Close Surgical Margins Research Articles

Radical prostatectomy and the effect of close surgical margins: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

To evaluate biochemical recurrence (BCR) patterns amongst men undergoing radical prostatectomy (RP) with specimens having negative (NSM), positive (PSM), and close surgical margins (CSM) from the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort, as PSM after RP are a significant predictor of biochemical failure and possible disease progression, with CSM representing a diagnostic challenge for surgeons. Men undergoing RP between 1988 and 2015 with known final pathological margin status were evaluated. The cohort was divided into three groups based on margin status; NSM, PSM, and CSM. CSM were defined by distance of tumour ≤1 mm from the surgical margin. BCR was defined as a prostate-specific antigen (PSA) level of >0.2 ng/mL, two values at 0.2 ng/mL, or secondary treatment for an elevated PSA level. Predictors of BCR, metastases, and mortality were analysed using Cox proportional hazard models. Of 5515 men in the SEARCH database, 4337 (79%) men met criteria for inclusion in the analysis. Of these, 2063 (48%) had NSM, 1902 (44%) had PSM, and 372 (8%) had CSM. On multivariable analysis, relative to NSM, men with CSM had a higher risk of BCR (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.25-1.82; P < 0.001) but a decreased risk of BCR when compared to those men with PSM (HR 2.09, 95% CI 1.86-2.36; P < 0.001). Metastases, prostate cancer-specific mortality and all-cause mortality did not differ based on margin status alone. Management of men with CSM is a diagnostic challenge, with a disease course that is not entirely benign. The evaluation of other known risk factors probably provides greater prognostic value for these men and may ultimately better select those who may benefit from adjuvant therapy.

Outcomes Following Radiation Therapy for Anaplastic Thyroid Cancer

Anaplastic thyroid cancer is a highly aggressive malignancy with dismal survival rates. The role of radiation therapy for this disease has not been clearly defined. Herein, we report on a large cohort of locally advanced or metastatic anaplastic thyroid cancer treated with radiation therapy in the pre-operative or adjuvant settings. We identified 104 patients who received definitive or postoperative radiation therapy for anaplastic thyroid cancer between 1984-2017. We assessed overall survival (OS), locoregional control (LRC), and distant metastasis (DM) using the Kaplan-Meier method and performed survival analysis using Cox proportional hazard models. The median age at diagnosis was 63 (range 28-87). The median follow-up was 5.5 months in the entire cohort and 72 months in surviving patients. Twenty-seven patients (26%) had evidence of metastatic disease at diagnosis or developed metastasis prior to radiation therapy start. Ninety-nine patients (98%) received concurrent chemotherapy with radiation, and 52 (50%) received trimodality therapy with surgical resection followed by concurrent chemoradiation. Of those patients receiving surgical intervention, 37 (67%) had close surgical margins and 33 (59%) had positive lymph nodes. Of the patients who received systemic therapy, 70 (70%) received doxorubicin, 25 (25%) received paclitaxel and pazopanib, and 5 (5%) received other systemic agents. Median radiation dose was 5940cGy (range 600-7025cGy). Ninety (87%) patients died at the time of last follow-up. For those patients who were M1 at time of diagnosis (n=27), 10 underwent trimodality treatment and 17 proceeded with chemoradiation only. The median OS for the entire cohort was 5.6 months after initiation of radiation. The 1-year rates of OS and LRC were 31±5% and 81%±5%, respectively. DM was assessed among patients with non-metastatic disease at radiation therapy start (n=76). The 1-year rate of DM in patients with locally advanced disease at diagnosis was 33%±6%. Patients who received a radiation dose >5000 cGy had longer 1-year OS (38% vs. 11%, log-rank P<.001) compared to those receiving dose <5000 cGy. Multivariate Cox regression restricting to those patients without DM at diagnosis and controlling for age, sex, surgical status, and concurrent chemotherapy, radiation demonstrated persistent OS benefit of receiving radiation >5000 cGy (Hazard Ratio=0.3; 95% CI=0.2-0.7) and surgical resection (Hazard Ratio=0.5; 95% CI=0.3-0.9). There was no difference in LRC and DM between patients receiving different doses of radiation. Results from the current study suggest a beneficial role of aggressive radiation therapy in addition to surgical resection in the management of anaplastic thyroid cancer.

