Final Margin Research Articles

Impact of postoperative complications on oncologic outcomes after rectal cancer surgery: An analysis of the United States Rectal Cancer Consortium.

41 Background: Postoperative complications (POCs) are associated with worse oncologic outcomes in several cancer types. The implications of complications after rectal cancer surgery are not known. Methods: The US Rectal Cancer Consortium (2007-17) was reviewed for patients with primary rectal adenocarcinoma who underwent R0/R1 low anterior resection (LAR) or abdominoperineal resection (APR). 90-day POCs were categorized as major vs minor and grouped into infectious, cardiopulmonary (CP), thromboembolic (TE), renal, or intestinal dysmotility. Primary outcomes were 5-yr overall survival (OS) and recurrence-free survival (RFS). Results: Of 1136 pts, median age was 59 yrs (IQR 51-67), 61% were male (n = 693), median f/u was 31 mos (IQR 13-54). 70% underwent LAR (n = 799) and 30% APR (n = 337). Complication rate was 46% (n = 527), with 63% minor (n = 330) and 32% major (n = 170). Of all POCs, infectious complications comprised 20% (n = 105), cardiopulmonary 3% (n = 14), thromboembolic 5% (n = 25), renal 9% (n = 46) and intestinal dysmotility 19% (n = 100). When compared to minor or no POCs, major POCs were associated with both worse RFS (48 vs 63 vs 76% p < 0.01) and OS (64 vs 76 vs 80% p < 0.01). While a single POC was associated with worse RFS (61 vs 76% p < 0.01), multiple POCs were associated with worse OS (62% vs 79% p = 0.02). Regardless of complication grade, infectious POCs were associated with worse RFS (56 vs 76% p < 0.01) while CP and TE POCs were associated with worse OS (CP 40 vs 78% p < 0.01; TE 63 vs 78% p < 0.01). Postoperative renal dysfunction was associated with both worse RFS (26 vs 76%, p < 0.001) and OS (62 vs 78% p = 0.01). This persisted on MV analysis for OS when accounting for pathologic stage, receipt of neoadjuvant therapy, and final margin status (CP: HR 3.6 p = 0.01; TE: HR 19.4 p < 0.01; renal: HR 2.4 p = 0.01) and for RFS (infectious: HR 2.1 p < 0.01; renal: HR 3.2 p < 0.01). Conclusions: Major complications after proctectomy for cancer are associated with decreased recurrence-free and overall survival. Given the association of infectious complications and postoperative renal dysfunction with earlier recurrence of disease, efforts must be directed towards defining best practices and standardizing care.

Robot-assisted Nipple-sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience

Seeking smaller and indistinct incisions, physicians have attempted endoscopic breast surgery in breast cancer patients. Unfortunately, there are some limitations in the range of movement and visualization of the operation field. Potentially addressing these limitations, we investigated the outcomes of gas and gasless robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR). Ten patients underwent 12 RANSM with IBR between November 2016 and April 2018. Patients with tumors measuring >5 cm in diameter, tumor invasion of the skin or nipple-areolar complex, proven metastatic lymph nodes, or planned radiotherapy were excluded. Age, breast weight, diagnosis, tumor size, hormone receptor status, and operation time were retrospectively collected. Postoperative outcomes including postoperative complications and final margin status of resected were analyzed. The median total operation time and console time were 351 min (267–480 min) and 51 min (18–143 min), respectively. The learning curve presented as a cumulative sum graph showed that the console time decreased and then stabilized at the eighth case. There was no open conversion or major postoperative complication. One patient had self-resolved partial nipple ischemia, and two patients experienced partial skin ischemia. We deemed that RANSM with IBR is safe and feasible for early breast cancer, benign disease of the breast, and BRCA 1/2 mutation carriers. RANSM is an advanced surgical method with a short learning curve.

Predictors of Outcome in Mammary Adenoid Cystic Carcinoma: A Multi-Institutional Study.

Mammary adenoid cystic carcinoma (ACC) is a rare subtype of breast cancer with a favorable prognosis. Here we report on predictors of outcome based on a detailed morphologic review and analysis of 108 mammary ACC. Sixty-four tumors (59.2%) were pure conventional ACC, 23 (21.3%) were pure basaloid ACC. Follow-up was available for 87 patients (median: 51 mo). Eighteen patients (20.7%) developed recurrence: 7 (8%) had local recurrence and 14 (16%) had distant metastasis. Two patients died of disease, 1 died of an unrelated cause, 14 were alive with disease (including 8 in palliative care), and 70 (80.5%) were alive with no evidence of disease. Of 90 patients with known lymph node (LN) status 9 (10%) had nodal involvement (all with basaloid ACC). Distant metastases in patients with predominantly basaloid ACC compared with pure conventional ACC were more common (40% vs. 7.7%) and occurred earlier (22 vs. 84 mo). The following factors were found to be predictive of recurrence-free survival: positive margin, Nottingham grade, neovascularization, basaloid component, perineural invasion, lymphovascular invasion, >30% solid growth, necrosis and LN involvement; the first 3 remained statistically significant on multivariate analysis. Factors predictive of distant disease-free survival were neovascularization, Nottingham grade, lymphovascular invasion, solid component >50%, LN involvement, basaloid component >50%, tumor necrosis, perineural invasion, and final margin. Only neovascularization remained statistically significant on multivariate analysis. Basaloid ACC is an aggressive variant of mammary ACC with more frequent nodal involvement and higher incidence of distant spread. LN staging should be performed for all mammary basaloid ACC.

