Clear Margins Research Articles

Update and Trends in Breast Reconstruction After Mastectomy

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

Successful laparoscopic resection of a rare focal form of congenital hyperinsulinism: Case report and literature review

Congenital hyperinsulinism is a severe disease that causes irreversible damage to the cerebral cortex. This article presents a clinical observation of successful surgical treatment for a child with an extremely rare form of hyperinsulinism accompanied by two foci in the opposite ends of the pancreas. The child was in extremely critical condition from birth due to recurrent hypoglycemia and was diagnosed with hyperinsulinism at the age of two weeks. Specific therapy with diazoxide and octreotide was initiated but proven to be ineffective (parenteral glucose administration was still needed, and octreotide only provided partial results). When the child was one month old, positron emission tomography-computed tomography with 18F-DOPA was performed and revealed the focal hyperfixation of the radiopharmaceutical in the tail and head of the pancreas. This finding indicated the presence of two pathological foci or a focus in the tail and the physiological accumulation of the radiopharmaceutical in the head. At the age of one month and 20 days, the child underwent laparoscopic revision of the pancreas to visualize a focus in the tail that was confirmed by express biopsy. The resection of the tail (15%) was performed with confirmation of clear resection margins. During further revision, a focus was detected in the head. Resection was again performed with histological confirmation of complete resection. On the 12th day after the operation, the child was discharged without therapy with clinical recovery. The child is currently being monitored (for over six months), growing and developing according to age. A fasting test was performed, and the recurrence of hyperinsulinism was ruled out. This article presents a detailed description of the clinical and radiological examination results, the patients history, the surgical techniques, and the intervention results. As part of the discussion, a literature review on the behavior of laparoscopic resections of the pancreas in children with congenital hyperinsulinism was carried out.

Translated article] Basal Cell Carcinoma in the Southern Health Area of Tenerife: Key Clinical and Pathological Factors and Margin Status After Excision

Background and objectiveSurgical excision is the treatment of choice for basal cell carcinoma (BCC). Complete excision with clear margins is important for reducing the risk of recurrence. The aims of this study were to describe the characteristics of BCCs in our health care area, calculate the percentage of positive margins after surgical excision, and determine the risk factors for incomplete excision. Material and methodsRetrospective observational study of BCCs that were surgically removed at Hospital Universitario Nuestra Señora de Candelaria, in Santa Cruz de Tenerife, Spain, between January 1, 2014 and December 31, 2014. Information was collected on demographic, clinical, and histologic variables, surgical approach, margin status, and the department responsible. ResultsIn total, 966 BCCs were diagnosed in 776 patients. Nine percent of tumors with complete data were biopsied, 89% were surgically excised, and 2% were removed by shave excision. The median age of patients with excised tumors was 71 years and 52% were men. BCCs were most often located on the face (59.1%). Surgical margins were analyzed in 506 cases, 17% of which had positive margins. Incomplete excision was significantly more common in tumors located on the face (22% vs. 10% for other locations) and in high-risk subtypes according to the World Health Organization classification (25% vs. 15% for low-risk subtypes). ConclusionsThe characteristics of BCCs in our health care area are similar to those described elsewhere. Facial location and histologic subtype are risk factors for incomplete excision. Careful surgical planning is therefore important in the initial management of BCCs with these characteristics.

