Final Pathologic Analysis Research Articles

Intraoperative Parathyroid Hormone Aspiration: Implementation and Technique

Introduction: Fine-needle aspiration with parathyroid aspiration has been described as a preoperative adjunct to confirm parathyroid tissue. However, intraoperative parathyroid hormone (IOPTH) wash can also be used to replace the need for frozen section confirmation of parathyroid tissue during parathyroid exploration. This video describes the implementation and validation of the operative technique. Materials and Methods: Preclinical implementation—Ex vivo aspiration of two hyperfunctional parathyroid glands and two thyroid lobectomy specimens prospectively stored in our tissue bank was evaluated using the IOPTH assay (Roche E411) to establish reproducibility and reference standards. Tissue IOPTH samples were centrifuged and run just as serum IOPTH samples, with no homogenization required. Clinical implementation—During parathyroid exploration, 1 mL of normal saline was drawn into a 3 mL syringe. After resection of each culprit parathyroid gland or glands, a 25-gauge needle was passed back and forth through the resected tissue several times with aspiration until a flash was seen in the hub. The aspirate was sent to the laboratory for analysis of an IOPTH level, the parathyroid gland was weighed intraoperatively, and the IOPTH tissue result was reported back to the operating room. The hyperfunctional parathyroid tissue was later sent for routine histology analysis. Results: In preclinical implementation, the mean IOPTH level of the hyperfunctional parathyroid tissue was 5000 pg/mL vs 86 pg/mL for thyroid tissue. Clinically, from July 1, 2015, to October 31, 2015, there were 72 IOPTH aspirates in 55 patients. Overall, 68 samples (94.4%) were identified to be enlarged hyperfunctional parathyroid glands on final pathology analysis with mean tissue IOPTH level of 3533 ± 661 pg/mL. Conversely, three samples with mean PTH 15 ± 6 pg/mL were confirmed on final pathology analysis to be thyroid, thymus, and lymph node tissues, respectively. There was one false positive result with a PTH aspirate value of 968 pg/mL, which on final pathology analysis was extrathyroidal thyroid tissue. The mean time to receipt of tissue IOPTH result was 16 minutes (range 14–20). For hyperfunctional parathyroid glands, IOPTH sensitivity was 100%, positive predictive value was 98.6%, and the negative predictive value was 100%. Conclusion: Intraoperative PTH aspirate analysis can be used to replace frozen section confirmation of parathyroid tissue during parathyroidectomy. The technique is easy to implement, provides prompt results, has a positive predictive value of 98.6%, and readily differentiates parathyroid tissue from other nearby tissues during parathyroid exploration. This project used the Tissue and Research Pathology Services/Health Sciences Tissue Bank which receives funding from P30CA047904. No competing financial interests exist. Runtime of video: 4 mins 6 secs

Application des recommandations dans la prise en charge du cancer de l’endomètre en pratique clinique. Étude rétrospective bretonne

To assess the use of French Cancer Institute recommendations for the diagnosis and treatment of endometrial cancer. Retrospective observational study involving 137patients with endometrial cancer between 2011 and 2013. Both MRI and pathological assessment with correct report as recommended were used for 66.4% of patients with endometrial cancer. For patients with correct preoperative assessment, 44.9% of patients were uncorrectly classified and upgraded on final pathological analysis of hysterectomy concerning lymph node involvement risk. These patients did not have confident surgical assessment, according this risk. To improve relevance of preoperative assessment in endometrial cancer, radiological and pathological expertise is required. However, even performed optimally, preoperative assessment does not allow correct risk stratification of lymph node involvement in endometrial cancer. This ineffective stratification leads to propose sentinel lymph node biopsy with hysterectomy in case of preoperative low risk endometrial cancer assessment.

