Distance Of Extension Research Articles

Determining optimal clinical target volume margins based on microscopic extracapsular extension of metastatic nodes in patients with non-small-cell lung cancer after chemotherapy or chemotherapy combined with immunotherapy

BackgroundNo standard has been established for the clinical target volume (CTV) margins of lymph nodes (LNs) in patients with non-small-cell lung cancer (NSCLC) receiving chemotherapy or chemotherapy combined with immunotherapy followed by radiotherapy. This study aimed to discuss the CTV range of NSCLC after chemotherapy or chemotherapy combined with immunotherapy by observing the microscopic extent of tumor spread beyond the LN capsule.MethodsWe retrospectively analyzed the data of 240 patients with stage II and III NSCLC who underwent surgery without neoadjuvant therapy, with neoadjuvant chemotherapy (NAC), or with NAC combined with immunotherapy (NACI). We measured the maximal distance of extracapsular extension (ECE) using a digital microscope, analyzed the correlation between clinicopathological features and ECE distance, and determined the CTV margins of metastatic LN under different treatment methods.ResultsThe ECE distance differed significantly among the three groups (p < 0.001). We determined appropriate margin widths based on a 5% error risk as 3.00, 2.30, and 1.40 mm for direct surgery, NAC, and NACI, respectively. Multivariate analysis revealed that the ECE of metastatic LN correlated with the treatment methods and LN size.ConclusionThe existing CTV delineation standards may increase the radiation toxicity of patients. We believe that different CTV margins should be used for LN in patients with NSCLC receiving different treatments. To ensure 95% coverage of ECE, the gross tumor volume of untreated, chemotherapy-treated, and chemotherapy combined with immunotherapy-treated patients should be expanded by 3.00, 2.30, and 1.40 mm, respectively, to obtain the CTV.

Nose tip defect reconstruction with a modified extended Rintala flap: A case report.

Nose tip defect reconstruction with a modified extended Rintala flap: A case report.

The Impact of Various LED Light Spectra on Tomato Preservation

Major losses of fresh tomatoes happen during post-harvest storage due to prompt senescence and diseases. The aim of the research was to evaluate the effects of different spectra of LED lights on the post-harvest preservation of ascorbic acid, lycopene, and total soluble solids, the weight and size of tomato fruits, as well as to determine the optimal exposure time and distance of irradiation and extension of shelf-life. Therefore, experiments were carried out in a climate chamber with shelves equipped with three different light spectra: red light-emitting diodes, red–blue–white light-emitting diodes, and ultraviolet-light-emitting diodes. Light treatment had a certain positive effect on the firmness, size, and mass of samples. Thus, tomato fruits (Panekra) exposed to the spectra of LED lights demonstrated a better quality of firmness and mass compared to the control samples (non-preserved) of tomatoes. The treatments with RL significantly improved the concentration of lycopene than FL and UV-LED lights, although the highest concentration of lycopene was observed in the control samples for the first 7 days of the storage. After 21 days, the ascorbic acid content in the red spectrum was found to be much higher than in the other two spectra and control samples, coming in at about 1.8 mg/100 mL compared to 1.0 mg/100 mL for the control samples. Total soluble solids also increased significantly after preservation, rising from 3.9 °Brix in the control samples to roughly 7.3 °Brix in samples preserved using the full spectrum after 21 days. Overall, the results of the study demonstrated that tomato preservation using the investigated techniques induced lycopene concentration, ascorbic acid, and total soluble solids concentrations. The results derived from this study provide highly useful information in the field of post-harvest preservation.

Delineating the Subarachnoid Space in the Adult Lumbosacral Spine Using Computed Tomographic Myelography: An Aid for Clinical Target Volume Delineation in Craniospinal Irradiation