Surgical management of giant skin tumor – A case report

Malignant non-melanoma skin cancers (NMSC) are of two main types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). In rare occasions, some of the malignant skin lesions show histopathological characteristics of both BCC and SCC and are known as basosquamous carcinomas (BSC). In some cases of large tumors, extensive reconstructive surgery might be needed to correct the skin defect after the primary excision. We report a case of a 76-year-old Bulgarian male patient who presented with a neglected giant cutaneous tumor with more than a 15-year history of a growing mass in the right deltoid area. On physical exam an enormous exophytic ulcerated and crusted skin lesion measuring around 11×11cm was found. Wide local excision of the lesion with 10-mm resection margins and partial resection of the underlying deltoid muscle were performed due to signs of infiltration. A full-thickness total skin graft from the left inguinal area was harvested to cover the skin defect. Final histopathological examination showed metatypical carcinoma with mixed characteristics of SCC and BCC-BSC, with infiltration of the fatty tissue, deltoid muscle and clear margins of resection, staged as T4R0. Two and a half years after surgery there are no signs of upper arm motor dysfunction and no evidence of local recurrence and distant metastasis on a follow-up PET/CT. Following current National Comprehensive Cancer Network's guidelines for primary treatment of BCC, surgical candidates should undergo standard excision with wider surgical margins, postoperative margin assessment and second intention healing, linear repair, or skin graft. Therapeutic strategy for non-operable cases includes administration of radiotherapy or system therapy in the face of Hedgehog pathway inhibitors and programmed cell death protein 1 inhibitor. They can provide an alternative solution to unresectable or difficult-to-treat locally advanced cases of BSC. Similarly to BCC and SCC, the first-line treatment option for BCS is surgical excision, but surgical margins should be wider than those for low-risk BCC due to the infiltrative growth pattern of this tumor. Favorable esthetic outcome requires precise planning of the reconstructive technique.

Diagnosis and management of intercostal intramuscular hemangioma: an updated review

BackgroundIntramuscular hemangioma (IMH) is an uncommon type of hemangioma, and primary IMH of the intercostal muscle is even rarer. Only a few reports describe IMH of the intercostal muscle, and there are no review articles on this topic. We report our experience with a younger female patient, who underwent video-assisted thoracic surgery with tumor resection and review the previous literatures of intercostal IMH.Case presentationAn asymptomatic 17-year-old woman showed a 29-mm, homogeneous, intrathoracic nodule in the left chest wall, attached to the second and third ribs on computed tomography. We performed exploratory thoracoscopic surgery and the tumor was excised without surrounding rib resection. Histopathologic examination of the surgical specimen revealed proliferation of small blood vessels within the surrounding striated muscle, leading to the diagnosis of intercostal IMH. The surgical margin was negative. The patient’s postoperative course was uneventful, and there has been no evidence of recurrence for more than 18 months after surgery.ConclusionsWe describe a case of intercostal IMH, who received tumor resection with clear excision margin without surrounding rib resection. Preoperative diagnosis is challenging due to its rarity, but intercostal IMH should be recalled as a differential diagnosis of chest wall tumor. Tumor excision without surrounding rib resection is acceptable for intercostal IMH, when there is a good possibility of achieving negative surgical margin.

Minimally-invasive approach via percutaneous femoral cannulation for the resection of intra-cardiac masses: a single center experience in the Middle-East

BackgroundIntra-cardiac masses are rare and challenging lesions with an overall incidence ranging of 0.02–0.2%. Minimally invasive approaches have been recently introduced for surgical resection of these lesions. Here, we evaluated our early experience using minimally invasive techniques in addressing intra-cardiac lesions.MethodologyThis is a retrospective descriptive study conducted between April 2018 to December 2020. All patients were diagnosed with cardiac tumors and treated via a right mini-thoracotomy with cardiopulmonary bypass through femoral cannulation at King Faisal Specialist Hospital and Research Centre, Jeddah.ResultsMyxoma was the most common pathology representing 46% of cases followed by thrombus (27%), leiomyoma (9%), lipoma (9%) and angiosarcoma (9%). All tumors were resected with negative margins. One patient was converted to open sternotomy. Tumor locations were in the right atrium, left atrium, and left ventricle in 5, 3, and 3 patients, respectively. The median ICU stay was 1.33 days. The median length of hospitalization was 5.7 days. There was no 30-days hospital mortality recorded in this cohort.ConclusionOur early experience shows that minimally invasive resection can be performed safely and effectively for intra-cardiac masses. The minimally invasive approach using a mini-thoracotomy with percutaneous femoral cannulation can be an effective alternative in resecting intra-cardiac masses that achieves clear margin resection, quick post-operative recovery, and low rates of recurrence for benign lesions.