Local Relapse and Survival Outcomes in Patients with Scalp Sarcoma: A Retrospective Study of 95 Patients Treated in a Provincial Cancer Care Institution Over 25 Years.

ObjectivesThere is limited literature on the optimal treatment of sarcoma arising in the scalp. This study evaluates local relapse (LR) and survival outcomes of patients with scalp sarcoma treated at a provincial cancer care institution.MethodsA retrospective review of 95 patients with a primary diagnosis of scalp sarcoma referred from 1990-2015 was completed. Kaplan-Meier statistics were used to estimate LR-free survival (LRFS) and overall survival (OS). Survival curves were compared using log-rank tests. Regression analyses were performed using Cox proportional hazards model.ResultsThe median age at diagnosis was 77 years. The most common histologies were angiosarcoma (27%), undifferentiated pleomorphic sarcoma (24%), and pleomorphic dermal sarcoma (21%). Final margins were 36% positive, 28% close, 31% negative, and 5% unknown. Of 73 patients treated with curative-intent, 32 (44%) experienced LR. Five-year LRFS was 56.0% and overall survival was 48.3%. Patients with close or positive margins who received pre- or post-operative radiotherapy (n=19) had similar LR risk compared to patients who did not (n=34) (five-year LRFS 41.8% vs 69.1%; p=0.145). On multivariate analysis, angiosarcoma was associated with a higher LR risk (Hazard ratio (HR) 12.06, p<0.001). The use of radiotherapy showed a trend towards reduced LR risk but did not reach statistical significance (HR 0.37, p=0.066).ConclusionsPatients with scalp sarcoma have high risk of LR, particularly in cases with positive margins. Adjuvant radiation was not associated with improved local control for close or positive margins. Complete surgical excision to establish negative margins remains the primary standard treatment for patients with this rare disease.

Frozen Section Assessment of Bronchial Margins during Lung Carcinoma Surgeries: Report of the Experience at a Single Institution

Introduction Many thoracic surgeons consider frozen section analysis of bronchial margins during lobectomies “obligatory” although routine frozen section analysis of the bronchial margin rarely yields positive results and infrequently changes intra-operative management in patients undergoing Non-Small Cell Lung Carcinoma (NSCLC) resection. Materials and methods 234 cases of lobectomies with carcinoma were reviewed at our institution to assess bronchial margin involvement, correlation between frozen section and final bronchial margin status, gross distance between tumor and margin, and tumor type. Results Tumor distance to margin varied in the 234 cases from grossly involved to 10 cm away. 5 cases out of 234 (approximately 2.1%) had a positive bronchial margin in the final report. 3 out of the 5 cases were poorly differentiated squamous cell carcinoma grossly abutting the bronchial margin, two cases were of poorly differentiated adenocarcinoma located grossly 0.5 cm away from the bronchial margin. 4 out of 5 cases were called positive intra-operatively. In none of the 4 out of the 5 positive cases did frozen section exam of the bronchial margins change the intra-operative management of the case. Conclusion Our study supports selective use of intra-operative frozen section of bronchial margins during lobectomies for carcinoma. On the basis of our findings, a distance of approximately 1 cm or less is suggested as a threshold for intra-operative microscopic examination of the bronchial margins. However, routine examination of the bronchial margins, regardless of the location of the tumor upon gross examination, and in the absence of empirical evidence supporting this practice, is only time consuming intra-operatively, wasteful of resources and has no therapeutic or prognostic value.

CORR® Tumor Board: Can Navigation Improve the Ability to Achieve Tumor-free Margins in Pelvic and Sacral Primary Bone Sarcoma Resections? A Historically Controlled Study

CORR® Tumor Board: Can Navigation Improve the Ability to Achieve Tumor-free Margins in Pelvic and Sacral Primary Bone Sarcoma Resections? A Historically Controlled Study

Survival Outcomes for Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck.

