Deep Surgical Margins Research Articles

Intraoperative rapid assessment of the deep muscle surgical margin of tongue squamous cell carcinoma via Raman spectroscopy.

An accurate assessment of the surgical margins of tongue squamous cell carcinoma (TSCC), especially the deep muscle tissue, can help completely remove the cancer cells and thus minimize the risk of recurrence. This study aimed to develop a classification model that classifies TSCC and normal tissues in order to aid in the rapid and accurate intraoperative assessment of TSCC surgical deep muscle tissue margins. The study obtained 240 Raman spectra from 60 sections (30 TSCC and 30 normal) from 15 patients diagnosed with TSCC. The classification model based on the analysis of Raman spectral data was developed, utilizing principal component analysis (PCA) and linear discriminant analysis (LDA) for the diagnosis and classification of TSCC. The leave-one-out cross-validation was employed to estimate and evaluate the prediction performance model. This approach effectively classified TSCC tissue and normal muscle tissue, achieving an accuracy of exceeding 90%. The Raman analysis showed that TSCC tissues contained significantly higher levels of proteins, lipids, and nucleic acids compared to the adjacent normal tissues. In addition, we have also explored the potential of Raman spectroscopy in classifying different histological grades of TSCC. The PCA-LDA tissue classification model based on Raman spectroscopy exhibited good accuracy, which could aid in identifying tumor-free margins during surgical interventions and present a promising avenue for the development of rapid and accurate intraoperative techniques.

Extended segmentectomy for intersegmental lesions with intraoperative surgical margin assessment by radiofrequency identification markers

ObjectiveWe developed a technique to determine deep surgical margins using radiofrequency identification markers. This study assessed the feasibility of this technique during extended segmentectomy of intersegmental lesions. MethodsA single-center, prospective, single-arm study was performed from 2020 to 2023. Small pulmonary lesions suspicious for malignancy locating the virtual intersegmental plane based on 3-dimensional imagery were included. Markers were placed in the vicinity of the lesions using electromagnetic navigation bronchoscopy. In addition to indocyanine green injection, surgeons used wireless signal strength to determine the best resection line without lung palpation to obtain surgical margins of 10 mm or the same size as the tumor. ResultsWe analyzed 75 lesions in 75 patients. Median lesion size and depth from the pleura were 12.0 mm and 23.6 mm, respectively. Three-dimensional imagery identified lesions at a median distance of 7.0 mm from the virtual intersegmental plane. The median marker-lesion and marker-virtual intersegmental plane distances were 5.8 mm and 4.9 mm, respectively. Complex segmentectomy was performed in 64 of 75 patients (85.3%). The indocyanine green and preoperative simulated intersegmental lines agreed in 92.0% (69/75). In 6 cases (8.0%), the resection line was determined using radiofrequency identification markers to obtain adequate margins because the indocyanine green undyed area was smaller than the preoperatively simulated one. In 1 patient, planned segmentectomy was converted to lobectomy because of a misplaced radiofrequency identification marker (1.3%). The successful tumor resection rate was 98.7%. The median surgical margin was 16.0 mm. ConclusionsUse of radiofrequency identification markers enabled precise extended segmentectomy with adequate surgical margins.

Role of Imaging in Predicting the Deep Surgical Margin in Gingivobuccal Complex Cancers: A Pilot Study.

Cancers arising from the gingivobuccal complex are one of the most common types of cancer in the oral cavity and are associated with poor prognosis. Among the various prognostic factors, positive surgical margin is the most important one that can be controlled by the operating surgeon. The deep surgical margins for buccal mucosa cancers is normally assessed by palpating the skin for induration and skin pinchability. The present study evaluates the role of imaging in assessing the deep surgical margin and its efficacy for skin preservation in buccal mucosa/ gingivobuccal carcinomas. The patients of gingivobuccal complex squamous cell carcinomas after histopathological confirmation were selected for the study. In imaging, the distance between the base of the tumour and skin (epidermis) of the cheek was measured by a senior radiologist preoperatively. The frozen section findings were confirmed by histopathological examination and the depth of invasion of the tumour was measured and the clearance of the deep surgical margin was confirmed. The correlation between imaging, skin pinch test and histopathological examination of the specimen was assessed. The sensitivity and specificity of imaging to predict the skin preservation (deep surgical margin more than 5mm) is 100% and 75% respectively compared to sensitivity and specificity of skin pinch test of 82.6% and 50% respectively. Imaging is an effective tool in predicting the skin preservation and skin excision compared to skin pinch test. Compared to the skin pinch test, imaging appears to be a useful tool for advising surgeons on skin preservation vs excision.