Real-world efficacy of postoperative radiotherapy with a moderate dose-escalation for phyllodes tumors of the breast.

Phyllodes tumors are rare breast tumors comprising less than 1% of cases, categorized as benign, borderline, or malignant. Treatment typically involves complete surgical excision with wide margins. Adjuvant radiotherapy may be recommended for borderline or malignant tumors, or when clear margins cannot be achieved through surgery alone. We conducted a retrospective review of 14 women diagnosed with phyllodes tumors between 2015 and 2023. Among them, 36% had benign tumors and 64% had borderline/malignant tumors. The majority (86%) underwent breast-conserving surgery. Postoperative radiation therapy was delivered to the whole breast/chest wall, with a median biologically effective dose (BED) of 92.7 Gy (90.0-102.6 Gy), representing a moderate dose-escalation over conventional breast cancer schedules. After a median follow-up of 48.5 months, no local or distant recurrence were observed. Mild to moderate skin toxicity occurred in all patients: 36% reported grade 1, 43% grade 2, and 21% grade 3 toxicity. One patient developed grade 2 fibrosis during follow-up. No significant correlations were found between the severity of acute/late toxicity and tumor size, surgical approach, or the radiation field's planning target volume (PTV). Adjuvant radiation therapy appears to be well tolerated and feasible for high-risk phyllodes tumors. However, the decision to utilize radiotherapy should be personalized, considering tumor characteristics and the risks and benefits associated with treatment.

A New Approach: Determination of the Safe Surgical Margin in Pterygium Surgery.

In this retrospective study, we aimed to determine the safe surgical limit for excision of pterygium tissue. Therefore, we aimed to prevent excessive or incomplete normal conjunctival tissue excision during surgery in the coming years. Autografted pterygium surgery was performed between January 2015 and April 2016, and the excised pterygium tissue was examined histopathologically. The files of 44 patients, who had not previously undergone any ocular surgery, who did not have an inflammatory disease and who continued to be checked for at least 1 year, were retrospectively examined. The distance (P-DSEM) from the excised pterygium tissue to the surgical excision margin was measured by a pathologist. Postoperative recurrence rates were evaluated according to this value. In this way, the clean surgical margin was determined. The mean age of the participants was 44.77 ± 12.70, and the mean follow-up time was 55.61 ± 16.38 months. Recurrence developed in 5 out of 44 patients (11.4%). The average recurrence duration was 51 ± 13.87 days. Distance to the average surgical margin was 3.88 ± 0.91 mm. The surgical distances of 5 patients with recurrence were 2, 2.5, 2, 3, and 3 mm, respectively. It was determined that recurrence was less as the distance (P-DSEM) from the tissue to the surgical excision margin increased (p = 0.001). We found that the recurrence rate in pterygium surgery was linked to the clean surgical margin. When planning pterygium surgery, we believe that determining the amount of tissue to be excised before surgery will reduce recurrence rates.

Repere anatomice în histerectomia radicală

Introduction. Customizing surgical radicality is a crucial element in contemporary cervical cancer surgery. Currently, anatomic structures are characterized based on many anatomic interpretations. In order to suggest its general applicability, this study proposes to standardize the definitions and anatomic landmarks of the various types of radical hysterectomy. Methodology. This paper is a literature review in which we selected relevant articles from PubMed database, starting with the year of publication 2010 until 2023, using the following keywords: “cervical cancer”, “radical hysterectomy”, “classification of radical hysterectomy”, “anatomic landmarks”, “tailoring surgery”, “nerve-sparing procedure”. Results. The lateral extent of resection serves as the basis for the updated Querleu-Morrow classification. The three-dimensional anatomic template used to define the resection limits is based on the precise anatomy of the paracolpium and parametrium. The main anatomic landmarks and avascular spaces of the pelvis serve as the basis for the oncologic procedures, including nerve-sparing techniques. There are four different types of radical hysterectomy, each type described with three-dimensional landmarks. There are three main objectives that never change: excising the central tumor with clear margins, removal of any possible lymph dissemination sites, and the control of metastatic disease. Conclusions. It is essential to base research evaluating radicality in the surgical treatment of cervical cancer on precise and generally accepted nomenclature and descriptions. Since the degree of parametrium excision affects late morbidity, particularly bladder and rectal dysfunctions, the thorough explanation and understanding of the many forms of radical hysterectomy are crucial.

