Clear Margins Research Articles

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.

Epidemiology, staging and management of mucosal melanoma of the head and neck: a narrative review.

Mucosal melanoma of the head and neck (MMHN) are rare, aggressive neoplasms of melanocyte origin that remain incompletely understood and have a poor prognosis, with high rates of locoregional recurrence and distant metastasis. Several recent studies having expanded understanding of MMHN, we undertook a review of the latest evidence pertaining to its epidemiology, staging, and management. A literature search was conducted for peer-reviewed articles reporting and discussing the epidemiology, staging, and management of MMHN. PubMed, Medline, Embase and the Cochrane Library were searched to identify relevant publications. MMHN remains an uncommon disease. The current TNM staging system for MMHN provides inadequate risk stratification, and consideration of an alternative staging model such as one based on a nomogram may be justifiable. Tumour resection with clear histological margins remains the cornerstone of optimal treatment. Adjuvant radiotherapy may improve locoregional control but does not appear to affect survival. Immune checkpoint inhibitors and c-KIT inhibitors demonstrate promising efficacy in patients with advanced or unresectable mucosal melanomas, and warrant further research exploring the utility of combination therapies. Their roles as adjuvant therapies have not been determined. The efficacy of neoadjuvant systemic therapy is also not yet clear, although early results suggest that it may improve outcomes. New insights into the epidemiology, staging and management of MMHN have transformed the standard of care for this rare malignancy. Nonetheless, the results of ongoing clinical trials and future prospective studies are required to better understand this aggressive disease and optimise its management.

Giant Fungating Borderline Phyllodes Tumor of the Breast

Phyllodes Tumors are rare fibroepithelial neoplasms of the breast, accounting for less than 1% of all breast neoplasms. Preoperative diagnosis of Phyllodes Tumors is not easy, and a definitive diagnosis depends on a complete excision of the tumor. We present a case of a Giant Fungating Borderline Phyllodes Tumor of the breast. The main objective is to share our experience with the Phyllodes tumor of the breast from Mankweng Academic Hospital, Limpopo, South Africa. Case Report: A 50-year-old postmenopausal patient presented to our Breast Oncology clinic with a history of a slow-growing left breast mass for a duration of more than 1 year. It started as a small mass and progressively increased in size. She previously had two core needle biopsies, of which both histological analyses were inconclusive. In the last four months, there were multiple ruptured round masses associated with pain, bleeding, and an offensive discharge. The patient does not have any family history of breast cancer. On examination, the left breast has a fungating mass of 15×15 cm, with areas of necrosis and hemorrhage. There were no associated axillary lymph nodes and no abnormal findings in the right breast. Chest X-ray: normal. A mammogram was not done owing to the fear and risk of bleeding. A mastectomy was performed, and it was a highly vascularized mass. The excised specimen weighed 2.7 kg and was sent for histological assessment, which showed features of fibroepithelial proliferation consistent with Borderline Phyllodes Tumor with areas of stromal atypia, focal increase in cellularity, mitosis 5 per 10 High Power Field (HPF), and clear surgical margins of 0.9 millimeters (mm). The patient was reviewed six weeks after the operation. Conclusion: Owing to the rare nature and misdiagnosis of Phyllodes tumors, it is important to obtain a tissue biopsy for histological assessment of all suspicious breast lesions, regardless of age. Doi: 10.28991/SciMedJ-2023-05-02-04 Full Text: PDF

Gender and postoperative surgical margin status in MIBC: An analysis of the National Cancer Database.

4599 Background: Women with muscle-invasive bladder cancer (MIBC) continue to experience persistent disparities in health outcomes despite accounting for less than 1/3 of newly diagnosed bladder cancer cases. Multiple studies have acknowledged the aggressive profile of female bladder cancer. This study aims to identify tangible areas to intervene and improve the delivery of oncologic care. Methods: The National Cancer Database (NCDB) was queried from 2004-2017 to conduct a retrospective cohort analysis of men and women with MIBC (cT2a-T4). N=41,037 patients with MIBC were reviewed, (30,313 male; 10,724 female). The primary endpoints were OS and surgical margin status. Logistic regression was performed to determine whether female sex conferred differential impact on surgical margin status when controlling for baseline clinical stage, age, receipt of neoadjuvant chemotherapy (NAC), Charleson-Deyo Comorbidity Classification (CDCC), and facility type. Cox proportional hazards assessed the impact of age, gender, margin status, CDCC and NAC on OS. Results: Logistic regression showed that sex, age, baseline clinical stage, CDCC, facility type and NAC were significant predictors of surgical margin status (p&lt;.001). Female sex was found to have a 14.4% higher probability of having positive residual margins (HR 1.144 (95% CI: 1.07-1.23), p&lt;.001). When adjusting for age, margin status, CDCC and NAC, Female gender (OS HR 1.063 (95% CI: 1.03-1.09), p&lt;.001), positive microscopic margins (OS HR 2.0 (95% CI: 1.90-2.10), p&lt;.001) and positive macroscopic margins (OS HR 2.62 (95% CI: 2.40-2.90), p&lt;.001) independently portended poorer OS and necessitated increased adjuvant XRT (p&lt;.001). Unexpected demographic findings included a significantly greater number of females than expected with a median household income &lt;$38,000 (p= 0.047) and a greater number of females in the upper quartile of patients without a HS diploma (p&lt;.001). The median days from diagnosis to definitive surgical treatment was significantly lower compared to males (58 vs 67 days; p&lt;.001). Conclusions: Women with MIBC faced obstacles to getting treatment (less education and lower median income). Despite these hurdles they may be more proactive with their health as seen by a shorter time from diagnosis to the surgical table. However, this proactivity has yet to pay off as women undergoing surgical treatment for MIBC were significantly less likely to have clear margins post-operatively. The urologic community must mirror female patient’s proactivity and further investigate the gender disparity in surgical treatment of MIBC. [Table: see text]

