Complete Excision Rate Research Articles

Pathological handling of radioactive seed localisation (RSL) breast specimens: the Western Australian Experience

<h3>Introduction</h3> Mammographic screening has resulted in detection of increased numbers of impalpable <i>in situ</i> and invasive carcinomas that require localisation for surgical excision. Radioactive seed localisation (RSL), locally referred to as radio-guided occult lesion localisation using iodine 125 seeds (ROLLIS), is a novel alternative to hookwire guided techniques, with excellent complete excision rates, that has been the subject of a recent pilot study in Western Australia. <h3>Aim</h3> To develop safe and effective procedures for the pathological handling of RSL specimens including seed tracking and retrieval. <h3>Methods</h3> The pilot study involved 116 patients (62 at QEII and 54 at RPH). Robust protocols for pathological handling of specimens were developed to minimise risk of seed loss. Radioactive hazard stickers were mandatory for specimen containers and request forms. Seed retrieval was conducted by either immediate retrieval from fresh specimens (QEII) or following overnight formalin fixation (RPH). Once retrieved, seeds were placed into lead containers labelled with radioactive hazard stickers, that were collected from the laboratory by medical physics. All involved personnel received training in radiation safety. <h3>Results</h3> Both immediate and delayed retrieval techniques resulted in acquisition of all seeds. Immediate retrieval necessitated re-approximation of a specimen incision to prevent distortion of margins. Delayed retrieval meant the radioactive seed remained within the department for longer. Both techniques have been incorporated into the day-to-day running of the laboratories. <h3>Conclusion</h3> Our pathological handling of RSL specimens, developed during the pilot study, are safe and effective and now routine. These techniques will continue in the randomised control study phase.

Pre-operative Histoscanning™ as an adjunct to preoperative staging improves complete excision rates for locally advanced prostate cancer after radical prostatectomy

Pre-operative Histoscanning™ as an adjunct to preoperative staging improves complete excision rates for locally advanced prostate cancer after radical prostatectomy

What Have We Gained by Performing Robotic Rectal Resection? Evaluation of 64 Consecutive Patients Who Underwent Laparoscopic or Robotic Low Anterior Resection for Rectal Adenocarcinoma

Robotic surgery is thought to be a solution to overcome the limitations of laparoscopy in sphincter-saving resections. In this study, we present our results on patients undergoing robotic and laparoscopic low anterior resection (LAR) consecutively for rectal adenocarcinoma. Between February 2008 and June 2011, consecutive patients who underwent laparoscopic or robotic LAR by a single surgical team for rectal cancer were evaluated. The patients' demographic, operative, postoperative short-term follow-up, and histopathologic data were analyzed. Twenty-seven patients underwent robotic LAR, whereas 37 patients underwent laparoscopic LAR. The operation time of the laparoscopy group was significantly shorter than that of the robotic group (P=0.02). The complete total mesorectal excision rate was significantly higher in the robotic group (P=0.02). The overall complication rates were 11.11% and 21.62% in the robotic and laparoscopy groups, respectively (P=0.45). Good quality of resected specimens could be achieved with robotic LAR. Further prospective studies including long-term oncologic outcomes and costs with higher patient number are definitely needed to assess the benefits of robotic resection in rectal cancer treatment.

The Efficacy of Complete Surgical Excision of Keloid and Piercing Sinus Tract on Earlobe Keloid

The Efficacy of Complete Surgical Excision of Keloid and Piercing Sinus Tract on Earlobe Keloid

Efficacy of ‘radioguided occult lesion localisation’ (ROLL) versus ‘wire-guided localisation’ (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial

For the management of non-palpable breast cancer, accurate pre-operative localisation is essential to achieve complete resection with optimal cosmetic results. Radioguided occult lesions localisation (ROLL) uses the radiotracer, injected intra-tumourally for sentinel lymph node identification to guide surgical excision of the primary tumour. In a multicentre randomised controlled trial, we determined if ROLL is superior to the standard of care (i.e. wire-guided localisation, WGL) for preoperative tumour localisation. Women (>18 years.) with histologically proven non-palpable breast cancer and eligible for breast conserving treatment with sentinel node procedure were randomised to ROLL or WGL. Patients allocated to ROLL received an intra-tumoural dose of 120 Mbq technetium-99 m nanocolloid. The tumour was surgically removed, guided by gamma probe detection. In the WGL group, ultrasound- or mammography-guided insertion of a hooked wire provided surgical guidance for excision of the primary tumour. Primary outcome measures were the proportion of complete tumour excisions (i.e. with negative margins), the proportion of patients requiring re-excision and the volume of tissue removed. Data were analysed according to intention-to-treat principle. This study is registered at ClinincalTrials.gov, number NCT00539474. In total, 314 patients with 316 invasive breast cancers were enrolled. Complete tumour removal with negative margins was achieved in 140/162 (86 %) patients in the ROLL group versus 134/152 (88 %) patients in the WGL group (P = 0.644). Re-excision was required in 19/162 (12 %) patients in the ROLL group versus 15/152 (10 %) (P = 0.587) in the WGL group. Specimen volumes in the ROLL arm were significantly larger than those in the WGL arm (71 vs. 64 cm(3), P = 0.017). No significant differences were seen in the duration and difficulty of the radiological and surgical procedures, the success rate of the sentinel node procedure, and cosmetic outcomes. In this first multicentre randomised controlled comparison of ROLL versus WGL in patients with histologically proven breast cancer, ROLL is comparable to WGL in terms of complete tumour excision and re-excision rates. ROLL, however, leads to excision of larger tissue volumes. Therefore, ROLL cannot replace WGL as the standard of care.

PWE-070 Outcomes following local excision of benign rectal lesions—network MDT results

IntroductionA regional Small and Early Rectal Cancer (SERC) MDT was established in 2008. In line with NICE guidance, all patients with stage 1 rectal cancer are referred, as well as...

P3-12-01: ROLL Trial – Radio-Guided Occult Lesion Localization Versus Wire Guided Localization in Breast Conserving Surgery for Non-Palpable Breast Cancer: A Multicenter Randomized Controlled Trial.

Abstract Background: For the management of non-palpable breast cancer, accurate preoperative localization is essential to achieve complete resection with acceptable cosmetic results. ROLL takes advantage of the intratumorally injected radiotracer, that is already used for the sentinel node procedure, to localize the primary tumor during surgery. In a multicenter randomized controlled trial, we determined if ROLL is superior to the standard of care (i.e. wire guided localization, WGL) for preoperative tumor localization. Methods: Women (&amp;gt;18 yrs.) with histologically proven non-palpable breast cancer and eligible for breast conserving treatment (BCT) with sentinel node procedure were randomized to ROLL or WGL. Patients allocated to ROLL received an intra-tumoral dose of 120 Mbq Technetium99 nanocolloid. Guided by a gamma detection probe, the surgeon excised the primary tumor and the sentinel node(s). In the WGL group, patients received a similar intra-tumoral or periaureolair dose of technetium in order to allow sentinel node biopsy. Ultrasound or mammography guided insertion of a hooked wire provided surgical guidance for excision of the primary tumor. Primary outcome measure was the proportion of complete tumor excisions (i.e. with negative margins). Furthermore, the proportion of patients requiring re-excision was assessed. Data were analyzed according to intention to treat analysis. Results: Three hundred and fourteen patients with 316 invasive breast cancers were enrolled. There were no significant differences in proportion of complete tumor removal with free margins and re-excision rate; complete tumor removal with negative margins was seen in 87.7% of patients in the ROLL group versus 87.5% (p=0.97) of patients in the WGL group Re-excision was required in 11.7% of patients in the ROLL group versus 9.2% (p=0.47) in the WGL group. Incorrect preoperative localization (i.e. failure to identify the correct localization of the lesion) occurred in 5 (3%) patients in the ROLL group versus 0 patients in the WGL group (p=0.029). Differences in the volume of the excised specimen, duration of the procedure, success rate of the sentinel node procedure, surgeons’ preferences and patients’ pain perception are currently being analyzed. Conclusion: With this multicenter randomized controlled comparison, the first of its kind in patients with histologically proven breast cancer, we show that ROLL is not superior to WGL in terms of complete tumor excision and re-excision rates. Furthermore incorrect lesion localization occurred more frequently when applying ROLL. Data on long term (6 months) cosmetic results and quality of life (6 weeks, 3 months, 6 months) are awaited. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-01.

