Adequate Margins Research Articles

Hepatic hemangioma in a simple liver cyst mimicking biliary cystic neoplasm

BackgroundFollow-up is recommended for an asymptomatic unilocular hepatic cystic lesion without wall-thickness and nodular components. A few liver cystic lesions represent biliary cystic neoplasms, which are difficult to differentiate from simple cysts with benign mural nodules on imaging alone.Case presentationAn 84-year-old woman with a history of simple liver cyst diagnosed one year prior was admitted for evaluation of a developed mural nodule in the cystic lesion. She had no specific symptoms and no abnormalities in blood tests except for carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (43.5 U/mL) levels. Contrast-enhanced computed tomography revealed a well-defined, low-attenuation lesion without a septum that had enlarged from 41 to 47 mm. No dilation of the bile duct was observed. A gradually enhancing mural nodule, 14 mm in diameter, was confirmed. MRI revealed a uniform water-intense cystic lesion with a mural nodule. This was followed by T2-enhanced imaging showing peripheral hypointensity and central hyperintensity. Enhanced ultrasonography revealed an enhanced nodule with a distinct artery within it. A needle biopsy of the wall nodule or aspiration of intracystic fluid was not performed to avoid tumor cell spillage. The possibility of a neoplastic cystic tumor could not be ruled out, so a partial hepatectomy was performed with adequate margins. Pathologically, the cystic lesion contained a black 5 mm nodule consisting of a thin, whitish fibrous wall and dilated vessels lined by CD31 and CD34 positive endothelial cells. The final diagnosis was a rare cavernous hemangioma within a simple liver cyst.ConclusionsCavernous hemangiomas mimicking well-enhanced mural nodules can arise from simple liver cysts. In less malignant cases, laparoscopic biopsy or percutaneous targeted biopsy of the mural nodules, together with needle ablation, may be recommended to avoid unnecessary surgery.

What Is an Adequate Margin During Sublobar Resection of ≤3 cm N0 Subsolid Lung Adenocarcinomas?

BackgroundSublobar resection offers noninferior survival vs lobectomy for ≤2 cm non-small cell lung cancer and is commonly used for subsolid tumors. Although data exist for solid tumors, the minimum adequate margin of resection for subsolid adenocarcinomas remains unclear. MethodsThis was a retrospective review of 1101 adenocarcinoma resections at our institution from 2006 to 2022. Inclusion criteria were tumors ≤3 cm with ≥10% radiographic ground glass, excised by sublobar resection. Exclusions were positive nodes or positive or unreported margin. The primary outcome was the rate of local recurrence (LR) at multiple thresholds of margin distance. The relationship between margin distance and solid component size was also explored. ResultsInclusion criteria were met by 194 patients. Median (interquartile range) tumor diameter and margin distance were 12 mm (9-17 mm) and 10 mm (5-17 mm), respectively. Median follow-up was 42.5 months. There was a progressive increase in LR with diminishing margin (0.1-cm decrements) from 1.5 cm to 0.5 cm. The difference in the rate of LR between “over” (n = 143) and “under” (n = 51) was most significant at 0.5 cm (8 of 51 [15.7%] vs 6 of 143 [4.2%]; P = .01) but did not reach α adjusted for multiple comparisons. On Cox regression for LR-free survival, margin ≤0.5 cm (P = .19) and solid component percentage (P = .14) trended to significance. Combining these using a ratio of margin distance–to–solid component size, a ratio of ≤1 showed a significantly higher rate of LR (7 [14.3%] vs 2 [2.0%], P = .009). Treatment of LRs provided at least intermediate-term survival in 87% of recurrences (median postrecurrence follow-up was 44 months). ConclusionsDuring sublobar resection of subsolid lung adenocarcinomas, a margin distance–to–solid component size ratio of >1.0 appears to be a more reliable factor than margin distance alone to minimize local recurrence. Local recurrence, however, may not impact survival in patients with subsolid adenocarcinomas if timely treatment is administered.