Role of PET/CT in Gastrointestinal Stromal Tumors

The first accurate description of mesenchymal neoplasms of the gastrointestinal tract (GIT) was in 1941. With the advent of immuno-histochemical analysis a definition of a new entity among gastrointestinal mesenchymal tumors called the gastrointestinal stromal tumors (GISTs); which particularly express the kit (CD117) protein; a growth factor trans-membrane receptor with tyrosine kinase activity(1 ) . Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal tumors of the gastrointestinal tract(2). GISTs are usually found in the stomach or small intestine but can occur anywhere along the gastrointestinal tract and rarely have extra-gastrointestinal involvement. Approximately 50-70% of GISTs originate in the stomach. The small intestine is the second most common location, with 20-30% of GISTs arising from the jejuno-ileum. Less frequent sites of occurrence include the colon and rectum (5-15%) and esophagus (<5%). Primary pancreatic, omental, or mesenteric GISTs have been reported but are very rare (3). Surgery remains the mainstay of therapy for patients with primary GIST who do not have evidence of metastasis and should be the initial therapy if the tumor is technically resectable with acceptable risk of morbidity. Regarding patients with a positive microscopic margin on final pathologic analysis, the management is still not well defined. There is no evidence that those patients with complete resection of all macroscopic disease, but still have microscopically positive margins, need to undergo re-excision. Lymphadenectomy is usually unnecessary because lymph node metastases are rare with GIST and sarcomas in general (4). There are different schemes for classification of GISTs on the basis of tumor size and mitotic count into very low risk, low risk, intermediate risk, and high risk. Alternatively, they are classified

Microscopic Positive Tumor Margin Does Not Increase the Risk of Recurrence in Patients with T1-T2 Well-Differentiated Thyroid Cancer.

Incomplete surgical resection with gross positive tumor margin increases the risk of recurrence in patients with well-differentiated thyroid cancer (WDTC); however, it is not clear whether a microscopic positive margin found only on final pathology has similar implications on patient outcomes. We conducted a single-institution retrospective review of all patients undergoing total thyroidectomy for T1-T2 WDTC (January 2000-January 2010). Factors that may influence the risk of locoregional recurrence or distant metastasis were evaluated by univariate and multivariate analysis. Of 1000 consecutive patients undergoing surgical resection for WDTC, 684 T1-T2 cancers were included. Mean age was 46years and 81% were women. Of this total cohort, 78 (11%) patients had microscopic positive margins. Radioactive iodine (RAI) was administered in 47/78 (60%) patients with positive margins versus 312/606 (51%) patients without positive margins. After a mean follow-up of 46months, 53 (8%) patients developed recurrent disease (1 local and 52 nodal). On multivariate analysis, nodal metastases (N1, odds ratio [OR] 7.7) and contralateral multifocality (OR 3.7) were independent risk factors for recurrent disease. A microscopic positive margin was not a risk factor for recurrence. A microscopic positive margin found only on final pathological analysis does not increase the risk of recurrence in T1-T2 WDTC. Clinicians should interpret such pathology findings accordingly when considering further surveillance and treatment decisions such as the use of RAI ablation.

Laparoscopic Indocyanine Green Sentinel Lymph Node Mapping in Pregnant Cervical Cancer Patients

We present cases of 2 pregnant patients with early-stage cervical cancer who have undergone indocyanine green (ICG) sentinel lymph node (SLN) mapping followed by laparoscopic SLN biopsy, pelvic lymphadenectomy, and cervical conization. Eight milliliters of ICG were injected in the 4 quadrants of the cervix after having obtained an adequate pneumoperitoneum and having inspected the abdominal cavity. SLNs were identified in both hemipelvises in both patients. In the final pathologic analysis, both SLNs and non-SLNs were negative for metastatic disease. No adverse events from ICG injection were recorded. ICG SLN mapping seems to be feasible in pregnant cervical cancer patients.

When Does Neoadjuvant Chemotherapy Really Avoid Radiotherapy? Clinical Predictors of Adjuvant Radiotherapy in Cervical Cancer.

The aim of this study was to identify clinical variables that may predict the need for adjuvant radiotherapy after neoadjuvant chemotherapy (NACT) and radical surgery in locally advanced cervical cancer patients. A retrospective series of cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) stages IB2-IIB treated with NACT followed by radical surgery was analyzed. Clinical predictors of persistence of intermediate- and/or high-risk factors at final pathological analysis were investigated. Statistical analysis was performed using univariate and multivariate analysis and using a model based on artificial intelligence known as artificial neuronal network (ANN) analysis. Overall, 101 patients were available for the analyses. Fifty-two (51 %) patients were considered at high risk secondary to parametrial, resection margin and/or lymph node involvement. When disease was confined to the cervix, four (4 %) patients were considered at intermediate risk. At univariate analysis, FIGO grade 3, stage IIB disease at diagnosis and the presence of enlarged nodes before NACT predicted the presence of intermediate- and/or high-risk factors at final pathological analysis. At multivariate analysis, only FIGO grade 3 and tumor diameter maintained statistical significance. The specificity of ANN models in evaluating predictive variables was slightly superior to conventional multivariable models. FIGO grade, stage, tumor diameter, and histology are associated with persistence of pathological intermediate- and/or high-risk factors after NACT and radical surgery. This information is useful in counseling patients at the time of treatment planning with regard to the probability of being subjected to pelvic radiotherapy after completion of the initially planned treatment.