PurposeOur aim was to characterize the patterns of cerebrospinal fluid (CSF) extension in the lumbosacral spine using computed tomography (CT) myelograms to provide an evidence base for clinical target volume (CTV) definition in adults receiving craniospinal irradiation. Methods and MaterialsThis was a retrospective analysis of diagnostic CT lumbar myelograms performed in 30 patients between the ages of 22 and 50. Lateral extension of CSF beyond the thecal sac was measured along each lumbar and sacral nerve root to the nearest millimeter, as was the distance of inferior extension of CSF beyond the caudal end of the thecal sac. Each patient's lateral and inferior CSF extensions were mapped onto a standardized CT data set to create a model target volume in the lumbosacral spine that would contain the aggregate observed CSF distributions from the analyzed CT myelograms. The median extension distances, interquartile ranges, and 90th percentile for distance at each level were calculated. ResultsThe median lateral extension of CSF along nerve roots beyond the thecal sac—as measured perpendicular to the longitudinal axis—increased from 0 mm (interquartile range [IQR], 0-4 mm) at L1 to 8 mm (IQR, 6-12 mm) at S1 and 0 mm (IQR, 0-0 mm) at S4. The 90th percentile ranged from 5 to 14 mm laterally, with a pattern partially extending into the S1 and S2 sacral foramen. Median CSF extension inferior to the caudal sac was 5 mm (IQR, 2-8 mm), with 90% of patients within 12 mm. An atlas was generated to guide CTV delineation for highly conformal radiation techniques. ConclusionThese results provide information on patterns of CSF extension in the lumbosacral spine of adults and can serve as a model for CTV guidelines that balance comprehensive coverage of the CSF compartment while minimizing the dose to nontarget tissues.

Prognostic factors and nomogram prediction of survival probability in primary spinal cord astrocytoma patients.

Knowledge on the management of spinal cord astrocytoma (SCA) remains scarce. Here, the authors constructed and validated a predictive nomogram, often used for individualized prognosis and evaluations, to estimate cancer-specific survival (CSS) and overall survival (OS) for patients with SCA. Epidemiological characteristics were compared between low-grade SCA (LGSCA) and high-grade SCA (HGSCA) patients from the Surveillance, Epidemiology, and End Results (SEER) database. Risk factors for CSS and OS were determined using univariate and multivariate analyses and Kaplan-Meier curves. A nomogram was developed to individually predict the 3-, 5-, and 10-year CSS and OS rates. The clinical usefulness of the nomogram was assessed using calibration plots, the concordance index (C-index), and time-dependent receiver operating characteristic curves. A total of 468 LGSCA and 165 HGSCA patients were eligible for inclusion. LGSCA and HGSCA patients demonstrated differences in age, tumor extension, insurance status, adjuvant treatment, and survival. Multivariate analysis demonstrated that in the LGSCA group, tumor extension, surgery type, and adjuvant therapy were individually associated with CSS. The distance of tumor extension and WHO grade were individually associated with CSS in the HGSCA group. The prognostic variables were further demonstrated using the Kaplan-Meier method, which also suggested that adjuvant treatment provided no advantage to HGSCA patients. A nomogram was constructed, and the C-index for CSS was 0.84 by internal validation (95% CI 0.79-0.90). This research suggests that the distance of tumor extension, type of surgery, and adjuvant therapy are significant risk factors for CSS using multivariate analysis in the LGSCA group. Adjuvant treatment provided no advantages for CSS or OS in patients with HGSCAs. The nomogram may be clinically useful to healthcare providers.

Microscopic examination of striation spacing during ductile crack growth in Fe-3wt%Si single-crystalline thin plates in air and hydrogen

Abstract Microscopic features of crack growth in thin plates of single-crystalline Fe-3wt%Si alloy in both air and hydrogen environments were investigated by electron channeling contrast imaging (ECCI), electron backscattering diffraction (EBSD), as well as scanning electron microscopy fractography. The goal was to elucidate the discontinuous crack growth as well as the constant unit distance of crack extension (striation spacing). Center-cracked specimens were tested under a sustained load in a hydrogen environment, while they were under continuous stretching in the air environment. The following results were obtained. (1) Striation is formed by extensive slips emitted from the crack tip, mainly contributed from specific ( 1 1 ‾ 2 )[ 1 ‾ 11 ] and ( 1 ‾ 12 )[ 1 ‾ 1 1 ‾ ] slip systems. The discontinuous crack growth is mainly caused by interaction of the crack and ( 1 1 ‾ 2 )[ 1 ‾ 11 ] and ( 1 ‾ 12 )[ 1 ‾ 1 1 ‾ ] slip bands/cell walls formed ahead of the crack tip. These slip bands/cells show that the spacing between slip bands/cells is constant and independent of the crack length. Hence, the striation spacing is the same as that of the slip bands/cells ahead of the crack tip. (2) Hydrogen may affect the slip behavior by reducing the spacing between slip bands/cells ahead of the crack tip compared to that in the air environment.