Abstract PO3-07-09: B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors

Abstract Background Lesions of uncertain malignant potential in the breast (B3 lesions) are composed of a wide spectrum of pathologies with differing risks of breast cancer. With the widespread implementation of screening programs globally, the incidence of these lesions has increased substantially. Asian women tend to have smaller and denser breasts than Western women, making identifying and treating these lesions more challenging. Previous papers quote an upgrade of B3 lesions to malignancy such as ductal carcinoma in situ (DCIS) or cancer at rates of 9.9% to 35.1%. Malignant upgrade on final histology increases patient anxiety and healthcare costs as a second surgical intervention is often required for pathological clearance or lymph node staging. This study aimed to assess the malignant upgrade rate of B3 lesions in Asian women and to evaluate any key factors that may predict the risk of a malignant upgrade. Materials and Methods A retrospective multicentre international study was done on patients at Seoul National University Hospital (SNUH), South Korea, from April 2021 to 2023, and Tan Tock Seng Hospital (TTSH), Singapore, between March 2006 and 2023. Patients who were diagnosed with a B3 lesion on initial breast core needle biopsy and underwent surgical open excision were included in the study. Results A total of 1049 patients were diagnosed with B3 lesions, with 154 (14.7%) upgrading to malignancy. The most common malignancy was DCIS, 118 (76.6%), followed by invasive ductal carcinoma (IDC), 20 (13.0%) and papillary carcinoma, 4 (2.6%). Within the types of B3 lesions, the malignant upgrade rates were found: atypical ductal hyperplasia (ADH), 88/252 (35%); intraductal papilloma (IDP) with atypia, 16/55 (29%); lobular neoplasia (LN), 9/34 (26%); and radial scar (RS), 5/21 (24%). Most patients had both ultrasound and mammographic evaluation, and all lesions in the study were graded BIRADS 4A and above. Univariate analysis showed that age >50 (OR 2.30 [1.61-3.31], p< 0.001), BMI >23 (OR 2.21 [1.20-4.12], p=0.01), post-menopausal status (OR 2.43 [1.34-4.34], p< 0.001), lesion being identified on mammography (OR 3.00 [2.04-4.51], p< 0.001) and presence of microcalcifications on mammography (OR 0.63 [0.41-0.98], p=0.04) were risk factors for malignant upgrade. Conclusion Based on our analysis of Asian women, post-menopausal patients with microcalcifications on mammography and a B3 biopsy result should be treated with a higher degree of suspicion for underlying malignancy. Surgical excision with adequate margins should be routinely considered for B3 lesions such as ADH, IDP with atypia, LN and RS. Avoidance of surgery or vacuum-assisted removal can be considered for younger patients with only ultrasound findings and diagnosis of FEA and IDP. Table 1. Malignant upgrade after excision Table 2. Clinical characteristics of all patients according to malignant upgrade Table 3. Univariate and multivariate analysis for malignant upgrade Citation Format: Wei Wen Ang, Ji-Jung Jung. B3 breast lesions in Asian Centers: malignant upgrade rates and risk factors [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-07-09.

Abstract PS01-06: The relationship between margin status of <2mm and local recurrence in DCIS patients