Survival outcomes for advanced non-melanoma skin cancers of the head and neck treated with surgical resection are not well described in the literature. We aimed to describe outcomes for T3 and T4 cutaneoous squamous cell carcinoma of the head or neck treated with surgical resection at 1 tertiary academic medical center. We analyzed a retrospective cohort of patients diagnosed with T3 or T4 cutaneous squamous cell carcinoma (SCC) of the head or neck from 2005 to 2016 treated with definitive surgical resection. Survival outcomes were examined using Kaplan-Meier analysis, and multivariate analysis was completed with Cox proportional hazard model. Forty-three patients met inclusion criteria. The mean age at diagnosis was 74.7 years (SD = 10.2), and 34 (79.1%) patients were male. Twelve (27.9%) patients were immunosuppressed. Radical resection, defined as temporal bone resection, orbital exenteration, calvarial resection, mandibulectomy, or maxillectomy, was performed in 25 (58.1%) cases. Final surgical margins were positive in 19 (44.2%) cases. Patients with tumors of the scalp/neck had a 1-year survival probability of 85.7%, and the probability of survival 1 year after a neck dissection was greater than 93%. Anatomical subsites, specifically scalp/neck tumors, tended to have worse overall survival. Positive final margins tended to indicate a worse prognosis, and overall survival and recurrence were not significantly different among patients who underwent radical surgical resection compared to soft tissue resection.

Soft tissue sarcoma of the hand: Is unplanned excision a problem?

BackgroundSoft tissue sarcoma (STS) of the hand are prone to unplanned excisions, altering oncologic outcomes. The aim of this study is to compare STS of the hand with initial treatment at an oncology center versus those initially treated at a non-oncology center. Additionally, we evaluated what factors were associated with oncologic outcomes. MethodsWe retrospectively identified patients with a STS of the hand using ICD-9 codes along with an institutional oncologic database. We included all adult patients with a non-metastatic STS of the hand (n = 64) with a median follow up of 4.0 years (IQR:1.7–10.0). ResultsEight-three percent (n = 53) of tumors had an unplanned excision, of which one was treated at the oncology center. Patients treated primarily at an oncology center were older (57.6 vs. 43.6 years), had fewer operations and tended to have a larger tumors (median 4.7 cm vs. 3.0 cm) compared to those initially treated at a non-oncology center. The 5-year survival for patients treated at an oncology center was 60% compared to 89% in those initially treated at a non-oncology center. Worse disease-free survival was associated with positive final margins and subfascial tumors. ConclusionTumors with primary treatment at an oncology center were larger and presented in older patients, having worse overall survival compared to those initially treated at a non-oncology center. Initial treatment at a non-oncology center did not influence the oncologic outcomes, but lead to more re-excisions and amputations. Final tumor margins and tumor depth determined oncologic outcomes.

The Relationship of Breast Density and Positive Lumpectomy Margins.

A positive lumpectomy margin after breast-conserving surgery (BCS) is a significant predictor for ipsilateral cancer recurrence. The MarginProbe, a Food and Drug Administration (FDA)-approved device for intraoperative assessment of lumpectomy margins, is associated with a reduction in re-excision surgery. This study aimed to evaluate the relationship of mammographic breast density (MBD) and clinicopathologic characteristics with margin status in women undergoing BCS with the MarginProbe. The institutional database was queried for patients with breast cancer who had BCS with the MarginProbe from 2013 to 2017. Clinicopathologic characteristics were collected. The study defined MBD as less dense (Breast Imaging Reporting and Data System [BI-RADS] A and B) and more dense (BI-RADS C and D). A positive margin was defined as smaller than 1mm. Pearson Chi square and uni- and multivariate logistic regression were performed. Of 1734 patients, 341 met the study criteria. The median patient age was 63years. The patients with higher mammographic density were younger (p < 0.0001) and had a lower body mass index (BMI) (p < 0.0001). The patients with higher MBD were more likely to present with a palpable mass (p = 0.0360). Of the 341 patients, 135 (39.6%) had one or more positive margins on the main specimen, and 101 (74.8%) were converted to final negative margins after the MarginProbe directed re-excisions. Positive final margins were associated with larger tumor size (p = 0.0242) and more advanced stage of disease at diagnosis (p = 0.0255). In this study of patients undergoing BCS, breast density was not correlated with the likelihood of a positive margin. The presence of positive final lumpectomy margins was associated with older age and more extensive disease.

Positive surgical margins after radical nephrectomy for localized kidney cancer: Impact on survival.

