matsumoto, Shinya Morita, Kazunobu Shinoda, Takeo Kosaka, Ryuichi Mizuno, Toshiaki Shinojima, Hiroshi Asanuma, Akira Miyajima, and Mototsugu Oya Keishiro FukumotoKeishiro Fukumoto More articles by this author , Eiji KikuchiEiji Kikuchi More articles by this author , Shuji MikamiShuji Mikami More articles by this author , Kazuyuki YugeKazuyuki Yuge More articles by this author , Ogihara KoichiroOgihara Koichiro More articles by this author , Kazuhiro MatsumotoKazuhiro Matsumoto More articles by this author , Shinya MoritaShinya Morita More articles by this author , Kazunobu ShinodaKazunobu Shinoda More articles by this author , Takeo KosakaTakeo Kosaka More articles by this author , Ryuichi MizunoRyuichi Mizuno More articles by this author , Toshiaki ShinojimaToshiaki Shinojima More articles by this author , Hiroshi AsanumaHiroshi Asanuma More articles by this author , Akira MiyajimaAkira Miyajima More articles by this author , and Mototsugu OyaMototsugu Oya More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.660AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tumor budding was defined as an isolated single cancer cell or a cluster composed of fewer than 5 cancer cells scattered in the stroma at the invasive tumor margin (Figure 1). It is a strong predictor for lymph node metastasis in T1 colorectal cancer and current guidelines recommend additional excision after endoscopic therapy when tumor budding is positive. We introduced this concept to T1 non-muscle invasive bladder carcinoma (NMIBC) and evaluated whether tumor budding could have a prognostic impact on T1 NMIBC clinical outcome. METHODS We identified 116 consecutive patients with newly diagnosed T1 NMIBC from 1994 to 2013 at Keio University Hospital. All slides were re-reviewed by a dedicated uro-pathologist. After choosing one field where tumor budding was the most intensive, budding foci count was performed under ×200 magnification. When the number of budding foci was 10 or more, tumor budding was defined as positive. We assessed the prognostic significance of tumor budding on tumor recurrence and stage progression. RESULTS The median follow-up period was 53 months. Twenty one patients had positive tumor budding. Patients with tumor budding tended to have positive lymphovascular invasion status (p = 0.002). There were no other significant differences in clinical features between patients with and without tumor budding. Kaplan-Meier curves showed that 5-year progression free survival in T1 patients without tumor budding was 87.9%, which was significantly higher than in those with tumor budding (48.0%, p <0.001). In multivariate analysis, tumor budding was also associated with progression (p = 0.001, Hazard ratio = 5.21). In a subgroup of patients treated with BCG instillation (n = 85), tumor budding was independently associated with stage progression (p = 0.002, Hazard ratio = 5.95). CONCLUSIONS Tumor budding might be a novel indicator for predicting stage progression in T1 NMIBC. Tumor budding can be easily introduced in clinical practice with high reproducibility and without additional immunohistochemical staining. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e381-e382 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Keishiro Fukumoto More articles by this author Eiji Kikuchi More articles by this author Shuji Mikami More articles by this author Kazuyuki Yuge More articles by this author Ogihara Koichiro More articles by this author Kazuhiro Matsumoto More articles by this author Shinya Morita More articles by this author Kazunobu Shinoda More articles by this author Takeo Kosaka More articles by this author Ryuichi Mizuno More articles by this author Toshiaki Shinojima More articles by this author Hiroshi Asanuma More articles by this author Akira Miyajima More articles by this author Mototsugu Oya More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Randomized Prospective Study of Lumpectomy Margin Assessment with Use of MarginProbe in Patients with Nonpalpable Breast Malignancies