Abstract Background: There has been controversial evidence regarding adequate margin in breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS). However, the consensus is a surgical margin distance of 2 mm. Moreover, recent recommendations advised on ‘’clinical judgement’’ approach to re-excision in cases of margin distance < 2mm. The ongoing controversy in DCIS margin compared to invasive cancer margin is due to the differences in post operative management. This is important as margin status is one of the modifiable risk factor for local regional recurrence in DCIS. In our study we evaluated margin distance in patient diagnosed with DCIS who underwent BCS on local recurrence Methods: Patients who underwent breast conserving surgery between February 2000 and December 2018 at Asan Medical Center were retrospectively reviewed. Patients with involved resection margins were excluded. Kaplan-Meier survival analysis and Cox proportional hazard models were applied to determine the relationship between negative margin width and local recurrence. Results: A total of 1,858 patients were included in the study. Almost half of the patients had a tumor size of 1cm or smaller (n=876, 47.1%). Only 98 (5.3%) patients did not undergo radiation therapy. A negative margin width of < 1mm, < 2mm, < 5mm were all not associated with local recurrence (log-rank test p-value 0.1, 0.1, 0.078, respectively). For patients who underwent radiation therapy, a negative margin of any width was not related to local recurrence. Whereas, for patients who did not undergo radiation therapy, those with margins ≤2mm were significantly more likely to develop local recurrence than those with margins < 2mm (10-yr local recurrence rate, 16.4% vs 5.5%, respectively; hazard ratio, 5.709; 95% CI, 1.106-29.46, p=0.038). Conclusion: A negative margin is not related to local recurrence in DCIS patients who undergo breast conserving surgery with radiation therapy. Routine additional surgery for wider negative margin may only be needed for patients who do not undergo radiation therapy. Citation Format: Sarah Al Safi, Tae-Kyung Yoo, Sae Byul Lee, Jisun Kim, Il-Yong Chung, Hee Jeong Kim, Beom Seok Ko, Jong Won Lee, Byung Ho Son, Hee Jin Lee, Gyungyub Gong. The relationship between margin status of <2mm and local recurrence in DCIS patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS01-06.

Abstract PO5-18-03: A Randomized Controlled Trial to Evaluate the Safety and Efficacy of 1 cm versus 2 cm resection margins in Phyllodes Tumours of the Breast - An Exploratory Study

Abstract Introduction Phyllodes tumors are rare fibroepithelial tumors constituting 0.3-1% of breast tumors. It presents as a rapidly growing breast lump, with a bosselated surface and overlying shiny stretched skin with dilated prominent veins. Diagnosis is made by mammography and ultrasonography and tissue diagnosis is made by core needle biopsy. The tumor is known for its propensity to grow rapidly within the mesenchymal elements of breast tissue, and to locally recur. Surgery with adequate margins of excision has been known to prevent local recurrence. Phyllodes tumors have inspired much debate among surgeons, regarding the extent of margins during resection. These margins have been defined clearly for carcinoma of the breast (no ink on tumor) but the same consensus has not been reached for Phyllodes tumor. We carried out the world’s first randomized trial to settle the debate to compare the effects of a 1cm margin with that of a 2 cm margin, aiming to arrive at a consensus on the appropriate surgical margin to prevent re-excision and recurrences. We also aimed to compare cosmetic outcomes both subjectively and objectively between the 2 arms. Materials and Methods We carried out a prospective exploratory randomized control trial on patients with suspected phyllodes tumors of the breast from July 2020 to January 2022. After establishing diagnosis, and obtaining informed consent, patients were randomized to either of the 2 arms, to undergo resection with a lcm vs a 2 cm margin. Intraoperatively, the margin of the tumor was delineated by ultrasound for maximum accuracy. The incision made was deepened through the breast and pectoralis major muscle at a distance of exactly 1 cm or 2 cm from the tumor edge. The entire mass was excised en bloc with a 3 dimensional clearance from all sides. If the tumor was found infiltrating the underlying muscle (e.g Pectoralis major muscle, Serratus anterior), a full thickness section of the muscle was also excised with the specimen. The patients were followed up every 3 months with clinical examination and ultrasonography (followed by core needle biopsy for any suspicious mass), for a period of 12-18 months, to evaluate for recurrence.Cosmesis was evaluated by a 5-point Likert scale evaluated by the patient and the surgeon, and objectively using Breast Retraction Assessment and Nipple Deviation. Results We analysed the results of 41 patients who underwent surgery for Phyllodes tumor of the breast. All patients had negative margins after surgery. The mean margin distance (SD) in the 1 cm arm was 0.69 (0.20) cm and 1.83 (0.67) cm in the 2 cm arm. which was statistically significant between the groups. On the follow up ultrasound examination at 12 months, 1 patient (5.3%) was found to have a locoregional recurrence, but this was not statistically significant. There was no statistically significant difference in cosmesis between the arms. Conclusions We achieved our primary objective of histologically negative margins in all patients within both the groups. However, due to the limited number of patients recruited in the study, and due to the short duration of follow-up, we are not able to report significance in terms of recurrences between the 2 groups, to advocate for one over the other. The practice in our unit has been the 2 cm margin, as it offers good oncological outcomes and is definitely safe. Given that cosmetic outcomes were comparable in both arms, one can be assured that a 2 cm margin does not offer worse cosmesis compared to a 1 cm margin. However, our study at this point in time, establishes non inferiority of a 1 cm margin. There have been no randomized control trials conducted in world literature to influence guidelines and clinical practice regarding the ideal margin resection for phyllodes tumor. Our study would be the first of its kind, and is a novel concept not yet conducted for phyllodes tumor. We will continue this trial for years to come, and hope to generate level I data, with increased patient enrolment and a longer duration of follow up. Citation Format: Vandhana Rajgopal, Anita Dhar, Kamal Kataria, Piyush Ranjan, Anurag Srivastava. A Randomized Controlled Trial to Evaluate the Safety and Efficacy of 1 cm versus 2 cm resection margins in Phyllodes Tumours of the Breast - An Exploratory Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-18-03.