676 Background: Impact of positive surgical margins (PSM) in patients undergoing radical nephrectomy (RN) in localized renal cell carcinoma (RCC) is poorly understood. We sought to understand the impact of PSM for on overall survival (OS) after RN in clinically localized RCC. Methods: Retrospective analysis of patients from the US National Cancer Database who RN for clinically localized (cT1a-cT2b cN0M0) RCC between 2003-13, were stratified into their pathological stage group [pT1a, pT1b, pT2a, pT2b, and pT3a ( = Upstaged)] and analyzed by final margin status. Cox Regression Multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on OS. Kaplan-Meier analysis (KMA) of OS was performed for PSM verses NSM for the overall cohort and by stage. Results: 37,656 RN events [14312 (38%) pT1a, 13598 (36.1%) pT1b, 6551 (17.4%) pT2a, 2937 (7.8%) pT2b, and 4286 (11.3%) with pT3a upstaging]. PSM rate was 0.9% overall (0.4% pT1a, 0.4% pT1b, 0.4% pT2a, 0.4% pT2b, and 4.7% pT3a upstaged). On MVA for all-cause mortality, PSM was independently predictive for decreased OS (HR 1.51, p &lt; 0.001), along with increasing age (HR 1.04, p &lt; 0.001), non-Caucasian race (HR 1.199, p &lt; 0.001), increasing charlson score (HR 2.23, p &lt; 0.001), non-private insurance (HR 1.61, p = 0.001), high grade histology (HR 1.21, p = 0.001), and sarcomatoid histology (HR 3.61, p &lt; 0.001). Pathologic T-stage was also predictive of decreased OS (Referent pT1a, HR 1.17, 1.47, 1.74, and 1.93, for pT1b, pT2a, pT2b, pT3a, respectively; all p &lt; 0.001). KMA revealed worsened 5-year OS for PSM vs. NSM for the overall cohort (62.4% vs. 81%, p &lt; 0.001), pT2a (61% vs. 79.4%, p = 0.013), and pT3a (50% vs. 68.3%, p &lt; 0.001) groups. Conclusions: PSM is a rare event after RN, but is associated with worsened OS, particularly in pT2 and pT3a upstaged patients. Mechanism of decreased OS cannot be clarified given limitations of the NCDB, these suggest that PSM may pose increased oncologic risks in higher pathological stage. Consideration of further definitive strategies (ex: preemptive wide field resection) may be warranted in select circumstances. Furthermore, our findings call for re-consideration of exclusion of PSM patients from adjuvant therapy trials.

Role of robot assisted retroperitoneal lymph node dissection in metastatic malignant mesothelioma of the tunica vaginalis: Case series.

536 Background: The management of malignant mesothelioma of the tunica vaginalis of the testes (MMTVT) is not clearly defined, though retroperitoneal lymph node dissection has been reported as a diagnostic and potentially therapeutic option. Herein we present our experience with robot assisted retroperitoneal lymph node dissection (RARPLND) in a series of patients with MMTVT. Methods: The Mayo Clinic cancer registry was queried from 1972-present for all patients who had a diagnosis of MMTVT. Six patients were identified, five of whom were treated with RPLND, where four underwent RARPLND. Data was collected on pertinent demographic, preoperative, perioperative, postoperative outcomes and follow-up oncological data. Results: In five patients who underwent RPLND, the median age was 50 years (IQR 34-51), median BMI was 26.9 (IQR 26.4-30.6). Four patients originally presented with right sided symptomatic hydroceles, while one presented with right sided chronic epididymitis. Orchiectomy (one simple, two inguinal radical) was performed in three patients and hydrocelectomy in the other two patients prior to presentation. Preoperative cross-sectional imaging, including PET-CT scan in three patients, was negative for lymphadenopathy or metastasis. RARPLND was performed in 4/5 (80%) cases and concomitant hemiscrotectomy in 4/5 (80%) cases. Full bilateral template was performed in three patients and right modified template was performed in the remaining two. Median lymph node yield was 29 (IQR 22-32) and median blood loss was 275 cc (IQR 200-300). Positive retroperitoneal lymph nodes were found in 3/5 (60%) cases. Final margins of hemiscrotectomy were negative in all four cases. All patients who underwent RARPLND were discharged home on postoperative day one. One patient received four cycles of adjuvant Cisplatin and Pemetrexed. Mean follow-up was 27 months (range 2-47). No patients recurred. Conclusions: MMTVT is a very rare malignancy with high potential for retroperitoneal lymph node dissemination. Regardless of the approach, RPLND may provide both a diagnostic and therapeutic benefit, with the robotic approach affording a potentially expedited recovery.

Abstract P3-13-12: The margin of breast-conserving surgery when ductal carcinoma in situ is present within invasive ductal carcinoma

Abstract Objective: The presence of ductal carcinoma in situ (DCIS) in invasive ductal carcinoma (IDC) may increase the rates of positive margins and re-excision. Literature addressing this association is limited. This study aimed to explore the factors that are associated with positive margins and re-excision, as well as to evaluate the influence of positive margins on the survival of patients with breast cancer containing both invasive and in situ ductal carcinoma. Methods: A retrospective medical chart review of patients diagnosed with DCIS within IDC who underwent BCS at the Revlon/UCLA Breast Center between January 2003 and December 2008 was performed. Results: Of the 488 eligible patients, 267 patients (53.9%) underwent re-excision. The presence of residual disease upon re-excision was the highest in patients who initially had positive margins involved by both DCIS and IDC. In multivariate analysis, calcifications, tumor size, positive lymph nodes, and the presence of extensive intraductal component (EIC) were significantly associated with initial positive margins, with the latter having the highest hazard ratio (HR, 5.5–5.7, P = 0.000). Tumor size, molecular subtype, and final margin status were associated with disease-free survival. The final margin and regional lymph node status are significant prognosticators for breast cancer-specific survival. Conclusions: In patients with ductal carcinoma of the breast containing both invasive and in situ components, the rate of initial positive margin after BCS was high and was significantly associated with calcifications, tumor size, regional lymph node status, and the presence of EIC. Citation Format: Chen J, Ro A, Tan Q-W, Wang Z, Chang HR. The margin of breast-conserving surgery when ductal carcinoma in situ is present within invasive ductal carcinoma [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-12.