BackgroundThe presence of tumor cells at the margins of breast lumpectomy specimens is associated with an increased risk of ipsilateral tumor recurrence. Twenty to 30 % of patients undergoing breast-conserving surgery require second procedures to achieve negative margins. This study evaluated the adjunctive use of the MarginProbe device (Dune Medical Devices Ltd, Caesarea, Israel) in providing real-time intraoperative assessment of lumpectomy margins.MethodsThis multicenter randomized trial enrolled patients with nonpalpable breast malignancies. The study evaluated MarginProbe use in addition to standard intraoperative methods for margin assessment. After specimen removal and inspection, patients were randomized to device or control arms. In the device arm, MarginProbe was used to examine the main lumpectomy specimens and direct additional excision of positive margins. Intraoperative imaging was used in both arms; no intraoperative pathology assessment was permitted.Results In total, 596 patients were enrolled. False-negative rates were 24.8 and 66.1 % and false-positive rates were 53.6 and 16.6 % in the device and control arms, respectively. All positive margins on positive main specimens were resected in 62 % (101 of 163) of cases in the device arm, versus 22 % (33 of 147) in the control arm (p < 0.001). A total of 19.8 % (59 of 298) of patients in the device arm underwent a reexcision procedure compared with 25.8 % (77 of 298) in the control arm (6 % absolute, 23 % relative reduction). The difference in tissue volume removed was not significant.ConclusionsAdjunctive use of the MarginProbe device during breast-conserving surgery improved surgeons’ ability to identify and resect positive lumpectomy margins in the absence of intraoperative pathology assessment, reducing the number of patients requiring reexcision. MarginProbe may aid performance of breast-conserving surgery by reducing the burden of reexcision procedures for patients and the health care system.

Absence of Residual Microcalcifications in Atypical Ductal Hyperplasia Diagnosed via Stereotactic Vacuum-Assisted Breast Biopsy: Is Surgical Excision Obviated?

PurposeThe purpose of our study was to evaluate the underestimation rate of atypical ductal hyperplasia (ADH) on vacuum-assisted breast biopsy (VABB), and to examine the correlation between residual microcalcifications and the underestimation rate of ADH.MethodsA retrospective study was performed on 27 women (mean age, 49.2±9.2 years) who underwent additional excision for ADH via VABB for microcalcifications observed by using mammography. The mammographic findings, histopathologic diagnosis of all VABB and surgical specimens, and association of malignancy with residual microcalcifications were evaluated. The underestimation rate of ADH was also calculated.ResultsOf the 27 women with microcalcifications, nine were upgraded to ductal carcinoma in situ (DCIS); thus, the underestimation rate was 33.3% (9/27). There was no difference in age (p=0.40) and extent of microcalcifications (p=0.10) when comparing benign and malignant cases. Six of 17 patients (35.3%) with remaining calcifications after VABB were upgraded to DCIS, and three of 10 patients (30%) with no residual calcifications after VABB were upgraded (p=1.00).ConclusionThe underestimation rate of ADH on VABB was 33.3%. Furthermore, 30% of patients with no remaining calcifications were upgraded to DCIS. Therefore, we conclude that all ADH cases diagnosed via VABB should be excised regardless of the presence of residual microcalcifications.

Delayed Treatment and Inadequate Surgical Margins for Invasive Melanoma in Elderly Patients

As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFranceand theUnited States, it becomesparamount fordermatologists tousediminishing resources judiciously to optimize melanoma management. Well-established guidelines of care, however, neither stratify nor adjust primarymelanoma treatment according to patient age.1,2 The article by Ciocan et al3 describes several patient and tumor characteristics of invasive melanoma in an elderly Frenchpopulationcomparedwithayounger cohort.Thestudy alsohighlights significant practice gaps in themanagement of melanoma in patients 70 years or older that present a challenge for dermatologists to understand and overcome. Age-relatedandsocioeconomic factorsmaycauseexplainabledelays indiagnosis. Prioritizinggeriatricprimarycareover dermatologic specialty care likely contributed to themore frequentlydiagnosedthicker,ulcerated, higher-grade category T3 or T4 tumors. The increased frequencyof nodular andacral lentiginousmelanomas is potentially explainable by impaired vision, selfsurveillance, and immunity in older patients. Despite these patient and tumor variances, a fundamental tenet of oncologic management protocols is their universal application toappropriatecases.Ciocanetaldescribeaclear deviation fromsuchanapproach in2 specific areas.First, older patients experienced a significant delay in treatment. Second, andmore important, definitive surgical excisionwas often inadequate. Although more elderly patients underwent an appropriate initial diagnostic excisional biopsy, almost 1 in 4 of them received no additional definitive excision when indicated, a rate 3-foldhigher than that inyoungerpatients.Thosewhounderwent additionalwide excisionwere alsodisadvantagedby inadequate surgical margins. The 5-fold increased incidence of lentigomalignamelanomaand a relative preponderance of head and neck tumors likely factored intomore conservative surgery to limit complications. Many prospective randomized clinical trials, however, have defined excisional margins that clearly reducemortality.4 The possibility that elderly patients may not receive this established standard of care represents a significant practice gap. Furthermore, regardless of the specific treatment, subsequent care was delayed beyond 6 weeks in almost a third of elderly patients. Optimal timing of definitivemelanomaexcisionhasnotbeenas rigorously studiedas surgicalmargins and represents a valuable research opportunity. Prolonged delays in treatment,however, clearly constitute anotherpracticegap. This importantstudybyCiocanetal should increaseawareness that agebias can influencedecisions inpotentially harmful ways. We do not know the dialogue exchanged between physician and patient thatmay have colored these decisions. Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primaryoradjuvant treatment.This studyalsoneitherasksnor answers whether these older patients were satisfied with the quality of their care. The true challenge in bridging these specific melanoma managementpracticegaps in theelderlymirrorsamuchgreater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?