Endoscopic versus microscopic trans‐sphenoidal pituitary surgery: a systematic review and meta‐analysis

Endoscopic trans-sphenoidal surgery has been increasingly replacing microscopic surgery as the state of the art trans-sphenoidal approach. To assess the efficacy and safety of pure endoscopic approach in comparison with microscopic approach in pituitary surgery. Literature review and meta-analysis. Systematic literature searches of MEDLINE (1952-10th February 2010), EMBASE (1974-10th February 2010) and the Cochrane Central Register of Controlled Trials to the 10th February 2010. Review of all English-language studies comparing endoscopic and microscopic techniques. Eleven relevant studies were identified with a total of 806 patients, 369 of whom had endoscopic surgery and 437 microscopic surgery. The initial remission rate of hypersecretion of functioning adenomas was not significantly different between the endoscopic and the microscopic group [(OR: 1.34(95% CI: 0.73-2.47); P=0.35; 66% remission rate in endoscopic group versus 60% in microscopic)].The proportion of patients with complete tumour removal was not significantly different in the endoscopic group than in the microscopic group [(OR: 0.83, (95% CI: 0.52-1.33); P=0.44]. The rate of CSF leak attributable to the surgical method did not differ significantly between endoscopic and microscopic group. Post-operative diabetes insipidus was less frequent in those having endoscopic surgery [15%versus 28%P=0.003]. Regarding the other intra cranial and nasal complications attributable to surgical technique, the occurrence rate in endoscopic group was significant lower compared with microscopic group (13%versus 1.2% respectively, P<0.05). Patients in the endoscopic group had significant shorter postoperative hospital stay with a range from 3.7 to 4.4 days, than those of microscopic group with a range from 5.4 to 5.7 days [(WMD: -1.53, (95% CI: -2.30 to -0.77); P<0.00001)]. Notwithstanding its limitations, the present systematic review, based on the currently available evidence, suggests that endoscopic trans-sphenoidal pituitary surgery is associated with similar rates of complete tumour excision and remission rates. Endoscopic surgery was associated with fewer complications related to surgical technique and a shorter hospital stay.

Percutaneous excisional biopsy of clinically benign breast lesions with vacuum-assisted system: Comparison of three devices

The aim of this study was to compare three devices in percutaneous excisional biopsy of clinically benign breast lesions in terms of complete excision rate, duration of procedure and complications. In a retrospective study from March 2005 to May 2009, 983 lesions underwent ultrasound-guided excisional biopsy with three vacuum-assisted systems, respectively. The lesions were category 3 lesions as determined by ultrasound imaging according to Breast Imaging Reporting and Data System (BI-RADS) (n=951) or had been confirmed as benign by a previous core needle biopsy (n=32). The completely excision rate, duration of procedure and complications (hematoma, pain and ecchymosis) were recorded. 99.7% (980/983) lesions were demonstrated to be benign by pathology after percutaneous excisional biopsy. The overall complete excision rate was 94.8% (932/983). In lesions whose largest diameter equal to or larger than 1.5cm, the complete excision rates of EnCor(®) group (97.8%, 348/356) and Mammotome(®) group (97.2%, 139/143) were significantly higher than that of Vacora(®) group (91.9%, 445/484) (P<0.05). The EnCor(®) group (6.6±6.5min) had a significant less duration than Mammotome(®) (10.6±9.3min) and Vacora(®) group (25.6±23.3min) (P<0.05). Hematoma occurred more in EnCor(®) group and Mammotome(®) group than in Vacora(®) group (P<0.05). All these three vacuum-assisted systems are highly successful for excisional biopsy of benign breast lesions.