Recurrent versus non-recurrent triple negative breast cancer: An institutional study.

e13094 Background: Triple negative breast cancer(TNBC) is associated with(w/) worse outcomes than hormone positive cancers(CAs). We compared patients(pts) w/ TNBC recurrence at 5 years (recurrence cohort-R) against pts without(w/o)(non-recurrence cohort-N). Methods: Retrospective review. Inclusion criteria: female, 18-85, stage 1-3 TNBC, between 2010-2015. Results: The population had 219 pts. R: 36 pts(16.4%); N: 183 pts(83.6%). Most pts (95.9%) were Caucasian; Black pts: 3.2%, Asian pts: 0.5%, unknown race: 0.5%. Most pts (94.1%) were non-Hispanic; Hispanic:5.5%; unknown ethnicity:0.5%. No differences in race and ethnicity existed between (btwn) R and N. Mean age was 57.3 (standard deviation(σ) 12.8); mean BMI: 31.0 (σ 7.4); mean Charlson Comorbidity Index: 2.3 (σ 2.0); mean ECOG score: 0.3 (σ 0.6). No differences existed btwn R and N regarding the above variables. A personal hx of CA was present in 17.3% (38/219); there were no differences btwn R (19.4%) and N (16.9%), p 0.717. Genetic testing was performed in 37.8% (83/219); positive results were similar btwn R (20.0%) and N (25.0%); p 0.777. Mean tumor size was 25.2mm (σ 23.3); R had a larger mean size (34.4mm, σ 30.3) than N (23.3mm, σ 21.2), p 0.009. The most common disease stage was stage 2 (97/219, 44.3%). R had a greater proportion of stage 3 (30.6% vs 11.5%) and 2 disease (47.2% vs 43.7%) than N. There were no differences in the prevalence of histological grades (p 0.612) or subtypes (p 0.221) btwn R and N. All pts had surgery; clear margins occurred in 86.3%(189/219); margins were similar btwn R and N. Radiotherapy (RDT) was performed in 75.3% (165/219); more N pts (78.7%) received RDT than R (58.3%), p 0.01. Chemotherapy (CMT) was administered in 79.9%(175/219), and there were no differences btwn the prevalence of CMT btwn N (79.2%) and R (83.3%), p 0.575. Adjuvant CMT was received by 60.7% (133/219); there were no differences btwn N (62.3%) and R (52.8%), p 0.285. Neoadjuvant CMT was administered to 20.5% (45/219); there was a greater prevalence in R (33.3%) than in N(18.0%); p 0.038. Doxorubicin, cyclophosphamide and taxane(ACT) regimen was administered in 57.1% (125/219), while the combination of a taxane and cyclophosphamide (TC) was administered in 20.1% (44/219); there were no differences btwn R and N regarding ACT (p 0.073) or TC (p 0.069). Within 5 years of diagnosis, 31.5% were deceased. In N, 21.3% were deceased, while 83.3% were deceased in R(p&lt;0.001). The mean time-to-mortality (TTM) from CA diagnosis was 51.1 months (σ 38.9). TTM was significantly shorter in R (37.4 months, σ 20.0) than in N (61.7 months, σ 46.2), p 0.005. Conclusions: R had more advanced (stage II and III) disease, while the N had less advanced (Stage 0 and I) disease. More N pts received RDT compared w/ R pts. Neoadjuvant CMT was more prevalent in R than N. R pts had significantly larger tumor sizes than N pts. Mortality was significantly greater in the R than N, and the TTM was almost twice as long in the N than R.

Compression OCT-elastography combined with speckle-contrast analysis as an approach to the morphological assessment of breast cancer tissue.

Currently, optical biopsy technologies are being developed for rapid and label-free visualization of biological tissue with micrometer-level resolution. They can play an important role in breast-conserving surgery guidance, detection of residual cancer cells, and targeted histological analysis. For solving these problems, compression optical coherence elastography (C-OCE) demonstrated impressive results based on differences in the elasticity of different tissue constituents. However, sometimes straightforward C-OCE-based differentiation is insufficient because of the similar stiffness of certain tissue components. We present a new automated approach to the rapid morphological assessment of human breast cancer based on the combined usage of C-OCE and speckle-contrast (SC) analysis. Using the SC analysis of structural OCT images, the threshold value of the SC coefficient was established to enable the separation of areas of adipose cells from necrotic cancer cells, even if they are highly similar in elastic properties. Consequently, the boundaries of the tumor bed can be reliably identified. The joint analysis of structural and elastographic images enables automated morphological segmentation based on the characteristic ranges of stiffness (Young's modulus) and SC coefficient established for four morphological structures of breast-cancer samples from patients post neoadjuvant chemotherapy (residual cancer cells, cancer stroma, necrotic cancer cells, and mammary adipose cells). This enabled precise automated detection of residual cancer-cell zones within the tumor bed for grading cancer response to chemotherapy. The results of C-OCE/SC morphometry highly correlated with the histology-based results (r =0.96-0.98). The combined C-OCE/SC approach has the potential to be used intraoperatively for achieving clean resection margins in breast cancer surgery and for performing targeted histological analysis of samples, including the evaluation of the efficacy of cancer chemotherapy.

A rapidly-growing erythematous nodule on the right upper neck

A rapidly-growing erythematous nodule on the right upper neck