Active Token Mixer

The three existing dominant network families, i.e., CNNs, Transformers and MLPs, differ from each other mainly in the ways of fusing spatial contextual information, leaving designing more effective token-mixing mechanisms at the core of backbone architecture development. In this work, we propose an innovative token-mixer, dubbed Active Token Mixer (ATM), to actively incorporate contextual information from other tokens in the global scope into the given query token. This fundamental operator actively predicts where to capture useful contexts and learns how to fuse the captured contexts with the query token at channel level. In this way, the spatial range of token-mixing can be expanded to a global scope with limited computational complexity, where the way of token-mixing is reformed. We take ATMs as the primary operators and assemble them into a cascade architecture, dubbed ATMNet. Extensive experiments demonstrate that ATMNet is generally applicable and comprehensively surpasses different families of SOTA vision backbones by a clear margin on a broad range of vision tasks, including visual recognition and dense prediction tasks. Code is available at https://github.com/microsoft/ActiveMLP.

A Benchmark and Asymmetrical-Similarity Learning for Practical Image Copy Detection

Image copy detection (ICD) aims to determine whether a query image is an edited copy of any image from a reference set. Currently, there are very limited public benchmarks for ICD, while all overlook a critical challenge in real-world applications, i.e., the distraction from hard negative queries. Specifically, some queries are not edited copies but are inherently similar to some reference images. These hard negative queries are easily false recognized as edited copies, significantly compromising the ICD accuracy. This observation motivates us to build the first ICD benchmark featuring this characteristic. Based on existing ICD datasets, this paper constructs a new dataset by additionally adding 100,000 and 24, 252 hard negative pairs into the training and test set, respectively. Moreover, this paper further reveals a unique difficulty for solving the hard negative problem in ICD, i.e., there is a fundamental conflict between current metric learning and ICD. This conflict is: the metric learning adopts symmetric distance while the edited copy is an asymmetric (unidirectional) process, e.g., a partial crop is close to its holistic reference image and is an edited copy, while the latter cannot be the edited copy of the former (in spite the distance is equally small). This insight results in an Asymmetrical-Similarity Learning (ASL) method, which allows the similarity in two directions (the query ↔ the reference image) to be different from each other. Experimental results show that ASL outperforms state-of-the-art methods by a clear margin, confirming that solving the symmetric-asymmetric conflict is critical for ICD. The NDEC dataset and code are available at https://github.com/WangWenhao0716/ASL.

DS10 Down to the bone: bone burring under local anaesthesia for skin cancers involving periosteum at the time of Mohs extirpation — a service evaluation and assessment of patient tolerability

Abstract We present the initial evaluation of bone burring under local anaesthesia (LA) for skin cancers involving periosteum at the time of Mohs extirpation. Bone burring under LA enables patients to have their procedure on the same day. Including the bone burring as part of the Mohs process is logical as we can most accurately assess the location of the involved periosteal tissue. Our evaluation highlights the evolution of our service, our technique, the cost savings and an assessment of patient tolerability with qualitative data. We use a pneumatic De Soutter microdrill with a rose head drill tip. We have evolved to use a crosshatch pass technique with burring to enable the treated field to have two passes bidirectionally. Bone fragments are gathered and sent for histological and immunohistochemical analysis. Local anaesthesia bone burring is rapid, taking < 5 min. At the time of submission, three patients (aged 78–83 years) with skin cancers were offered the option of bone burring under LA. In each case, the bone appeared clinically normal. All tumours were histologically confirmed infiltrative squamous cell carcinomas on the frontal scalp, nasal dorsum and chin, ranging in size from 30 × 22 to 42 × 30 mm. Mohs stages ranged from two to four, all with periosteal involvement confirmed in the Mohs layer with frozen sectioning. At least a week after the procedure, all patients were asked to rate the pain from the bone burring procedure (0 being no discomfort and 10 being intolerable). The patients all reported a value of 0 (no discomfort). All patients confirmed that they would not have chosen differently between having the procedure done under LA vs. GA. The implementation of LA bone burring not only offers greater convenience to often elderly or frail patients, but also confers a considerable cost-saving. Initial outlay with equipment and maintenance costs are minimal, and staffing costs are modest compared with the general anaesthesia approach, when considering the avoided appointments, dermatology theatre staffing and procedure speed. Bone burring under LA represents an effective, safe, well-tolerated and cost-effective method of achieving clear deep margins in cases of tumour periosteal/bone involvement. Bone burring can be undertaken as part of the Mohs process so that the patient can still have the benefit of a definitive surgical reconstruction on the same day.