Bioclimatic distance and performance of apical shoot extension: Disentangling the role of growth rate and duration in ecotypic differentiation

Under the same environmental conditions, southern and northern populations of temperate and boreal ecosystems exhibit different growth performance. However, which growth trait drives this difference is still unresolved. This study aimed to disentangle the effect of duration and rate of growth on shoot extension of five black spruce [Picea mariana (Mill.)] populations originating from a latitudinal gradient in Quebec, Canada, and growing in a common garden at the southern border of the boreal forest to simulate warming conditions. Bud phenology was monitored weekly during the growing seasons 2017–2019, and shoot length was recorded in autumn, representing annual growth of the primary meristem. Populations originating from the colder sites showed a lower annual shoot increment compared to those originating from the warmer sites. Despite similar durations of bud phenology, the period of shoot extension occurred between the beginning of June and the beginning of July and was longer in the provenances originating from the colder sites. The period of shoot extension, on average, was shortened by 0.9 days for each degree Celsius of increase in annual mean temperature of the site of origin. Moreover, the populations originating from warmer sites showed higher growth rates, which increased by 0.1 cm day−1 for each degree Celsius of increase in the annual mean temperature of the site of origin. Our results confirmed ecotypic variation in growth performance among black spruce populations and demonstrated that differences in shoot length are related to both rate and duration of growth. In the context of a warming climate, northern populations may be unable to reach the current growth performance of southern ones because of their adaptations to harsh local conditions and low intrinsic growth rates.

Additional value of MRI-detected EMVI scoring system in rectal cancer: applicability in predicting synchronous metastasis.

Extramural vascular invasion (EMVI) has been recommended as an independent prognostic factor for poor overall survival rate in rectal cancer and can be used as a potential biomarker. Early prediction of prevalence of synchronous metastasis can elevate the disease-free survival rate. We aimed to evaluate the magnetic resonance imaging (MRI)-detected EMVI (mrEMVI) scoring system in predicting distant metastasis in T3 rectal cancer. Patients with postoperative histopathologically confirmed T3 rectal cancer without previous treatment from July 2014 to December 2015 were enrolled in this study. Two blinded radiologists evaluated mrEMVI status. mrEMVI was categorized as EMVI-positive or EMVI-negative in T2-weighted images using an mrEMVI scoring system. The results, along with other clinical characteristics (age, sex, tumor location, MRI-detected distance of mesorectal extension, lymphatic invasion, perineural invasion, mrEMVI score, and carcinoembryonic antigen [CEA]), were then correlated with synchronous metastases to determine the risk factors using univariate and multivariate analysis. Of 180 patients, 38 were confirmed to be mrEMVI-positive, 142 mrEMVI-negative. There were 34 patients with synchronous metastasis, of whom 25 were mrEMVI-positive and 9 were mrEMVI-negative. Three factors were significantly associated with synchronous metastasis: mrEMVI (p = 0.001; odds ratio = 8.665), histopathologic lymphatic invasion (p = 0.001; odds ratio = 12.940), and preoperative CEA (p = 0.026; odds ratio = 4.124). mrEMVI score 4 was more likely for synchronous metastasis (p = 0.044; odds ratio = 9.429) than mrEMVI score 3 in rectal cancer. mrEMVI positivity is an independent risk factor for synchronous distant metastasis in rectal cancer. mrEMVI score 4 is a stronger risk factor for synchronous metastasis than mrEMVI score 3 in rectal cancer.