Flavouring group evaluation 419 (FGE.419): 2-methyl-1-(2-(5-(p-tolyl)-1H-imidazol-2-yl)piperidin-1-yl)butan-1-one.

The EFSA Panel on Food Additives and Flavourings (FAF) was requested to evaluate the safety of 2-methyl-1-(2-(5-(p-tolyl)-1H-imidazol-2-yl)piperidin-1-yl)butan-1-one [FL-no: 16.134] as a new flavouring substance, in accordance with Regulation (EC) No 1331/2008. The substance has not been reported to occur naturally and is chemically synthesised. In food, it is intended to be used as a flavouring substance only in chewing gum. The chronic dietary exposure to [FL-no: 16.134] was estimated to be 45 μg/person per day for a 60-kg adult and 28.4 μg/person per day for a 15-kg 3-year-old child. [FL-no: 16.134] did not show genotoxicity in a bacterial reverse mutation test and an invitro mammalian cell micronucleus assay. Based on the submitted toxicokinetic and metabolism data, it can be predicted that the flavouring substance is metabolised to innocuous products only. The Panel derived a lower confidence limit of the benchmark dose (BMDL) of 0.71 mg/kg bw per day for a 20% increase in the relative thyroid (including parathyroid) weight observed in a 90-day toxicity study in rats. Based on this BMDL, adequate margins of exposure of 887 and 374 could be calculated for adults and children, respectively. The Panel concluded that there is no safety concern for [FL-no: 16.134], when used as a flavouring substance at the estimated level of dietary exposure, based on the intended use and use levels as specified in Appendix B. The Panel further concluded that the combined exposure to [FL-no: 16.134] from its use as a food flavouring substance and from its presence in toothpaste and mouthwash is also not of safety concern.

Does the use of intraoperative frozen section of bone marrow from the cut end of the mandible help assess the adequacy of bone margins following mandibulectomy for oral cancer?

