Definitive Histological Analysis Research Articles

Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study.

Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.

WIDENED PDL SPACE: MALIGNANCY OR FRACTURED TOOTH? SHAHBAZI

Background Despite the development of several modern imaging modalities, radiography remains the first and the most important mode of investigation for evaluating jaw lesions. Osteosarcoma is the most common primary malignant bone tumor, accounting for approximately 20% of the sarcomas, but only 5% of the osteosarcomas occur in the jaws. Malignant lesions are known to quickly grow downward into the periodontal ligament (PDL) space, resulting in an irregular widening and destruction of the lamina dura. Often, root fractures can result in a similar radiographic appearance of the surrounding periodontium. We present a case series of 2 patients with vertical root fractures and 1 case of osteosarcoma of the jaw. Clinical and Radiographic Findings The 3 patients portrayed similar radiographic findings. Cone beam computed tomography (CBCT) images and panoramic radiography images revealed osseous defects resembling periodontal destruction, periradicular radiolucency, and irregular widening of the surrounding PDL space. Clinically, the 3 patients did not suffer from pain. However, the last of the three patients presented with tooth mobility. Differential or Definitive Interpretation Biopsy and histologic analysis revealed case #1 to have osteosarcoma and cases #2 and #3 to have a periodontal defect resulting from a root fracture. Discussion/Conclusions Localized swelling, with or without pain, is the characteristic feature of osteosarcoma. A purely osteolytic lesion demonstrates a radiolucency with “moth-eaten” or irregular borders that seem to infiltrate into the surrounding bone. Early-stage osteosarcoma of the jaw can also appear as symmetric widening of the PDL space. Therefore, when there is suspicion, biopsy should be performed to rule out malignancy.

Evaluation of sentinel lymph node biopsy after previous breast surgery for breast cancer: GATA study

AimSentinel lymph node (SLN) biopsy was recently recommended after prior breast tumour surgery and lymphadenectomy is not the gold standard anymore for nodal staging after a lesion's removal. The purpose of our study was to evaluate the good practices of use of SLN biopsy in this context. Patients and methodsFrom 2006 to 2012, 138 patients having undergone a surgical biopsy without prior diagnosis of an invasive carcinoma with a definitive histological analysis in favour of this diagnosis were included in a prospective observational multicentric study. Each patient had a nodal staging following SLN biopsy with subsequent systematic lymphadenectomy. ResultsThe detection rate of SLN was 85.5%. The average number of SLNs found was 1.9. The relative detection failure risk rate was multiplied by 4 in the event of an interval of less than 36 days between the SLN biopsy and the previous breast surgery, and by 9 in the event of using a single-tracer detection method. The false negative rate was 6.25%. The prevalence of metastatic axillary node involvement was 11.6%. In 69% of cases only the SLN was metastatic. The post-operative seroma rate was 19.5%. ConclusionPrevious conservative breast tumour surgery does not affect the accuracy of the SLN biopsy. A sufficient interval of greater than 36 days between the two operations could allow to improve the SLN detection rate, although further studies are needed to validate this statement. Clinical trial registration numberNCT00293865.

Epithelioid Sarcoma of the Penis: A Case Report

Epithelioid sarcoma of the penis is a slowly growing soft tissue neoplasm that rarely arises from the penis. The aim of this case is to describe this rare pathology and to underline the importance of differential diagnosis with benign diseases such as Peyronie's disease. We report the case of a 20-year-old man who referred the onset of a progressive left dorsolateral penile curvature (about 60°) started 3 years before. The patient was evaluated with two US examinations that revealed two sites of tunical thickening with normal hemodynamic evaluation. The physical examination demonstrated a dorsal fibrotic plaque of about 2.5 cm. A juvenile form of Peyronie's Disease was diagnosed, and the patient was scheduled for surgical treatment (plaque's incision/excision and grafting). Intraoperative appearance showed that the great part of the left cavernous body was substituted by a very tough tissue which deeply involved the erectile tissue; intraoperative frozen section was suspicious for mesenchymal epithelioid neoplasm. In order to obtain definitive histological analysis and collect proper informed consent, we preferred to proceed with our original project, applying a dual graft (buccal mucosa and allograft dermal matrix) to cover the wide excised area. The final histological report confirmed the diagnosis of epithelioid sarcoma. Postoperative CT and MRI, at 3 and 6 months from surgery, were negative for metastases. The patient underwent radical intervention after 6 months. Epithelioid sarcoma of the penis and Peyronie's Disease can present with similar clinical findings although they obviously entail a different clinical progress. Since the diagnosis of neoplasm can be established only by the pathologist on biopsy specimen, in cases of unusual clinical presentation of Peyronie's disease (especially in young men suffering from a fast-growing penile induration), an early histological assessment should be performed to avoid the possibility of misdiagnosis in case of this poor-prognosis disease and to assure the definitive diagnosis.

