Final Pathological Evaluation Research Articles

Prognostic impact of microscopic residual disease after neoadjuvant chemotherapy in patients undergoing interval debulking surgery for advanced ovarian cancer.

To determine the prognostic impact of microscopic residual disease after neoadjuvant chemotherapy (NACT) in patients undergoing interval debulking surgery (IDS) for advanced epithelial ovarian cancer (AEOC). Patients affected by FIGO stage IIIC-IV ovarian cancer undergoing IDS between October 2010 and April 2016 were selected. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier analysis. In total, 98 patients were identified. Four patients (4.1%) were considered inoperable. Overall, 67 patients (out of 94; 71.3%) had macroscopic disease, equating Chemotherapy Response Score (CRS) 1 and 2, 7 (7.4%) had microscopic residuals, equating CRS3, rare CRS2, while 20 (21.3%) had both microscopic and macroscopic disease. Median OS and PFS were, respectively, 44 and 14months in patients with no macroscopic residual disease (RD = 0) compared to 25 and 6months, in patients with RD > 0 (OS: p = 0.001; PFS: p = 0.002). The median PFS was 9months compared to 14months for patients with more or less than 3 areas of microscopic disease at final pathologic evaluation (p = 0.04). The serum Ca125 dosage after NACT was higher in patients with RD > 0 compared to those without residue (986.31 ± 2240.7µg/mL vs 215.72 ± 349.5µg/mL; p = 0.01). Even in the absence of macroscopic disease after NACT, the persistence of microscopic residuals predicts a poorer prognosis among AEOC patients undergoing IDS, with a trend towards worse PFS for patients with more than three affected areas. Removing all fibrotic residuals eventually hiding microscopic disease during IDS represents the key to improving the prognosis of these patients.

Encapsulated papillary carcinoma of the breast clinicopathological features and management: Could sentinel lymph node biopsy be exempted?

Papillary lesions in the breast pose diagnostic and therapeutic challenges. Encapsulated papillary carcinoma (EPC) is a rare breast cancer. However, evidence-based guidelines are limited. For this reason, there is no complete clarity in diagnosis and treatment management, and there are insufficient studies in the literature. This study aimed to examine the necessity of sentinel lymph node sampling in the management of EPC, in line with patients' clinicopathological data. We retrospectively screened patients with EPC in our clinic between January 2012 and March 2022. We recorded and statistically evaluated patients' demographic, clinical, radiological, pathological, and treatment management. Sixty-four patients with EPCs were identified. The final pathologic evaluation revealed that 19 patients (18.7%) had pure EPC, 27 patients (43.7%) had EPC with associated ductal carcinoma in situ and 18 patients (37.5%) had EPC associated with invasion. The mean age was 61 years, and two patients were male. Breast-conserving surgery was performed in 62 patients, and simple mastectomy was performed in two patients. Sentinel lymph node biopsy (SLNB) was positive in only one patient. Sixty-three patients with EPC were hormone receptor-positive, and one patient was triple-negative and was associated with invasion. None of the patients died, one had a local recurrence, and a mastectomy was performed. The overall prognosis and long-term survival of patients with EPC were excellent. Our study and the current literature indicate that routine SLNB is overtreatment because surgical excision with negative margins is sufficient in EPC cases and lymph node metastasis is rare, even with an invasive component.

A rare cause of dysphagia due to retropharyngeal foregut duplication cyst: case report and review of the literature

BackgroundThe retropharyngeal space is a deep compartment of the head and neck region which extends from the base of the skull to the mediastinum, between the posterior pharyngeal wall and vertebral muscles, delimited laterally by carotid sheaths. Pathological processes of the retropharyngeal space are rarely encountered, generally are isolated and painless masses often cystic, and they usually originate from branchial arch anomalies, but only in rare cases, they turn out to be foregut duplication cysts. Foregut duplication cyst is rare congenital malformations arising along primitively derived alimentary tract during the first trimester in the developing embryo, mostly seen in the thorax and abdomen, with just few cases reported in the head and neck region. We report an extremely rare case of a foregut duplication cyst lined with respiratory epithelium located in the retropharyngeal space, at the level of the oropharynx, of an adult patient with dysphagia surgically treated, and we also made an analysis of the published literature about this very uncommon condition.Case presentationA 63-year-old male patient with chronic dysphagia was diagnosed with a retropharyngeal cystic lesion, which was surgically treated. Final pathologic evaluation confirmed the diagnosis of a rare foregut duplication cyst lined with respiratory epithelium. A review of the pertaining published literature about the head and neck foregut duplication cysts was made, with a particular emphasis on retropharyngeal ones.ConclusionsRetropharyngeal foregut duplication cysts are a very rare congenital cyst of the head and neck. Clinical symptoms such as dysphagia and dyspnea should be evaluated with fibrolaryngoscopy, and CT and MRI scans are of great significance for definitive diagnosis, which should include the possibility of a foregut duplication cyst in the differential diagnosis. Surgical excision is the elective treatment for this lesion, in order to prevent complications including infection and compression symptoms or eventually malignant transformation.

