Disease-free Resection Margins Research Articles

486 Are Surgical Resection Margins A Risk Factor for Crohn’s Disease Recurrence?

Abstract Despite advances in treatment, Crohn’s disease (CD) recurrence is still high. Various factors correlated with recurrence are studied however, there is no consensus regarding the importance of disease-free resection margins. Our goal was to ascertain whether surgical margins predict recurrence rates of CD and identify other potential factors correlated with recurrence. This is a retrospective cohort study on patients who have had a colonic resection for CD from December 2016 to November 2019. Demographics, surgical procedure details, disease activity at resection margins and number of readmissions were recorded. Clinical recurrence was defined as readmission to hospital for a Crohn’s related flare-up within 12 months of surgical resection. Positive disease activity at the resection margins was defined histologically. We compared the readmission rate between all categories. Of the 55 patients identified, 52 (22 female) were included. Of these, seven were readmitted, six are smokers, 19 had mesenteric excision and 33 had Crohn’s positive resection margins. Chi-squared tests showed there are no significant correlations between patient and procedure variables, and readmission rates (p > 0.05). We have not found sufficient evidence to conclude that a disease-free resection margin post colonic resection or any other patient-related factors are associated with decreased recurrence of CD.

Robotic Versus Open Liver Resection in Hepatocarcinoma: Surgical and Oncological Outcomes.

Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited. We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma. No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203). The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

A randomized phase II clinical trial of dendritic cell vaccination following complete resection of colon cancer liver metastasis

Surgically resectable synchronic and metachronic liver metastases of colon cancer have high risk of relapse in spite of standard-of-care neoadjuvant and adjuvant chemotherapy regimens. Dendritic cell vaccines loaded with autologous tumor lysates were tested for their potential to avoid or delay disease relapses (NCT01348256). Patients with surgically amenable liver metastasis of colon adenocarcinoma (n = 19) were included and underwent neoadjuvant chemotherapy, surgery and adjuvant chemotherapy. Fifteen patients with disease-free resection margins were randomized 1:1 to receive two courses of four daily doses of dendritic cell intradermal vaccinations versus observation. The trial had been originally designed to include 56 patients but was curtailed due to budgetary restrictions. Follow-up of the patients indicates a clear tendency to fewer and later relapses in the vaccine arm (median disease free survival –DFS-) 25.26 months, 95% CI 8.74-n.r) versus observation arm (median DFS 9.53 months, 95% CI 5.32–18.88).

Acetic Acid and Lugol Tests in Colposcopic Assessment and Surgical Management of Cervical Intraepithelial Lesions

Colposcopy is used predominantly to evaluate women with abnormal Babes - Papanicolaou test results, to locate abnormal appearing epithelium and to direct biopsies as well as the surgical management, in areas in which cervical intraepithelial neoplasia is suspected. The purpose of our study is to analyze the value of acetic acid and Lugol tests in the colposcopic assessment and surgical management of cervical intraepithelial neoplasia, and to evaluate the patient outcome after uterine cervix surgery, by postoperative colposcopic determination of the disease-free resection margins

Methylene Blue Test in Assessing Disease Free Margins in Lingual Carcinoma Resection

Lingual squamous cell carcinoma is one of the most frequent localization of the oral carcinomas. The tongue neoplasia represents nearly 40% of the oral carcinomas. Recent studies showed an increasing trend of lingual carcinoma in young patients. Several staining tests have been described to early detect the disease. After detection, disease free margins resection will increase the survival rate. This study aims to analyze the methylene blue staining test in achieving disease free resection margins in lingual squamous cell carcinoma.

Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases

BackgroundHepatocellular carcinoma has a growing incidence worldwide, and represents a leading cause of death in patients with cirrhosis. Nowadays, minimally invasive approaches are spreading in every field of surgery and in liver surgery as well. Materials and methodsWe retrospectively reviewed demographics, clinical, and pathologic characteristics and short-term outcomes of patients who had undergone minimally invasive resections for hepatocellular carcinoma at our institution between June 2012 and May 2016. ResultsNo significant differences in demographics and comorbidities were found between patients in the laparoscopic (n = 24) and robotic (n = 22) groups, except for the rates of cirrhotic patients (91.7% and 68.2%, respectively, P = 0.046). Perioperative data analysis showed that the operative time (mean, 211 and 318 min, respectively, P < 0.001) was the only parameter in favor of laparoscopy. Conversely, robotic-assisted resections were related to less Clavien I-II postoperative complications (22 cases versus 13 cases; P = 0.03). As regards resection margins, the two groups were similar with no statistically significant differences in rates of disease-free resection margins. ConclusionsA modern hepatobiliary center should offer both open and minimally invasive approaches to liver disease to provide the best care for each patient, according to the individual comorbidities, risk factors, and personal quality of life expectations. Our results show that the robotic approach is a reliable tool for accurate oncologic surgery, comparable to the laparoscopic approach. Robotic surgery also allows the surgeon to safely approach liver segments that are difficult to resect in laparoscopy, namely segments I-VII-VIII.