Adeno cystic carcinoma of salivary glands

Background: adenoid cystic carcinoma is the most frequent malignant tumor of submaxillary and minor salivary glands. Despite its slow growth, it shows an unfavorable prognosis because of its distant dissemination.Objective: to analyse our series of patients in relation to the literature.Materials and methods: 44 patients with mean age 52.47 years female gender. Of them, 61.3% were of minor salivary glands, 20.4% of submaxillary gland, and 18.2% the parotid gland. All patients underwent complete resection of the tumor followed by neck dissection in 34%. Co60 radiotherapy was administered to 43.2%. Mean follow up was 52.5 (range, 1-120) months.Results: 5-year recurrence rate was 36.8%. At 5 and 10 years, overall survival was 60 and 36%,respectively. Close surgical margins, requirement of adjuvant radiotherapy and stage significantly affected survival rate. The multivariate analysis showed that close margins was statistically significant for survival and associated with an unfavorable tendency for disease-free interval.Conclusions: extention of surgery to the neck and adyuvant radiotherapy was dependent of stage, clear surgical margins, neural invasion, positive nodes in the neck and hystological subtype.

Abstract P2-11-24: Disparities in the application of post-mastectomy radiotherapy in Switzerland: A pooled analysis of 7 cancer registries over the 2003-2005 period

Abstract Background: The aim of this study was to identify factors that influence the delivery of post-mastectomy radiotherapy (PMRT) in Switzerland, and to analyze the adherence to consensus guidelines. Methods: Based on 7 regional cancer registries covering 45% of the Swiss population, we identified 1408 women which underwent mastectomy for stage I-III breast cancer between January 1, 2003 and December 31, 2005. We categorized patients according to ASCO grouping in similar fashion to other comparable studies: low-risk group (T1/T2 N0): PMRT not routinely recommended; intermediate-risk group (T1/T2 N1): PMRT controversial; high risk group (T3-T4 and/or N2-N3): PMRT recommended. We further investigated factors leading to potential overtreatment (PMRT in low-risk group) or undertreatment (absence of PMRT in high-risk group). Data analysis was performed for the entire cohort, and separately for patients &amp;lt;70 years and ≥ 70 years of age. Probability of receiving PMRT was assessed using multivariable logistic regression. Results: A total of 421 patients (29.9%) received adjuvant RT after mastectomy. The rate of PMRT delivery was 67% in the high-risk group, compared to 6% and 18% in the low-risk and intermediate-risk groups, respectively. For patients at high-risk of chest wall recurrence after mastectomy (T3-T4 or N2-N3 disease), the risk of PMRT omission wassignificantly associated to older age (OR 4.25 [95% CI: 2.27-7.95] for patients ≥ 70 years) and to the absence of chemotherapy (OR 4.30 [95% CI: 1.97-9.36]). In patients with T3-T4 disease, PMRT was delivered in 77% of patients &amp;lt; 70 years and in 42% of patients ≥ 70 years (p&amp;lt;0.001). In patients with N2-N3 disease, PMRT was delivered in 82% of patients &amp;lt; 70 years and in 51% of patients ≥70 years (p&amp;lt;0.001). PMRT was delivered to 28 patients (7%) at low-risk of recurrence after mastectomy (T1-T2 N0, negative margins). It was more frequently offered to patients &amp;lt;40 years of age (OR 3.86 [95% CI: 1.01-14.76]), with T2 tumors (OR 3.43 [95% CI: 1.45-8.11]) and negative hormone receptor status (OR 2.60 [95% CI: 1.04-6.50]). Positive or close surgical margins (&amp;lt; 1mm) were a strong indicator for PMRT (p=0.001) and chest wall boost (p&amp;lt;0.03). Conclusions: After mastectomy, one third of patients (33.26%) with high-risk disease did not receive PMRT. Even if we consider only patients &amp;lt; 70 years, a non-trivial proportion of patients with clear indication for treatment delivery did not receive PMRT (T3-T4 disease: 23%; N2-N3 disease: 18%). Further analyses are planned to explain the apparent failure of evidence-based guidelines to impact the adoption of PMRT in women with high-risk breast cancer. Citation Format: Zwahlen DR, Ess S, Zimmermann M, Bordoni A, Bouchardy C, Frick H, Konzelmann I, Mousavi M, Rohrmann S, Oehler C. Disparities in the application of post-mastectomy radiotherapy in Switzerland: A pooled analysis of 7 cancer registries over the 2003-2005 period [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-24.