Study on microscopic marginal extensions of malignant liver tumors based on tumor types and ultrasonic characteristics

Objective To study the relationships between microscopic marginal extensions and tumor types, and ultrasonic characteristics of malignant liver tumors. Methods Two-dimensional ultrasonography, contrast-enhanced ultrasonography and ultrasound-guided biopsy of hepatic tumors and surrounding hepatic tissues were performed in 78 patients with malignant liver tumor. Pathological microscopic extensions were observed after hematoxylin-eosin staining of biopsy specimens. Results The microscopic marginal extension rates of hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and metastatic liver cancer (MLC) were 62.5%(30/48), 87.5%(7/8), and 91.0% (20/22), respectively. For tumors with well-defined and poorly-defined two-dimensional ultrasound boundary, microscopic marginal extension rates were 50%(14/28), and 86%(43/50). Tumor type and two-dimensional ultrasound boundary were independent predictors for microscopic extension rate (P<0.05). The median microscopic extension distances of HCC, ICC and MLC were 1.0(0, 3.0)mm, 4.0(2.3, 4.0)mm, and 2.0(1.8, 4.0)mm, respectively. The distance of microscopic extension increased with tumor size. Tumor type and tumor size were independent predictors for the distance of microscopic extension (P<0.05). Conclusions ICC, MLC, and tumors with larger diameter or poorly-defined two-dimensional ultrasound boundary have a larger distance of microscopic extension. Key words: Ultrasonography; Contrast-enhanced ultrasonography; Liver tumors; Tumor micro-invasion

Relationship between distal tibial transosseous wires and ankle joint synovium: A cadaveric analysis

Background: Distal tibial fractures are managed with external fixation techniques such as Ilizarov to prevent soft-tissue-related complications. In spite of adequate care in wire placement techniques, some cases experience synovitis of ankle joint, stiffness of joint due to pin-tract infections, and deep-seated infection. The accurate description of the ankle joint capsular and synovial recess anatomy is still not clear. The purpose of our study was to study the accuracy of the available guidelines for wire insertion by identifying the relationship between the ankle capsular attachments and the wires in an Indian population. Materials and Methods: 1.8-mm Ilizarov transosseous wires were inserted percutaneously through the distal fibula to tibia from posterolateral to anteromedial direction 2 cm above the joint line in 20 embalmed cadaveric limbs. Dissection of the ankle joint was performed after a dye was introduced into the joint capsule to look for the extent of synovium from the joint line, medial malleolus, and lateral malleolus by the visible bulging and color change of the membrane. Distance from the wire to the synovial extensions distally was measured with a vernier caliper. Results: The mean distance of synovial extension from the joint line, medial malleolus, and lateral malleolus were 20.2 mm, 30.8 mm, and 41.4 mm, respectively. Distal wire-to-synovial extension distance anteriorly was ± 0.2 mm. Wire-to-joint line distance after dissection was 20 mm. The proximal synovial extension was found to be in the 101% from the joint line to the wire. Conclusion: The synovial extensions were found to be close to the distal tibial transosseous wires. A minimum distance of 2.5–3 cm from the joint line proximally should be the safe extent for passing the wires to prevent the risk of synovitis.

Insertional anatomy of the anterior medial collateral ligament on the sublime tubercle of the elbow

Acute injuries to the anterior medial collateral ligament (AMCL) can occur due to valgus trauma or during other dislocating events to the elbow. AMCL lesions are often associated with bony lesions, such as radial head fractures or fractures of the coronoid process. We analyzed the insertion of the AMCL on the sublime tubercle in relation to surrounding osseous structures. We aimed to increase the understanding of the involvement of the AMCL in bony lesions to the sublime tubercle. We investigated 86 elbows from 43 embalmed human specimens. We measured the most ventral extensions of the AMCL at the sublime tubercle in relation to a clearly defined and reproducible landmark. We used as our landmark a horizontal line (baseline) originating on the lesser sigmoid notch in a right angle to the ulnar ridge. The mean distance of the coronoid process tip to the baseline was 4.0 mm (standard deviation [SD], 1.3 mm; range, 1.4-6.7 mm). The mean distance of the ventral extension of the AMCL to the horizontal line was 3.7 mm (SD, 2.6 mm; range: 9.4-2.2 mm). The mean horizontal distance between the ventral aspect of the AMCL and the coronoid tip was 13.7 mm (SD, 2.5 mm; range, 7.7-20.5 mm). We present a detailed description of the insertional anatomy of the AMCL at the sublime tubercle. These values could be helpful for classifications of coronoid fractures and to estimate the involvement of the AMCL in fractures of the sublime tubercle.