Extra-abdominal fibromatosis: Clinical and therapeutic considerations based on an illustrative case.

Extra-abdominal fibromatosis is a rare, benign disease that is characterized by a local but not metastatic invasivity. In particular, desmoid tumors of the chest wall represent only 10-20% of all deep fibromatoses. The disease occurs more often in females and has a higher incidence between puberty and the fourth decade of life. The present study reports the case of a 34-year-old female who came to our attention due to a voluminous mass in the right subcostal region. The magnetic resonance imaging of the upper abdomen confirmed the presence of a neoplasm localized between the anterior hepatic margin and the right costal plane. Through a right subcostal laparotomy, the voluminous 95×45×94-mm neoplasm was excised. Histological examination showed evidence consistent with extra-abdominal fibromatosis. The patient has not shown recurrence of the disease for 4 years since the surgery. Overall, radical surgery with disease-free resection margins is the prime treatment option for this disease. Other therapeutic options, such as radiotherapy, hormonal therapy or treatment with imatinib mesylate, can also be considered in certain cases.

Intraoperative Ultrasound in the Treatment of Breast Cancer.

Purpose: The aim of this study was to investigate the value of intraoperative ultrasound in breast-conserving operations and to compare it with standard procedures. Methods: For this purpose 307 women with palpable breast cancers and 116 patients with non-palpable breast cancers were compared retrospectively. In the group with palpable breast cancers 177 patients were treated by US-guided operations and 130 patients underwent palpation-guided breast-conserving operations. As primary outcomes, the resection margins and the rate of re-operations were evaluated. Results: With regard to disease-free resection margins, intraoperative ultrasound was significantly superior to palpation alone. In the group of patients in whom the tumours were extirpated with the help of palpation, R1 resections were observed almost twice as often (16.9 %) as in the US-guided group (8.5 %). In the group with non-palpable breast cancers, intraoperative ultrasound was employed in 61 patients. As a control, 43 cases were evaluated in whom the breast-conserving operation was performed after wire marking. In this group US-guided tumour removal proved to be superior to that after wire marking for tumours that did not exhibit any intraductal components. Otherwise the redo resection rate was reduced by use of ultrasound. Furthermore, the surgeon was able by means of intraoperative ultrasound to identify "problematic" margins and to excise them in the same sitting. Conclusions: The US-guided, breast-conserving operations led to a lower rate of R1 resections and redo operations in comparison to operations with palpation alone or those after wire marking.

KRAS mutation analysis in ductal carcinoma of the pancreas; prognostic implications in elderly patients

Ductal adenocarcinoma of the pancreas is one of the highly aggressive tumors; the overall survival rate of less than 6% is probably due to biological rapid development and late tumor stage at the time of diagnosis [1]. Recently a progression model suggested that infiltrating pancreatic cancer arises from pancreatic duct lesions that shows to harbour activating KRAS point mutation [2]. Since 1988 KRAS is the most significant genetic alteration in pancreatic cancer and is considered as an early event in tumor progression [3]. In the present study we investigated a selected population of patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma, with disease free resection margins, in order to evaluate whether a specific mutation could be related to a worst median survival time or onset of tumor recurrence and metastatisation.

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

Natural History of Pediatric Crohn Disease T he natural history of pediatric Crohn disease (CD) remains unpredictable, although some trends are observed that differentiate children from adults. Pediatric CD often presents with more severe disease and more frequent need for immunosuppressive therapy (1). Growth failure, present in 15% to 20% of patients, is a unique characteristic of pediatric CD not seen in adult-onset CD (2). Colonic disease distribution is common in patients younger than 10 years (1). The need for surgical intervention also varies, with 1 study reporting the actuarial risk of having undergone an extensive intestinal resection being 48.6% 5% in a childhood-onset group versus 14.6% 2% in the adult-onset group (P< 0.001) (1). More recently, long-term follow-up of patients enrolled in pediatric registries shows a cumulative surgical rate of 14% to 17% at 5 years and 28% at 10 years (3,4).