Extensive ossification of an intramuscular venous malformation in the submental region

We describe a 62-year-old male patient with an extensively ossified venous malformation within the mylohyoid muscle. Phleboliths and calcifications are characteristic of venous malformations, while massive ossification is rare. To our knowledge, no extensive ossified venous malformation within the mylohyoid muscle has been reported. Intramuscular vascular lesions occur with an incidence of 0.8 in 10, occurring in the head and neck region in 15% of cases. Most are venous malformations. The diagnosis is rarely made before surgery and requires a definitive histological analysis, as there are no pathognomonic clinical or radiographic findings, especially with extensive ossification. Spontaneous regression does not occur, and treatment must be based on aesthetic and functional disturbances. We reviewed the classification of vascular anomalies, focusing on differentiating between venous malformations and haemangiomas, which are frequently confused in the literature.

92 EX-VIVO ULTRANSONOGRAPHIC CONTROL OF RESECTION MARGIN DURING PARTIAL NEPHRECTOMY

Introduction & Objectives: Surgery remains the treatment of choice for localized renal cell neoplasia. While radical nephrectomy was long considered as gold standard, partial nephrectomy (PN) has widened its indications over the past twodecades and has shown oncological results equivalent to radical nephrectomy for small tumors. Moreover, it is considered superior to radical nephrectomy in terms of non-cancer related mortality. The role of negative surgical has been widely debated. Intraoperative frozen section analysis has been shown to be unreliable, expensive, time-consuming and not well correlated to final pathology. The goal of the present study was to assess the correlation of intraoperative exvivo ultrasonographic (US) evaluation of resection to definitive pathology in patients undergoing PN.Materials & Methods: An observational study was carried out in ours 2 institutions from February 2008 to October 2010. Patients undergoing PN for T1-T2 renal tumors were included. Ex vivo US evaluation was performed. Considering availability of US engine, not all consecutive eligible patients were included. PN was undertaken either by open surgery or laparoscopic access in a standardized technique. The minimal healthy tissue margin technique was applied. Once resected, the specimen was kept in a saline solution and US determination of tumor margins was performed. Sequential images were captured in order to evaluate the whole capsule.Results: Twenty-two patients (9 women, age 63±11 years[46-78]) were included in the present analysis. Open or laparoscopic PN was performed in 19 and 3 patients, respectively. Intraoperative ex-vivo US showed negative surgical in all cases except one, needing a complementary renal parenchyma resection. US duration ranged from 1 to 4 minutes, with a median time of 1 minute. Definitive histological analysis confirmed the presence of 3 angiomyolipoma, 15 clear cell carcinoma (11 pT1a,3 pT1b,1 pT2), 3 chromophobe carcinoma (1 pT1a,1 pT1b,1 pT2) and 1 pT1a type II papillary tumor. Mean tumor size was 3,4±2.1 cm [0,6-7,2]. Final pathology revealed R0 margins in all cases.Conclusions: Intraoperative ex-vivo US evaluation of resection in patients undergoing PN is feasible, time-efficient, well correlated to definitive pathological examination, and should be evaluated in further prospective trials.