Large Colorectal Polyps - Endoscopic Polypectomy as an Alternative to Surgery

Endoscopic polypectomy of colorectal polyps is a common procedure. However, endoscopic treatment of large polyps (those with a diameter exceeding 2 cm) remains questionable. There is a serious risk of colorectal carcinoma presence inside these lesions, which eventually would require surgical intervention. Apart from this fact endoscopic polypectomy of large polyps is connected with substantial risk of complications, such as perforation and bleeding. Many patients with large colorectal polyps are qualified for surgical intervention. THE AIM OF THE STUDY was to determine the efficacy and safety of polypectomy of large colorectal polyps. The study presented results of endoscopic treatment in case of patients with large colorectal polyps at the Department of General and Colorectal Surgery, Medical University in Łódź. Patients were admitted to the hospital during the period between January, 2008 and January, 2010. The following parameters were analysed: location of polyps, percentage of high grade dysplasia, complete excision rate, and complications connected with polypectomy procedures. During the analyzed period of time 488 endoscopic polypectomies were performed. Forty-three large colorectal polyps were removed (8.8%). Seven (16.3%) of them were classified as flat polyps. Out of 488 removed polyps, 39 were classified as adenomas with high grade dysplasia (7.9%), while 16 were large-exceeding 2 cm (37.2%). Considering the group of large polyps no invasive carcinoma case was detected. The radical excision rate for large pedunculated polyps was obtained in 88.8% (32/36) of cases. In case of flat adenomas the above-mentioned parameter was lower--57.1% (4/7). During polypectomy of large colorectal polyps one perforation was observed during the excision of a flat cecal polyp. In two cases immediate bleeding occurred (2/43). In both cases endoscopic treatment of bleeding proved sufficient. Endoscopic polypectomy of large pedunculated polyps is a safe and efficient method, which makes it a rationale alternative for surgery. Polypectomy of flat adenomas is connected with a lower radical excision rate and higher risk of perforation.

Surgical excision of skin cancer: the importance of training

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3-month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21.5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.

Diagnosis and surgical treatment of intraveneous leiomyomatosis extending into the heart: two cases report and review of the literature

Objective To investigate the clinical characteristics, diagnosis and surgical treatment of intravenous leiomyomatosis (IVL), and outline the differences between Chinese and overseas cases. Methods Clinical data of two IVL cases, treated in our hospital, were analyzed retrospectively and the related literature was also reviewed. The data of preoperative diagnostic rate, surgical procedures, and postoperative recurrence between patients in China and other countries were compared. Results The first stage operation was performed successfully in 2 patients. However, they refused subsequent therapies, including a second stage operation to excise the remnants of the tumor, uterus, bilateral oviducts and ovaries, and anti-estrogen therapy. Both suffered from IVL recurrence, one at 6-month and the other at 9-month, and died at 16-month and 12-month respectively after the first stage surgery. Worldwide reports of 110 IVL cases were reviewed, which included 28 cases in China and 82 cases in other countries. In the majority of the Chinese patients, tumors only extended into the right atrium rather than the right ventricle (RA 22 cases vs RV 4 cases). However, among the overseas patients, the rate of extension into the right atrium was similar to that of extension into the right ventricle (RA 41 cases vs RV 38 cases). The rate of hysterectomies was not significantly different between Chinese and overseas patients (67.86% vs 55.9%, P=0.278). The rate of correct preoperative diagnosis in the Chinese patients was significantly lower than that in the overseas patients (32.14% vs 80%, P=0.000002), as well as the rate of complete excision of the tumor (22.7% vs 75.5%, P=0.000001). The proportion of patients who undergoing a single-stage or a two-stage operation was similar in Chinese and overseas patients. The recurrence rate was significantly higher in the Chinese patients than in the overseas patients (36.8% vs 9.1%, P=0.0055), and the patients with tumor recurrence were partial tumor excision patients. Conclusion The possibility of IVL should be considered if echocardiography in female patients demonstrates a tumor in the right heart and a mass in the inferior vena cava (IVC). Further imaging should be performed to confirm the diagnosis. The correct diagnosis and accurate preoperative delineation of tumor extension are essential for an optimal surgical outcome. The key point in IVL treatment is the complete excision of tumors (single-stage or two-stage surgical procedure).

The safety and efficacy in humans of endoscopic mucosal resection with hydroxypropyl methylcellulose as compared with normal saline

Endoscopic mucosal resection (EMR) is a therapeutic modality that utilizes fluid to form a submucosal fluid cushion (SFC) for the treatment of early gastrointestinal neoplasia. The goal of this study was to determine the safety and efficacy in humans of EMR with hydroxypropyl methylcellulose (HPMC) as compared with historical controls of EMR performed with normal saline. A retrospective cohort study presented data on EMR performed in 89 lesions in 88 patients was compared with 22 control EMRs performed with normal saline. Indications for EMR included known or suspected cancerous or precancerous lesions of the gastrointestinal tract. Efficacy of EMR was based on rates of complete excision and tumor recurrence. EMR was performed in 89 lesions with HPMC-EMR used in 67 lesions and compared with 22 historical control lesions treated with saline EMR by the same five endoscopists. Lesion size and location were similar in both HPMC and saline groups. Complications were observed in six patients [5/67 (8%) HPMC and 1/22 (5%) saline, p > 0.2]. Long-term follow-up with repeat endoscopy was available on 43 lesions and identified 35/43 to be completely excised [20/25 (80%) HPMC-EMR and 15/18 (83%) saline EMR, p > 0.2]. Size of the lesion was not associated with success. Both HPMC and normal saline are effective agents for creating a submucosal cushion for EMR. Larger randomized studies are needed to determine statistically significant differences in efficacy.