The adequacy of the cut end of the mandible following a segmental mandibulectomy done for oral cancer intraoperatively is at times assessed using a frozen section (FS)of the bone marrow (BM)at the cut ends. The study aimed to assess its utility to guide the intraoperative decision on the adequacy of bony margins. All patients with oral squamous cell carcinoma (OSCC)who underwent segmental mandibulectomy from January 2012 to December 2021 at our institute and for whom intraoperative FS of BM was utilized were included. We analyzed the sensitivity, specificity, and positive and negative predictive value (PPV,NPV) of this in predicting positive bone margins. A total of 457 patients were included in the study. The majority of the cases were per premium cases (n = 372, 81.4%). The median age of the cohort was 52 years (range: 22-80 years). Most patients had T4 disease (n = 406, 88.8%). On FS, BM was positive in only 18 patients (3.9%) for whom the bone margin was revised. BM biopsy report in the final histopathology was positive in 12 patients (2.2%). The sensitivity, specificity PPV, and NPV were 52.3%, 98.65%, 64.7%, and 97.7% respectively. No factors predicting BM positivity on FS could be identified in this cohort. The BM FS was positive in only a small percentage of patients, and it helped in reducing the bone margin positivity rate from 3.9% to 2.2% only. Hence the intraoperative BM FS seems to have limited utility as seen from our study.

Adequacy of Surgery of Head and Neck Cancers

Adequacy of Surgery of Head and Neck Cancers

Evaluation of a 3D Printed Silicone Oral Cavity Cancer Model for Surgical Simulations.

Adequate surgical margins are essential in oral cancer treatment, this is, however, difficult to appreciate during training. With advances in training aids, we propose a silicone-based surgical simulator to improve training proficiency for the ablation of oral cavity cancers. A silicone-based tongue cancer model constructed via a 3D mold was compared to a porcine tongue model used as a training model. Participants of varying surgical experience were then asked to resect the tumors with clear margins, and thereafter asked to fill out a questionnaire to evaluate the face and content validity of the models as a training tool. Eleven participants from the Otolaryngology-Head and Neck Surgery unit were included in this pilot study. In comparison to the porcine model, the silicone model attained a higher face (4 vs. 3.6) and content validity (4.4 vs. 4.1). Tumor consistency was far superior in the silicone model compared to the porcine model (4.1 vs. 2.8, p = 0.0042). Fellows and staff demonstrated a better margin clearance compared to residents (median 3.5 mm vs. 1.0 mm), and unlike the resident group, there was no incidence of positive margins. The surgical simulation was overall useful for trainees to appreciate the nature of margin clearance in oral cavity cancer ablation.

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience.

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections. In 2013, alaparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study. A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94patients (84%). Among the complications, wound infection was seen in sevenpatients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively. This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

A combined subsegmentectomy of right S9 + 10b with single direction thoracoscopic surgery

Segmentectomy is widely used to treat pulmonary nodules and more functional lungs can be preserved in patients. For pulmonary nodules deep near the intersegmental border, only one single segmentectomy may not achieve adequate surgical margins, and combined subsegmental resection becomes the most suitable treatment option. Thoracoscopic combined anatomical resections involving both of right S9 and S10b are one of the most challenging cases, especially in the right chest. We previously reported a case of combined subsegmental resection of the left complex basal segment (LS9b + 10b). To our knowledge, there has been no report of combined subsegmental resection of the right S9 and S10b. Here, we aim to introduce a different technique named as “open-gate”, which means that the intersegmental border between S7 and S10 was cut open along the intersegmental septa, to deal with complex combined basal subsegmental resections.

Nipple-Sparing Mastectomy and Adequate Margins for Patients With Ductal Carcinoma In Situ.

For patients with ductal carcinoma in situ (DCIS) undergoing breast conservation surgery (BCS), guidelines advise a margin width of at least 2mm, with studies demonstrating decreased recurrence risk compared to narrower margins. However, limited data exist establishing if this margin is appropriate in mastectomies, and specifically for nipple-sparing mastectomy (NSM). Consequently, we evaluated the margins of DCIS patients undergoing NSM and resulting oncologic outcomes. A single-institution retrospective review was performed in patients with DCIS or DCIS with microinvasion (DCIS + MI) undergoing NSM from April 2010 to December 2021. Patient and tumor characteristics, margin status, treatment, and outcomes information were collected. The association between margins and local-regional (LRR) and distant recurrence (DR) were examined. 161 patients were included, comprising 284 NSM (164 therapeutic, 120 prophylactic). 153 patients had DCIS and 8 had DCIS + MI. Most patients had hormone sensitive, 123 (76.4%), and nuclear grade 2, 72 (44.7%), disease. In total, 35 (21.7%) patients had positive or <2mm margins. Of these, 21 (60%) involved the anterior margin. At a median follow-up of 45 months (range 0-151), 2.5% (n = 4) had a LRR and .6% (n = 1) had a DR. Of patients with a recurrence, only 2 had positive or <2mm margins, 1 had received endocrine therapy, and none received adjuvant radiation. No specific margin status was found to correlate with recurrence for patients with DCIS or DCIS + MI undergoing NSM, with an altogether low recurrence risk. Overall, this suggests that recommended DCIS margins in BCS doesn't necessarily apply in NSM, where margins of <2mm may be acceptable.