Large-Muscle Endometriosis Involving the Adductor Tight Compartment: Case Report

Extrapelvic endometriosis is an uncommon condition but can involve nearly every organ, resulting in a wide range of clinical manifestations. Herein, we describe the case of a 45-year-old woman not a candidate for hormonal therapy who had cyclic pain in the left thigh associated with progressive impairment of walking ability. Clinical, instrumental, and laboratory data supported the diagnosis of endometriosis involving the adductor muscles compartment associated with ovarian endometriomas. Laparoscopic bilateral salpingo-oophorectomy and local wide excision in collaboration with an experienced orthopedic oncologist were performed, and definitive histologic analysis confirmed the diagnosis of endometriosis. The patient was pain-free at 6-month follow-up and demonstrated substantial improvement in ambulation and quality of life. Large-muscle endometriosis is a rare entity that can compromise musculoskeletal integrity and decrease quality of life. In this case, surgical excision in collaboration with an orthopedic oncologist was the cornerstone of treatment.

The surgical resection margin

In the treatment of cancer the fundamental surgical goal is to remove all local malignant disease and leave no residual malignant cells. Studies have demonstrated the benefit of achieving negative resection margins in terms of disease free local recurrence and overall survival. The surgical margins for Head & Neck cancer may vary widely depending on the site of disease. This variation reflects the biological and anatomical environment of the tumour site at macroscopic and microscopic levels. There is no accepted standard for the quantity of normal tissue to be removed and the effect of positive margins on recurrence rate appears to be considerably dependent on the site of the tumour. The extent of tumour volume resection is determined by the need for cancer control and the peri-operative, functional and aesthetic morbidity of the surgery. Resection margins are assessed intra-operatively by frozen section and retrospectively after definitive histological analysis of the resection specimen. There are limitations to this assessment. The margin may not be consistent in three dimensions and may be susceptible to errors in sampling and histological interpretation. Assigning the true excision margin may be difficult due to post-excision changes secondary to shrinkage and fixation. Local recurrence occurs even among tumours with extensive histological demonstration of adequate resection margins. Sites with significant recurrence rates after negative resection margins are oral cavity, submandibular region, tonsil and pharynx. Therefore, it is accepted that cancers at these sites require larger margins of excision than tumours elsewhere in the head and neck. Achieving the histologically adequate margin is insufficient to predict clinical outcome. Multiple parameters in the histological assessment have been developed and refined to predict outcome based on a number of variables including pattern of invasion, keratinisation, nuclear pleomorphism and mitotic rate. Recently molecular technology has been employed to provide a more objective assessment of the margins but these techniques are not yet validated. The current approaches to histological risk assessment and evaluation of the surgical margin in Head & Neck cancer and the limitations will be discussed.

The use of core biopsy imprint cytology in the ‘one-stop’ breast clinic

Aims The aims of this study were to evaluate the sensitivity, specificity; accuracy, usefulness and role of core biopsy imprint cytology (CBIC) in the one-stop breast clinic in a District General Hospital. Methods A retrospective study was made of symptomatic patients attending a district general hospital one-stop clinic over a five year period where a core biopsy had been performed and an imprint of the core had been made for cytological analysis. The performance of the technique was evaluated by comparing the results of CIBC with the definitive histological analysis of the core biopsy tissue. Results Over a five year period, imprints were made from 819 core biopsies. Adequate cellularity for cytological analysis was found in 94.8% (778/819) of the imprints. Out of the 778 lesions analysed, 432 were malignant (55.5%). The sensitivity, specificity, positive predictive value, negative predictive value and concordance were 97.7%, 94.2%, 93.1%, 98.1% and 95.5% respectively. Conclusion Core Biopsy Imprint Cytology is a rapid, reliable and accurate technique which enhances the known benefits of automated core biopsy. It allows core biopsies to be used successfully in the ‘one-stop’ clinic setting and obviates the need to use Fine Needle Aspiration Cytology (FNAC). When CBIC is used, there is a reduction in diagnostic waiting time (over core biopsy on its own) and an increase in diagnostic performance (over FNAC). This translates to an improvement in the management of patients with breast cancer through the earlier availability of the diagnosis and fewer out-patient appointments.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30–88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