Is head and neck melanoma a distinct entity? A clinical registry-based comparative study in 5702 patients with melanoma

The head and neck region is more heavily exposed to ultraviolet (UV) radiation than any other body site. Therefore, cutaneous malignant melanoma (CMM) of the head and neck area is proposed to have notable differences from melanoma at other body sites regarding clinicopathological features and survival of patients. The present retrospective study based on clinical registry data aims to compare clinical features and prognostic factors of head and neck melanoma (HNM) vs. melanoma at other anatomical regions (MOR) in order to detect differences which may be associated to the mode of sun exposure. The clinical records and histopathological findings of 844 patients with clinical stage I and II invasive HNM were compared with the data of 4858 patients with MOR. Survival analysis was performed using the Kaplan-Meier estimate, and the multivariate Cox proportional hazard model was used to evaluate independent prognostic factors. Melanoma density was clearly higher for HNM than for MOR: this was particularly true for the face, where it was elevated by a factor of 2.6. There was a higher male/female ratio in patients with HNM and they were significantly older than patients with MOR (P < 0.0001). Breslow tumour thickness did not differ between HNM and MOR. However, CMMs at the scalp were significantly thicker and to a higher degree ulcerated. Concerning clinicopathological CMM subtypes, there was an increased proportion of lentigo maligna melanoma among HNM and of nodular melanoma in the scalp and neck regions. Excision margins were narrower and the rate of complete primary excision was lower in HNM than in MOR. Overall, there was no significant statistical difference in cumulative 10-year survival rates according to Kaplan-Meier estimates among patients with HNM (84.6%) and MOR (87.8%). Tumour thickness turned out to be the variable with the highest prognostic impact followed by ulceration in both HNM and MOR. In relation to the skin surface significantly more CMMs were found in the head and neck area than in other anatomical regions. This might indicate, but does not prove, that UV exposure promotes the development of CMM. Although HNM showed specific clinicopathological features, prognosis remained unaffected. Thus HNM seems not to be a distinct subtype of CMM.

Specimen-orientated radiography helps define excision margins of malignant lesions detected by breast screening.

Eighty patients with impalpable breast lesions detected by mammographic screening underwent hookwire-guided wide local excision. Excision specimens were orientated with Ligaclips and submitted to radiography; if, on the specimen radiograph, the mammographic lesion crossed any visible margin, further tissue was excised. Clear histological margins were obtained on the initial excision in 52 (68 per cent) of 77 carcinomas. After inspection of the orientated specimen radiograph, further tissue was excised from 22 patients; this significantly increased the rate of complete excision to 86 per cent (P < 0.01). Significantly more patients with invasive cancer had a complete excision than those with ductal carcinoma in situ (52 of 57 versus 14 of 20, P < 0.02).

MULTICENTRE COLLABORATIVE PROSPECTIVE STUDY OF ENDOSCOPIC TREATMENT OF EARLY GASTRIC CANCER

Aims: The present study was conducted with the aims of elucidating the present state of endoscopic treatment, in particular endoscopic mucosal resection (EMR) of early gastric cancer, as well as any associated problems, and the prospects for further broadening of the indications for EMR. Subjects and methods: This study was begun in 1994 and completed in 2002. Lesions were classified into Group I, with macroscopic appearance of 0–I, IIa, IIb or IIc·U1(–), well- to moderately differentiated intramucosal carcinoma ≤ 20 mm in diameter, and Group II, with the same macroscopic appearance as Group I, intramucosal carcinoma either the same histological type with diameter 21–40 mm, or undifferentiated carcinoma ≤ 40 mm in diameter. Of the 412 subjects registered (Group I, 305 subjects; Group II, 107 subjects, including seven undifferentiated carcinoma cases), 258 were evaluated (Group I, 199 subjects; Group II, 59 subjects including seven undifferentiated carcinoma). Results: The overall complete excision rate for Group I was 71.9%, and was 82.4% for ≤ 10 mm, 67.2% for 11–15 mm, and 45.5% for 16–20 mm, thus declining with increasing lesion size. The long-term results, including cases of additional treatment for residual cancer following the original EMR, showed that recurrence occurred in eight out of 199 cases (4.0%), in five of whom local cure was achieved with endoscopic treatment, giving a final local cure in 196 cases (98.5%). The overall complete excision rate for Group II differentiated carcinoma was 46.2%. With the inclusion of additional treatment, local cure was achieved with endoscopic treatment in 57 out of 59 cases (96.6%). The remaining two cases of recurrence underwent open surgery. Conclusion: Regardless of Group I or II classification, if the diagnosis of intramucosal cancer from the specimen resected at the initial EMR is histologically correct, then local cure can be achieved with endoscopic treatment, including cases of recurrence, with appropriate follow up and use of concomitant techniques such as piecemeal resection and coagulation therapy. The indications for endoscopic treatment can now reasonably be widened to include Group II lesions.