Surgical treatment of symptomatic epilepsy in patients with brain cavernomas

Introduction. Epileptic seizures are one of the most common clinical manifestations of brain cavernomas. The purpose of study is to assess the efficiency of symptomatic epilepsy surgical treatment in patients with cerebral cavernomas.Methods. The study included 22 patients with brain cavernomas caused symptomatic epilepsy. Patients were divided on two groups: I group consists 8 patients with cavernomas in the temporal lobe, II group consists 14 patients with extratemporal lesion’s localization. In all patients microsurgical resection of cavernomas was performed, 3 patients underwent additional anterior temporal lobectomy. Follow-up was from 10 months to 3,5 years.Results. In I group 5 (62.5%) patients became seizure-free or have rare seizures, in 3 (37,5%) cases seizure frequency reduced slightly or did not change. Control for seizures was most effective in patients who underwent topectomy with additional anterior temporal lobectomy. In group II seizure control or significant seizure reduction was achieved in 7 (50%) patients, in other 7 (50%) — seizure frequency reduced slightly or did not change.Conclusion. Surgical strategy of patients with symptomatic epilepsy associated with cavernomas should focus on the lesion resection with additional excision of the hemosiderin-stained tissue. In temporal cavernomas such surgery should be supplemented by anterior temporal lobectomy.

Loop electrosurgical excision procedure for the treatment of cervical intraepithelial neoplasia: How much excision is enough?

This is a retrospective observational study to compare outcomes in patients with cervical intraepithelial neoplasia (CIN) treated with loop electrosurgical excision procedure (LEEP) using combined ectocervical/endocervical resection vs ectocervical resection alone. We demonstrated that additional endocervical resection during loop electrosurgical excision procedure did not significantly lower the risk of subsequent recurrence compared with ectocervical resection alone, in the treatment of CIN. With current published data supporting subsequent increased adverse effects of LEEP on future obstetrical outcomes, endocervical excision should be applied selectively. We recommend that additional endocervical excision should be reserved only for patients with a strong suspicion of underlying endocervical canal involvement based on colposcopic assessment or in patients with unsatisfactory colposcopy, where it is essential to evaluate the endocervical canal.

Transoraler Zugang bei sublingualer Tauchranula

The case of a 7-year-old boy suffering from progressive submental/submandibular swelling is reported. Following clinical and imaging diagnostics (MRI), the suspected diagnosis of a sublingual-plunging ranula was made. Surgery was performed with transoral excision of the sublingual gland in combination with excision of the ranula. Additional submandibular gland excision should be avoided.

小児の舌に発生した胞巣状軟部肉腫の1例

Alveolar soft-part sarcoma is considered an extremely rare disease in young people, and its tissue origin remains unclear. We report a case of alveolar soft-part sarcoma that developed in the tongue of a child.A 9-year-old boy had a tumor mass on the central dorsum of the tongue since the age of 4 years. It was left untreated for 5 years, until he was referred to our department by a dentist for detailed evaluation and treatment. We observed a hemispherical tumor mass (20 × 30 mm) with elastic hard and indolent properties and an ill-defined border on the central dorsum of the tongue. Histopathological diagnosis based on a biopsy performed under local anesthesia suggested a granular cell tumor, without providing a definitive diagnosis. Subsequently, surgery was performed with the patient under general anesthesia to remove the tongue tumor. An additional excision performed after histopathological examination led to a definitive diagnosis of alveolar soft-part sarcoma. Four years after surgery, the patient is in stable condition without any local recurrence or metastasis.