Refining Target Volume Coverage After Parotidectomy for Cutaneous Squamous Cell Carcinoma: Omission of the Cervical Neck From the Radiation Field

For patients without pathologic evidence of cervical disease after neck dissection for cutaneous squamous cell carcinoma involving the parotid region, inclusion of the ipsilateral cervical neck in the postparotidectomy radiation volume is routinely performed. We report our experience with selective avoidance of the ipsilateral neck for patients undergoing postoperative radiation to the parotid bed. From January 2014 to December 2023, a total of 30 consecutive patients underwent postoperative radiation after parotidectomy for cutaneous squamous cell carcinoma involving the parotid area. All patients had previously had a neck dissection confirming pathologic N0 disease. Treatment was delivered using intensity modulated radiation therapy to a median dose of 60 Gy (range, 56-66 Gy). The radiation target volumes included the parotid bed only, with deliberate avoidance of the ipsilateral cervical neck. The median pathologic tumor size of the parotid tumor was 3.3 cm (range, 0.2-9.4 cm). Final pathologic evaluation showed positive microscopic margins in 8 patients (27%), perineural invasion in 17 patients (57%), and facial nerve involvement in 6 patients (20%). There were no isolated nodal failures. One patient developed an ipsilateral neck recurrence approximately 8 months after completion of radiation therapy. This occurred 2 months subsequent to the development of local recurrence. The 5-year actuarial rates of local (parotid) control, neck control, and overall survival were 87%, 97%, and 76%, respectively. Omission of the ipsilateral neck from the parotid volume does not compromise disease control for pathologically N0 patients undergoing postoperative radiation for cutaneous squamous cell carcinoma involving the parotid region. Practical implications are discussed.

Lowering the bar for consideration of neoadjuvant chemotherapy in early-stage HER2-positive breast cancers.

e12534 Background: The use of neoadjuvant chemotherapy (NAC) has contributed to increased rates of disease-free survival (DFS) as well as overall survival in breast cancer patients, specifically those with HER2-positive disease. Stage 2 patients with HER2-positive disease including tumors > 2cm as well as node positive disease receive neoadjuvant chemotherapy as per current NCCN guidelines. The aim of our study was to understand outcomes in patients with early breast cancer receiving chemotherapy. Methods: We extracted data on patients with initial clinical stages IA-IB breast cancer who had HER2-positive status on initial biopsy and received chemotherapy plus anti-HER2 therapy in the Henry Ford Health System between January 2016 to June 2020. Patients with T2 or above and/or node positive disease were excluded. Results: Of the 229 total patients that met eligibility criteria, 159 (71%) were white, 65 (28%) were African American. 99% were females. The median age at diagnosis was 61 years. Estrogen receptor positivity was noted in 85% (196/229) of the patients. NAC was given to 56 patients (24%) of which 26 (46%) were African American and 45 (80%) were hormone receptor positive. 5 (9%) patients achieved pathological complete remission (CR). Remaining 51 patients (91%) did not have pathological CR. Of these, 17 (33%) patients had the same stage at surgery after NAC and 34 (66%) were upstaged on final pathological evaluation. 21 patients with residual disease (41%) underwent treatment change in the form of either ado-trastuzumab emtasine (TDM-1) or additional radiation therapy or repeat surgery. Of note, 34 of the 51 patients were treated for residual disease after 2019 with TDM-1. 54 (95%) patients are alive currently. Of the 173 patients that received adjuvant chemotherapy (76%), 39 (23%) were African American and 150 (87%) had hormone receptor positive disease. 19 of these (11%) were upstaged at surgery compared to the initial biopsy requiring treatment change. 163 (94%) are alive currently with no disease recurrence. Conclusions: Our study results suggest that NAC is used in minority of breast cancer patients, especially with stages 1A and 1B. Pathological CR rate in our study population was low and majority of patients who got NAC as well as a small percent of those who received adjuvant chemotherapy had disease upstaged based on surgical pathology results. We believe that this could be because of inaccurate initial staging due to limitations of imaging techniques and our population being mostly hormone receptor positive. With approval of TDM-1 in patients with residual disease post NAC, we may be able to improve outcomes in terms of recurrences and survival in these patients. Thus, consideration of NAC for early stage HER2-positive breast cancers appears attractive and data like our study may support ongoing prospective clinical trials.

DOES THE PRESENCE OF CHRONIC LYMPHOCYTIC THYROIDITIS AFFECT DIAGNOSTIC VALUE OF FINE NEEDLE ASPIRATION BIOPSY IN BETHESDA CATEGORY III NODULES?

This study aimed to determine the relationship between the presence of Hashimoto's thyroiditis (HT) and malignancy rates with prognostic factors in thyroid nodules diagnosed as Bethesda category III, and to examine the effect of HT on diagnostic value of fine-needle aspiration biopsy (FNAB). Demographic information, preoperative examination, and final pathological evaluation of patients with Bethesda category III (AUS-FLUS) nodules who had been operated on in our department over the last 6 years were analyzed. Statistical analyses were performed using the Student's t-test, Mann-Whitney U test and χ2-test and logistic regression analysis using SPSS version 22 software. The malignancy rate on final pathology of 159 patients was 24.5%. Malignancy rates were found to be higher in patients with HT coexistence (30.7% vs. 21.5%, p=0.20). Poor prognostic factors such as multifocality, number of metastatic lymph nodes (p=0.04), and extrathyroidal extension were more common in patients with cancer in the pathology specimen who were in the non-HT group. It cannot be said that HT decreases diagnostic value of FNAB in lesions diagnosed with AUS-FLUS. The lower incidence of poor prognostic factors in the HT group may be attributed to cytotoxic cell dominance in tumor immunity.