Elective parotidectomy and neck dissection are not beneficial in cutaneous squamous cell carcinoma of the head

ObjectiveCutaneous Squamous Cell Carcinoma (cSCC), a tumor with a significantly increasing incidence, is mostly diagnosed in the head region, where tumors have a worse prognosis and a higher risk of metastases. The presence of metastases reduces specific five-year survival from 99% to 50%. As the risk of occult metastases does not exceed 10%, elective dissection of the tributary parotid and neck lymph nodes is not recommended. MethodsWe retrospectively analyzed a group of 12 patients with cSCC of the head after elective dissections of regional (parotid and cervical) nodes by means of superficial parotidectomy and selective neck dissection. ResultsWe diagnosed occult metastases neither in the cervical nor parotid nodes in any patient. None were diagnosed as a regional recurrence during the follow-up period. ConclucionOur negative opinion on elective parotidectomy and neck dissection in cSCC of the head is in agreement with the majority of published studies. These elective procedures are not indicated even for tumors showing the presence of known (clinical and histological) risk factors for lymphogenic spread, as their positive predictive value is too low. Elective parotidectomy is individually considered as safe deep surgical margin. If elective parotidectomy is planned it should include only the superficial lobe. Completion parotidectomy and elective neck dissection are done in rare cases of histologically confirmed parotid metastasis in the parotid specimen. Preoperatively diagnosed parotid metastases without neck involvement are sent for total parotidectomy and elective selective neck dissection. Cases of clinically evident neck metastasis with no parotid involvement, are referred for comprehensive neck dissection and elective superficial parotidectomy. The treatment of concurrent parotid and cervical metastases includes total conservative parotidectomy and comprehensive neck dissection. Level of evidenceHow common is the problem?Step 4 (Case-series)Is this diagnostic or monitoring test accurate? (Diagnosis)Step 4 (poor or non-independent reference standard)What will happen if we do not add a therapy? (Prognosis)Step 4 (Case-series)Does this intervention help? (Treatment Benefits)Step 4 (Case-series)What are the COMMON harms? (Treatment Harms)Step 4 (Case-series)What are the RARE harms? (Treatment Harms)Step 4 (Case-series)Is this (early detection) test worthwhile? (Screening)Step 4 (Case-series)

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas

BackgroundAchieving adequate surgical margins and preventing recurrence are important in the treatment of basal cell carcinoma (BCC). ObjectivesThe objectives of this study were to evaluate the adequacy of surgical margins and the re-excision rates in patients with primary BCC who underwent standard surgical treatment using our proposed algorithm and to define the risk factors in patients with recurrent BCC. MethodsThe medical records of patients who were histopathologically diagnosed with BCC were reviewed. An algorithm created based on previous literature was used to determine the distribution of optimal surgical margins adequacy and re-excision rates. ResultsStatistically significant differences were observed between the cases with and without recurrence in age at diagnosis (p=0.004), tumor size (p=0.023), tumor location in the H zone of the face (p=0.005), and aggressive histopathological subtype (p=0.000). When the tumors were evaluated for adequacy of deep and lateral surgical margins and re-excision rates, higher rates of adequate excision (457 cases, 68.0%) and re-excision (43 cases, 33.9%) were noted for tumors in the H or M zone. Study limitationsInadequate follow-up of newly diagnosed patients in terms of recurrence and metastasis and the retrospective application of our proposed algorithm are the limitations of the present study. ConclusionsOur results showed that if BCC was detected at an early age and at an early stage, recurrence was lower. The H and M zones were the regions with the highest rates of optimal surgical outcomes.

Intra-operative intaoral ultrasonograpy ensures free deep resection margins in carcinoma tongue: A pilot study.