Abstract P3-13-08: Usefulness of periareolar zigzag incision in oncoplastic breast-conserving surgery

Abstract Background Breast-conserving surgery (BCS) has been performed as a standard procedure because the addition of radiation therapy after breast-conserving surgery in early breast cancer patients is similar to that of mastectomy.The surgical methods for breast cancer have been developed in recent years, and the cosmetic aspect has become important.Several incisions are used to reduce the scar to the incision site during BCS. The periareolar incision is often used when the small tumor relatively close to the nipple. However, periareolar incision does not have sufficient field of sight, which can result in difficult or impossible operations if the tumor is large or far from the nipple. In plastic surgery, various methods such as zigzag incisions have been recommended to achieve satisfactory esthetic results. The periareolar zigzag incision has the advantage of a not only good surgical field but also contributed to better surgical scars. The purpose of this study was to evaluate the oncological safety of procedures by studying the status of the surgical margins of the excised tumor specimen and reduces the need for further surgery Methods From January 2016 to November 2017, we conducted a survey of female patients who underwent BCS using zigzag incision. Patients with exclusion criteria were excluded from this study if they had a Patients with bilateral breast cancer or neoadjuvant chemotherapy was included in the study. Intraoperative frozen section margin was evaluated in all patients and additional resection was performed when the positive margin was present. Final margin status was determined by examination of the permanent paraffin-embedded sections. In patients with invasive breast cancer or relatively large carcinoma in situ, axillary surgery was performed according to the presence of axillary metastasis. Patients characteristics, tumor characteristics, operative time, size of the specimen and the distance from the tumor to nipple were evaluated Results 393 patients were enrolled in the study, including 9 patients with bilateral breast cancer, and a total of 402 cases of BCS surgery were analyzed. Thirty-five patients received neoadjuvant chemotherapy. The median age of the patients was 51 (range: 25-84 years), the median time of operation was 72 minutes in patients who did not undergo axillary surgery or sentinel node biopsy only, and 83 minutes in patients who underwent axillary node dissection or supraclavicular node dissection. The median tumor size was 1.6 cm (range: 0-8.8 cm), median tumor distance from the nipple was 3.0 cm (range: 0.4-8.1 cm), mean excised specimen sized was 5.0 cm (range: 0.9-15.0 cm). Frozen biopsy of the resection margin during surgery revealed tumor-positive in 69 (17.2%) cases and re-excision was performed. All patients were discharged with no sign of infection or skin necrosis. Conclusions The periareolar zigzag incision technique has good cosmetic results and provides a sufficient surgical field, which can be useful for removing relatively large tumors or tumors far from the nipple. Citation Format: Ko B, Kim H, Chung I, Lee S, Kim J, Lee J, Son B, Ahn SH. Usefulness of periareolar zigzag incision in oncoplastic breast-conserving surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-08.

The Influence of Smoking and Age on Pathologic Features and Outcomes in Oral Cavity Squamous Cell Cancer: A Multi-institutional Collaborative Study

To evaluate the impact of smoking and age on the frequency of pathological risk factors and outcomes for surgically staged oral cavity squamous cell carcinoma (OCSCC) in a multi-institutional analysis. A collaborative database of patients with primary OCSCC among 6 academic medical centers encompassing non-metastatic cases diagnosed between 2005 and 2015 was constructed. All cases were treated with surgery +/- adjuvant radiation therapy (RT) +/- concomitant chemotherapy (CRT) according to risk factors. Patients were categorized based on smoking history and age and the resultant groups were compared for demographic data, pathologic features and treatment modalities using t-test and Chi-squared tests. Kaplan-Meier curves and Log-rank p-values as well as multivariate analysis (MVA) for recurrence free survival (RFS). We identified 1055 cases that met our inclusion criteria after excluding 227 patients with unknown smoking history and incomplete records. Median age was 61 years, 60% of cases were men, 88% were White; and oral tongue (22%) followed by floor of mouth (18%) were the most common sub-sites. The median follow up time was 40 months (15-195 months). Surgery alone, surgery + RT and surgery + CRT were utilized in 32%, 37% & 31% of cases respectively. Smokers either during or at any point before diagnosis (“Ever Smoked”) were 730 cases (69%), whereas “Never Smoked” constituted the remaining 31% (n=325). Smoking was significantly associated with male sex, heavy alcohol use (38% vs 3%) and floor of mouth location (28% vs 6%) (p<0.001 for all). Adverse pathologic features were similar in both groups including grade, AJCC stage, lymphovascular (LVI) and extracapsular space invasion (ECE); except for perineural invasion (PNI) that was detected more in smokers (48% vs 37%; p=0.003). Three and 5 years RFS were not influenced by smoking (62.8% & 57.7% for Ever Smoked vs. 62% & 56.2% for Never Smoked; p=0.553). Even when we further categorized our study population into current (36%), former (33%) and never smokers (31%) similar results were attained both for risk features and RFS and the same occurred within different AJCC stages. RFS for patients younger than 50 years (n=193; 18%) was also not significantly different when compared to older ones 50-70 (n=584; 56%) and > 70 years (n=278; 26%) with 3-year RFS of (67%, 74% & 51%) and 5-year RFS of (64%, 73% & 51%) for the three groups respectively (p=0.74). On MVA, classical factors namely higher AJCC stage, PNI, LVSI, ECE and positive final margins were independently associated with worse RFS (p<0.05 for all). Both smoking and young age were not associated with any detrimental effect. In our multi-institutional analysis that included one of the largest cohorts to date for oral cavity squamous cell carcinoma treated with modern modalities with adequate follow up, smoking history and young age did not skew outcomes. Smoking was not correlated with any adverse risk feature except for perineural invasion.