The influence of intraoperative frozen section analysis in patients with total or extended maxillectomy

Intraoperative frozen sections and final pathology may influence treatment with regards to intraoperative and postoperative treatments, respectively. A retrospective study comparing intraoperative frozen section analysis with final pathologic analysis in patients who had total or extended maxillectomies for malignant disease between 2008 and 2013. Twenty-five patients met the inclusion criteria. The mean age was 67.8 years. The majority of patients (76%) had stage IV disease (American Joint Committee on Cancer [AJCC] staging). Intraoperative frozen sections were positive in 24% (n = 6) compared with 60% (n = 15) on final pathologic analysis. Frozen section analysis had a sensitivity of 40%. Positive margins were resected where possible, unless limited by proximity to vital structures. Patients were statistically more likely to follow a recommendation for adjuvant therapy (P < .05) compared with adjuvant chemotherapy (P > .05). Intraoperative frozen section analyses are unreliable in predicting positive margins in patients with late-stage maxillary malignancies. Patients were more likely to accept adjuvant radiation than adjuvant chemotherapy.

PWE-303 The accuracy of magnetic resonance imaging in the management of rectal cancer – are we meeting the standard?

Introduction Magnetic Resonance Imaging (MRI) of the pelvis informs treatment strategy in rectal cancer. Complex multidisciplinary treatment plans are formulated on the basis of TNM status and proximity of the tumour to the circumferential resection margin (CRM). Previous studies 1 report a high degree of MRI accuracy. We sought to assess the regional performance of MRI assessment of CRM. Method A total of 150 consecutive patients with rectal cancer who underwent staging MRI were identified from a prospectively collected audit database comprising 6 units within Greater Glasgow and Clyde (West of Scotland Colorectal Cancer Managed Clinical Network) between April 2012 and March 2013. Pre-operative MRI prediction of circumferential resection margin (CRM) involvement was studied in both groups receiving neoadjuvant therapy and those proceeding directly to surgical resection. In all cases the MRI prediction of CRM was compared with final pathological assessment of CRM status. Patients who had metastatic disease at initial diagnosis, did not undergo MRI or did not proceed to surgical resection were excluded. Results Of 102 patients who underwent resection of rectal cancer (either APR or anterior resection) 74 patients proceeded directly to surgery and 28 underwent neoadjuvant chemoradiotherapy prior to resection. Four patients were found to have an involved CRM at final pathological analysis (4%) (2 in the group proceeding direct to resection and 2 in the neodjuvant therapy group). The specificity of MRI prediction of CRM involvement, in the direct-to-surgery cohort was 100% (95% CI 95–100), and negative predictive value (NPV) was 97% (95% CI 90–99). However in the group receiving neoadjuvant therapy prior to resection, the post-treatment MRI had a specificity of 53% (95% CI 33–73) and NPV of 100% (95% CI 76–100). Conclusion Pelvic MRI has become commonplace in the staging of rectal cancer. The prediction of CRM involvement is critical to complex decision making 2 about treatment modalities and in particular whether neoadjuvant therapy is instituted. Local institution of MRI assessment has resulted in a favourably low rate of CRM involvement at final pathology (4%). A high NPV allows selective use of neoadjuvant therapy for those at risk of an involved CRM. Disclosure of interest None Declared. References Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. MERCURY Study Group. BMJ. 2006 Oct 14;333(7572):779 Multicenter Evaluation of Rectal cancer ReImaging pOst Neoadjuvant (MERRION) Therapy. Hanly AM, Ryan EM, Rogers AC, McNamara DA, Madoff RD, Winter DC; MERRION Study Group. Ann Surg . 2014. Apr;259(4):723–7. doi: 10.1097/SLA.0b013e31828f6c91. PMID:23744576

Laparoscopic Supracervical Hysterectomy With Morcellation: Should It Stay or Should It Go?