Simultaneous Visualization of Lung Tumor and Intersegmental Plane during Pulmonary Segmentectomy by Intravenous Injection of Indocyanine Green.

Segmentectomy is a targeted surgical approach tailored for patients with compromised health and early-stage lung cancer. The key to successful segmentectomy lies in precisely identifying the tumor and intersegmental planes to ensure adequate resection margins. In this study, we aimed to enhance this process by simultaneously visualizing the tumor and intersegmental planes through the intravenous injection of indocyanine green (ICG) at different time points and doses. Lung tumors were detected by intravenous injection of ICG at a dose of 2 mg/kg 12 h before surgery in a rabbit model. Following the dissection of the pulmonary artery, vein, and bronchi of the target segment, 0.6 mg/kg of ICG was injected intravenously to detect the intersegmental plan. Fluorescent images of the lung tumors and segments were acquired, and the fluorescent signal was quantified using the signal-to-background ratio (SBR). Finally, a pilot study of this method was conducted in three patients with lung cancer. In a preclinical study, the SBR of the tumor (4.4 ± 0.1) and nontargeted segments (10.5 ± 0.8) were significantly higher than that of the targeted segment (1.6 ± 0.2) (targeted segment vs. nontarget segment, p < 0.0001; target segment vs. tumor, p < 0.01). Consistent with preclinical results, lung tumors and the intersegmental plane were successfully detected in patients with lung cancer. Consequently, adequate resection margins were identified during the surgery, and segmentectomy was successfully performed in patients with lung cancer. This study is the first to use intravenous ICG injections at different time points and doses to simultaneously detect lung cancer and intersegmental planes, thereby achieving segmentectomy for lung cancer.

Gender affirming care for the minimally invasive gynecologic surgeon.

Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists. The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure. Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.

Embryonal sarcoma of the liver in pediatric and young adult patients: A report from Children's Oncology Group study ARST0332.

Embryonal sarcoma of the liver (ESL) is a rare mesenchymal tumor most common in childhood; the optimal treatment approach is uncertain. The clinical features and outcomes of patients with ESL enrolled in a Children's Oncology Group (COG) clinical trial that evaluated a risk-based strategy for treating soft tissue sarcomas in patients aged <30 years were evaluated. This subset analysis included patients with ESL enrolled in COG study ARST0332. Central review of records, pathology, and imaging confirmed the diagnosis, presenting features, and surgery extent and complications. All patients received dose-intensive ifosfamide/doxorubicin chemotherapy, with cycle timing dependent on surgery and radiotherapy. Tumor resection occurred before study entry or after four cycles of chemotherapy; radiotherapy for residual tumor was optional. Thirty-nine eligible/evaluable patients with ESL were analyzed. All tumors were >10 cm in diameter; four were metastatic. Tumor resection was performed upfront in 23 and delayed in 16. Positive surgical margins (n=6) and intraoperative tumor rupture (n=6) occurred only in upfront resections. Eight patients received radiotherapy. Estimated 5-year event-free and overall survival were 79% (95% confidence interval [CI], 65%-93%) and 95% (95% CI, 87%-100%), respectively. Positive margins increased the local recurrence risk. One of 13 patients with documented hemorrhagic ascites and/or tumor rupture developed extrahepatic intra-abdominal tumor recurrence. The treatment strategy used in ARST0332 achieved favorable outcomes for patients with ESL despite a substantial proportion having high-risk disease features. Deferring tumor resection until after neoadjuvant chemotherapy may decrease the risk of intraoperative tumor rupture and improve the likelihood of adequate surgical margins.