Pathological determinants of outcome following resection of locally advanced or locally recurrent rectal cancer

IntroductionPathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance. Materials and methodsA retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS). Results388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49–67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC. ConclusionsA positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.

DS06 Does the content of patient information leaflets reflect real-life practice? A comparison of four patient information leaflets in Mohs micrographic surgery

Abstract In our experience, patients referred for Mohs micrographic surgery (MMS) often have unrealistic expectations, anticipating defects that are small in size and depth, and incorrectly describe the procedure as removal of skin cancer by ‘taking away thin slices’ or ‘skimming the skin layer by layer’. This observation prompted us to critically appraise four widely accessed online patient information leaflets (PILs) on MMS produced by the British Association of Dermatologists, the American Academy of Dermatology, Dermnetnz.org and the European Society of Micrographic Surgery. Our aim was to evaluate the wording used and propose evidence-based changes to help manage patients’ expectations. We focused on two core themes: (i) excision of tumour by MMS, including the number of stages, and (ii) cosmetic benefit of MMS over standard excision (SE). All of these PILs state the need for ‘stages’ to achieve margin clearance, with an initial margin of excision as low as 1 mm per stage mentioned in one PIL. The leaflets suggest cosmetic benefit and tissue preservation of MMS over SE, and one leaflet ranked this higher than other advantages offered by MMS. We feel that these points are overstated and better addressed with evidence-based facts. Studies have shown that 60% of cases of MMS are cleared in one stage; > 90% of tumours are cleared within two stages, and the number of patients needing three or more stages is only 6% (Macfarlane L, Waters A, Evans A et al. Seven years’ experience of Mohs micrographic surgery in a UK centre, and development of a UK minimum dataset and audit standards. Clin Exp Derm 2013; 38:262–9). In our experience, a surgical margin of 1 mm is not feasible in MMS. There is no direct evidence that MMS improves cosmesis compared with SE (Brown AC, Brindley L, Hunt WTN et al. A review of the evidence for Mohs micrographic surgery. Part 2: basal cell carcinoma. Clin Exp Dermatol 2022; 47:1794–804). Cosmetic and functional outcomes are usually only relevant in high-risk sites (e.g. the central face H zone) and in certain high-risk tumours where wide local excision would be the alternative treatment. In conclusion, we propose that PILs in MMS should avoid using misleading language like ‘thin’ and ‘small’ when describing the procedure. Patient information leaflets should clarify that the vast majority of tumours are cleared after two stages rather than requiring multiple stages. Tissue sparing should not be highlighted as the main advantage of MMS, and patients should not be pledged small wounds and better cosmetic outcomes.