Systematic Review of Prognostic Factors Related to Overall Survival in Patients with Stage IV Colorectal Cancer and Unresectable Metastases

With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision. A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review. Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases. Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.

Unusual Metastases in Renal Cell Carcinoma: A Single Institution Experience and Review of Literature.

BackgroundTo report location and management of atypical metastases from renal cell carcinoma (RCC) in the Instituto Nacional de Ciencias Medicas e Investigacion Salvador Zubiran (INCMNSZ) in Mexico City.MethodsBetween 1987 to 2009, 545 patients with RCC were retrospectively identified at the INCMNSZ. Patients with unusual metastases confirmed by histopathology were analyzed. Epidemiological, clinical, diagnosis, treatment and outcome data were reviewed.ResultsSixty patients developed 98 unusual metastases secondary to RCC. The group was comprised of 35 men (58.3%), with a median age of 60 years at diagnosis. Metachronous unusual metastases with primary renal cancer were observed in 37 individuals (61.7%). Median time from primary RCC diagnosis to the first unusual metastasis was 16.5 months. Median survival from diagnosis of the first unusual metastasis to death was 5.0 months (CI 95%: 2.8-7.2 months). Patients with an initial solitary metastatic lesion in an unusual site (28.3%) had a better survival compared to patients who primarily presented with multiple metastases, 17.0 (CI 95%: 6.1-27.9) Vs 3.0 months (CI 95%: 0.9-5.1), p = 0.001. Unusual metastasis resection (21 patients) improved survival, 25.0 (CI 95%: 5.1-44.9) Vs 3.0 months (CI 95%: 0.8-5.2), p < 0.0001. No survival difference was observed between localization of unsual metastases (p = 0.72).ConclusionsIn patients with advanced RCC we suggest an individual diagnostic and surgical approach to achieve complete resection with disease-free margins, even in the presence of unusual metastatic sites, multifocality, or history of metastasectomy. These strategy might provide not only palliation for symptoms, but an opportunity for meaningful disease free and overall survival.

Plexitis as a predictive factor of early postoperative clinical recurrence in Crohn’s disease

Background and aims:A previous study suggested that the presence of myenteric plexitis in the proximal resection margins could be predictive of early endoscopic recurrence after ileocolonic or ileal resection for...

S1107 Plexitis As Predictive Factor of Early Postoperative Clinical Recurrence in Crohn's Disease

A previous study suggested that the presence of myenteric plexitis in the proximal resection margins could be predictive of early endoscopic recurrence after ileocolonic or ileal resection for Crohn's disease (CD). The aim of the present study was to assess the predictive value of plexitis for early clinical CD recurrence.All consecutive patients with ileocolonic or ileal resection for active CD in Lariboisière Hospital (Paris) between 1995 and 2006 were included. Clinical, surgical, histological and follow-up data were extracted from medical charts. Early clinical recurrence was defined as the reappearance of CD clinical manifestations requiring a specific treatment within 2 years postsurgery. The proximal resection margin was analysed using haematein eosin saffron (HES) staining and immunochemistry targeting mastocytes (anti-CD117 antibody) and lymphocytes (anti-CD3 antibody). Eosinophils were detected by HES staining. Ten cases of ileocolonic resections for caecal carcinoma served as controls.Data were available from 171 postoperative follow-up periods in 164 patients with CD. Early clinical recurrence of CD occurred in 28.1%. In multivariate analysis, factors associated with postoperative recurrence were active smoking (hazard ratio (HR) = 1.94; 95% CI 1.06 to 3.60; p = 0.033), submucosal plexitis with >or=3 mastocytes (HR = 1.87; 95% CI 1.00 to 3.46; p = 0.048) and a disease-free resection margin <5 cm (HR = 0.52; 95% CI 0.27 to 1.02; p = 0.059).Submucosal plexitis is associated with early clinical recurrence and could be taken into account in studies searching for new treatment strategies in the immediate postoperative period.

Total laparoscopic left lateral sectionectomy performed in a child with benign liver mass

Despite the increasing number of recent reports on laparoscopic liver resection in adults, there are only rare reports on such a procedure being performed in children. The authors report here on a total laparoscopic left lateral sectionectomy that was performed in a 5-year-old girl who had a cystic tumor of the liver. The operative time was 150 minutes, the estimated blood loss was about 100 mL, and no intraoperative transfusion was required. The patient was discharged on postoperative day 11 without any significant complications. The postoperative pathology of the specimen confirmed it to be a mesenchymal hamartoma of the liver with a disease-free resection margin. This case demonstrates that laparoscopic liver resection can be a safe and feasible operative procedure for the pediatric patient with liver disease.