EUS/IDUS AND ENDOSCOPIC PAPILLECTOMY

In our institute, the indication of endoscopic papillectomy is set for adenoma or early cancer without tumor growth in the bile duct or the pancreatic duct. The substantial complete excision rate was 78.8%. One out of 11 incomplete excision cases was removed surgically for tumor persistence, and, as for remaining the 10 cases without persistence had been under serial observations. One case out of the serial observations had local recurrence in 5 years 5 months after papillectomy and surgical resection was performed. Further cases and long‐term serial observations may be required to get evidence of an appropriate indication.In addition, for 60 cases experienced in our institute, the safety of this therapy was reviewed. We experienced bleeding (13.3%), pancreatitis (10%), and cholangitis (3.3%) as early complications, but all cases were successfully treated conservatively. There were no serious conditions as late complications, and endoscopic papillectomy was evaluated as a safe therapy.

MULTICENTRE COLLABORATIVE PROSPECTIVE STUDY OF ENDOSCOPIC TREATMENT OF EARLY GASTRIC CANCER

Aims: The present study was conducted with the aims of elucidating the present state of endoscopic treatment, in particular endoscopic mucosal resection (EMR) of early gastric cancer, as well as any associated problems, and the prospects for further broadening of the indications for EMR.Subjects and methods: This study was begun in 1994 and completed in 2002. Lesions were classified into Group I, with macroscopic appearance of 0–I, IIa, IIb or IIc·U1(–), well‐ to moderately differentiated intramucosal carcinoma ≤ 20 mm in diameter, and Group II, with the same macroscopic appearance as Group I, intramucosal carcinoma either the same histological type with diameter 21–40 mm, or undifferentiated carcinoma ≤ 40 mm in diameter. Of the 412 subjects registered (Group I, 305 subjects; Group II, 107 subjects, including seven undifferentiated carcinoma cases), 258 were evaluated (Group I, 199 subjects; Group II, 59 subjects including seven undifferentiated carcinoma).Results: The overall complete excision rate for Group I was 71.9%, and was 82.4% for ≤ 10 mm, 67.2% for 11–15 mm, and 45.5% for 16–20 mm, thus declining with increasing lesion size. The long‐term results, including cases of additional treatment for residual cancer following the original EMR, showed that recurrence occurred in eight out of 199 cases (4.0%), in five of whom local cure was achieved with endoscopic treatment, giving a final local cure in 196 cases (98.5%). The overall complete excision rate for Group II differentiated carcinoma was 46.2%. With the inclusion of additional treatment, local cure was achieved with endoscopic treatment in 57 out of 59 cases (96.6%). The remaining two cases of recurrence underwent open surgery.Conclusion: Regardless of Group I or II classification, if the diagnosis of intramucosal cancer from the specimen resected at the initial EMR is histologically correct, then local cure can be achieved with endoscopic treatment, including cases of recurrence, with appropriate follow up and use of concomitant techniques such as piecemeal resection and coagulation therapy. The indications for endoscopic treatment can now reasonably be widened to include Group II lesions.