Study ObjectiveTo establish the risk of unidentified neoplasia and subsequent adverse outcomes of laparoscopic supracervical hysterectomy (SCH) with morcellation. DesignRetrospective review (Canadian Task Force classification II-2). SettingUniversity community hospital. PatientsConsecutive women who had undergone SCH with morcellation between January 2002 and December 2008. Measurements and Main ResultsMedical records were assessed for patient characteristics and outcomes. We identified 808 women who had undergone planned laparoscopic SCH with morcellation. Their median age was 44.1 years (range, 23.4–79.8 years). The most common indications were menorrhagia in 472 patients (58.4%) and leiomyomas in 400 patients (49.5%). Of the 30 patients in whom laparoscopy was converted to an open procedure before morcellation, 1 had leiomyosarcoma at final pathologic analysis. Of the 778 patients who underwent laparoscopic SCH with morcellation, 16 (2.0%) had endometrial hyperplasia and 3 (0.4%) had cancer at final pathologic analysis. Abnormal pathologic findings were more likely in women older than age 50 years with abnormal bleeding. Of the 778 patients, 189 were younger than 40 years, and 4 of these 189 women (2.1%) had hyperplasia at final pathologic analysis; none had cancer. Of the 433 patients aged 40 to 49 years, 8 (1.8%) had hyperplasia or cancer. Of the 156 patients aged 50 years or older, 7 (4.5%) had hyperplasia (p = .18); none had cancer. No patient with hyperplasia or morcellated cancer experienced adverse sequelae after a median follow-up of 90.4 months. ConclusionIn this cohort of patients who underwent laparoscopic SCH, the risk of hyperplasia or malignancy was low. Laparoscopic SCH with morcellation seems to be a low-risk procedure.

Implication of Microscopic and Macroscopic Vascular Invasion for Liver Resection in Patients with Hepatocellular Carcinoma

Background and Aim: Long-term data after liver resection for hepatocellular carcinoma (HCC) with vascular invasion are rare for non-Asian patients. The aim of the present study was to analyze the long-term outcome of liver resection for HCC with vascular invasion and to compare the results of subgroups with micro- and macrovascular invasion. Methods: From January 2000 to September 2010, 288 patients without extrahepatic metastases underwent liver resection for HCC. In 107 out of 288 patients (37%), vascular invasion was found in the final pathological analysis. The long-term outcome as well as the perioperative course of these patients was analyzed using a prospective database. Results: The 1-, 3- and 5-year cumulative survival rate of HCC patients with vascular invasion was 64.3, 41.4 and 23.9%, respectively. The median survival was 19 months. In the multivariate analysis, the overall survival was not influenced by the type of vascular invasion (micro- vs. macrovascular invasion), however overall survival was significantly impaired in case of lymphatic vessel invasion, intraoperative blood transfusions, need of fresh frozen plasma application, prolonged ICU stay and elevated preoperative bilirubin levels. Conclusions: Acceptable survival rates can be achieved in selected patients with macrovascular invasion after surgical resection, which is not markedly different from those with microvascular invasion. In view of an otherwise poor prognosis, liver resection seems to be justified for selected HCC patients with macrovascular invasion, although this stands in contrast with the BCLC recommendations. However, it is in accordance for example with the guidelines of the Asia-Pacific Association for the Study of the Liver.

Testicular‐sparing surgery for bilateral or monorchide testicular tumours: a multicenter study of long‐term oncological and functional results

To review long-term oncological and functional outcomes of testicular-sparing surgery (TSS) in men presenting with bilateral or monorchide testicular tumours at one of five reference centres for testicular neoplasm and infertility. We review 25 cases of bilateral synchrone and metachrone testicular tumours treated in five academic centres between 1984 and 2013. Clinical, biological, ultrasonography and pathological tumour findings, overall survival (OS) times, local or metastatic recurrence, pre- and postoperative hormonal profile, paternity and the need for androgen substitution were assessed. Eleven patients with a bilateral synchrone tumour and 14 patients with a testicular tumour on a solitary testicle underwent a tumorectomy. The mean (sem) patient age was 31.9 (1.04) years, total testosterone level was 4.5 (0.57) ng.mL and tumour size was 11.66 (1.49) mm. Tumour types were as follows: 11 seminoma, nine non-seminomatous or mixed germ cell tumours, four Leydig tumours, and one hamartoma. Frozen-section examination was performed in 14 patients, and matched the final pathological analysis in 11 patients. There was an OS rate of 100% and three patients (12%) presented with a local recurrence after a mean follow-up of 42.7 months. Radical orchiectomy was performed for six patients. No patient with a preserved testicle required androgen therapy; the mean postoperative total testosterone level was 4.0 ng/mL. No patient remained fertile after radiation therapy. TSS for bilateral testicular tumour is safe and effective in selected patients, and should be considered to avoid definitive androgen therapy. Adjuvant radiotherapy remains poorly described in the literature, leading to adjuvant treatment heterogeneity for testicular tumours.