Serum miRNA-204-5p as a potential non-invasive biomarker for the diagnosis of endometrial cancer with sentinel lymph node mapping.

The lymph node status is one of the most critical prognostic factors used in determining adjuvant treatment in endometrial cancer (EC). Lymphadenectomy is associated significant surgical and postoperative risks. The use of sentinel lymph node mapping (SLNM) has emerged as an alternative method to complete lymphadenectomy in EC. However, there remains controversy surrounding the use of SLNM in high-risk disease and its false-negative rate (3%). The authors previously identified miR-204-5p as a tumor-suppressor miRNA associated with lymph node metastasis in EC tissues. The present study demonstrated that serum miR-204-5p in patients with EC has the potential for use as an early diagnostic biomarker combined with SLNM to assess the lymph node status prior to surgery. The present study also aimed to identify the optimal cut-off value of serum miR-204-5p. The relative expression levels of miR-204-5p were detected using reverse transcription-quantitative PCR in the serum of 52 patients with EC (total SLNM). A total of 20 patients diagnosed with ovarian cysts, 20 patients diagnosed with myoma, and 20 participants diagnosed with endometrial polyps or endometrial hyperplasia were included as the control group. miR-204-5p expression was also detected in lymph node tissues using in situ hybridization. The results revealed that serum miR-204-5p expression was downregulated in patients with EC compared with its expression in patients with benign ovarian cysts, myoma and endometrial hyperplasia/polyps (P<0.01). In accordance with the final pathological evaluation, patients with EC with a positive SLN status had a significantly lower level of miR-204-5p compared with those with a negative SLN status (P<0.01). The area under the ROC curve of miR-204-5p was 0.923, 95% CI (0.847-1.000), and the diagnostic value had a sensitivity of 87.2% and specificity of 80.0%, with an optimal cut-off value of 0.253. On the whole, it was demonstrated that a lower miR-204-5p expression is associated with lymph node metastasis in these SLN(+) EC tissues, indicating that the downregulation of serum miR-204-5p in patients with EC has potential for use as an early diagnostic biomarker combined with SLNM. In addition, with a cut-off value of 0.253, it appeared optimal for the prediction of lymph node metastasis in EC.

Neoadjuvant immunotherapy facilitates resection of surgically-challenging lung squamous cell cancer.

BackgroundLocally-advanced lung squamous cell carcinoma represents a special subset that is challenging to resect completely with surgery alone. Immunotherapy has achieved great success in treating late-stage lung cancer. However, whether neoadjuvant immunotherapy can facilitate resection of initially locally-advanced and surgically-difficult locally-advanced lung squamous cell carcinoma remains to be investigated.MethodsWe retrospectively collected clinical records of locally-advanced lung squamous cell carcinoma patients who received neoadjuvant immunotherapy followed by surgery between 2018 and 2020 at a large academic thoracic cancer center.ResultsA total of 23 patients (22 males, 1 female) with locally-advanced locally-advanced lung squamous cell carcinoma were included, initially clinically staged at IIIA (16, 69.6%), IIIB (n=4, 17.4%), IIB (n=2, 8.7%) and IIIC (n=1, 4.3%). The median interval between final treatment to surgery was 36 days (range, 25–93 days), without treatment-related delay in surgery. The neoadjuvant treatment resulted in a high rate of radical resection (n=20, 87.0%). The final histopathological examination demonstrated 6 (26.1%) cases with pathological complete response and 8 (34.8%) with pathological major response. Comparing with the computed tomography scan-based response, we observed a very low consistency (weighted kappa =0.122, P=0.315) between the computed tomography scan-based and final pathological evaluation. The median follow-up time was 510 days (range, 217–920 days). At the end of the follow-up, 1 patient died.ConclusionsOur findings showed the clinical promise of neoadjuvant immunotherapy plus surgery for locally-advanced lung squamous cell carcinoma. Computed tomography scan displays a poor role in assessing the resectability after neoadjuvant immunotherapy.

Laparoscopic Hysterectomy for Uteri >250g: Analysis of Outcomes in a Single Surgery Center

<h3>Study Objective</h3> There is conflicting data regarding the safety of hysterectomy performed on large uteri. This study aims to examine the outcomes of laparoscopic and robotic hysterectomies for large uteri in a referral tertiary academic center. <h3>Design</h3> This is a retrospective chart review study examining surgical characteristics and complications of laparoscopic/robotic hysterectomies performed for large uteri over a year-long period. <h3>Setting</h3> The setting for the study is tertiary academic institution. <h3>Patients or Participants</h3> A total of 67 laparoscopic/robotic hysterectomy cases with final pathological evaluation yielding a specimen weight of >250g were examined. <h3>Interventions</h3> The interventions for the study included laparoscopic/robotic hysterectomy. <h3>Measurements and Main Results</h3> All procedures were completed in a minimally invasive fashion. Patient characteristics included a median BMI of 31.8 (range 21-64). Average pre-operative uterine size was 16.5 weeks. The final specimen weight ranged from 255g to 2825g. The mean procedure time was 195 minutes (SD 69 minutes). Intraoperative complications included three serosal injuries and six vaginal/peroneal lacerations. In 76% of the cases, the uterine artery was ligated at the origin to minimize the blood loss. The estimated blood loss for surgery ranged from 25 to 600cc, with a median blood loss of 150cc. All the specimens were removed vaginally. Morcellation was completed in a contained fashion within a bag. The median post-operative stay in the hospital was 0 days (range 0-2 days). Post operatively, three patients had vaginal cuff dehiscence's with only one patient requiring readmission and reoperation. There were two admissions for post-operative small bowel obstruction vs ileus which were managed conservatively, and one readmission for post-operative pain. Final pathological evaluation of specimens showed leiomyomata in 91% of cases, adenomyosis in 51%, endometriosis in 18%, and malignancy in 1%. <h3>Conclusion</h3> The findings from this study add to existing data confirming that laparoscopic/robotic hysterectomy for large uteri is a feasible surgical approach without compromising patient safety or increasing surgical risks.