Incidence of avascular necrosis of native femur following hip transposition surgery for periacetabular malignancies: a single-centre experience.

Hip transposition surgery after surgical resection of large pelvic tumours is a well-established alternate to endoprosthetic reconstruction. The major goals of surgery are to ensure adequate resection margins with limb salvation, albeit with acceptable levels of morbidity. While surveillance is aimed at diagnosing local recurrence or distant metastasis primarily, other complications may occasionally be seen.The aim of this study was to assess incidence of avascular necrosis (AVN) in the preserved native femoral heads after hip transposition surgery for periacetabular malignancies, also known as hanging hip surgery. Patient records and follow-up imaging of 22 patients who had undergone hanging hip surgery from 1999 to 2020 were retrospectively analysed to assess for any probable causes of AVN. Of the 22 patients, 5 (22.7%) had developed AVN on follow-up with a mean time of onset of about 10.5 months from surgery (5 months-2 years). A review of the patient demographics, surgical notes, preoperative management did not offer any clues as to the cause of AVN in these patients. Osteopenia was the most common radiological finding (59%) in most patients, but this also did not herald AVN onset. The theory that loss of major vascular supply to the femoral head from capsular disruption during hip transposition surgery would lead to AVN in most patients did not hold true as AVN occurred in a small number of patients.

Deep margin assessment by intraoperative ultrasound in tongue cancer- dust trial

Introduction: Oral cancer ranks sixth among all cancers globally and India has the most significant number of cases, one-third of the total burden of oral cancer cases globally. The aim of the study was to conduct deep margin assessment using intraoperative ultrasound in superficial oral tongue carcinomas, ensuring adequate surgical resection for early-stage oral tongue cancer minimizing loco regional recurrence risks. Methodology: This is a prospective observational study involving 91 diagnosed tongue malignancies. The study included biopsy verified tongue cancer. During the surgical procedure and effect of general anaesthesia the tongue lesions of the patient were evaluated with intraoral sonography. An intraoral transducer probe characterized by an 8 to 10 MHz ultrasonic beam Siemens Acuson NX3 was used to assess the deep margin, tumor thickness, margins, and other findings like lingual nodes are noted. Results: A total of 91 patients that underwent resection using intraoperative USG were included in the study. The majority of the patients were in the age group 41 - 60 years. As carcinoma tongue is more common in males our study has a sex distribution of 63 male and 28 females. The mean deep margin assessed by USG - is 0.901cm and the mean deep margin assessed by the frozen section is 0.762 cm. The mean deep margin assessed by final histology is 0.748 cm. Conclusion: USG guided resection of early tongue cancers is a technique that is able to increase the frequency of free margins and decrease the close margin and positive margin frequency when compared to conventional treatment. USG being noninvasive is a very fast method in comparison to the frozen section and seems to be a promising technique. Larger studies are needed with control groups to possibly confirm a statistically significant difference in adequate deep resection margin and improvement in DSS and quality of life in future. Keywords: deep margin; tongue; carcinoma

Best Estimate Plus Uncertainty Analysis of Station Blackout Transient in Pool-Type Research Reactor