Le prélèvement du ganglion sentinelle sous anesthésie locale ou comment s’affranchir des limites de l’analyse histologique peropératoire

The sentinel lymph node procedure has become the standard in the surgical management of localised breast cancer. However, it is submitted to the uncertainties of intraoperative examination. Indeed, intraoperative examination has three major disadvantages: the type of histological method (frozen section versus imprint cytology), the size of sentinel node metastasis (macro- versus micrometastases) and the time requested for this technique. All of these limits are responsible for secondary re-interventions to complete axillary lymph node dissection. Few medical teams have described a new surgical strategy to avoid these limits. They proposed the detection of the sentinel lymph node under local anaesthesia and to wait for the definitive histological analysis before carrying out lumpectomy and axillary lymphadenectomy if necessary under general anaesthesia. We realized a review of the literature on this new procedure to evaluate its feasibility and to assess the technical aspects.

Tratamiento quirúrgico de la displasia de alto grado en el esófago de Barrett

Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia. Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients. Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14). In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.

Rare breast neoplasms: is there any peculiar feature on magnetic resonance mammography?

The purpose of this study is to describe the semiological features of rare breast neoplasms at magnetic resonance mammography (MRM). Out of 468 MRMs of patients with a histological diagnosis of breast malignancy, 27 (5.7%) cases of rare breast neoplasms, confirmed by definitive histological analysis on surgical specimens, were selected: four (0.9%) intracystic papillary neoplasms, four (0.9%) intraductal papillary neoplasms, five (1.0%) invasive papillary neoplasms, two (0.4%) medullary carcinomas, seven (1.5%) mucinous carcinomas, three (0.6%) tubular carcinomas, one (0.2%) tubulo-lobular carcinoma and one (0.2%) desmoid tumour. Two radiologists evaluated the MRM images according to Fischer criteria and indicated a level of diagnostic suspicion. In particular, MRM lesion morphology and enhancement characteristics were analysed. No semiologic features of malignancy or peculiar appearances indicating rare breast neoplasm were identified. On the contrary, MRM appearance was nonspecific and often suggestive of probably benign (Breast Imaging Reporting and Data System-BI-RADS 3) (40%) or benign lesions (BI-RADS 2) (7.5%), or lesions were undetectable at MRM (BI-RADS 1) (7.5%). Frequently, rare breast neoplasms show low suspicious morphologic and kinetic patterns at MRM, and they are often classified as indeterminate lesions. This is probably due to their high grade of differentiation and their histological features.

Chondrocalcinosis

In this paper introduces a rare case of chondrocalcinosis of the temporomandibular joint secondary to hyperparathyroidism, diagnosed in a 64-year-old man. The patient complained of symptoms characterized by the presence of a swelling in the left pretragic preauricular region, accompanied by a limitation of the mandibular movements. Radiographic examinations suggested a diagnosis of synovial chondromatosis. Subsequently definitive histological analysis removed mass stated for a chondrocalcinosis of the left temporomandibular joint. The differential diagnosis is very hard, in this case it has been difficult for the rarity of the pathology described in literature; the exact diagnosis can be only formulated on histologic and citologic examination of the mass excised.

Microsurgical “testis-sparing” surgery for nonpalpable hypoechoic testicular lesions

Objectives With the increased use of trans-scrotal ultrasonography, the unexpected detection of nonpalpable hypoechoic testicular lesions has become more frequent. The different approaches vary from radical orchiectomy to simple ultrasound follow-up, but definitive guidelines do not yet exist about the management of these lesions. We report our series of patients with hypoechoic testicular lesions who underwent surgical exploration with the aid of an operating microscope. Methods A total of 7 patients were considered for microsurgical exploration of a nonpalpable hypoechoic testicular lesion from April 2003 to June 2005. The hospital records and ultrasound and operative reports were reviewed retrospectively. Results The side of the lesion was the left testis in 4 patients and the right testis in 3. The mean size of the hypoechoic area was 5.7 ± 4.6 mm (range 2.5 to 16). The microsurgical technique allowed us to identify and successfully excise the lesion in all patients. Intraoperative frozen section examination revealed a benign lesion in 6 cases and testicular intraepithelial neoplasia in 1. The patient with testicular intraepithelial neoplasia underwent radical orchiectomy. The definitive histologic analysis always confirmed the frozen section examination report. The patients were evaluated clinically and by ultrasonography for a mean follow-up of 15 months. No complications occurred. Conclusions Microsurgical exploration of the testis combined with frozen section examination represents a safe, effective, and reliable technique for evaluation of nonpalpable hypoechoic testicular lesions. This approach has significant advantages and should be considered in particular for patients with a solitary testis or presenting with bilateral lesions and wishing to father a child.