Perineural Invasion of the Intratemporal Facial Nerve: How Far Proximally Do We Chase the Positive Margin?

To determine recurrence patterns in patients with head and neck cancers requiring facial nerve sacrifice and to determine the optimal management of the positive proximal facial nerve margin. Case series with chart review. Tertiary care center. One hundred fifty-five patients with head and neck malignancies who underwent sacrifice of the facial nerve between March 1, 1999 and October 31, 2020. Demographics, preoperative facial nerve function, prior oncologic treatment, histologic type, operative details, adjuvant treatment, recurrence patterns, and overall survival were reviewed. Recurrence rates and recurrence location. Thirteen patients (8%) had positive proximal margins on final pathologic evaluation. Six of 13 (46%) experienced disease recurrence. No disease recurred proximally along the facial nerve. The recurrence rate was 26% for negative proximal facial nerve margins. Segments of the facial nerve biopsied included: extratemporally (n = 78), at the stylomastoid foramen (36), mastoid segment (22), second genu (7), tympanic (6), geniculate (3), labyrinthine (1), and IAC (2). Median patient follow-up was 30.3 months. Our data suggest that a conservative approach to a positive proximal facial nerve margin is optimal with respect to operative planning, patient morbidity, and disease recurrence patterns. Recurrence proximally along the facial nerve is an exceedingly rare event and the necessity of biopsy proximal to the geniculate ganglion, and in some cases even to the second genu, is called into question.

Progression vs Cyst Stability of Branch-Duct Intraductal Papillary Mucinous Neoplasms After Observation and Surgery

The progression of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas to malignant disease is still poorly understood. Observational and surgical series have failed to provide comprehensive information. To identify dynamic variables associated with the development of malignant neoplasms by combining pathological features with data from preoperative repeated observations. The Crossover Observational Multicentric Study included a retrospective cohort of patients with branch-duct IPMNs (BD IPMNs) enrolled in a surveillance program from January 1, 2000, to December 31, 2019. Patients were enrolled from 5 referral centers: the Pancreas Institute, Verona, Italy; Seoul National University Hospital, Seoul, South Korea; Singapore General Hospital, Singapore; Johns Hopkins School of Medicine, Baltimore, Maryland; and University of Texas MD Anderson Cancer Center, Houston. Patients underwent a minimum of 12 months of preoperative surveillance (median, 37 [interquartile range (IQR), 20-68] months). Dynamic variables associated with malignant disease were explored to estimate the presence of high-grade dysplasia (HGD) and invasive cancer at final pathological examination. A total of 292 patients were included in the analysis (137 women [46.9%] and 155 men [53.1%]; median age, 64 [IQR, 56-71] years). During surveillance, 27 patients (9.2%) developed a worrisome feature after 5 years, and 46 of 276 (16.7%) developed high-risk stigmata (HRS). At final pathological evaluation, 107 patients (36.6%) had HGD or invasive cancer, and 16 (5.5%) had IPMNs with concomitant pancreatic ductal adenocarcinoma. Rates of HGD and invasive cancer at pathological evaluation significantly differed between those without worrisome features and those developing HRS from a previous worrisome feature (9 [27.3%] vs 13 [61.9%]; P < .001). Developing an additional worrisome feature during surveillance (odds ratio [OR], 3.24 [95% CI, 1.38-7.60]; P = .007) or an HRS from a baseline worrisome feature (OR, 2.87 [95% CI, 1.01-8.17]; P = .048) was associated with HGD at final pathological evaluation. Among HRS, development of jaundice on a low-risk cyst was independently associated with invasive cancer (OR, 16.04 [95% CI, 2.94-87.40]; P = .001). These findings suggest that in BD IPMNs under surveillance, harboring a stable worrisome feature carries the lowest risk of malignant disease. Development of additional worrisome features or HRS is associated with the presence of HGD, whereas the occurrence of jaundice is associated with invasive cancer.

Unusual location of a second branchial cleft cyst presenting in the suprasternal notch

Second branchial cleft cysts (SBCCs) are congenital benign tumors that comprise up to 90% of all branchial cleft anomalies. SBCCs typically present in the lateral neck along the anterior border of the upper third of the sternocleidomastoid muscle. We describe a case of a SBCC presenting in an unusual location in the lower neck close to midline. An 18-year-old male presented with a 2-year history of a neck mass in the suprasternal notch. Imaging findings were reviewed with a head and neck radiologist who felt that the findings were highly suggestive of a fourth branchial cleft cyst. The patient underwent surgical excision of the mass. Final pathologic evaluation confirmed the diagnosis of a second branchial cleft cyst. Though extremely uncommon, second branchial cleft cysts can extend to the suprasternal notch and should not be excluded from the differential diagnoses of lower neck masses.