Resection of primary in carcinoma tongue is challenging as the tumor often spreads submucosal and deep in muscles. There are various Intraoperative tools available to guide tumor resection margins. We studied the use of intraoperative ultrasound-guided resection for obtaining free deep resection margins in cases of oral carcinoma tongue. To assess the feasibility of resection of tongue tumor using intraoral ultrasound intraoperatively. 5 patients of oral tongue squamous cell carcinoma were included in this prospective pilot study. Intraoral ultrasound-guided resection of the primary tongue tumor was done. The surgeon moved the probe over the tumor and focussed on the point of maximum invasion by the tumor. A 26 G needle was passed in the tongue at a point that was 10 mm away from the deepest point of infiltration. It marked the deepest plane of resection. Following the above marking, a resection of tumor was done. Deep surgical resection margin was found to be >5 mm (free) in all the USG-guided surgically resected primary tongue tumors on histopathological examination. We have found intraoperative ultrasonography a useful tool for the surgical resection of primary tongue tumours.

795 Adequacy of Surgical Excision Margins in Lentigo Maligna: An Audit

Abstract Aim The optimal excision margin for Lentigo Maligna (LM) lesions has been a frequent topic of debate. An audit was carried out to compare the excision margins used for LM excisions with current NICE guidelines, and to assess the adequacy of these excision margins. Method A retrospective study was carried out to analyse all excisions of LM lesions in 2018. 33 patients were identified from the plastic surgery departmental database. Patient demographics, the site and distribution of LM lesions, and any history of previous skin cancer were analysed. Patient electronic records, operative notes, and histopathological reports were examined to determine the number of excisions done for each LM lesion along with the peripheral and deep surgical excision margins, and the histological clearance achieved. Complete histological clearance was determined by the Multidisciplinary team for each lesion. Results 60 cases were identified. 60% of cases were located on the head and neck. The average peripheral surgical excision margin at first excision was 2.3mm. 55% of patients had a 2nd excision. The average peripheral surgical excision margin at 2nd excision was 5.4mm. 70.6% of cases achieved complete histological clearance at 2nd excision. 72.7% of lesions excised at 2nd excision with a 5mm or less surgical excision margin achieved complete histological clearance. Conclusions Taking >5mm surgical excision margins did not increase the rate of complete histological clearance for Lentigo Maligna lesions.

Aberrant expression of E-cadherin in infiltrating ductal and lobular breast carcinomas and its correlation with clinicopathological parameters – A hospital-based study

Introduction: Breast carcinoma is one of the commonest malignant tumours in women, leading topremature deaths and morbidity. E-cadherin is a 120kDa calcium-dependent transmembraneglycoprotein encoded by the CDH1 gene located on chromosome 16q21 and is expressed in mostepithelial cells. Loss of E Cadherin expression implies cell discohesion and favours metastasis.Materials and Methods: A total of 30 cases of breast carcinomas were studied, over two years.Histological grade and type were assessed by staining the paraffin-embedded sections with H & E.Using IHC technique, E-cadherin antigen was retrieved by Heat-Induced Epitome Retrieval method,and immunostaining was scored semiquantitatively. Cases were grouped as ‘preserved,’ whenpositivity was strong membranous, and occurred in more than 75% of the neoplastic epithelial cellsand ‘aberrant’ in all the remaining cases. Results: E-cadherin was found to be preserved in 46.7%of all the breast carcinomas and aberrant in 51.7% of invasive ductal carcinomas (IDC) alone, while100% of invasive lobular carcinomas showed aberrant expression. No significant correlation wasfound with E-cadherin grading and histological type of carcinoma, histopathological grade orinvolvement of deep surgical margin. Conclusion: Differentiation between invasive ductal andinvasive lobular carcinoma based on the loss of E-cadherin has to be done cautiously given itsaberrant expression in ductal carcinomas as well.

High-frequency (22-MHz) ultrasound for assessing the depth of basal cell carcinoma invasion.

High-frequency ultrasound (HFUS) has been studied in the diagnosis and therapeutic management of basal cell carcinoma (BCC). The accuracy of this method for location of deep margins remains unknown. This study evaluates HFUS for localization of deep surgical margins in BCC. Ultrasound images of 83 lesions from 67 patients with clinical and dermoscopic diagnosis of BCC were compared with histopathological findings. Pearson's correlation coefficient was used to assess the relationship between thickness as measured by HFUS and histopathology. A strong correlation between HFUS and histopathological measurements was identified (r=0.9744, P<.001). HFUS had sensitivity of 96%, specificity of 84%, and accuracy of 91% for measurement of deep tumor margins. Factors affecting tumor measurement on HFUS include marked basophilic degeneration of collagen, presence of peritumoral hypertrophic glands or hair follicles, fibrosis, and dense inflammatory changes related to the tumor itself or to prior procedures. High-frequency ultrasound was effective in localizing deep tumor margins in BCC. Therefore, we believe that this diagnostic imaging method is important when selecting a therapeutic approach, considering Mohs micrographic surgery, and evaluating the surgical site.