Equivalent Outcomes for Accelerated Partial Breast Irradiation for Invasive Lobular Carcinoma: A Matched Pair Analysis

The 2009 ASTRO consensus guidelines considers invasive lobular histology (ILC) a cautionary feature in patient selection for accelerated partial breast irradiation (APBI). Patients with ILC have either been excluded or underrepresented in previous studies. The aim of this retrospective study is to review an institutional review board-approved single institution prospectively maintained database to compare outcomes in patients with ILC treated with APBI or Whole Breast Irradiation (WBI). The database was queried to examine all patients with ILC histology who underwent breast conserving therapy (BCT) at a single institution from 1981-2017. Patients were excluded if node positive, positive margins (considered to be tumor on ink for invasive or < 2mm for non-invasive tumors), received neoadjuvant chemotherapy or were undergoing retreatment. The patients were stratified by treatment type (APBI vs WBI). APBI techniques included Mammosite, Contoura, SAVI, insterstitial needle placement and 3D conformal radiation. WBI includes conventional and hypofractionated irradiation. Clinicopathologic characteristics were compared between groups. Patient age, laterality, surgical tumor size, grade, final margin status, presence or absence of extensive intraductal component (EIC), lymph-vascular invasion (LVSI), multifocality, ER positivity, and the use of adjuvant hormonal therapy or chemotherapy were reviewed. A propensity score match on a 1:1 basis for each of the above features was performed. Crude rates and Kaplan Meier estimates were obtained for LR, RR, DM, DFS, CSS or OS for each group. Median follow-up was 6.09 years for the APBI cohort (N=26) and 8.49 years for the WBI cohort (N=232). APBI patients tended to be older (69 +/− 12 vs 63 +/− 11 (years +/− sd)) and have smaller tumors (12.3 +/− 8.8 vs 16.7 +/− 11 (mm +/− sd), p = 0.05). The propensity score match successfully found a cohort of patients treated with WBI that was comparable to the APBI cohort in the factors listed in the methods (N=52). There were no significant differences in outcome in LR, RR, DM, DFS, CSS or OS. This match pair analysis further suggests that APBI is an effective alternative in well-selected patients with ILC histology. Patients with ILC should be considered for enrollment on randomized clinical trials to further clarify the role of APBI in patients with ILC.

Outcomes in DCIS Patients Treated with Hypofractionated Whole Breast Radiation Therapy with Integrated Boost Compared to Standard Fractionation with Concomitant Boost

Hypofractionation for ductal carcinoma in situ (DCIS) is not yet formally recommended by national guidelines. We compared outcomes after hypofractionated radiation therapy (HRT) with an integrated boost to conventional fractionation (CRT) with sequential boost for DCIS. We queried our institutional database for DCIS patients treated with whole breast RT after lumpectomy between Jan 2004 and Nov 2015 and followed for greater than 2 years. HRT delivered 2.25 Gy per fraction (fx) to 45 Gy to the whole breast with an integrated 2.8 Gy tumor bed boost per fx for a total of 56 Gy in 20 fx over 4 weeks. CRT delivered 50 Gy in 2 Gy fx to the whole breast plus a sequential 10-16 Gy tumor bed boost. Treatment fields utilized field-in-field tangential design or IMRT. CRT patients were propensity score matched to HRT patients in a 2:1 ratio using age, bra cup size, DCIS grade, histologic subtype (comedo vs non-comedo) and use of endocrine therapy. Toxicity was graded using CTCAE v3 and stratified as early (<6 weeks from RT completion) vs late. Acute toxicity was reported weekly during radiation. Physician reported cosmesis was scored using the Harvard scale (1 excellent, 2 good, 3 fair, 4 poor). Kaplan Meier estimates for ipsilateral invasive/DCIS recurrence at 5 years were calculated. Univariate logistic regression to predict toxicity outcomes employed generalized estimating equations to control for the within subject correlation. Forty-six patients undergoing HRT were eligible and were matched to 92 CRT patients. Median follow-up of all patients was 76 months (range 24-164). Median age was 59 years (40-91). Cup size was B or smaller in 31%. Comedo and grade 3 histology were present in 28% and 46%, respectively. Endocrine therapy was taken by 55%. Final margin status was close or positive in 12% and 2% of patients, respectively. There were no statistically significant differences in any demographic, clinical or treatment characteristics following matching. Recurrence free survival after CRT and HRT was 93.7% and 97.8% at 5 years (p=0.74), respectively. In patients who had cosmesis reported (61% available), median final score was 1.27 for CRT and 1.25 for HRT (chi square p=0.96).Abstract TU_4_3355; Table 1VariableHRT%CRT%Odds RatioP-valueCIAcute skin color change19%38%0.400.030.17-0.93All acute toxicity ≥ Grade 222%52%0.25<0.010.12-0.55Acute tissue complications ≥ Grade 22%26%0.06<0.010.01-0.51All late toxicity ≥ Grade 22%5%0.390.300.06-2.32Late tissue complications ≥ Grade 22%4%0.490.420.09-2.77 Open table in a new tab In this single institution experience, DCIS patients treated with HRT with concurrent boost experienced similar or improved toxicity compared to CRT matched controls. Rates of recurrence were similar between CRT and HRT groups. HRT toxicity data and rate of recurrence was consistent with other investigations utilizing HRT and boost.