Ultrasound-guided Spinal Needle Localization for Resection of Abdominal Wall Endometrioma

A 47-year-old patient with 2 previous cesarean sections presented with 2 years of right lower quadrant spasm-inducing pain. The pain began with menses and lasted for 15 days each month. Magnetic resonance imaging revealed a 3.3 × 1.9 × 6.0-cm lesion in the medial aspect of the right rectus abdominis muscle, consistent with abdominal wall endometrioma (Fig. 1A). No fascial involvement was identified. At the time of surgery, intraoperative ultrasound was used to map the endometrioma (Fig. 1B). Under ultrasound guidance, the endometrioma borders were marked using 3.5-cm 20 gauge needles through the anterior abdominal wall (Fig. 2). During robotic-assisted excision of the endometrioma, the needles were intermittently advanced and withdrawn from the peritoneal cavity by the bedside assistant to delineate the limits of necessary dissection (Fig. 3). This technique contributed to efficient and complete excision. Postoperatively, the patient reported complete resolution of right lower quadrant pain. Final pathologic evaluation confirmed extensive endometriosis. Abdominal wall endometriosis (AWE) is most often found in previous abdominal surgical incisions. In women undergoing surgical excision of endometriosis, AWE was noted in 1.34% [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. The most common procedure before AWE is cesarean section with a higher risk reported with Pfannenstiel incision vs vertical midline incision [1Khan Z Zanfagnin V El-Nashar SA Famuyide AO Daftary GS Hopkins MR. Risk factors, clinical presentation, and outcomes for abdominal wall endometriosis.J Minim Invasive Gynecol. 2017; 24: 478-484Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 3Zhang P Sun Y Zhang C et al.Cesarean scar endometriosis: presentation of 198 cases and literature review.BMC Womens Health. 2019; 19: 14Crossref PubMed Scopus (23) Google Scholar]. Cesarean scar endometriosis is likely secondary to direct implantation of endometrial tissue in the incision [2Horton JD Dezee KJ Ahnfeldt EP Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases.Am J Surg. 2008; 196: 207-212Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar]. Surgical excision allows pathologic evaluation and therapeutic resection [4Karapolat B Kucuk H. A rare cause of abdominal pain: scar endometriosis.Emerg Med Int. 2019; 20192584652Crossref PubMed Google Scholar,5Behbehani S Magtibay P Chen L Wasson M. Clear cell carcinoma of the anterior abdominal wall secondary to iatrogenic endometriosis.J Minim Invasive Gynecol. 2020; 27: 1230-1231Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. Excision is often planned with preoperative ultrasound or magnetic resonance imaging. Previously reported surgical approaches to AWE include ablative techniques such as percutaneous cryoablation or ethanol injection [6Welch BT Ehman EC VanBuren WM et al.Percutaneous cryoablation of abdominal wall endometriosis: the Mayo Clinic approach.Abdom Radiol (NY). 2020; 45: 1813-1817Crossref PubMed Scopus (6) Google Scholar]. If AWE involves the fascia, surgical excision can still be performed by a minimally invasive approach with endoscopic mesh placement and fascial repair by general surgery. Intraoperative techniques to assist with excision include injecting the lesion with methylene blue or ultrasound-guided wire localization [7Lee MMH Robson NK Carpenter TT. Ultrasound-guided wired localisation for resection of impalpable anterior abdominal wall scar endometriomas.Gynecol Surg. 2012; 9: 103-105Crossref Scopus (2) Google Scholar,8Takmaz T Kiran G Ozcan P Sahin N Tanoglu B. Total surgical excision by ultrasound–guided wire localization for spontaneous abdominal-wall endometriosis.J Gynecol Surg. 2020; 36: 76-79Crossref Scopus (1) Google Scholar]. Ultrasound-guided localization with spinal needles is a simple, practical technique that can assist with complete excision of abdominal wall endometriomas.

A modified technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation through a mini-laparotomy

Radical trachelectomy is an optional fertility-sparing treatment for early-stage cervical cancer, and recently, the minimally invasive approach (MIA) has become a major trend in radical trachelectomy. MIA radical trachelectomy requires a more careful surgical technique to avoid tumor spillage and exposure of the cancerous tissue under carbon dioxide pneumoperitoneum to reduce the risk of recurrence. We present a case of a 33-year-old nulliparous woman with stage IB1 cervical cancer who underwent MIA radical trachelectomy through a combination of laparoscopic surgery and mini-laparotomy, mainly to prevent postoperative complications and tumor spread during cervical amputation. A Papanicolaou test suggested the diagnosis of squamous cell carcinoma of the cervix without any symptoms such as atypical bleeding. The subsequent biopsy revealed squamous cell carcinoma with stromal invasion of the cervix. Cervical amputation was performed extracorporeally through a small incision in the lower abdomen. There were no perioperative complications. The patient was discharged on postoperative day 13. The final pathological evaluation revealed residual microinvasive cancer of the endocervical canal with clear margins, no lymphovascular space involvement, and 27 negative lymphatic nodes. The joint of the neo-cervix and vagina had healed completely without erosion or stenosis of the cervical canal, and no problems occurred during sexual intercourse. No cancer recurrence or menstrual disorders have been reported in the short postoperative period of 6 months. The surgical technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation may be an acceptable alternative to reduce the risk of recurrence by preventing intraperitoneal tumor spillage.