Impact of Surgical Margin in Skull Base Surgery for Head and Neck Sarcomas.

Objective This study aimed to determine the adequate resection margin in skull base surgery for head and neck sarcoma. Design We retrospectively reviewed 22 sarcomas with skull base invasion. Induction chemotherapy, followed by surgery and postoperative radiotherapy and adjuvant chemotherapy, was performed in 18 patients with chemosensitive sarcomas, and surgery with or without postoperative radiotherapy was performed in four patients with chemoresistant sarcomas. Radical resection was performed in patients with chemosensitive sarcomas with a poor response to induction chemotherapy and in patients with chemoresistant sarcomas. Conservative resection with close surgical margin was performed in patients with chemosensitive sarcomas with a good response to induction chemotherapy. Setting and Participants This single-centered retrospective study included patients from the National Cancer Center Hospital, Japan. Results The response to induction chemotherapy was significantly associated with the 3-year local control rate (LCR; good response versus poor response: 100% versus 63%, p = 0.048). Patients with a good response to chemotherapy had a favorable local prognosis even when the local therapy was conservative resection. In radical skull base surgery, patients whose surgical margins were classified as "wide margin positive" had significantly poorer 3-year LCR than did patients with "margin negative" or "micro margin positive" margins (25% versus 83%, p = 0.014). Conclusion Conservative resection with close surgical margins might be acceptable for chemosensitive sarcomas with a good response to chemotherapy. Resection margin status was an important predictive factor for local recurrence after radical skull base surgery. Microscopic microresidual tumor might be controlled by postoperative treatment.

The pattern of failure and predictors of locoregional control in lateralized buccogingival cancer after postoperative radiation therapy

BackgroundTo evaluate the failure pattern and identify predictors of locoregional control in lateralized buccogingival cancer after postoperative radiotherapy (RT) at a single institution. MethodsWe retrospectively reviewed the clinical data of 150 patients with lateralized oral squamous cell carcinoma, including carcinoma of the buccal mucosa, gingiva and retromolar trigone. All patients underwent radical surgery followed by postoperative RT with or without concurrent chemotherapy. We registered planning computer tomography images with images obtained at recurrence and categorized the failure pattern as in-field, marginal, or out-field recurrence. ResultsThe median follow-up duration was 47 months (range, 2–131 months). Twenty-eight patients (19%) experienced locoregional failure, including 20 local failure, 5 regional failure and 3 with both. Among the 24 patients who had image studies at recurrence, 15 patients had in-field recurrence, 5 were marginal recurrence and 4 were out-field recurrence. Seven patients (5%) had contralateral neck failure. Four of 5 patients with marginal failure had recurrent tumors in the infratemporal fossa. In multivariate analysis, extracapsular spread and positive or close surgical margin were associated with poor locoregional control. ConclusionLocal in-field recurrence is the most common failure pattern in lateralized buccogingival cancer after postoperative RT. The infratemporal fossa is a risk area for marginal failure and should be encompassed adequately in the postoperative RT field. Extracapsular spread and positive or close margin are predictors of locoregional control for lateralized oral cancer. Patients exhibiting such adverse features require more aggressive treatment.