Prognostic Comparison of the Longitudinal Margin Status in Distal Bile Duct Cancer: R0 on First Bile Duct Resection vs. R0 After Additional Resection

Background: This study investigated survival differences following intra-operative frozen-section examination of bile duct resection margins and final longitudinal margin status (LMS) in distal bile duct cancer confined to the intra-pancreatic portion. No studies have examined the relationship between LMS and survival for distal bile duct cancer. Methods: Overall, 193 patients underwent Whipple's operation for curative resection of distal bile duct cancer from 2008 to 2016 at the Asan Medical Center, Seoul, Republic of Korea. Patients were sorted into 2 and 3 groups according to LMS of frozen-sections and LMS of the final pathological specimen results: R0 on first bile duct resection (Primary R0), R0 after additional resection (Secondary R0), and no evidence of residual carcinoma (FR0), carcinoma in situ or high-grade dysplasia (FR1-CIS/HGD), or invasive carcinoma (FR1-INV). Survival and prognostic factors according to LMS were analyzed. Findings: There were no differences between primary R0 and secondary R0 in 5-year overall survival (OS) (60.8% vs. 46.1%, P = 0.969) or diseasefree survival (DFS) (54·6% vs. 54·9%, P = 0·903). The 5-year OS after FR0, FR1-CIS/HGD, FR1-INV were 59·3%, 59·5%, 14·3%, respectively. There was no difference between FR0 and FR1-CIS/HGD (P = 0·842). Final margin status of the bile duct was an independent prognostic factor by multivariable analyses. Interpretation: If R0 of final longitudinal margin status was achieved, it would help to improve survival regardless of R0 through additional resection. And, it should be avoided remaining invasive cancer at the longitudinal margin whenever possible. Funding Statement: This study was supported by the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (grant number: HI14C2640). Declaration of Interests: The authors declare no competing interests in relation to this study. Ethics Approval Statement: Data collection and analysis were performed according to the institutional guidelines, which conformed to the ethical standards of the Declaration of Helsinki. Institutional Review Board approval was obtained on December 22, 2017 (No. 2017-1407).

Treatment of Tonsillar Carcinoma following Nononcologic Tonsillectomy: Efficacy of Transoral Robotic Revision Tonsillectomy

To evaluate whether transoral robotic surgery (TORS) is a suitable treatment approach for patients diagnosed with tonsillar carcinoma after a standard palatine tonsillectomy. Retrospective cohort study. Tertiary care medical center. Patients who underwent TORS at the University of Washington from 2010 to 2017 (n = 150) were identified. All patients who were diagnosed with tonsillar carcinoma following a nononcologic tonsillectomy and subsequently underwent TORS radical tonsillectomy were included (n = 14). Tumor stage-matched subjects (n = 44) were included who did not undergo standard tonsillectomy prior to TORS. Our primary outcome was final margin status. Secondary outcomes were presence of residual tumor, receipt and dose of postoperative adjuvant therapy, disease-free survival (DFS), and disease-specific survival. Patients with <6 months of follow-up following definitive treatment were excluded from survival analyses. Final margin status was clear in all subjects. Residual tumor was not identified in 13 of 14 (92.9%) prior-tonsillectomy subjects following TORS radical tonsillectomy. Seven of 14 (50%) prior-tonsillectomy subjects and 12 of 44 (27.3%) TORS-matched subjects did not require adjuvant therapy due to favorable pathology. Among subjects who received post-TORS radiation therapy (RT) at our institution, RT dose reduction was achieved in 3 of 4 (75%) prior-tonsillectomy subjects and 21 of 24 (87.5%) TORS-matched subjects. Ten of 14 (71.4%) prior-tonsillectomy subjects and 31 of 44 (70.5%) TORS-matched subjects avoided post-TORS chemotherapy. DFS was not significantly different ( P = .87) between prior-tonsillectomy and TORS-matched groups, and no subjects died of related disease. Patients diagnosed with tonsillar carcinoma following a prior nononcologic standard palatine tonsillectomy are suitable candidates for revision surgery with TORS radical tonsillectomy.