Simulation of a station blackout (SBO) scenario was carried out for an open pool–type nuclear research reactor. The SBO transient was analyzed using the best estimate (BE) thermal-hydraulic code RELAP5/MOD3.2 to evaluate the performance of safety systems and inherent thermal inertia provided by the reactor pool in ensuring adequate core cooling during a prolonged SBO condition lasting up to 7 days. This encompasses assessment of cooling provided by battery-operated auxiliary pumps in the initial phase followed by setup of the natural convection cooling mode for the extended period. Best Estimate Plus Uncertainty (BEPU) methodology was applied for assessment of safety margins. This involved estimation of required simulations using the Wilks first-order formulation to achieve results within the tolerance limit of 95/95. Identification of relevant uncertainties and their propagation was carried out; subsequently, a case matrix for 59 simulation runs was generated using the Latin hypercube sampling method. The upper/lower bounds of uncertainty results were analyzed and compared with the BE code results. Later, sensitivity analysis was carried out using sensitivity coefficients generated using the Pearson and Spearman coefficient. The results show that the values of the crucial thermal-hydraulic parameters obtained with the tolerance limit of 95/95 met the acceptance criteria, with adequate safety margins.

Iron Fortification and Inulin Supplementation in Early Infancy: Evaluating the Impact on Iron Metabolism and Trace Mineral Status in a Piglet Model

BackgroundInfant formula in the United States contains abundant iron, raising health concerns about excess iron intake in early infancy. ObjectivesUsing a piglet model, we explored the impact of high iron fortification and prebiotic or synbiotic supplementation on iron homeostasis and trace mineral bioavailability. MethodsTwenty-four piglets were stratified and randomly assigned to treatments on postnatal day 2. Piglets were individually housed and received an iron-adequate milk diet (AI), a high-iron milk diet (HI), HI supplemented with 5% inulin (HI with a prebiotic [HIP]), or HIP with an oral gavage of Ligilactobacillus agilis YZ050, an inulin-fermenting strain, every third day (HI with synbiotic [HIS]). Milk was provided in 14 meals daily, mimicking formula feeding in infants. Fecal consistency score and body weight were recorded daily or every other day. Blood and feces were sampled weekly, and tissues collected on postnatal day 29. Data were analyzed using mixed model analysis of variance with repeated measures whenever necessary. ResultsDiet did not affect growth. HI increased hemoglobin, hematocrit, and serum iron compared to AI. Despite marginal adequacy, AI upregulated iron transporter genes and maintained satisfactory iron status in most pigs. HI upregulated hepcidin gene expression in liver, caused pronounced tissue iron deposition, and markedly increased colonic and fecal iron. Inulin supplementation, regardless of L. agilis YZ050, not only attenuated hepatic iron overload but also decreased colonic and fecal iron without altering pH or the expression of iron regulatory genes. HI lowered zinc (Zn) and copper (Cu) in the duodenum and liver compared to AI, whereas HIP and HIS further decreased Zn and Cu in the liver and diminished colonic and fecal trace minerals. ConclusionsEarly-infancy excessive iron fortification causes iron overload and compromises Zn and Cu absorption. Inulin decreases trace mineral absorption likely by enhancing gut peristalsis and stool frequency.

Effect of palatine tonsil tumor resection on postoperative velopharyngeal insufficiency in transoral surgery.

Velopharyngeal insufficiency (VPI) is a known complication of transoral surgery (TOS) for oropharyngeal HPV-mediated squamous cell carcinoma. Controversy exists regarding adequate resection margins for balancing functional and oncologic outcomes. This retrospective study was exempted by the IRB. Patients who underwent TOS from January 2017 to October 2022 were included. Patient characteristics, treatment details, and oncologic and functional outcomes were evaluated. Fifty-five patients were included. Mean and median follow-up was 34 months. 98% of patients were AJCC stage I/II. Recurrence-free survival was 96% with no local recurrences. Univariate analysis demonstrated an association between VPI and pT stage (p = 0.035), medial pterygoid resection (p = 0.049), and palatal attachment sacrifice (p < 0.001). Multivariate analysis showed sacrifice of the palatal attachments remained a significant risk for VPI (p = 0.009). Loss of soft palate pharyngeal attachments is an independent risk factor for VPI. When oncologically appropriate, the palatal attachments to the pharynx may be preserved.