The profile of extremity and trunk soft tissue sarcoma in a tertiary referral center

BackgroundProper surgery with adequate safety margin and adjuvant radiotherapy is the main line of treatment of extremity and trunk soft tissue sarcoma (STS). In spite of improved management, the long term follow up is still not satisfactory. ObjectiveTo evaluate long term outcome of STS of extremities and trunk regarding adequacy of resection, recurrence and survival. Patients and methodsThis prospective study included 25 patients with STS involving extremity and trunk. All patients were treated with wide radical excision and had adjuvant irradiation and followed up for a median of 26months. ResultsThe mean age was 40.0±15.3years. They were 16 males and 9 females. Eight patients (32%) had positive or close surgical margins. The median overall survival (OS) was 26.5months. In univariate analysis, lower limb tumors, stage III and grade 3 were significantly associated with worse overall survival (OS) (p=0.007, 0.02, and 0.020, respectively) and disease free survival (DFS) (p=0.005, 0.001, and 0.001, respectively). On multivariate analysis the only independent factor that affects the OS and DFS was the stage (p value=0.029, Hazard ratio: 3.64, 95% confidence interval: 1.14–11.61 and p value=0.003, Hazard ratio: 5.75, 95% confidence interval: 1.82–18.18 respectively). ConclusionDespite adequate surgery and adjuvant irradiation, 5years follow up results of treatment of extremity and trunk soft tissue sarcoma is still poor. This highlights the importance of early detection of small STS in extremity and trunk.

Background parenchymal enhancement on breast MRI: association with recurrence-free survival in patients with newly diagnosed invasive breast cancer.

To determine whether BPE in preoperative breast MRI influences patients' recurrence-free survival (RFS). Between February 2010 and December 2011, 804 consecutive women with invasive breast cancer who had undergone preoperative breast MRI and curative cancer surgery were identified. BPE was visually graded by two reviewers. We determined the correlation between BPE grade and other clinicopathological variables, including age, adjuvant therapy, menopausal status, histologic grade, T stage, N stage, lymphovascular invasion, molecular subtype, surgical margin status, and mammographic density. A Cox proportional hazards model was used to analyze the effects of clinicopathological variables and radiological findings (BPE grade, mammographic density) on RFS. High BPE was associated with premenopausal status (Ps<0.0001), higher mammographic density (Ps<0.0001), progesterone receptor positivity (Ps=0.039, 0.007, respectively), presence of lymphovascular invasion (Ps=0.008, 0.001, respectively), and close surgical margin (Ps<0.0001). Recurrences were observed in 75 patients after a mean follow-up period of 61.8months (range 4-81months). Non-minimal BPE grade (RFS hazard ratio=3.086, P=0.003 for reader 1; RFS hazard ratio=2.221, P=0.075 for reader 2) and T3 stage were associated with worse outcomes in postmenopausal women. In premenopausal women, non-minimal BPE grade by readers 1 and 2 did not affect the patients' outcomes. Increased BPE on preoperative breast MRI in postmenopausal women has potential as a predictor of poor RFS.

Close surgical margin after conservative parotidectomy in early stage low-/intermediate-grade parotid carcinoma: Outcome of watch and wait policy

AimThe aim of the study was to assess the watch&wait strategy for management of patients with close surgical margin after conservative parotidectomy due to early low/intermediate grade parotid carcinoma. Patients and methodsOut of 78 patients operated on due to primary parotid gland cancer we selected 32 patients with a history of parotidectomy, and preservation of 7th nerve, with negative (≥1mm), but close (≤5mm) surgical margin and who did not receive supplementary radiotherapy due to other indications. Margins ranged from 1 to 3mm (in 27 cases it was 1mm, in 3 cases – 2mm and in 2 cases – 3mm), average 1.2mm. The patients underwent further clinical-histological analysis. Results3 of 32 (9.38%) patients experienced a local recurrence 36, 53 and 56months post-surgery. The 5-year disease-free survival (DFS) was 90.6%. Recurrences were treated surgically, followed by radiotherapy, which resulted in an overall survival of 107, 104 and 104months. One patient died 72months after surgery due to non-oncological causes. The 10-year disease-free survival (DFS) was 96.3%. The 3 patients with recurrence of cancer had histological diagnosis of epithelial-myoepithelial carcinoma LG, with a margin of 2, 1 and 3mm, respectively. There were no other distinctive features. ConclusionThe watch&wait strategy with intensive follow-up seems justified in cases of close margin after excision of I/LG T1/T2 parotid tumors. EMC should be considered as a neoplasm associated with higher risk of recurrence.

Avoidance of postoperative irradiation for cervical lymph node metastases of human papillomavirus-related tonsillar cancer.