Use of Endoscopic Ultrasound in the Preoperative Staging of Gastric Cancer: A Multi-Institutional Study of the US Gastric Cancer Collaborative

Endoscopic ultrasound (EUS) can be used to guide the therapeutic plan for patients with gastric adenocarcinoma (GAC), but data on its use and accuracy remain poorly defined. We sought to define the use of EUS, as well as characterize the diagnostic accuracy of EUS among patients with GAC. We identified 960 patients who underwent resection of GAC between 2000 and 2012 from 7 major academic institutions participating in the US Gastric Cancer Collaborative. Clinicopathologic and EUS data were collected and analyzed using chi and kappa statistics. Of 960 patients, 223 (23.2%) underwent evaluation with preoperative EUS. Among patients who underwent EUS, 74 (33.2%) received neoadjuvant chemotherapy; 149 (66.8%) proceeded directly to resection. Among patients who did not receive neoadjuvant therapy and received curative intent gastric resection, the EUS T classifications were T1 (33.3%), T2 (35.6%), T3 (18.9%), T4 (12.1%) and the N classifications were N0 (68.1%) and N ≥ 1 (31.9%). In contrast, when tumor stage was based on the final surgical specimen, there was a higher proportion of cases with more advanced T stage (T1, 36.4%; T2, 14.4%; T3, 23.5%; T4, 25.7%) and N stage (N0, 51.3%; N ≥ 1, 48.7%). The agreement of preoperative EUS compared with surgical staging for T (kappa= 0.28, p < 0.001) and N (kappa= 0.33, p < 0.001) classification was only fair. Less than one-quarter of patients with GAC underwent preoperative EUS staging. In patients who did not receive preoperative chemotherapy, tumor stage on EUS often did not correlate with T stage and N stage on final pathologic analysis. Endoscopic ultrasound should be combined with other staging modalities to optimize staging of patients with GAC.

Preoperative Assessment of Chest Wall Invasion in Non-Small Cell Lung Cancer Using Surgeon-Performed Ultrasound

Chest wall invasion in operable lung cancer upgrades the stage and can affect operative planning. Diagnosing chest wall invasion preoperatively is important in patient consent, in the choice of operative incision placement, and can be helpful in choosing an operative approach (open vs thoracoscopic). The objectives of this study were to determine the diagnostic accuracy of preoperative, surgeon-performed ultrasound (US) in assessing tumoral chest wall invasion (T3) in non-small cell lung cancer (NSCLC) patients and to compare its accuracy vs preoperative computed tomography (CT). This study was a prospective clinical trial (ClinicalTrials.gov: NCT01206894) that prospectively enrolled patients between September 2010 and January 2013. Eligible patients included those with NSCLC abutting the parietal pleura or invading the chest wall on preoperative CT scan of the chest and who were planned for surgical resection. Criteria for chest wall invasion on US included (1) disruption of the parietal pleura, (2) invasion of the ribs, or (3) impairment of pleural movement with respiration. The US chest wall examination was performed by the thoracic surgical team immediately before the surgical intervention. Sensitivity and specificity for CT scan and US in assessing chest wall invasion were calculated using definitive chest wall invasion on final pathologic analysis as the gold standard for chest wall invasion. During a 28-month period, 28 patients (15 men and 13 women) patients were prospectively enrolled. Mean age was 62 ± 11 years, and mean body mass index was 25.3 ± 4.5 kg/m(2). The average time for surgeon-performed US assessment looking for chest wall invasion was 5.3 ± 5 minutes. The sensitivity of US in evaluating chest wall invasion was 90.9% and the specificity was 85.7%. CT scan was associated with a sensitivity of 61.5% and a specificity of 84.6%. The positive and negative predictive values of surgeon-performed US for tumoral chest wall invasion were 83.3% and 92.3%, respectively, compared with 80% and 68.8% for CT scan. Surgeon-performed preoperative chest wall US can reliably diagnose tumoral chest wall invasion in patients with NSCLC. CT scan has poor sensitivity in predicting chest wall invasion preoperatively. Surgeon-performed US can be considered as a complementary adjunct to preoperative imaging in patients with pulmonary lesions abutting the chest wall to improve preoperative diagnosis, staging, and operative planning.