Clinical Feasibility Assessment of T3 Sub-Stage in Rectal Cancer Using MRI

Background: MRI predicted distance of mesorectal extension (mrDME) in rectal cancer is one of the independent risk factors for recurrence and poor overall survival. In T3 rectal cancer, if no lymph node or distant metastasis is seen, the selection of optimum treatment is based on the distance of mesorectal extension. Therefore, it is very crucial to investigate the reproducibility of DME in T3 rectal cancer. Objectives: To investigate the reproducibility of the distance of mesorectal extension by tumor invasion in T3 stage rectal cancer by evaluating sub-stages T3a, T3b T3c and T3d individually versus T3a, T3b (T3ab) and T3c, T3d (T3cd) combined together using MRI. Patients and Methods: From July 2014 to December 2015, 188 patients with surgically and histologically confirmed T3 rectal cancer who underwent preoperative MRI were enrolled into this study. Two blinded radiologists evaluated the maximum distance of mesorectal extension (mrDME) in T2 weighted image in MRI. The study population was sub classified into T3a ( 15 mm) according to the distance of mesorectal extension by tumor invasion. The inter-observer and intra-observer agreements were then assessed using kappa (k) coefficient of agreement and intraclass correlation coefficient (ICC). Results: Difference in the value of inter-/intra-observer kappa, and inter-/intra-observer ICC between the two groups was very distinct. In the individual group (T3a, T3b, T3c and T3d), the inter-observer and intra-observer (k) for the mrDME was 0.700 and 0.718 respectively; the inter-observer and intra-observer ICC was 0.772 and 0.786 respectively. In the combined group (T3ab and T3cd), the inter-observer and intra-observer kappa (k) for the mrDME was 0.819 and 0.883 respectively; the inter-observer and intra-observer ICC was 0.829 and 0.796 respectively. Conclusion: There was a distinct increase in the kappa and ICC value in the combined group compared with the individual group. This high reproducibility result suggested that it is more reliable to measure T3ab and T3cd combined together than individually. This finding can play a crucial role in the management of rectal cancer and clinical decision making for non-expert radiologists in non-academic setting.

Correlating pre-operative MRI measurements of metatarsal Osteomyelitis with surgical clean margins reveals the need for a one centimeter resection margin

BackgroundDue to the high incidence of forefoot ulcerations with associated osteomyelitis, there has been an increased demand for partial ray amputations. In order to ensure complete removal of infected metatarsal bone, a clean margin amount is chosen based on the surgeon’s intraoperative visual subjective evaluation. The margin is resected and sent to pathology. Currently the literature shows positive proximal margin rates of 35–40%. The purpose of this study was to reduce the rate of positive proximal margins by effectively resecting all infected bone using pre-operative MRI measurements with an added resection margin.MethodsTwenty-four osteomyelitis positive metatarsals were included in this exploratory study. The distance of proximal osteomyelitic extension within the metatarsal was measured on MRI in centimeters. Intra-operatively, the partial ray amputation cut was determined by adding an extra 0.5 cm resection margin to the MRI measurement. At the study’s mid-point, bone histopathology revealed an increase in positive proximal margin rates-so the resection margin was increased to 1 cm. Descriptive outcomes included the mean distance of osteomyelitis propagation, proximal margin rates, as well as diagnostic statistics.ResultsAfter removing the specimens with false positive MRI results, the study sample included 21 metatarsals positive for osteomyelitis. A 0.5 cm resection margin proximal to the osteomyelitis resulted in a 50% positive proximal margin rate. After increasing the resection margin to 1 cm, there was found to be an improved positive proximal margin rate of 9%. Based on MRI findings, the mean distance + standard deviation of osteomyelitis propagation along the metatarsal proximally was 1.81 cm + 0.74 cm. The metatarsal specimen was processed by pathology into multiple pieces and compared to MRI, resulting in MRI sensitivity of 67%, specificity of 74%, positive predictive value of 79%, and negative predictive value of 60%.ConclusionsBy performing a 1 cm resection margin proximal to the metatarsal osteomyelitis the proximal margin rate was reduced to clinically meaningful levels. These preliminary findings support using a 1 cm resection margin when performing any form of metatarsal amputation, to reduce the risk of residual osteomyelitis post-operatively.Trial registrationSt. Luke’s Hospital, IRB National Protocol ID SLHN2015–112. Date:1–13-16.