Background Several reports have suggested that selected patients with human papillomavirus‐related oropharyngeal cancer can be managed with surgery alone. We retrospectively reviewed tonsillar cancer cases to analyze treatment de‐intensification after transoral resection.MethodsEighteen patients with tonsillar cancer who had undergone transoral resection were included. The patients' characteristics, p16 status, adverse features, clinical course, overall survival, and relapse‐free survival according to p16 status were retrospectively examined.ResultsFour lesions showed positive surgical margins and one lesion showed close surgical margin; these patients were treated with postoperative irradiation. Seven p16‐positive patients had multiple node metastases and two had extracapsular spread. No p16‐positive patients agreed to postoperative irradiation, and recurrence within the surgical field was not observed. The five‐year overall and relapse‐free survival rates were 89% and 74%, respectively. The five‐year relapse‐free survival rates of p16‐positive and p16‐negative patients were 81% and 50%, respectively (p = .075).ConclusionsPostoperative irradiation for cervical lymph node metastases might be avoidable in selected patients with human papillomavirus‐related tonsillar cancer.Level of Evidence4.

A Proposal to Redefine Close Surgical Margins in Squamous Cell Carcinoma of the Oral Tongue

Resection of the primary tumor with negative margins is the gold standard treatment for squamous cell carcinoma of the oral tongue (SCCOT). A microscopically positive surgical margin is clearly associated with a higher risk for local recurrence, whereas a negative margin has traditionally been defined as greater than 5.0 mm clearance from the tumor, with lesser margins arbitrarily designated as close. The precise cutoff at which the risk for local recurrence with a close margin approximates that of a microscopically positive margin remains unclear. To determine whether the arbitrarily defined close margin (<5.0 mm) would portend as high a risk for local recurrence as a positive margin after resection of SCCOT. In this retrospective study, head and neck pathologists reviewed archived tumor specimens from 381 patients with SCCOT who underwent primary surgical resection at a tertiary care center from January 1, 2000, through December 31, 2012. Data were analyzed from November 15, 2015, to January 5, 2016. Time-dependent receiver operating characteristic curve analysis was used in patients who did not have a microscopically positive margin to determine an optimal margin cutoff for local recurrence-free survival (LRFS). Pathologic factors were assessed for LRFS in a multivariate Cox proportional hazards regression model. The primary end point was evaluation of the margin distance associated with LRFS. Among the 381 patients included in the analysis (222 men [58.3%] and 159 women [41.7%]; mean [SD] age, 58 [14.7] years), the optimal cutoff associated with LRFS was determined to be 2.2 mm. This cutoff was compared with the traditionally accepted cutoff of 5.0 mm. Patients with a margin of 2.3 to 5.0 mm had similar LRFS as patients with a margin of greater than 5.0 mm (hazard ratio [HR], 1.31; 95% CI, 0.58-2.96), and all other comparisons were significantly different (HR for positive margin, 9.03; 95% CI, 3.45-23.67; HR for 0.01- to 2.2-mm margin, 2.83; 95% CI, 1.32-6.07). Based on this result, negative margins were redefined as those with a clearance of greater than 2.2 mm. In a multivariate model adjusting for pathologic factors, positive margins (adjusted HR, 5.73; 95% CI, 2.45-13.41) and margins of 0.01 to 2.2 mm (adjusted HR, 2.00; 95% CI, 1.13-3.55) were the variables most significantly associated with LRFS. In this study, local recurrence-free survival was significantly affected only with surgical margins of less than or equal to 2.2 mm in patients with SCCOT. This new definition of close margins stratifies the risk for local recurrence better than the arbitrary 5.0-mm cutoff that has been used.

713 - The significance of close surgical margins in organ sparing surgery for penile squamous cell cancer

713 - The significance of close surgical margins in organ sparing surgery for penile squamous cell cancer

Abstract P1-11-01: The effect of close and positive surgical margins on 10-year local recurrence and survival outcomes in women treated with breast conserving surgery plus adjuvant radiotherapy

Abstract This abstract was withdrawn by the authors.