Role of [18F]Fluorodeoxyglucose Positron Emission Tomography—Computed Tomography, Sonography, and Sonographically Guided Fine–Needle Aspiration Biopsy in the Diagnosis of Axillary Lymph Nodes in Patients With Breast Cancer

The aim of this study was to compare the diagnostic performance of [(18)F]fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) with that of sonography and sonographically guided fine-needle aspiration (FNA) for determining the preoperative axillary lymph node (ALN) status and to evaluate the factors related to false-negative PET-CT, sonographic, and FNA results in ALN staging of invasive ductal carcinoma. From March 2009 to July 2012, 226 patients had a diagnosis of primary breast cancer. Among these patients, 107 constituted the study population after exclusion of transferred patients and patients with breast cancer other than invasive ductal carcinoma. The diagnostic performance of the modalities was compared with pathologic reports. Univariate and multivariate analyses were used to evaluate the relationship between clinicopathologic factors (symptoms, T stage, hormone receptors, and histologic grade), false-negative results, and true-negative results on PET-CT, sonography, and FNA. Of the 107 patients, 45 (42.1%) had positive results on final pathologic analysis of ALNs. Sonographically guided FNA had a significantly higher specificity, positive predictive value, accuracy, and area under the receiver operating characteristic curve than sonography and PET-CT (P < .01). When sonography and PET-CT were combined, the sensitivity was significantly improved (P = .019) compared with sonography alone. When FNA and PET-CT were combined, the sensitivity and negative predictive value were significantly increased compared with each modality (P < .01). Sonographically guided FNA was found to be an excellent diagnostic tool for preoperative evaluation of the ALN status. To obviate the step of sentinel lymph node biopsy for determining the ALN status, combined evaluation of ALNs by these modalities may be more complementary than the use of a single modality.

Preliminary experience with transperitoneal laparoendoscopic single-site radical nephrectomy using a home-made single-port device in China

Background Laparoendoscopic single-site (LESS) surgery represents a technique to further reduce morbidity and scarring associated with surgery. We present our preliminary experience with transperitoneal LESS radical nephrectomy (RN) using a home-made single-port device in China. Methods From July 2010 to November 2011, eleven patients with renal tumor not greater than T2 underwent LESS-RN by an experienced laparoscopic surgeon. A home-made single-port device was used through a 5-cm umbilical incision. A combination of standard and articulating laparoscopic instruments was used. The sequence of steps of LESS-RN was similar to transperitoneal laparoscopic RN. Patient characteristics, perioperative variables and postoperative outcomes were recorded and analyzed. Results Except for two transperitoneal laparoscopic conversions and one hand-assisted laparoscopic conversion, the other procedures were completed successfully without conversion to open surgery. The mean operative time was 224.5 (155-297) minutes, estimated blood loss was 270.9 (50-900) ml, and hospital stay was 10.4 (5-15) days. The mean visual analog pain scale (VAPS) on the first postoperative day was 4.0/10. Final pathological analysis revealed renal cell carcinoma in all cases with a stage distribution of three T1a, five T1b, and three T2a tumors. With the mean follow-up period of 21.4 (12-28) months, all patients were alive without evidence of tumor recurrence or metastasis, and were satisfied with the appearance of the scars. Conclusion Transperitoneal LESS-RN using a home-made single-port device is technically feasible and safe in a selected group of patients (low body mass index and stage tumor) and has excellent cosmetic results. Although preliminary oncologic outcome is not compromised, the long-term evaluation of these patients is awaited.

Robotic surgery compared with laparotomy for high-grade endometrial cancer.

High-grade endometrial cancer often presents with occult metastatic disease and this presentation pattern can be considered a contraindication to minimally invasive surgery. We sought to compare the surgical and oncologic outcomes of patients with high-grade endometrial cancer who underwent surgical management/staging via the robotic approach versus the traditional open approach. A retrospective analysis was performed of patients with high-grade endometrial cancer who were treated at a single institution from January 2008 through December 2011. High-grade endometrial histology was defined as FIGO grade 2 or 3 endometrioid, serous, clear cell or uterine carcinosarcoma. Pre-operatively, all patients had clinical stage I disease based on a combination of physical examination and imaging studies. Baseline patient demographics, operative results, complications and oncologic outcomes were analyzed. Eighty consecutive patients were included. Forty-seven patients underwent surgical management using the robotic approach and 33 patients underwent a traditional operation via laparotomy. The groups were well matched in terms of age, body mass index, medical co-morbidities, stage and histology. The average hospital stay for patients who underwent open surgery was significantly longer than for those who underwent a robotic approach [5.6 versus 1.4days (p=0.0001)]. Of the patients who underwent robotic surgery, 7/47 (15%) experienced an operative complication versus 18/33 (55%) in the open surgery cohort (p=0.002). The average number of pelvic lymph nodes retrieved in each cohort was 12. The average number of para-aortic lymph nodes retrieved in each group was 4. On final pathologic analysis, 20 patients in the robotic surgery arm were found to have disease that had spread beyond the uterus (43%), compared to 14 in the traditional surgery group (42%). There were 11/47 (23%) recurrences in the robotic surgery group during the study period, compared to 8/33 (24%) in the laparotomy group. There were no significant differences in progression-free or overall survival between the two cohorts. Robotic surgery is safer than laparotomy for patients with high-grade endometrial cancer. The oncologic outcomes appear similar. Minimizing morbidity in this patient population is important since many are elderly and will require adjuvant therapy.