Narrow resection margins are not associated with mortality or recurrence in patients with Merkel cell carcinoma: A retrospective study

Wide local excision constitutes the standard of care for Merkel cell carcinoma, but the optimal margin width remains controversial. To assess whether narrow margins (0.5-1cm) were associated with outcome. Patients were recruited from a retrospective French multicentric cohort and included if they had had excision of primary tumor with minimum lateral margins of 0.5cm. Factors associated with mortality and recurrence were assessed by multivariate regression. Among the 214 patients included, 58 (27.1%) had undergone excision with narrow margins (0.5-1cm) versus 156 (72.9%) with wide margins (>1cm). During a median follow-up of 50.7months, cancer-specific survival did not differ between groups (5-year specific survival rate 76.8% [95% confidence interval 61.7%-91.9%] and 76.2% [95% confidence interval 68.8%-83.6%], respectively). Overall survival, any recurrence-free survival, and local recurrence-free survival did not significantly differ between groups. Cancer-specific mortality was associated with age, male sex, American Joint Committee on Cancer stage III, and presence of positive margins. Retrospective design, heterogenous baseline characteristics between groups. Excision with narrow margins was not associated with outcome in this cohort, in which most patients had clear margins and postoperative radiation therapy. Residual tumor, mostly found on deep surgical margins, was independently associated with prognosis.

Evaluation of a modified proportional margin approach for complete surgical excision of canine cutaneous mast cell tumours and its association with clinical outcome.

Canine cutaneous mast cell tumours (MCTs) represent a common neoplasm in veterinary practice. Several reported techniques are available to guide surgical excision. Our study examined one hundred cutaneous MCTs that were excised surgically using a modified proportional margin approach. A 2cm lateral margin upper limit was applied for any tumour diameter that exceeded this size with a deep surgical margin of one fascial plane applied. A retrospective, cross-sectional study with follow-up was used to determine the clinical utility of this excision technique. Associations between explanatory variables of tumour size and grade were compared with outcomes of complete excision and size of histologic tumour-free margins (HTFM) using the appropriate Pearson's χ2 and Fisher's exact tests. Follow-up data evaluated tumour recurrence and patient survival. Ninety-five percent of MCTs (95/100) were completely excised. No significant association in the achievement of complete excision between low- and high-grade MCTs (P=.48) was noted. Tumour size was not associated with the rate of complete excision (P=.06). Tumour grade and size did not influence the size of the HTFM (P =.94 and P =.14, respectively). Overall, a recurrence rate of 3% (3/100 tumours) and de novo MCT development rate of 7.7% (5/65 dogs) was noted, with median follow-up period of 593 days (range 180-1460 days). Post-operative metastases were seen in 4.6% of dogs (3/65). Therefore, a modified proportional margin approach with 2cm lateral margin upper limit is a suitable technique to guide surgical excision of canine cutaneous MCTs.

Invasive conjunctival melanoma mimicking ocular surface squamous neoplasia: a case series

BackgroundConjunctival melanoma is the second most common conjunctival malignant tumour after squamous cell carcinoma, usually arising from primary acquired melanosis and less commonly from a conjunctival naevus or de novo....

Prediction of the invasive level of basal cell carcinomas in the facial area: Analysis of 718 Japanese cases