Abstract P3-02-12: Impact of magnetic resonance imaging on conversion from wide local excision to mastectomy in patients with ductal carcinoma in situ: First results from the ECOG-ACRIN 4112 prospective study

Abstract Purpose: To estimate the proportion of patients with ductal carcinoma in situ (DCIS) judged to be candidates for wide local excision (WLE) based on mammography (+/- sonography) and clinical exam who: (A) convert from WLE to mastectomy as the first surgical procedure based on magnetic resonance imaging (MRI) findings, and (B) have a mastectomy as the final surgical procedure. Patients and Methods: The study population included women with DCIS diagnosed by core needle biopsy (and no evidence of invasive or micro-invasive disease) judged to be candidates for WLE by their surgeon based on standard imaging (mammogram +/-sonography) and clinical exam without prior breast MRI. After registration bilateral contrast enhanced breast MRI was performed, and a protocol management algorithm was followed. Before and after MRI, the surgeon documented the planned surgical procedure, including reason for conversion from WLE to mastectomy if the surgical plan changed. Prior evidence suggests that about 8-12% of patients initially considered candidates for WLE based on mammography ultimately require mastectomy, and the addition of MRI increases the likelihood of mastectomy by about 1.5-fold. A sample size of 350 (332 evaluable) was planned to ensure a 95% confidence interval (C.I.) of 8% if the actual mastectomy conversion rate was as high as 16%. Two-sided 95% Wilson confidence interval for proportion of patients converting to mastectomy based on MRI was derived. Results: Of 363 patients enrolled, 340 had sufficient information to assess aim A (conversion to mastectomy after MRI), and 322 for aim B (mastectomy as final surgical procedure). At study entry, median age (range) was 59 years (34-87). Features of DCIS lesions included: median longest diameter (range) 11 mm (1-100); ER positivity 76.2%; low, intermediate and high grade 15.9%, 40.9% and 39.4% respectively (3.8% unknown). Based on MRI findings (Aim A), mastectomy rather than WLE was recommended as the first surgical procedure in 25/340 (7.4%, 95% CI: 5.0%, 10.6%). Reasons included large lesion size (N=15), multi-centric disease (N=6), and contralateral disease prompting bilateral mastectomy (N=4). An additional 28/340 (8.2%) converted to mastectomy as the first surgery based on other factors, including patient preference (N=25), interval discovery of genetic mutation (N=2), or inability to receive radiation treatment (N=1). Of the 278 patients for whom initial WLE was performed after MRI, 10/278 (3.7%) converted to mastectomy, all due to positive or close (&amp;lt; 2 mm) surgical margins. Overall (Aim B), 62/322 (19.3%, 95% CI 15.3%, 23.9%) had mastectomy as the final surgical procedure. Conclusion: In women with DCIS judged to be candidates for WLE based on mammography (+/- sonography), conversion to mastectomy is fairly common with nearly 1 in 5 patients ultimately undergoing mastectomy. Breast MRI findings account for less than half of the conversions to mastectomy. For patients who remained candidates for WLE after MRI, 96.3% achieve successful WLE as the final surgical procedure. Citation Format: Lehman CD, Gatsonis C, Greco E, Khan SA, Sparano JA, Solin LJ, Badve SS, Corsetti RL, Rahbar H, Spell DW, Blankstein KB, Han LK, Sabol JL, Bumberry JR, Miller KD, Comstock C. Impact of magnetic resonance imaging on conversion from wide local excision to mastectomy in patients with ductal carcinoma in situ: First results from the ECOG-ACRIN 4112 prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-12.

Ultrasound Dye-Assisted Surgery (USDAS) for Regional Recurrence in Head and Neck Cancer: A Case Report