Periocular Mohs micrographic surgery: Results of a dual-site day-surgery service

PURPOSE . To assess the feasibility of day-surgery Mohs Micrographic Surgery (MMS) at dual sites. METHODS . MMS now has an established position for the management of skin tumour removal. The literature reports excellent results in terms of tissue preservation, complete tumour excision and recurrence rate. MMS involves an initial stage undertaken by dermatologists. The subsequent reconstructive phase can be undertaken either by the dermatologist or by an oculoplastic surgeon in cases of extensive defects. In the latter cases, special expertise is needed in order to achieve satisfactory cosmetic results. Centres offering MMS are few and are usually located in tertiary referral hospitals. In a large city of 12 million inhabitants like London there is only one centre offering MMS on the National Health Scheme. We have set up a dual-site day-surgery service since 1997, whereby a Mohs trained dermatologist in the first unit undertakes the initial ablative stage. The patient is then transferred to the second location, which is approximately three miles away; a trained oculoplastic surgeon then undertakes the reconstruction the same day. Rarely, defects are deemed too large for reconstruction and the patient discharged on the same day; patients are then admitted as inpatients for reconstruction the following day with oculoplastic, plastic, craniofacial and facio-maxillary services at hand. RESULTS . To date we have operated on 59 patients for removal of basal cell carcinomas (BCC). All patients had a biopsy-proven diagnosis of BCC before being referred to the dermatologist. Following liaison with the Dermatology Unit, surgery was scheduled so that the reconstruction could be undertaken in the Oculoplastic Unit at the second hospital on the same day. All patients' defects were reconstructed successfully. With the longest follow-up being 39 months so far, tumour recurrence has been 0%. CONCLUSIONS . A dual-site day-surgery service seems to be a feasible option where a MMS dermatologist is not present onsite. The logistic problem can be easily overcome with a proper liaison between the departments. A dual-site day-surgery MMS service provides a superior service compared with the 2 mm tumour-free margin excision and delayed surgical repair following histological examination advocated by other authors where MMS is not available on site. It is only with MMS that one can ensure complete tumour excision. Day-surgery is the preferred choice, both for patients and for financial considerations. We would therefore support the establishment of dual-site day-surgery MMS services where the reconstruction is undertaken in hospitals located away from the MMS dermatology unit, provided close collaboration exists between the two units to ensure the smooth transfer of patients.

Role of Nerve-Sparing Radical Prostatectomy for Clinical Stage B2 Prostate Cancer

To examine the role of nerve-sparing radical prostatectomy in patients with clinical stage B2 prostate cancer we reviewed the first 77 such patients in our series since we adopted the nervesparing technique. A total of 47 patients (61%) underwent bilateral and 26 (34%) underwent unilateral nerve-sparing prostatectomy, while in 4 (5%) both neurovascular bundles were resected. Among the patients followed for 12 months 27 of 41 (66%) treated with bilateral and 7 of 19 (37%) treated with unilateral nerve-sparing prostatectomy had potency preserved.With the strict clinicopathological criteria of organ-confined tumor, that is intracapsular tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels, complete tumor excision was achieved in 17 patients (36%) treated with bilateral and 7 of 26 (27%) treated with unilateral nerve-sparing prostatectomy. All patients in whom both neurovascular bundles were resected had pathological stage C or D1 disease. Of the 24 patients who had complete tumor excision by the strict criteria only 15 (19.5% of the 77 preoperatively potent patients) had potency preserved.Of these patients 19 had microscopically positive margins without seminal vesicle invasion (pathological stage Cl) with undetectable postoperative prostate specific antigen levels. In addition, 4 patients had seminal vesicle involvement with negative surgical margins and undetectable postoperative prostate specific antigen levels. If these patients also are considered as having complete tumor excision, there was an over-all complete tumor excision rate of 61% (47 of 77), of whom 25 (32% of the 77 patients) had preservation of potency. Ten patients with clinical stage B2 tumor whose potency was preserved had histological and serological evidence of incomplete tumor excision. Of 53 patients with pathological stage Cl disease 9 (17%) had margins positive only in the regions of the neurovascular bundles.Preoperative prostate specific antigen and acid phosphatase levels, and findings on transrectal ultrasonography failed to predict accurately which patients had extracapsular tumor extension. Patients with poorly differentiated tumors and/or bulky disease on rectal examination had a higher incidence of extracapsular extension and positive margins.We conclude that in the majority of potent patients with clinical stage B2 prostate cancer not all of the goals of nerve-sparing radical prostatectomy are realized. Because of the high incidence of extracapsular tumor extension and positive surgical margins in patients with clinical stage B2 disease, and because some positive surgical margins may be owing to attempts to preserve potency we question whether nerve-sparing prostatectomy should be attempted in patients with bulky clinical stage B2 prostate cancer.