PD63-09 ONCOLOGICAL OUTCOME OF LOCALIZED, LYMPH NODE-POSITIVE PROSTATE CARCINOMA AFTER RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V (PD63)1 Apr 2020PD63-09 ONCOLOGICAL OUTCOME OF LOCALIZED, LYMPH NODE-POSITIVE PROSTATE CARCINOMA AFTER RADICAL PROSTATECTOMY Lara Franziska Stolzenbach*, Philipp Mandel, Florian Loecherbach, Uwe Michl, Hans Heinzer, Markus Graefen, and Thomas Steuber Lara Franziska Stolzenbach*Lara Franziska Stolzenbach* More articles by this author , Philipp MandelPhilipp Mandel More articles by this author , Florian LoecherbachFlorian Loecherbach More articles by this author , Uwe MichlUwe Michl More articles by this author , Hans HeinzerHans Heinzer More articles by this author , Markus GraefenMarkus Graefen More articles by this author , and Thomas SteuberThomas Steuber More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000980.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pathologically confirmed regional lymph node metastases represent a major prognostic factor in patients with prostate cancer (PCa) who undergo radical prostatectomy (RP). Rarely, positive lymph nodes (pN1) are also observed in localized (pT2) PCa after RP. The aim of this study was to investigate the oncological outcomes after RP in patients with pT2 pN1 cM0 PCa. METHODS: Within a single institution database (1992-2018), we retrospectively analyzed 28,647 PCa patients who underwent radical prostatectomy between 1992 and 2018. Kaplan-Meier plots were used to depict biochemical recurrence (BCR)-free survival and multivariable Cox regression models were used to test for predictors of BCR, within patients who harboured pT2 N1 M0 PCa. RESULTS: Of 28,647 patients, 241 (0.8%) harboured pT2 N1 M0 PCa at the final pathological evaluation. This represents 1.3% of all pT2 PCa patients (n=18,369) and 8.9% of all pN1 (n=2,701) patients. Within the pT2 N1 M0 patients, the number of positive lymph nodes revealed as following: 175 (72.6%) patients had 1 positive lymph node, 41 (17.0%) patients had 2 positive lymph nodes, 25 (10.4%) patients had ³3 positive lymph nodes. The median follow-up of all patients was 36.3 months. 20 (8.3%) and 56 (23.2%) pT2 N1 M0 PCa patients received either adjuvant (aRT) or salvage radiation (sRT), respectively. 3 and 16 patients received additionally to the RT adjuvant antiandrogen therapy (ADT) or salvage ADT. 3 (1.2%) and 15 (6.2%) pT2 N1 M0 PCa patients were only treated with either adjuvant or salvage ADT. During the follow-up, 4 (1.6%) individuals died of PCA and 16 developed metastases, which resulted in a 5-year MFS of 92.5%. Median BCR-free survival was 36.3 months and 5-year BCR-free survival rate was of 54.7 %, within the entire pT2 N1 M0 PCa cohort. Of these, patients who received only aRT showed significantly higher BCR-free rates compared to patients who did not received any treatment (5-year BCR free survival: 94.1% vs. 80.5%; p=0.001). In the multivariable analyses adjusted for preoperative PSA value, two or more positive lymph nodes (HR 1.97, p=0.02 for 2 vs.1 and HR 4.41, p<0.01 for >=3 vs. 1), and Gleason grading group IV-V (HR 2.04, p=0.03) were associated with a higher risk of BCR. Conversely, use of aRT (HR 0.27, p=0.04) was associated with a lower risk of BCR. CONCLUSIONS: Pathologically confirmed positive lymph node disease is a rare finding within patients with pT2 PCa. 5-year BCR-free survival was 54.7% in pT2 pN1 patients. However, two or more positive lymph nodes, a Gleason grade group IV-V represent risk factors for BCR. In consequence, adjuvant radiotherapy should be recommended in patients with these clinical-pathological characteristics. Source of Funding: There was no external financial support for this study. The authors declare that they have no conflict of interest. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1296-e1296 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lara Franziska Stolzenbach* More articles by this author Philipp Mandel More articles by this author Florian Loecherbach More articles by this author Uwe Michl More articles by this author Hans Heinzer More articles by this author Markus Graefen More articles by this author Thomas Steuber More articles by this author Expand All Advertisement PDF downloadLoading ...