Radiofrequency localization of nonpalpable breast cancer in a multicentre prospective cohort study: feasibility, clinical acceptability, and safety

PurposeIn breast conserving surgery, accurate lesion localization is essential for obtaining adequate surgical margins. Preoperative wire localization (WL) and radioactive seed localization (RSL) are widely accepted methods to guide surgical excision of nonpalpable breast lesions but are limited by logistical challenges, migration issues, and legislative complexities. Radiofrequency identification (RFID) technology may offer a viable alternative. The purpose of this study was to evaluate the feasibility, clinical acceptability, and safety of RFID surgical guidance for localization of nonpalpable breast cancer.MethodsIn a prospective multicentre cohort study, the first 100 RFID localization procedures were included. The primary outcome was the percentage of clear resection margins and re-excision rate. Secondary outcomes included procedure details, user experience, learningcurve, and adverse events.ResultsBetween April 2019 and May 2021, 100 women underwent RFID guided breast conserving surgery. Clear resection margins were obtained in 89 out of 96 included patients (92.7%), re-excision was indicated in three patients (3.1%). Radiologists reported difficulties with the placement of the RFID tag, partially related to the relatively large needle-applicator (12-gauge). This led to the premature termination of the study in the hospital using RSL as regular care. The radiologist experience was improved after a manufacturer modification of the needle-applicator. Surgical localization involved a low learning curve. Adverse events (n = 33) included dislocation of the marker during insertion (8%) and hematomas (9%). The majority of adverse events (85%) occurred using the first-generation needle-applicator.ConclusionRFID technology is a potential alternative for non-radioactive and non-wire localization of nonpalpable breast lesions.

AMELOBLASTOMA IN THE POSTERIOR MAXILLA: A CASE REPORT

A 61-year-old male patient presented a painless, well-defined, expansive tumor on the left maxillary edentulous alveolar ridge, which had 18 months of evolution. The lesion measured 30 × 20 mm, had a soft consistency, and was covered by healthy mucosa, though with a localized ulcer. Medical history revealed type II diabetes, hypertension, and pulmonary tuberculosis. Panoramic radiograph showed an unilocular, radiolucent image expanding into the left maxillary sinus, with corticated margins. Cone-beam computed tomography revealed a well-defined, expansive, hypodense image involving the posterior alveolar ridge and extending into the maxillary sinus. Under a clinical hypothesis of mesenchymal neoplasia or fibro-osseous lesion, a puncture was performed, with a negative result. An incisional biopsy was undertaken and the histopathological diagnosis was ameloblastoma. The lesion was resected under general anesthesia, with clear margins. The final diagnosis was conventional (solid) ameloblastoma and the patient has been free of recurrence for 5 months. Support: CAPES. A 61-year-old male patient presented a painless, well-defined, expansive tumor on the left maxillary edentulous alveolar ridge, which had 18 months of evolution. The lesion measured 30 × 20 mm, had a soft consistency, and was covered by healthy mucosa, though with a localized ulcer. Medical history revealed type II diabetes, hypertension, and pulmonary tuberculosis. Panoramic radiograph showed an unilocular, radiolucent image expanding into the left maxillary sinus, with corticated margins. Cone-beam computed tomography revealed a well-defined, expansive, hypodense image involving the posterior alveolar ridge and extending into the maxillary sinus. Under a clinical hypothesis of mesenchymal neoplasia or fibro-osseous lesion, a puncture was performed, with a negative result. An incisional biopsy was undertaken and the histopathological diagnosis was ameloblastoma. The lesion was resected under general anesthesia, with clear margins. The final diagnosis was conventional (solid) ameloblastoma and the patient has been free of recurrence for 5 months. Support: CAPES.

Surgical Outcomes, Long-Term Recurrence Rate and Resource Utilization in a Prospective Cohort of 165 Patients Treated by Transanal Total Mesorectal Excision for Distal Rectal Cancer