Prognostic significance of a preoperative magnetic resonance imaging assessment of the distance of mesorectal extension in clinical T3 lower rectal cancer.

The aim of this study was to evaluate the association between the mesorectal extensions on high-resolution magnetic resonance imaging (MRI) and the prognosis of patients with clinical T3 lower rectal cancer. Fifty-eight patients with clinical T3 lower rectal cancer were investigated using high-resolution MRI. One radiologist who was blinded to the clinicopathological findings retrospectively examined the MRI-predicted circumferential resection margin (mrCRM) and the distance of mesorectal extension (mrDME) on the scans. If the imaging showed a tumor ≤1mm from the mesorectal fascia, then the mrCRM involvement was defined as potentially present. The tumors were divided into two groups: mrDME ≤4mm and mrDME >4mm. A survival analysis showed that mrCRM-positive patients had a significantly poorer prognosis in the RFS (p<0.01) and LRFS (p<0.01). Patients with mrDME >4mm revealed a significantly poorer prognosis than those with mrDME ≤4mm in the OS (p=0.04), RFS (p<0.01), and LRFS (p=0.04). A multivariate analysis revealed that both mrCRM and mrDME on MRI had a significant impact on the RFS (p=0.01 and 0.03, respectively). The mrDME, as well as the mrCRM, may be an important preoperative prognostic factor for patients with clinical T3 lower rectal cancer.

Spatial ability and learning anatomy

Understanding how spatial ability relates to learning anatomy is important in developing safe doctors and health care professionals. This study brings together three separate projects. Project 1 involved a series of spatial ability experiments on medical students (n=30) and doctors (n=20) at the University of Southampton, UK. It aimed to explore if spatial ability could be trained for. The results indicated that metric (depth) perception increased with training (p=0.007). Project 2 conducted at the University of Brighton and Sussex Medical School aimed to see if medical students (n= 105) previous experience of learning made a difference. The results indicated that students who had studied physics had an improved spatial ability (p=0.022). Project 3 measured the use of touch mediated perception during examination on a cadaver removing the heart/lungs using motion tracking devices. The results indicated that the total distance of flexion and extension was 8765 degrees with radial and ulna deviation of 5475 degrees. In conclusion these 3 projects inform us that spatial ability has an element of being a learned and trained ability and this is reflected by those who had studied a visual subject. Educational theory recommends an active learning approach as being an effective study method and using human cadavers has been proposed as a method that reflects active learning, the final experiment reflects how active examination of a specimen is!

Histopathological predictors for local recurrence in patients with T3 and T4 rectal cancers without preoperative chemoradiotherapy.

Identification of suitable predictors of local recurrence (LR) in patients with rectal cancer would be of clinical benefit. The aim of this study was to identify histopathological factors that could predict LR. A total of 796 stage II/III patients with pT3 and pT4 rectal cancer who did not undergo preoperative chemoradiation were enrolled. LR was defined as intra-pelvic recurrence only. Histopathological factors related to LR were investigated. LR was found in 25 patients (6.1%) with stage II and 54 patients (13.9%) with stage IIIB/IIIC. In patients with stage II, distance of mesorectal extension (DME) >4 mm (P = 0.011) and positive venous invasion (P = 0.035) were independent factors that predicted LR. In patients with stage IIIB/IIIC, circumferential resection margin (CRM) ≤1 mm (P = 0.003) and positive lymphatic invasion (P = 0.006) were independent factors. The cumulative 5-year LR rate was higher (11.9%) in patients with a combination of DME > 4 mm and/or positive venous invasion for stage II (P < 0.001), and was also higher in patients with a combination of CRM≤1 mm and/or positive lymphatic invasion for stage IIIB and IIIC (22.2%; P < 0.002, and 34.3%; P < 0.006, respectively). Important histopathological predictors for LR in patients with pT3 and pT4 rectal cancer were different at each stage.