Valor do dilatador higroscópico para visualização do canal endocervical na conização com cirurgia de alta freqüência

OBJETIVO: avaliar a eficácia do dilatador higroscópico para auxiliar o exame colposcópico do canal endocervical, em pacientes com lesão de alto grau e colposcopia insatisfatória. MÉTODOS: estudo prospectivo no qual foram incluídas 62 pacientes com exames colposcópicos insatisfatórios e citologia sugestiva de lesão de alto grau. Todas foram submetidas à dilatação do canal por meio de dilatador higroscópico. Após a dilatação os novos achados colposcópicos foram registrados e procedeu-se à conização por cirurgia de alta freqüência (CAF). Comparamos a incidência de comprometimento neoplásico das margens cirúrgicas operatórias entre as pacientes que modificaram o exame para satisfatório e aquelas que persistiram insatisfatórios. Para comparação entre a incidência de margens comprometidas e a incidência de doença residual, foram utilizados dois grupos controle retrospectivos: grupo GinSat (n=35): pacientes com colposcopias insatisfatórias; grupo GSat (n=38): pacientes com colposcopias satisfatórias e atipia de localização endocervical. RESULTADOS: em 80,6% dos casos a visão colposcópica após a dilatação foi satisfatória. Destes, 80,4% apresentaram margens livres de doença. A incidência de margens livres nas pacientes com colposcopias insatisfatórias persistentes após a dilatação foi de 36,3%. O comprometimento das margens cirúrgicas ocorreu em 28,0% no grupo submetido à dilatação, em 28,5% dos casos no grupo GinSat e em 31,5% no grupo GSat. No acompanhamento verificou-se a incidência de 7,5% de doença residual nas pacientes submetidas à dilatação. No grupo GinSat a incidência de doença residual foi de 28,6% e no grupo GSat foi de 28,9%. CONCLUSÃO: o uso do dilatador higroscópico facilitou a visualização de lesões de difícil acesso ao exame colposcópico, permitindo diminuir a porcentagem de doença residual em pacientes com colposcopias insatisfatórias submetidas à conização por cirurgia de alta freqüência.

Management of recurrent Crohn's disease

After partial small bowel or colonic resection for Crohn's disease, recurrence frequently follows. Within half a year 60–73% of patients have endoscopic recurrence. This percentage increases substantially in as time passes. Symptoms will not always be present when endoscopic lesions are detected.The etiology of recurrent Crohn's disease is unknown. Some studies show that initial complications or extra-intestinal manifestations are more frequently seen in patients with a recurrence. The recurrent pattern of the lesions is also comparable to the pre-surgical state. The length of recurrent ileal inflammation after ileocolonic resection correlates with the pre-surgical extent of the disease. Some investigators have found electron-microscopic lesions in histologically unaffected resection margins demonstrating the presence of lesions. Luminal factors probably plays an important role as bypassing an anastomosis prevents an endoscopic recurrence.Some factors are considered to be important to increase the chance of a recurrence. A more aggressive disease may lead to earlier recurrence. Onset of disease at a younger age, a short pre-operative time, and localization, might play an important role. Smoking certainly influences the clinical, endoscopic and surgical recurrence. The number of daily cigarettes smoked and the duration of smoking, significantly increases the risk of recurrence. The type of surgery (kind of anastomosis, multiple anastomoses, length of resection) are not important. A longer macroscopic disease-free resection margin or presence of granuloma does not influence the recurrence rate. Also, the presence of microscopic disease at the margin is not important.Prevention of recurrent disease can be provided by administrating sulphasalazine, 5-aminosalicylic acid or metronidazole. For this reason, prophylactic medication after surgical resection seems appropriate.