PD42-01 RESIDUAL MUSCLE-INVASIVE DISEASE AT CYSTECTOMY IS NOT ACCURATELY PREDICTED BY POST-CHEMOTHERAPY RESTAGING PROTOCOLS INCLUDING DNA DAMAGE RESPONSE GENE MUTATION ANALYSIS

You have accessJournal of UrologyBladder Cancer: Basic Research & Pathophysiology III (PD42)1 Apr 2020PD42-01 RESIDUAL MUSCLE-INVASIVE DISEASE AT CYSTECTOMY IS NOT ACCURATELY PREDICTED BY POST-CHEMOTHERAPY RESTAGING PROTOCOLS INCLUDING DNA DAMAGE RESPONSE GENE MUTATION ANALYSIS Russell Becker*, Alex Baras, Alexa Meyer, Aaron Brant, Adam Reese, George Netto, Andres Matoso, Jean Hoffman-Censits, Noah Hahn, Woonyoung Choi, David McConkey, Phillip Pierorazio, Michael Johnson, Mark Schoenberg, Max Kates, and Trinity Bivalacqua Russell Becker*Russell Becker* More articles by this author , Alex BarasAlex Baras More articles by this author , Alexa MeyerAlexa Meyer More articles by this author , Aaron BrantAaron Brant More articles by this author , Adam ReeseAdam Reese More articles by this author , George NettoGeorge Netto More articles by this author , Andres MatosoAndres Matoso More articles by this author , Jean Hoffman-CensitsJean Hoffman-Censits More articles by this author , Noah HahnNoah Hahn More articles by this author , Woonyoung ChoiWoonyoung Choi More articles by this author , David McConkeyDavid McConkey More articles by this author , Phillip PierorazioPhillip Pierorazio More articles by this author , Michael JohnsonMichael Johnson More articles by this author , Mark SchoenbergMark Schoenberg More articles by this author , Max KatesMax Kates More articles by this author , and Trinity BivalacquaTrinity Bivalacqua More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000922.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The standard of care for eligible patients with muscle-invasive bladder cancer (MIBC) includes neoadjuvant cisplatin-based chemotherapy (NAC), followed by radical cystectomy and urinary diversion (RC). Deleterious DNA damage response (DDR) gene mutations have been correlated with favorable response to NAC. Several groups have proposed that including DDR mutation analysis in post-NAC restaging algorithms may help define a subset of favorable responders who can safely forego RC. We sought to test this hypothesis in a cohort of patients undergoing NAC and RC. METHODS: We identified patients in our institutional RC registry who underwent a prospective protocol of post-NAC restaging prior to RC, between 2003 and 2016. Tumor DNA was captured from pre-NAC tumor specimens, and sequenced for mutations in the DDR genes ATM, RB1, ERCC2, and FANCC by Illumina HiSeq. Pathologic stages based on post-NAC restaging findings (rT) and final pathologic evaluation of the RC specimen (pT) were categorized into ≤ T1 (including carcinoma in situ) or ≥ T2, as this represents a critical inflection point in both prognosis and management strategy. RESULTS: A total of 47 patients received adequate NAC followed by restaging and RC, and had tumor tissue available for sequencing. Of these, 31 (66%) had DDR mutations, with ATM mutations being the most prevalent (21/47, 45%). Restaging and pathologic T-stage categories were concordant in 38/47 patients overall (81%), and 24/31 DDR(+) patients (77%). For patients with ≤ rT1 on post-NAC restaging, final RC pathology revealed residual muscle-invasive disease (≥ pT2) in 7/25 patients overall (28%), and 5/15 DDR(+) patients (33%, Fisher’s exact test p=0.66). CONCLUSIONS: For some favorable responders, MIBC can be downstaged or even eradicated by NAC alone. However, current restaging protocols lack the precision to reliably identify these patients, as evidenced by the 7 patients falsely downstaged in our series. The addition of DDR gene mutation analysis to restaging protocols does not enhance their accuracy. Until better discriminators are developed, post-NAC restaging and DDR mutations should not be routinely used to guide management decisions. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e827-e827 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russell Becker* More articles by this author Alex Baras More articles by this author Alexa Meyer More articles by this author Aaron Brant More articles by this author Adam Reese More articles by this author George Netto More articles by this author Andres Matoso More articles by this author Jean Hoffman-Censits More articles by this author Noah Hahn More articles by this author Woonyoung Choi More articles by this author David McConkey More articles by this author Phillip Pierorazio More articles by this author Michael Johnson More articles by this author Mark Schoenberg More articles by this author Max Kates More articles by this author Trinity Bivalacqua More articles by this author Expand All Advertisement PDF downloadLoading ...

Trocar site recurrence after robotic partial nephrectomy to treat of renal cell carcinoma.

Introduction:Wound seeding during surgical excision of malignant tumor is known problem in the oncologic surgery. Trocar site recurrence (TSR) is well described in laparoscopic oncologic surgery. Little has been reported about TSR after robotic partial nephrectomy (RPN) performed for renal cell carcinoma (RCC). Here, we report on the incidence of TSR and demonstrate the presentation of this type of RCC recurrence.Patients and Methods:We reviewed prospectively collected data about patient who underwent RPN at our institute from September 2009 to March 2018. We reviewed the medical record of the patients who had the diagnosis of RCC on the final pathology. We identified the patient with TSR and demonstrated their presentation and treatment along with the outcome.Results:A total of 335 patients underwent RPN during the study period for renal mass. Two hundred and sixty-nine (80.3%) patients were found to have RCC on the final pathologic evaluation of their mass. We identified two patients (0.7% of all the RCC in the study) who developed TSR during an average follow-up period of 31 months (ranging from 18 to 72 months). The first recurrence appeared 18 months after the surgery. The second recurrence presented 72 months after RPN. Both cases underwent open surgical excision of the trocar site, in which the recurrence appeared.Conclusion:TSR is potential type of RCC recurrence after RPN, though it is rare and underreported. Special attention should be given to examine the trocar site during the surveillance follow-up of RCC treated with RPN. It can develop up to 72 months after the surgery.