Primary fallopian tube carcinoma and ectopic pregnancy: A rare co-occurrence

Primary fallopian tube carcinoma is a rare gynecologic malignancy; conversely, tubal ectopic pregnancy is relatively common. Tubal carcinoma can be identified accidentally during surgery performed for ectopic pregnancy [1] .S urgery is not a routine procedure to screen for rare tubal carcinomas during ectopic pregnancy, although both medical conditions have well-established guidelines. Suitable diagnostic strategies are based on case studies and not on high-grade evidence. We present a case of primary fallopian tube carcinoma coinciding with an ectopic pregnancy in the same fallopian tube. A 35-year-old woman presented with lower abdominal pain associated with 52 days of amenorrhea. Her medical history revealed one live birth and one spontaneous abortion in the first trimester. On examination, her vital signs were stable (pulse 100 beats/minute; blood pressure 113/77 mmHg). A physical examination revealed right lower quadrant tenderness without rebound. A bimanual examination was remarkable for a right adnexal mass with cervical tenderness. Transvaginal ultrasonography showed a complex right adnexal mass of 8.7 � 6.6 � 6.0 cm 3 in size, with an anechoic area of fluid in the pelvic cavity. Her human chorionic gonadotropin level was 17,072.5 IU/L and hemoglobin was 70 g/L. Electrolyte (Na þ ,K þ ,a nd HCO 3e ) and liver function tests (bilirubin and alanine and aspartate aminotransferases) were normal. A provisional diagnosis of right tubal pregnancy was made and confirmed by subsequent laparoscopy. There was 1000 mL of blood and clots in the pelvic cavity. The ampullary segment of the right fallopian tube showed a dilated segment of 5 � 3 � 2c m 3 in size, with extrusion through the mucosa and active bleeding. The uterus, ovaries, and left tube appeared normal. A total right salpingectomy was performed to avoid a recurrent tubal pregnancy. The specimen was sent for pathologic examination and the final pathologic analysis confirmed the existence of a tubal pregnancy (Fig. 1A). A serous papillary carcinoma (well differentiated) was an incidental finding in the same fallopian tube (Fig. 1B and C). The tubal mucosa was involved and exhibited a papillary pattern. The tubal wall was not involved. As the patient declined to undergo a second operation and her husband supported her in this decision, we elected not to perform further surgery. The patient was discharged. Primary fallopian tube carcinoma is an uncommon malignancy, accounting for approximately 1% of female genital cancers [2]. Primary fallopian tube carcinoma most frequently occurs in women between 50 years and 69 years of age, with a median age of 55 years [3]. Primary fallopian tube carcinoma, which occasionally occurs in women of reproductive age, coinciding with an ectopic pregnancy in the same fallopian tube is extremely rare. Few reports have described such cooccurrence [1]. The difference is that fallopian tube carcinoma was observed by laparotomy in the previous report, whereas it was demonstrated by diagnostic laparoscopy in the case described here. Approximately 4% of primary fallopian tube carcinomas are diagnosed pre-operatively [3]. More often, primary fallopian tube carcinoma is first appreciated by a pathologist on histopathologic examination. In most cases, surgery is performed for suspicion of a benign or malignant ovarian tumor rather than tubal carcinoma, until pathology clarifies the correct diagnosis [4]. The case presented here suggests that the diagnosis of primary fallopian tube carcinoma may also be established when performing surgery for an ectopic pregnancy.