For patients with dukes' B (TNM stage II) colorectal carcinoma, examination of six or fewer lymph nodes is Related to poor prognosis

BACKGROUND Lymph node status is pivotal to the staging of colorectal carcinoma. The diagnosis of a lymph node negative tumor should imply a good prognosis; however, the outcomes for Dukes' B (TNM Stage II) patients remain variable, possibly in part due to understaging. The aim of this study was to determine whether examining a specified minimum number of lymph nodes using conventional techniques would eliminate the risk of understaging and thus have an effect on prognosis. METHODS Data on patients who underwent surgery for colorectal carcinoma at a single institution between 1985 and 1990 were reviewed. Patients with Dukes' B (TNM Stage II) or C (TNM Stage III) tumors and histologically confirmed disease-free resection margins who were treated with curative intent were included. Correlations among variables were assessed using the chi-square test, and survival comparisons were made using Kaplan-Meier curves and the log rank test. Multivariate analysis was performed using a Cox regression model. RESULTS Dukes' B (TNM Stage II) patients with ≤6 lymph nodes examined had significantly poorer overall survival than those with ≥7 lymph nodes examined (P = 0.0014). Such a significant difference was not observed among Dukes' C (TNM Stage III) patients (P = 0.7). Survival of Dukes' C patients was significantly worse compared with that of Dukes' B patients overall and Dukes' B patients with ≥7 lymph nodes examined (P < 0.0001). There was no significant difference in survival between Dukes' C and Dukes' B patients with ≤6 lymph nodes examined (P = 0.02). The number of examined lymph nodes was the only significant parameter correlated with survival in the multivariate analysis (P = 0.002). CONCLUSIONS Because Dukes' B patients with ≤6 examined lymph nodes have poorer outcomes than those with a higher number examined (probably due to understaging), the total number of examined lymph nodes should always be reported. Cancer 1998;83:666-672. © 1998 American Cancer Society.

For patients with dukes' B (TNM stage II) colorectal carcinoma, examination of six or fewer lymph nodes is Related to poor prognosis

Lymph node status is pivotal to the staging of colorectal carcinoma. The diagnosis of a lymph node negative tumor should imply a good prognosis; however, the outcomes for Dukes' B (TNM Stage II) patients remain variable, possibly in part due to understaging. The aim of this study was to determine whether examining a specified minimum number of lymph nodes using conventional techniques would eliminate the risk of understaging and thus have an effect on prognosis. Data on patients who underwent surgery for colorectal carcinoma at a single institution between 1985 and 1990 were reviewed. Patients with Dukes' B (TNM Stage II) or C (TNM Stage III) tumors and histologically confirmed disease-free resection margins who were treated with curative intent were included. Correlations among variables were assessed using the chi-square test, and survival comparisons were made using Kaplan-Meier curves and the log rank test. Multivariate analysis was performed using a Cox regression model. Dukes' B (TNM Stage II) patients with < or =6 lymph nodes examined had significantly poorer overall survival than those with > or =7 lymph nodes examined (P = 0.0014). Such a significant difference was not observed among Dukes' C (TNM Stage III) patients (P = 0.7). Survival of Dukes' C patients was significantly worse compared with that of Dukes' B patients overall and Dukes' B patients with > or =7 lymph nodes examined (P < 0.0001). There was no significant difference in survival between Dukes' C and Dukes' B patients with < or =6 lymph nodes examined (P = 0.02). The number of examined lymph nodes was the only significant parameter correlated with survival in the multivariate analysis (P = 0.002). Because Dukes' B patients with < or =6 examined lymph nodes have poorer outcomes than those with a higher number examined (probably due to understaging), the total number of examined lymph nodes should always be reported.

Integrated Radiosurgical Treatment of Resectable Pancreatic Head Carcinoma

Thirty-six patients with pancreatic head carcinoma entered a protocol, but only 20 were suitable for resection and evaluation of long-term survival. They were nine males and 11 females, with a mean age of 64.3 years. Following surgical resection, 10 Gy was delivered to the tumor bed intraoperatively. Postoperative radiotherapy was performed 4-6 weeks after surgery: patients were treated with 50.4 Gy (1.8 Gy/day, 5 days/week) to the tumor and nodal bed. Since 1991, 10 patients have also received preoperative short-course radiotherapy (5 Gy) of the liver and pancreas. Postoperative morbidity was 25%; two postoperative deaths were observed in patients with locally advanced neoplasms, in whom a vascular resection was also performed. Only 14 patients started postoperative radiotherapy, which was interrupted in two cases. At present, 14 patients are dead and four are alive and disease free. The local recurrence rate was 11.1% and distant metastases were observed in 66.7% of cases. The median actuarial survival was 11.9 months, but it was 18.5 months in patients with disease-free resection margins. A significantly better survival was also observed in patients submitted to short-course preoperative radiotherapy. These preliminary results show that intraoperative and perioperative radiotherapy is feasible and may improve local control of disease. Unfortunately, these results are not matched by a significant improvement in survival due to the high incidence of intraabdominal metastases. Thus, new therapeutic modalities, including preoperative radiotherapy (with or without chemotherapy), should be tested.