Histopathological and molecular insights into the ovicidal activities of two entomopathogenic fungi against two-spotted spider mite

Entomopathogenic fungi can infect and kill spider mite eggs but their ovicidal activities are poorly understood. Here we gain histopathogenical and molecular insights into the ovicidal activities of Beauveria bassiana and Isaria fumosorosea against the two-spotted spider mite, Tetranychus urticae. Scanning electronic microscopy indicated successful adhesion and germination of fungal conidia on egg shell at 24h post-spray (HPS). Germ tubes of both fungi could penetrate into egg shell with penetration pegs at 48 HPS. Interestingly, the germ tubes of B. bassiana may elongate on egg surface to locate appropriate sites for penetration, acting as ‘searching’ hyphae. Aside from the normal penetration, the germ tubes of I. fumosorosea can be completely or partially embedded into egg shell for a distance of extension, forming shell humps. Light microscopy of ultrathin sections of infected eggs showed shrunken (affected) or disrupted embryos at 48–96 HPS despite little effect on egg cleavage at 24 HPS. However, distinguishable hyphal cells were hardly found inside the embryos lacking oxygen although fungal outgrowths were abundant on unhatched (killed) eggs. In PCR with specific probes, the 18S rDNA signals of B. bassiana (412bp) and I. fumosorosea (454bp) in the DNA extracts from surface-cleaned mite eggs increased at 0–96 HPS, confirming fungal colonization in the infected eggs. We consider that the colonization on shell surface and underside could rely upon extending hyphae for uptake of egg nutrition, resulting in embryo disruption. Our observations add knowledge to microbial control of spider mites.

Pathological analysis of extracapsular extension of metastatic lymph node and its potential impact on nodal clinical target volume in the radiotherapy of esophageal squamous cell carcinoma.

There is no consensus regarding the clinical target volume (CTV) margins which surround the gross tumor volume of metastatic lymph nodes (LN) in radiotherapy of esophageal squamous cell carcinoma (ESCC). This study retrospectively assessed the distance of extracapsular extension (ECE) of metastatic LN in thoracic ESCC and defined nodal CTV margins. Histological sections of metastatic LNs from 217 patients with thoracic ESCC were re-examined. The incidence and maximal distance of ECE of metastatic LNs were assessed. The relationships between ECE and clinicopathologic features were also investigated. The ECE was found in 37.3% of patients (81/217) and 23.1% of metastatic LN (159/689), and the incidences had a significant relationship with N stage and LN size. The median distance of ECE was 1.0 mm (range, 0.2-9.7 mm). The distance of ECE showed a positive correlation with LN size (Spearman's correlation coefficient = 0.419; p<0.001). The ECE distances of LN with <10 mm diameter were significantly smaller than LN with 10-30 mm diameter (p<0.001). The 95th percentiles of ECE distances for these two groups were 3 mm and 5 mm, respectively. For pathologic LN <10 mm in diameter, a 3-mm CTV margin appears to be adequate to encompass 95% of the microscopic ECE, and for LN 10-30 mm, a 5-mm CTV margin is recommended.

Extramural extension as indicator for postoperative adjuvant chemotherapy in Stage IIA (pT3N0) colon cancer

The usefulness of adjuvant chemotherapy (CMT) in patients with Stage IIA colon cancer remains unclear. The present study aimed to investigate extramural extension as an indicator for adjuvant CMT. Data were reviewed from 202 consecutive patients with Stage IIA colon cancer that underwent curative surgery between 1995 and 2007. The distance of the extramural extension (DEE) was measured histologically. The optimal prognostic cut-off point of the DEE for oncologic outcomes was statistically determined. The eligible surviving patients had been followed for a median period of 75 months (range: 2–210 months). Patients were subdivided into two groups according to the optimal cut-off point; DEE ≤5 mm (pT3a) and DEE >5 mm (pT3b). The pT3b was the most powerful independent risk factor for postoperative recurrence (P = 0.0324, HR: 3.04, 95% CI: 1.098–8.408), and was significantly correlated with distant metastasis (P = 0.0161 HR: 5.19, 95% CI: 1.765–15.239). The recurrence-free and cancer-specific 5-year survival rates in patients with pT3b were significantly lower than in patients with pT3a (81.5% vs. 95.4%, P = 0.0003 and 85.9% vs. 97.4%, P = 0.0007, respectively). pT3b could be an important risk factor for distant metastasis in Stage IIA colon cancer. Postoperative adjuvant CMT may be indicated for patients with pT3b.J. Surg. Oncol. 2013; 108:358–363. © 2013 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Safe Distal Resection Margin in Patients With T3 Mid and Distal Rectal Cancer Who Underwent a Sphincter-Saving Resection Without Preoperative Radiotherapy