Traitement des kystes, tumeurs et pseudotumeurs bénignes des maxillaires

Although maxillary and mandibular cysts and benign tumours are very different with regard to their aetiology, diagnosis and evolution, they have in common to need surgical treatment as they are infected or so voluminous that they lead to dysfunction, dysmorphism and fracture risk. A first biopsy decision is a mistake because of the dissemination risk and the induced swelling reaction which could interfere with the future ablation and the definitive histological analysis. Of course, a reliable histological result takes advantage of a macroscopic, microscopic and ultrastructural analysis on the complete surgical piece. Also, the discovery of such a tumour will lead the clinician and the surgeon to a rigorous diagnosis estimation, taking into account both clinical and radiographic argues: the patient age, the lesion localisation, the evolution, the relation of the tumour with the teeth and cortical bone. This estimation will allow the surgeon to decide the best surgical preserving treatment before receiving the definitive histological result. In most of the cases, a benign tumour, even though voluminous, should be surgically removed taking care of the strong mucous and periosseous membrane. In few cases, tumoural extension in peripheral tissues imposes radical bone and muscular enlarged resection followed by a reconstructive method.

Frozen section examination of pelvic lymph nodes in endometrial and cervical cancer: accuracy in patients submitted to neoadjuvant treatments

Objective The aim of the study was to analyze the accuracy, the positive and negative predictive values, the specificity, and the sensitivity of the pelvic node frozen section examination in endometrial (EC) and cervical cancer (CC) patients. An accurate evaluation of the results of the frozen section examination in patients submitted to neoadjuvant treatments (chemotherapy and radiochemotherapy), and a comparison between specialist and general pathologist results were performed. Methods A total of 186 consecutive patients with endometrial [52 cases (27.9%)] and cervical [134 cases (72.1%)] cancer underwent surgery at our Department between January 2000 and September 2003. All patients underwent a systematic pelvic lymphadenectomy. While all definitive diagnosis were primarily performed or secondarily revised by the specialist pathologist, the frozen section examination was performed in 65 (35%) cases by the specialist pathologist and in 121 (65%) cases by a general pathologist. Results Two thousand seven hundred eighteen out of a total of 6710 pelvic lymph nodes, which underwent a definitive histological analysis, were also analyzed at intraoperative frozen section examination. In our series, we observed 10 false negative and five false positive cases. Six out of the 10 (60%) false negative cases and two out of the five (40%) false positive were found in the neoadjuvant treated cervical cancer patients. In this subgroup, five out the six (83.3%) false negative and the two false positive diagnoses were made by the general pathologist, while the specialist pathologist registered only one false negative diagnosis. Conclusion Intraoperative examination of pelvic lymph nodes during surgery for endometrial and cervical cancer can be considered a safe procedure in the presence of an expert gynecologic oncological team, and can be safely performed in patients submitted to neoadjuvant treatments.

Histological findings in surgical specimens after core biopsy of the breast

Pathological changes induced by needling procedures found in breast surgical specimens are rare but can induce misinterpretation or compromise the definitive histological analysis. These abnormal findings depend on the interval between the core biopsy and excision. Early findings are local haemorrhage, disrupted tissue and epithelial cell displacement, whereas, fibrosis, fat necrosis and inflammatory reaction are observed later in time. The radiologists must be aware of these histological pitfalls and must consider the benefits of their core biopsies (indications, surgeon's question, number of samples).