Results of 666 consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years

Our aim is to report the outcomes of hemorrhoidectomy performed via LigaSure™ with a minimum follow-up of 2 years. A total of 666 patients underwent hemorrhoidectomy for symptomatic prolapsed hemorrhoids (grade III and IV) via LigaSure between June 2006 and June 2008. Patient demographic and operative data were collected and analyzed. The mean patient age was 45.4 ± 11.1 years (x ± SD; range, 22-77), and approximately 72% had grade III hemorrhoids. All procedures were performed without complications. The operative time was 18.7 ± 4.1 minutes (range, 9-43), and hospital stay was 1.5 ± 0.6 days (range, 1-4). There was no immediate postoperative bleeding or other procedure-related complications. Twelve (1.8%) patients required urinary catheterization for a maximum of 1 day, and 21 (3.2%) patients had delayed postoperative bleeding. Most cases of bleeding resolved spontaneously; 3 patients (0.4%) required reoperation. A total of 645 patients (96.6%) responded to a follow-up telephone interview at a mean of 36 months (range, 24-49) after hemorrhoidectomy. After 1 year postoperatively, 2 patients received additional excisions for residual skin tags, 1 was treated for an anal stricture, 1 was treated for an anal fistula, and 3 were treated for anal fissures. Minor incontinence (flatus) was present in 11 (1.7%) patients, and 13 (2.0%) experienced mild bleeding caused by residual hemorrhoids; 1 patient underwent rubber-band ligation, and the others were successfully treated medically. No recurrent prolapse or persistent anal pain occurred during the follow-up period. The overall recurrence rate at 2-years follow-up was 3.1%. The long-term recurrence rate after hemorrhoidectomy with LigaSure is low and comparable with conventional hemorrhoidectomy.

EComment. Atrial fibrillation ablation - are we approaching an equivalent standard of cure?

We would like to highlight some important observations in the retrospective observational study by La Meir et al of a minimally invasive hybrid radiofrequency (RF) modified Maze ablation on the beating heart [1]. Common to both groups studied was a left atrial (LA) box ablation as well as a LA isthmus line in 16% to 20% respectively. The bipolar/bilateral group had 46% paroxysmal atrial fibrillation (PAF) patients versus 26% in the monopolar group. Nevertheless, analysis by AF type showed superior results in persistent AF with the bipolar/bilateral technique. The bipolar/bilateral technique allowed additional excision or closure of the LA appendage in 43% of patients, as well as additional RA lines in 29%, although 20% fewer LA interconnecting lines or complete box lesions were done. Assuming that the secondary hybrid transcatheter endocardial technique ensured that all lesion sets were complete and transmural (by subsequent endocardial gap lesion closure), then one can infer that it was the more extensive ablation pattern used in the bilateral/bipolar approach that was the reason for the superior results. Experimental studies by Cox showed that pulmonary vein isolation (PVI) alone had no effect on the ability to induce or maintain AF, and hence the original Maze procedure was designed to interrupt all potential pathways for atrial macro re-entrant circuits [2]. An important observation though, is the documented higher ‘device related’ incidence of incomplete, non-transmural ‘gap’ lesions with the non-irrigated epicardial monopolar RF device (Cobra Adhere XL; Estech) and unidirectional bipolar device (Coolrail; Atricure) used for the inferior and roof lines. One can therefore conclude that a bipolar bidirectional clamping RF device is a superior tool. The inability to have guaranteed transmural continuous RF ablation lines is not only a surgical epicardial ablation problem but applies equally to transcatheter endovascular ablation lesions. The Mayo clinic's 5-year freedom from recurrent AF is 87% following the cut-and-sew Maze procedure compared to their poorer 28% 5-year success following catheter ablation [3], which attests to both the validity of both Cox's original concept of interrupting all potential atrial macro re-entrant circuits with the cut-and-sew technique and need for permanent transmurality of ablation lines compared to subsequent concepts and approaches [2]. It is important to note that the patients in La Meir et al's study had lone AF [1] and these results may not be reproducible in patients with underlying structural heart disease, who constitute the current predominant surgical group undergoing concomitant AF ablation, having a 75-80% success rate in maintaining sinus rhythm at 1 year [4]. The cut-and-sew Cox-Maze via a median sternotomy using cardiopulmonary bypass remains the ‘gold standard’ in terms of a 90-95% success without any long-term attrition, but has not been widely accepted because it is a complex open surgical procedure with definite 1-2% perioperative mortality and morbidity risks [5]. La Meir et al's hybrid minimally invasive approach with a 1-year maintenance of sinus rhythm of 95% in lone AF patients appears to have a similar success rate [1]. In the lone AF population, especially if only mildly symptomatic apart from the thromboembolic risk, a hybrid ablation procedure with a mortality risk approaching 0%, minimized surgical incisions, short in-hospital stay, and with similar long-term 95% success rates to the ‘cut-and-sew’ Cox-Maze may well become the future standard of care. Conflict of Interest: None declared