See Article on Page 231-237 The Korean Clinical Practice Guideline for Colon and Rectal Cancer v.1.0 (2012) recommends preoperative chemoradiation as an initial treatment for patients with clinical stage II and III (cT3+ or cN+) rectal cancer [1]. The National Comprehensive Cancer Network guideline v.4. (2013) for rectal cancer also recommends preoperative chemoradiation as an initial treatment for T3N0 or TanyN1-2 rectal cancer. Preoperative chemoradiotherapy significantly decreases the local recurrence rate after a total mesorectal excision (TME) curative resection for rectal cancer, but the functional disability of the anal sphincter after radiation therapy cannot be neglected. In Japan, a major trend in the treatment of rectal cancer has been the radical low anterior resection including lateral node dissection without adjuvant radiotherapy. The Study Group of the Japanese Society for Cancer of the Colon and Rectum reported on the Clinical Significance of the Mesorectal Extension of Rectal Cancer that the distance of mesorectal extension (DME), which was measured with histology after fixation in 20% formalin, was a significant prognostic factor for recurrence-free survival (cut off point, 4 mm) [2]. The multivariate Cox regression analysis showed that the recurrence-free five-year survival rate was significantly higher in patients with a DME ≤4 mm than in patients with DME >4 mm in stage IIA and IIIA cancer, but not in stage IIIC cancer (P = 0.00015, P = 0.0001, and P = 0.2697, respectively). The reports suggested that local recurrences were increased by the status of cancer-positive lymph nodes even in the same category of T3 cancer in patients without radiation therapy. The distal resection margin (DRM) means the length of the tumor-free normal mucosa and rectal wall. Han et al. [3] published the manuscript, 'Association between a close distal resection margin and recurrence after sphincter-saving resections for T3 midor low-rectal cancer without radiotherapy.' With retrospective data, they described the 5-year local recurrence rates as 6.69% in patient with DRM ≤10 mm and 9.52% in patients with DRM >10 mm, respectively (DRM cut off point, 1 cm; P = 0.3981). However, they gave no descriptions of cancer-positive lymph nodes in the groups with stage IIA, IIIB, and IIIC cancer. The local recurrence may be influenced not only by DRM but also by the status of lymph nodes. A Norwegian national study recommended a DRM of >10 mm for rectal cancer patients treated without radiotherapy [4]. The 5-year local recurrence rate was 14.5% for patients with DRM of 0-10 mm compared to 8.66% for patients with DRM >11 mm (P < 0.001). The proportions of T3 cancer were 48% and 63%, respectively, in those two groups. Current Japanese guidelines state a 2-cm DRM is needed for rectal cancer with a distal edge below the peritoneal reflection. Intramural and extramural distal spread prevents local control and promotes systemic metastasis. If the specimen is not pinned, the length of the DRM can shrink by 50% in a nonradiated rectum after formalin fixation. A gross determination of a safe distal resection margin is difficult in the operating room. The frozen-section result for the DRM may be falsely negative in 12% of all cases. A systemic review supported the practice of sphincter preservation in selected settings of close distal resection margins (≤1 cm) after mesorectal excision for distal rectal cancer [5]. A further subgroup study suggested that margins as close as ≤5 mm, if they were indeed negative, might be acceptable. However, the importance of patient and tumor selection for this approach must be emphasized. In distal rectal cancer, the mesorectal fascia does not extend beyond the puborectalis level, and the anal sphincter is another barrier for safe distal resection margins. Local recurrence may develop with uninvolved margins related to lymphatic spread from the DRM. In preoperative radiation cases, a distal clearance margin of 1 cm or less may a safe distance in patients who undergo lower rectum cancer surgery [6]. We would like to conclude with the following remark. Although reduction of the DRM to less than 10 mm does not increase local recurrences in many low-risk patients, a DRM >10 mm is safe in cases of rectal cancer with lymphovascular invasion, perineural invasion and multiple lymph-node metastases.