Invited Commentary

Traditionally, invasive assessment of N1 nodes during the pretreatment evaluation of lung cancer has received little attention. Biopsy of N1 nodes before resection has not been possible, and the standard treatment, lobectomy, would remove these nodes anyway. However, many things are changing, and perhaps it is time to think differently. This article by Yasufuku and colleagues suggests that endobronchial ultrasonography (EBUS) may be a tool that makes invasive assessment of N1 nodes possible [1Yasufuku K. Nakajima T. Waddell T. Keshavjee S. Yoshino I. Endobronchial ultrasound-guided transbronchial needle aspiration for differentiating N0 vs N1 lung cancer.Ann Thorac Surg. 2013; 96: 1756-1760Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar]. At first glance, EBUS seems to perform well, at least in these expert hands. A negative result of EBUS assessment of N1 nodes carried only a 4% false-negative rate, and all EBUS-positive N1 nodes were confirmed at resection. However, there are limitations: the technique primarily assesses station 11 nodes (83% of all N1 nodes assessed), and only a few station 10 or 12 nodes were sampled. EBUS identified N1 disease in only 1% (and N2 disease in 6%) of cN0 patients by imaging. In cN1 patients by imaging, EBUS accurately confirmed either N0 or N1 status in all and identified N2 disease in 4%. Nevertheless, EBUS missed N1 disease in 5% and N2 disease in 3% of cN0 patients, and in 0 and 6%, respectively, in cN1 patients. Perhaps technologic advances and a smaller EBUS bronchoscope may eventually allow more extensive assessment of N1 nodes and decrease the rate of missed involvement. So what is the clinical impact of assessing N1 nodes (primarily station 11)? Yasufuku and colleagues suggest that we might consider preoperative chemotherapy. However, no data have suggested a major difference between preoperative and postoperative chemotherapy, especially for VATS resection, which makes adjuvant chemotherapy much better tolerated. If lobectomy is planned, there is probably still little benefit to assessing N1 nodes, and the same may be true for segmentectomy. However, if a truly localized treatment is contemplated (wedge, radiofrequency ablation, stereotactic body radiation therapy), confirmation of N0 status may be important. In cN0 patients by imaging, identifying 1% (and missing 5%) of patients as having N1 involvement does not provide strong justification for sampling N1 nodes by EBUS. Thus, at least with the current technology, in compromised cN0 patients considered for localized therapy, EBUS is unlikely to have a major impact in the assessment of N1 nodes (but may still be important for N2 nodes). Highly localized treatment is considered electively in noncompromised patients primarily for ground glass opacities or very small tumors. EBUS in such patients appears even more unlikely to find N1 involvement. However, the finding is important that 68% of cN1patients actually had N0 disease by final pathologic analysis and that this could be confirmed reliably by EBUS. It seems likely that the performance of EBUS demonstrated in this study would apply to these patients. Given the safety of EBUS in general, it seems that even compromised patients with severe chronic obstructive pulmonary disease would probably be able to tolerate EBUS assessment of N1 (and N2) nodes if they are candidates for treatment at all. Such patients may benefit the most: EBUS may allow many of these compromised cN1 patients to be treated, whereas by imaging alone they might be considered not candidates for any treatment. It remains to be seen whether the results demonstrated by this excellent team can be duplicated more broadly. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Differentiating N0 Versus N1 Lung CancerThe Annals of Thoracic SurgeryVol. 96Issue 5PreviewThe aim of this study was to assess the value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for differentiating cN0 versus cN1 non-small cell lung cancer. Full-Text PDF

Papillary thyroid carcinoma and laryngeal squamous cell carcinoma manifesting as a collision tumor of the neck: A case report

A 55-year-old male presented with a rapidly expanding mass on the right side of the neck and progressive hoarseness. An electronic laryngoscopy and a computed tomography scan were performed, and the patient was subsequently diagnosed with tumors of the larynx and the thyroid gland. An en bloc near-total thyroidectomy combined with a total laryngectomy was performed. The final pathological analysis revealed a collision tumor that was derived from a laryngeal squamous cell carcinoma and a papillary thyroid carcinoma. Collision tumors of the head and neck are rare. The therapy for a collision tumor should consist of a combination of the treatments that are normally used for each focus.

Parapharyngeal space neoplasm: pleomorphic adenoma or carcinoid tumour?

We present a case of a parapharyngeal tumour whose preoperative study suggested that it was a neuroendocrine tumour but the final pathologic analysis revealed a pleomorphic adenoma. A female patient aged 36 presented with a mass (5×4,5×2cm) located in the parapharyngeal space, incidentally identified in a sella turcica MRI, for Cushing syndrome suspicion. Simultaneously, was found a slight elevation of urinary catecholamines. The neck MRI and CT revealed a parapharyngeal mass with heterogeneous characteristics that could correspond a neurogenic tumour.