The incidence of regional recurrence in oral squamous cell carcinoma(SCC) after the neck dissection is 32.7%. Regional failure after definite neck treatment not only relates to poor prognosis but also leads to higher complication rate in the salvage neck dissection since the diseased structure is often surrounded by scar tissue and hard to be identified. The adequate and safe neck surgery is crucial for head and neck surgeons. Ultrasound dye-assisted surgery(USDAS) offers a simplified way to localize lesions clearly during the operation. Case report and literature review. We report a 53-year-old male who suffered from the left tongue border ulcer for 2 months. Transoral wide excision was performed for pT1, moderately differentiated SCC with negative p16 staining. 3 months later, the left level I neck mass was palpated. Sono-guided fine needle aspiration was done, and cytology revealed SCC. Bilateral neck dissection of the left level I-IV and the right level I-II was accomplished. Pathology reported ypN2b disease over the left level I and III with remarkable extracapsular spread(ECS) of the former one. However, the adjuvant concurrent chemoradiotherapy(CCRT) was incompletely conducted due to the progressive submental mass 5 weeks later. The sonography delineated one 1.33cm hypoechoic lesion with irregular boundary, incomplete halo and central necrosis over the midline of level IA. Fine needle aspiration was done, and cytology report confirmed SCC. For the adequately and completely wide excision of the malignancy, USDAS was done. Methyl blue in 1ml syringe was injected in the assistance with ultrasound-guided technique into the left periphery, right periphery, upper margin, lower margin and most importantly, the base of the tumor. Wide excision of the submental tumor was consequently executed. Final pathology indicated metastastic squamous cell carcinoma of dermis and subcutis sized 1.2cm. The closest surgical margin was 0.5cm from the peripheral margin. In our case, considering the infiltrative character of dermal pathology ensnared by postoperative fibrosis, USDAS was utilized to mark the surgical boundaries. Final pathology proved adequate margins, and there was no complication. This procedure offers precise localization with avoidance in unnecessary destruction and reduces operative time significantly. Based on the anatomic complexity in head and neck region, the USDAS can be extendedly used in the future. More studies investigating exact decreasing rate of complication and standard procedures regarding injection volume and washing-out time of dye should be achieved.

Chemoradiotherapy In Locally Invasive Parathyroid Cancer

Parathyroid cancers (PTC) are very rare and have a poor prognosis. A 48 year old case with locally invasive PTC that was positive for close surgical removal margin was treated with chemo radiotherapy after surgery. Even though this required bimodal chemo and radio adjuvant therapy, the patient was treated by chemo radiotherapy with some modifications, including oral administration of capestabine. These treatments were well tolerated with minimal side effects, which have proven to be very effective in freeing the patient from the invasive tumor for the following twenty six months of monitoring. This treatment method could be adopted in place of the widely preferred surgical therapy. We believe that this case report will guide future studies concerning with similar cases.

Definitive radiotherapy for inoperable adenoid cystic carcinoma of the trachea: A rare case report.

Adenoid cystic carcinoma (ACC) of the trachea is rare; it represents 1% of all respiratory tract cancers. It is generally considered as a slow-growing, with prolonged clinical course. Most patients present with dyspnea, and the symptoms often mimic those of asthma or chronic bronchitis. Surgical resection is the mainstay of treatment often combined to radiotherapy because of close surgical margins. When surgery is not possible, most tumors respond to radiotherapy alone which often results in long periods of remission. There is no consensus on the best treatment for locally advanced inoperable ACC of trachea. This case report describes a 51-year-old woman unresectable ACC of trachea due to comorbid conditions, successfully managed by intensity modulated radiotherapy. At 8 months follow-up, the patient is healthy and asymptomatic.

P2.04-010 Survival after Surgery and Radiotherapy for Thymic Epithelial Tumors: A Single-Centre Experience from the United Kingdom: Topic: Thymic Malignancies Clinical and Translational