BackgroundBasal cell carcinoma (BCC) is the most common skin cancer. While Mohs micrographic surgery is commonly accepted for BCC treatment, surgical excision with free margins is widely considered the best treatment modality for BCCs in Japan. However, little is known about the predictors of the invasion levels of BCCs. ObjectiveTo investigate the optimization of deep surgical margins by identifying factors significantly influencing the invasion levels of facial BCCs. MethodsThe tumor invasion level was defined as the deepest part of a tumor. Tumor thickness was measured from the top of the granular layer to the deepest extension of the tumor or from the ulcer base overlying the deepest point of invasion in ulcerated lesions. Factors independently associated with tumor thickness and invasion level were identified by multivariate analysis. Six variables were tested: age, sex, anatomical region (nose, orbit, others), histologic pattern (aggressive, non-aggressive), presence of pigmentation, and diameter. ResultsWe included 718 cases of facial BCCs involving 705 Japanese patients. The most frequent anatomical region and histologic pattern were the nose and nodular pattern, respectively. Only tumor diameter showed a correlation with tumor thickness (β = 0.377, P < 0.001). Tumor diameter (AOR = 71.189, 95 % CI: 11.420–430.931, P = 0.01) and the following anatomical regions showed correlations with the invasion level: nose/others: AOR=2.769, 95 % CI: 1.235–6.493, P = 0.01; orbit/others: AOR=6.369, 95 % CI: 2.728–15.429, P < 0.001; orbit/nose: AOR=2.300, 95 % CI: 1.056–4.984, P = 0.04. ConclusionsThis study serves as a guide for optimizing deep surgical margins and planning surgery for facial BCCs considering independently associated factors.

Incidence and Predictors of Recurrence among Breast Cancer Patients in Black Lion Specialized Hospital Adult Oncology Unit, Addis Ababa, Ethiopia: Retrospective Follow-up Study with Survival Analysis.

Currently, breast cancer is becoming a major public health problem for developing countries. In Ethiopia, breast cancer is the most prevalent cancer among women, and constitutes a major public health concern. Hence, this study was aimed to determine the incidence and predictor of recurrence among breast cancer clients at Black Lion Specialized Hospital, Ethiopia, in 2018. We analyzed 513 patients out of 835 women breast cancer patients treated at Black Lion Specialized Hospital. Recurrent-free survival was determined using the Kaplan–Meier method, with comparisons between groups through the log-rank test. The Cox proportional hazards model was used to identify predictors of recurrence among breast cancer clients. The incidence rate of recurrence among breast cancer was 6.5% per (95% CI = 6.49-12.47) follow-up. The median recurrent-free survival time was 60.33 months (95% CI = 54.46-62.30). Predictors of recurrence were negative estrogen receptor (hazard ratio [HR] = 1.8, 95% CI = 1.53-7.62), high histologic grade (HR = 2.8, 95% CI = 1.14-10.31), positive lymph node status (HR = 2.6, 95% CI = 1.14-10.31), clinical staging III (HR = 2.5, 95% CI = 1.26-9.42), and involved deep surgical margin (HR = 3.6, 95% CI = 2.14-8.61). This research showed that incidence of recurrence was high. Advanced clinical stage, positive nodal status, high histologic grade, negative estrogen receptor, and involved deep surgical margin were associated with higher recurrence rates. In contrast, hormonal therapy has a great role in decreasing the development of recurrence.

Comparison of lateral surgical margins of up to two centimeters with margins of three centimeters for achieving tumor-free histologic margins following excision of grade I or II cutaneous mast cell tumors in dogs

To determine whether conservative lateral surgical margins (equal to tumor diameter for tumors < 2 cm in diameter or 2 cm for larger tumors) were noninferior to wide (3-cm) lateral surgical margins for achieving tumor-free histologic margins following excision of grade I and II cutaneous mast cell tumors (MCTs) in dogs. 83 grade I and II MCTs excised with a deep surgical fascial margin and requisite lateral surgical margins from 68 dogs from 2007 to 2017. Tumors representing scar revision or local recurrence were excluded. A pathology department database was searched to identify qualifying MCTs, and medical records were cross-referenced to obtain data regarding patients and tumors. Outcome (complete vs incomplete excision as histologically determined) was compared between conservative- and wide-margin groups. A noninferiority margin of ≥ 0.9 was used for the risk ratio (probability of complete excision for the conservative- vs wide-margin group), implying that noninferiority would be established if the data indicated that the true risk of complete excision with the conservative-margin approach was at worst 90% of that for the wide-margin approach. The proportion of excised MCTs with tumor-free histologic margins was similar between the conservative- (43/46 [93%]) and wide- (34/37 [92%]) margin groups. There were no differences in tumor diameter or location between treatment groups. The risk ratio (1.02; 95% confidence interval, 0.89 to 1.19) met the criterion for noninferiority. The conservative-margin approach appeared to be noninferior to the wide-margin approach for achieving tumor-free histologic margins in the dogs of this study, and its use could potentially reduce the risk of postoperative complications. (J Am Vet Med Assoc 2020;256:567-572.