Margins in Breast-Conserving Surgery After Neoadjuvant Therapy.

Optimal margin width for breast-conserving therapy (BCT) after neoadjuvant chemotherapy (NAC) is unknown. We sought to determine the impact of margin width on local recurrence and survival after NAC and BCT. Patients treated with NAC and BCT for stage I-III breast cancer from 2002 to 2014 were identified. Multivariate Cox regression was performed to determine the relationship between margin width and local recurrence free-survival (LRFS), disease-free survival (DFS), and overall survival (OS). A total of 382 patients were included. Median age was 51years [range 22-79], median tumor size 3.0cm [range 0.6-11.0], and receptor subtypes included 144 (37.7%) HR-/HER2-, 47 (12.3%) HR-/HER2+, 118 (30.9%) HR+/HER2-, and 70 (18.3%) HR+/HER2+. Breast pathologic complete response (pCR) was achieved in 105 (27.5%) patients. Final margin status was positive in 8 (2.1%) patients, ≤ 1mm in 65 (17.0%), 1.1-2mm in 30 (7.9%), and > 2mm in 174 (45.5%). The 5-year LRFS was 96.3% (95% CI 94.0-98.6), DFS was 85.5% (95% CI 81.8-90.7), and OS was 90.8% (95% CI 87.4-94.2). There was no difference in LRFS, DFS, or OS for margins ≤ 2 versus > 2mm, and no difference in DFS or OS for margins ≤ 1 versus > 1mm. HR+ subtype (p = 0.04) and pCR (p = 0.03) were correlated with favorable DFS and node negativity (p < 0.001) with favorable DFS and OS. In this cohort treated with NAC and BCT, there was no association between margin width and LRFS, DFS, or OS. Although further studies are needed, the excellent long-term outcomes demonstrated in patients with close (≤ 2mm) margins following NAC suggest that a margin of "no-ink-on-tumor" may be acceptable in appropriately selected patients.

Association of Positive Initial Margins With Survival Among Patients With Squamous Cell Carcinoma Treated With Total Laryngectomy

Frozen-section analysis of margin status is routinely performed during total laryngectomy for squamous cell carcinoma; in the case of positive initial frozen margins, re-resection to negative margins can often be accomplished. Some evidence suggests that positive initial margins may be associated with worse survival among patients with head and neck cancer even when final margins are negative, but the significance of positive initial frozen margins in total laryngectomy is poorly understood. To determine the association between disease-free survival and positive initial margins among patients treated with total laryngectomy for squamous cell carcinoma. In this retrospective cohort study conducted at a tertiary care center, records of 237 consecutive patients treated with total laryngectomy for squamous cell carcinoma from February 2008 to July 2016 were reviewed for demographic characteristics, disease staging, pathologic markers, and outcomes. Margins were considered to be positive if they contained invasive carcinoma, carcinoma in situ, or severe dysplasia. Data analysis was performed from March to June 2018. All patients had undergone total laryngectomy for squamous cell carcinoma. Variables associated with disease-free survival were analyzed using a univariable and multivariable Cox proportional hazards model. Among all 225 patients (184 [92%] male; mean age, 63.9 years; range, 30-92 years) who underwent total laryngectomy and had negative final margins, 127 patients underwent primary total laryngectomy and 98 underwent salvage total laryngectomy, with mean (SEM) follow-up of 29.3 (1.8) months. Initial frozen margins were positive in 40 of 225 patients (18%); positive initial margins occurred in 21 of 127 patients who underwent primary total laryngectomy (17%) and in 19 of 98 patients who underwent salvage total laryngectomy (19%). On multivariable analysis, only salvage laryngectomy was associated with significantly worse disease-free survival (hazard ratio [HR], 3.35; 95% CI, 1.76-6.36). Among 98 patients who underwent salvage total laryngectomy, positive lymph nodes, lymphovascular invasion, extracapsular nodal extension, and adjuvant therapy were associated with worse disease-free survival on univariable analysis, but no factors remained significant on multivariable analysis. Among 127 patients who underwent primary total laryngectomy, positive nodes, lymphovascular invasion, extracapsular nodal extension, and positive initial margins were associated with worse disease-free survival; however, only positive initial margins were associated with significantly worse disease-free survival on multivariable analysis (HR, 5.01; 95% CI, 1.55-16.2). In this study, positive initial margins were associated with worse disease-free survival among patients who underwent primary total laryngectomy despite negative margins on final pathologic examination. This finding may indicate aggressive tumor behavior in the context of primary laryngeal squamous cell carcinoma.