Thymic epithelial tumors are rare thoracic tumors primarily treated with surgical excision. Adjuvant radiotherapy has been shown to be beneficial in locally advanced disease. There is limited published data on thymoma outcomes in the United Kingdom. We retrospectively reviewed records of patients who underwent thoracic surgery for thymic tumors between July 2005 and December 2015. Imaging, pathology reports and follow-up clinic records were evaluated. Kaplan-Meier curves were generated for overall survival, and the log-rank test was used for univariate survival analysis. 79 patients were identified. The median age was 58 years (range 16 - 83 years). 58% were female. 24% of patients had associated myasthenia gravis. Masaoka Stage 1 disease was most common (48%), with Stage 2a disease (27%) next in frequency. The most common histological grading was WHO B3 (33%) followed by AB (25%). 58% had surgical margins < 1 mm, with tumor at margin in 24%. 39 patients (51%) had adjuvant radiotherapy, with median follow-up of 5.1 years for these patients. A radiotherapy dose of 45 – 50.4 Gy in 1.8 Gy fractions was used. 5-year survival for the whole cohort was 68% after surgery alone, and 86% with adjuvant radiotherapy, but the difference was not statistically significant. There were no deaths during follow-up in patients who had clear surgical margins, with or without radiotherapy. If surgical margins < 1 mm, there was a trend towards improved overall survival with adjuvant radiotherapy (5-year survival 88%), compared to surgery alone (5-year survival 50%) (log-rank test chi-square 3.7, p = 0.056) (Fig. 1). The long-term outcomes of thymic epithelial tumors are excellent after complete surgical excision. There is a trend towards improved overall survival with adjuvant radiotherapy in patients with surgical margins less than 1 mm. Routine referral of patients with close surgical margins for consideration of radiotherapy is recommended.

Differential Impact of Close Surgical Margin on Local Recurrence According to Primary Tumor Size in Oral Squamous Cell Carcinoma.

The extent of surgical safety margin (gross tumor border to resection margin) in oral cancer surgery remains unclear, and no study has determined the differential impact of close surgical margin and microscopic extension according to primary tumor size in oral cancers. We retrospectively analyzed the clinical data of 325 patients with surgically treated oral cavity squamous cell carcinomas to determine the effect of a close surgical margin (<5mm) (cSM5) on local recurrence. In addition, the depth of microscopic tumor infiltration was determined in 90 available surgical specimens. The cSM5 was not related to the risk of local tumor recurrence in early-stage oral cancer, while it significantly increased the rate of local tumor recurrence in resectable advanced-stage oral cancers (hazard ratio 3.157, 95% confidence interval 1.050-9.407, p=0.041). Addition of postoperative adjuvant radiation to early-stage tumors with cSM5 did not further reduce the local recurrence rate compared to surgery alone. The depth of microscopic tumor extension from the gross tumor border was significantly associated with primary tumor thickness (ρ=0.390, p<0.001) and tumor sizes (ρ=0.308, p=0.003), which was a median (range) of 0.84 (0.14-2.32)mm in T1, 1.06 (0.20-4.34)mm in T2, and 1.77 (0.13-4.70)mm in T3-4. The cSM5 was a significant risk factor for local recurrence only in advanced oral cancers, but not in early-stage tumors, where microscopic tumor extension was not beyond 3mm in T1 tumors. Thus, the extent of surgical safety margin can be redefined according to the primary tumor size.

Primary radical ablative surgery and fibula free-flap reconstruction for T4 oral cavity squamous cell carcinoma with mandibular invasion: oncologic and functional results and their predictive factors.

The aims of this study were to evaluate clinical outcomes and to determine their predictive factors in patients with oral cavity squamous cell carcinoma (OCSCC) invading the mandibular bone (T4) who underwent primary radical surgery and fibula free-flap reconstruction. Between 2001 and 2013, all patients who underwent primary surgery and mandibular fibula free-flap reconstruction for OCSCC were enrolled in this retrospective study. Predictive factors of oncologic and functional outcomes were assessed in univariate and multivariate analysis. 77 patients (55 men and 22 women, mean age 62±10.6years) were enrolled in this study. Free-flap failure and local and general complication rates were 9, 31, and 22%, respectively. In multivariate analysis, ASA score (p=0.002), pathologic N-stage (p=0.01), and close surgical margins (p=0.03) were independent predictors of overall survival. Six months after therapy, oral diet, speech intelligibility, and mouth opening functions were normal or slightly impaired in, respectively, 79, 88, and 83% of patients. 6.5% of patients remaining dependent on enteral nutrition 6months after therapy. With acceptable postoperative outcomes and satisfactory oncologic and functional results, segmental mandibulectomy with fibula free-flap reconstruction should be considered the gold standard primary treatment for patients with OCSCC invading mandible bone. Oncologic outcomes are dependent on three main factors: ASA score, pathologic N-stage, and surgical margin status.