Ultrasound aids in intraoperative assessment of deep resection margins of squamous cell carcinoma of the tongue.

We wanted to find out whether ultrasound (US) can be used to assess the deep resection margins after excision of squamous cell carcinoma (SCC) of the tongue, as intraoperative feedback on their condition might help to prevent them being too close. Resected specimens of cancers of the tongue from 31 patients with SCC of the tongue were suspended in US gel and scanned with a small 5-10MHz US probe. The tumour was readily visible and US could differentiate it from muscle tissue. The margin of normal tongue musculature surrounding the tumour was measured on the US images, and the minimal resection margin was noted and compared with that reported by the histopathologist. The mean (SD) deep resection margins measured on the US images differed by 1.1 (0.9) mm from those reported by the histopathologist (Pearson's correlation coefficient: 0.79, p<0.01). The US measurements took a maximum of five minutes. It is feasible to use US to assess resection specimens of SCC of the tongue as an adjunct to existing strategies (such as frozen section analysis) to help achieve the desired deep surgical margins. The method is easy to incorporate into surgical routine as it does not take long.

Role of Intraoperative Clean Surgical Margin Determined With Lesion Size and Duration to Obtain Apropriate Histological Clean Surgical Margin in High-Risk Basal Cell Carcinoma Patients, According to National Comprehensive Cancer Network Criteria.

We aimed to elucidate the role of intraoperative clean surgical margin (iCSM) determined according to lesion size and duration to obtain appropriate histological clean surgical margin (hCSM) in high-risk basal cell carcinoma (BCC) patients evaluated according to National Comprehensive Cancer Network (NCCN) criteria considering the tumor size and/or location. The contribution of lesion area to determine iCSM was also evaluated. Patients with high-risk BCC requiring surgical management were included. iCSM, hCSM, and clinical variables including sec, age, longest edge, location and area, and follow-up duration were recorded. In total, 96 lesions were evaluated. Lesions were mostly located in the mask area and other face region (93.8%). Lesions located on the nose comprised 50%, 34.1%, and 26.3% in the BCC-5, BCC-7, and BCC-10 lesions, respectively. The hCSMs were positive in 11.5%, 9.1%, and 3.8% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The deep surgical margin was positive in 15.4%, 4.5%, and 7.7% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The calculated risk for the positive surgical margin if the BCC-10 lesions were done like the BCC-7 was 15.4%. No recurrence was during follow-up duration. As supported by the findings of the present study, to obtain an adequate hCSM in the high-risk BCC lesions, the iCSM determined according to NCCN recommendations may not be optimal. Nevertheless, after their categorization according to lesion size and disease duration for excision with 5-, 7-, and 10-mm iCSMs, it is possible to obtain a small but important improvement in the outcome of patients.

A retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin

Basal cell carcinoma (BCC) is the most common malignancy worldwide. Although rarely a risk to life, they are potentially destructive and disfiguring. Current treatment guidelines are predominantly based on low-risk BCC and make no recommendations regarding the deep excision margin. We aim to clarify the prevalence of high-risk BCC and appropriate surgical management of the deep margin. Data of 556 patients presenting for primary excision of 694 basal cell carcinoma to CUH Plastic Surgery between January 2017 and April 2018 were collected by capture of demographics, surgical notes and histology. We defined the deep surgical margin as numbered anatomical planes, with subcutaneous fat as 0, the first plane under this as 1 and so forth. This allowed comparison of the surgical excision depth, and resulting deep margin histology, across disparate sites. Histological margin clearance was analysed using ordinal regression of age, site, size, histological type and surgical margin. This allowed identification of factors associated with clear, close or incomplete lesion excision. Subgroup analysis was then performed to make recommendations for surgical margins to achieve adequate lesion clearance. Six hundred ninety-four BCCs were identified, 66% were male and the average age of patients was 74 years. Of the BCCs, 49% were nodular but 39% were mixed. An infiltrative component was seen in 24% (mixed infiltrative), but only 4% were purely infiltrative. Mean size, site and patient age were similar across histological types. Deep margin involvement was very rare in nodular or superficial BCCs but occurred in 7% of pure infiltrative and 5% of mixed infiltrative. Peripheral margins were very rarely involved in nodular BCCs but occurred in 9% of mixed infiltrative and 10% infiltrative despite similar surgical margins. A deep margin of the first underlying anatomical plane resulted uninvolved margins in 95% of infiltrative or mixed infiltrative BCC, but subcutaneous fat was sufficient for clearance in 95% of nodular, superficial and mixed non-infiltrative BCC. High-risk BCC was a common finding in our patient population. This was based not only on site and size but also on histological type. Infiltrative and mixed infiltrative BCCs have a higher risk of close or involved deep margins than other types. We recommend that they are excised to the first underlying anatomical plane. Nodular, superficial and mixed non-infiltrative BCC can usually be safely excised with a cuff of fat alone.