Role of Adjuvant Radiosurgery after Thoracoscopic Microsurgical Resection of a Spinal Schwannoma

Stereotactic radiosurgery to benign tumors of the spine has not been advocated as a primary treatment modality because of the favorable prognosis for these lesions after gross-total resection. There is even less evidence regarding its use as an adjuvant to neurosurgical resection of benign recurrent spinal disease. We describe the case of a 30-year-old man with a thoracic spinal schwannoma who had an interval increase of his lesion five months after thoracoscopic microsurgical resection. The patient opted for noninvasive stereotactic radiosurgery in lieu of additional surgical excision and has had stable disease 15 months after radiosurgical treatment with the linear accelerator (LINAC) system. In this setting, stereotactic radiosurgery provided a useful adjunct to thoracoscopic microsurgical resection. Future Class I and II evidence should be sought to evaluate the utility of stereotactic radiosurgery as a primary treatment modality or as an adjuvant for microneurosurgical resection of benign spinal lesions in patients who want noninvasive treatment after disease recurrence or who harbor medical comorbidities that would preclude them from being safe surgical candidates.

P2-08-13: Does Routine Use of Preoperative Magnetic Resonance Imaging (MRI) in Breast Cancer Influence the Outcome?

Abstract Introduction: The role of routine preoperative breast MRI in patients diagnosed with breast cancer is still under discussion. In a milestone review, Houssami et al. (CA Cancer J Clin 2009;59;290) did not demonstrate an advantage with regard to DFS or OS. We reviewed our case series (n=793) in order to add evidence to the current discussion of whether or not preoperative MRI would influence the outcome. Material and Methods: In our database we identified four years of diagnosis (2004-07) in which a high percentage (72%) of patients (349 of 483) with histologically confirmed invasive breast cancer received preoperative MRI. In the following years (2008/09), MRI was still done in 31% of the cases (97 of 309). All pts were treated according to national guidelines; however, patients with additional lesions in MRI were subjected to an additional MRI-guided needle biopsy or additional wire-guided excision. The median follow-up time was 31.5 months (0-81). The patients were followed clinically. In most cases local surveillance was done by mammography. Results: In the total cohort, 20% of the patients had additional needle biopsies and/or wire-localisation due to MRI-findings. By MRI, lesions that subsequently led to an additional preoperative needle biopsy were found in 82 pts. Interestingly, only ten contralateral second cancers were found. In 357 pts, MRI was used as guidance during the operation with (n=118) or without MRI-supported wire localization (n=238). The percentage of additional MRI-needle biopsy or MRI-supported localisation did not differ between invasive ductal (n=655) and lobular cancer (n=91): 10% versus 13% needle biopsies and 15% versus 20% wire localisations. The number of surgical procedures to achieve tumor-free margins did not differ between patients with or without preoperative MRI. In this series, 69 of 100 patients who received neoadjuvant chemotherapy, also had MRI-imaging. Considering the patient cohort with follow-up available (n=737), no significant difference of DFS probability was observed between pts with and without preoperative MRI. Discussion: This retrospective analysis did not demonstrate any advantage for routine preoperative MRI with regard to local treatment and DFS probability. The observed rate of 20% additional operative procedures corresponds to similar published data (16% additional multicentric or multifocal lesions found by MRI, Solin, Breast. 2010;19:7). Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-13.