The Reliability of Intraoperative Assessment on Predicting Tumor Size, Myometrial Invasion, and Cervical Involvement in Patients With a Preoperative Diagnosis of Complex Atypical Hyperplasia or (Clinical Stage I) Endometrial Cancer: A Prospective Cohort Study.

The objective of this study is to assess the reliability of intraoperative uterine assessment compared with the final pathologic evaluation in patients with endometrial cancer (EC) and whether assessment improves with experience. After Institutional Review Board approval, a prospective cohort study of women surgically managed with biopsy-proven complex atypical hyperplasia (CAH) or EC between March 2015 and December 2016 was performed. Demographics, preoperative biopsy results, procedure, intraoperative and final pathologic evaluation of lesion size, myometrial invasion, and lower uterine segment/cervical involvement were abstracted. The agreement between the intraoperative and final pathologic evaluation of tumor involvement of the uterus was determined using the kappa statistic and the intraclass correlation coefficient. A total of 264 patients with a preoperative diagnosis of CAH or EC were included-71 (26.9%) with CAH and 193 (73.1%) with EC. The mean age was 62.6±11.5, and mean body mass index was 37.2±10.1. The majority of women were white (67%). A total of 227 (85.9%) patients underwent a laparoscopic or robotic hysterectomy, whereas 36 (13.6%) underwent an abdominal hysterectomy. 233 (88.3%) patients had EC and 21 (7.9%) patients had CAH on final pathology. There was a fair agreement between the intraoperative estimation of myometrial invasion (κ=0.37). A moderate agreement exists between the intraoperative estimation of lower uterine segment/cervical involvement (κ=0.57). There was a strong agreement between intraoperative tumor size assessment and the final path (intraclass correlation coefficient=0.74). The intraoperative correlation of tumor size was similar for the first half of the cohort (κ=0.50) and the second half (κ=0.46) chronologically. Despite only a fair correlation in the myometrial invasion, intraoperative assessment of cervical involvement and especially tumor size is more readily identified and overall accurate. Therefore, intraoperative evaluation is an additional tool to use when making the decision to proceed with surgical staging.

Impact of preoperative prostate magnetic resonance imaging on the surgical management of high-risk prostate cancer

ObjectiveTo evaluate the effect of adding multiparametric magnetic resonance imaging (mpMRI) to pre-surgical planning on surgical decision making for the management of high-risk prostate cancer (HRPC).Patients and methodsA survey was designed to query multiple centers on surgical decisions of 41 consecutive HRPC cases seen from 2012 to 2015. HRPC was defined by the National Comprehensive Cancer Center Network guidelines. Six fellowship-trained urologic oncologists were asked for their surgical plan in regards to the degree of planned nerve-sparing and lymph node dissection. Two rounds of surveys were administered to six external urologic oncologists. The first survey included the case description only and the second included case description with mpMRI images and report. The correct surgical plan was analyzed by correlation of the degree of planned surgical excision and consistency with the final pathologic evaluation. A priori, an effect size of 20% change was used to determine statistical significance, at p < 0.05.ResultsAll cases had at least one change to surgical planning after mpMRI review. Forty (98%) patients had a change in the degree of planned nerve sparing: wider excision in 32% and increased nerve sparing in 24%. After mpMRI the correct surgical plan change was made in 49% for the right and left 51%, decreasing the potential for positive margins. Lymph node dissection was altered from standard to extended lymph node dissection in 17%.ConclusionsAlthough mpMRI is not integrated in guidelines for preoperative planning in HRPC, its use may impact surgical planning, cancer control, and quality of life.

Predictors of extensive lymphatic dissemination and recurrences in node-positive endometrial cancer

ObjectiveTo identify predictors of extensive lymphatic dissemination and distant recurrences in node-positive endometrial cancer (EC). MethodsClinicopathologic data were collected of patients who had fully staged EC with at least 1 positive lymph node. Permanent sections of metastatic lymph nodes were reviewed; metastases were characterized according to size (≤2 mm and >2 mm) and location in the lymph node (intra- vs extracapsular). Risk of occurrence of multiple pelvic and para-aortic lymph node dissemination was calculated by combining risk factors identified at multivariate analysis. ResultsOf 96 patients, 85 had positive pelvic nodes, of whom 71 (83.5%) had high-volume metastases. In the presence of both macrometastasis in the pelvic basin (odds ratio [OR], 13.42; [95% CI, 2.44–73.83]) and uterine serosal involvement of the tumor at final pathologic evaluation (OR, 11.84 [95% CI, 1.22–115.11]), multiple pelvic node dissemination occurred in 91.7% of cases (vs 7.7% in the absence of both). Concomitant presence of pelvic macrometastasis, lymphovascular space invasion (LVSI), and extracapsular invasion led to 85.7% occurrence of para-aortic involvement (vs 11.1% if no factors present). LVSI was independently associated with nonvaginal recurrences (hazard ratio, 2.62 [95% CI, 1.33–5.16]). ConclusionsPresence of high-volume metastases in the pelvic lymph nodes is associated with concomitant presence of multiple positive pelvic nodes, as well as para-aortic node involvement. LVSI is associated with both para-aortic node involvement and occurrence of nonvaginal relapses. In this era of sentinel lymph node mapping, these factors may help predict the extent of lymphatic dissemination in EC.