A study into the association between local recurrence rates and surgical resection margins in organ-sparing surgery for penile squamous cell cancer.

To evaluate the significance of close surgical margins in organ-sparing surgery (OSS) in the treatment of penile squamous cell carcinoma (pSCC) and clinicopathological factors that may influence local recurrence. At our tertiary referral centre, between March 2001 and September 2012, 332 patients treated with OSS for pSCC had clear surgical margins. As the focus was the impact of close clear margins on local recurrence, patients with positive margins were excluded for the purpose of this study. Our overall positive margin rate for OSS in penile cancer is 7.6% (42 patients). Analysis was carried out on an on-going prospective database, including prospective accurate pathological recording of surgical margins. Patients underwent OSS after multidisciplinary team (MDT) discussion. Local recurrence was the primary outcome measured and Fisher's exact test and time-to-recurrence curves were used in the analysis. All local recurrences were scrutinised by the MDT and were categorised into: true recurrences or metachronous new occurrences (i.e. tumours arising from a background of penile intraepithelial neoplasia and forming on an epithelial surface not related to the site of initial resection). A multivariate analysis was also conducted to elucidate other factors influencing local recurrence. In all, 64% of the patients had a <5 mm clear deep surgical margin, with 16% clear by <1 mm. Overall, 4% of patients had a true local recurrence, with a median time to recurrence of 6 months. In all, 53% were due to embolic spread, with residual occult local disease accounting for 47%. There was a statistically significant relationship between cavernosal involvement (P = 0.014) and lymphovascular invasion (LVI; P = 0.001) and local recurrence. Although multivariate analysis revealed that the extent of clear margin was not a predictor of disease (P = 0.405), we found an increased risk of local recurrence in the clear margin cohort of <1 mm compared to those of >1 mm (P < 0.001). Those patients considered to have metachronous tumours were scrutinised by our MDT, and eight patients (2.4%) were found to have new occurrences. Our overall proportion of patients therefore needing further treatment for either new occurrences or recurrent disease after OSS stands at 6.4%. Overall the presence of local recurrent disease in OSS in our experience is low (4%). We report an embolic mechanism of local recurrence, strongly suggested by the presence of cavernosal involvement and LVI. We conclude that a deep clear margin of >1 mm has a very low risk of local recurrence in penile OSS.

High Frequency Jet Ventilation during Transoral Laser Microsurgery for Tis-T2 Laryngeal Cancer.

Transoral laser microsurgery (TLM) for early to intermediate laryngeal squamous cell cancer (SCC) can be technically challenging when adequate exposure of the posterior laryngeal compartment is required due to the presence of the orotracheal tube. The goal of our study was to analyze the efficacy of high frequency jet ventilation (HFJV) in achieving appropriate laryngeal exposure and safe oncologic resection of lesions located in such a position. We reviewed the clinical records of 62 patients affected by Tis-T2 SCC of the posterior laryngeal compartment treated by TLM between 02/2012 and 12/2016. The cohort was divided into two groups according to the anesthesiologic technique used: Group A included patients treated using intraoperative infraglottic HFJV, while Group B encompassed patients treated by standard orotracheal intubation. The main outcome was postoperative surgical margin status. Group comparison analysis was performed. Significant difference in deep margin status was observed between the two groups: in Group A, the rate of negative deep margins was 86% compared to 56% in Group B (p = 0.04). A trend of better overall and superficial margin control was observed for patients treated using HFJV (Group A), although no statistical significance was achieved. Use of HFJV during TLM allows easier and safer management of patients affected by Tis-T2 SCC of the posterior laryngeal compartment, reducing the rates of positive superficial and deep surgical margins.