Abstract Background Transanal total mesorectal excision (taTME) is an alternative to laparoscopic and robotic TME owing to its reported superior ability to achieve clear margins in distal rectal cancers. Worrisome reports of high recurrence and complication rates triggered a moratorium in few countries. Aims This study assessed outcomes and resource utilization of taTME in a teaching hospital. Methods Patients with distal rectal cancer treated by taTME were prospectively included following ethical clearance and informed consent. Outcomes were reported as median & interquartile range (IQR). Results Audited yearly volume for TME was 43 (IQR 37-52). Consecutive 165 patients (67% male, 33% female) with a tumor 7cm (IQR 5-10) from the anal verge and a BMI of 26 (23-29) were followed for 50 months (IQR 32-79). Resection margins were threatened in 25% of the patients in preoperative MRI and 75% received neoadjuvant radiochemotherapy. Surgery lasted 348 min (293-425) and one conversion occurred (0.6%). Length of stay was 9 days (7-13). Good mesorectal dissection and clear margins were achieved in 96% of the specimen and 27 lymphnodes (IQR 20-38) were harvested. Ninety-day major morbidity affected 36 patients (21.8%), including 12 anastomotic leakages (7.2%). All leaks could be salvaged and ileostomy reversed within 6 months but for 2 patients who died (1.2%). Recurrence occurred locally in 9 patients (5.4%) and 44 had distant metastasis (26.7%). Five-year disease-free survival and overall survival were 67% and 90%. In multivariate analysis, long operation and frailty predicted anastomotic leak, while positive distal margin and lymphnodes predicted local recurrence and distant metastasis. A 2-team taTME saved 102 minutes operative time (422 (353-492) vs 320 (276-373) min. p<0.001) and EUR 1’385 when compared to a one-team approach, while allowing improved teaching opportunities. Conclusions Transanal total mesorectal excision allowed sound surgical quality and excellent oncologic outcomes in a Swiss teaching hospital.

Art and other group therapies with adolescents in inpatient mental health care

ABSTRACT Background: Group programmes are a common component of treatment in inpatient child and adolescent mental health service (CAMHS) units. There is evidence for specific group interventions, however, comparison across a multidisciplinary group programme is under-explored. Aims: This research examines young people's experiences of, and satisfaction with, a multidisciplinary group programme on an acute inpatient CAMHS unit. Methods: Weekly surveys were distributed to young people, and 37 responses were gathered across four months in 2018. Rates of attendance, enjoyment and perceived helpfulness of groups were calculated. Content analysis was used to explore key themes in qualitative responses. Results: Young people rated a creative activities and games group (54.05%) and the art therapy group (48.95%) as the two most enjoyable groups. Art therapy was reported to be the most helpful group overall (45.65%). Young people also expressed their dislike for verbal psychotherapy groups (43.24%), finding these confronting relative to other modalities in the programme. Conclusions: Art therapy and arts-based groups received the highest positive feedback relative to predominantly verbal psychotherapy groups. A multidisciplinary group programme which integrates art therapy and other creative modalities has the potential to enhance engagement in acute inpatient settings which may result in improved mental health outcomes for young people. Implications for future research and practice: Future research should aim to foreground young people's perspectives and experiences of therapeutic programmes, and provide opportunities for clinicians to redevelop programmes responsively to service user feedback. Survey findings support advocacy for consistent art therapy roles and services within inpatient CAMHS units.

Multiple Esophageal Leiomyomas: Case Report

Esophageal leiomyoma is uncommon. It is the most common benign tumor of the esophagus accounting for 0.4% of esophageal neoplasms and approximately two-thirds of benign esophageal tumors. About 90% of them are reported to be solitary and intramural lesions, and multiple or diffuse lesions seem to be very rare. We report the observation of a 75 years old male patient who was evaluated for chronic epigastric pain, Physical examination findings were typically normal, the patient underwent upper GI endoscopy. In esophagus, many submucosal tumor covered with intact mucosa, varying between 5mm and 20mm in size and located in the middle and lower part of oesophagus were noted. The radial endoscopic ultrasonography showed multiple (>10 masses), homogenous hypoechoic masses with clear margins, originated from the submucosa layer with normal surrounding structures, located in the middle and lower part of the oesophagus, and their size was < 2 cm, these lesions are followed periodically as they have a slow growth rate and negligible risk of malignant transformation. Multiple esophageal leiomyomas seems to be very rare, EUS is a valuable technique for the diagnosis of the disease and for making treatment decisions.

Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown’s classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.