Positive Final Margins Research Articles

Visual pathology reports for communication of final margin status in laryngeal cancer surgery

BackgroundPositive margins are frequently observed in total laryngectomy (TL) specimens. Effective communication of margin sampling sites and final margin status between surgeons and pathologists is crucial. In this study, we evaluate the utility of multimedia visual pathology reports to facilitate interdisciplinary discussion of margin status in laryngeal cancer surgery. MethodsEx vivo laryngeal cancer surgical specimens were three-dimensional (3D) scanned before standard of care pathological analysis. Using computer-aided design software, the 3D model was annotated to reflect inking, sectioning, and margin sampling sites, generating a visual pathology report. These reports were distributed to head and neck surgeons and pathologists postoperatively. ResultsFifteen laryngeal cancer surgical specimens were 3D scanned and virtually annotated from January 2022 to December 2023. Most specimens (73.3%) were squamous cell carcinomas (SCCs). Among the cases, 26.7% had final positive surgical margins, whereas 13.3% had close margins, defined as <5 mm. The visual pathology report demonstrated sites of close or positive margins on the 3D specimens and was used to facilitate postoperative communication between surgeons and pathologists in 85.7% of these cases. Visual pathology reports were presented in multidisciplinary tumor board discussions (20%), email correspondences (13.3%), and teleconferences (6.7%), and were referenced in the final written pathology reports (26.7%). Conclusions3D scanning and virtual annotation of laryngeal cancer specimens for the creation of visual pathology reports is an innovative approach for postoperative pathology documentation, margin analysis, and surgeon–pathologist communication.

Impact of pathologic features on local recurrence in penile squamous cell carcinoma after penectomy

BackgroundPenile squamous cell carcinoma (PSCC) is a rare malignancy that may be cured in cases of local disease by resection of the primary tumor. Risk factors and patterns of local recurrence (LR) have not been well described in cases requiring partial or radical penectomy. In this study, we evaluated risk factors for LR and the impact of frozen and final margin assessment. Materials and methodsWe evaluated 119 patients with PSCC who had undergone partial or radical penectomy from 2007 to 2023. Data regarding clinical and pathologic features were collected by retrospective chart review. The primary outcome of interest was LR. Determinants of LR were analyzed by Student's t, Fisher's exact, chi-square and logistic regression analysis. Predictive statistics of frozen margin status on final margin were assessed and LR rates for subsets of frozen and final margin interaction were defined. Finally, all cases of positive margins and LR were described to highlight patterns of LR and the importance of margin status in these cases. ResultsThere were 8 (6.7%) cases of local recurrence. There were no significant predictors of LR, although a trend toward increased LR risk was observed among those with a positive final margin. Positive final margins were found in 15 (13%) cases. Frozen margin analysis was utilized in 79 cases, of which 10 (13%) were positive. The sensitivity, specificity, positive predictive value, and negative predictive value of frozen margin status for final margins were 44%, 92%, 40%, and 93%, respectively. There were no LR among cases in which frozen margin was not sent. Analysis of all cases with positive margin and/or LR identified three subsets of patients: CIS or focally positive margin resulting in either no LR or LR managed with minimal local intervention, bulky disease in which survival is determined by response to subsequent therapy rather than local recurrence, and clinically significant local recurrence requiring continued surveillance and intervention despite negative margins. ConclusionsLR is rare, even in cases of larger, proximal tumors requiring partial or radical penectomy. In this study, no statistically significant risk factors for local recurrence were identified; however, analysis of frozen and final margins provided insight into the importance of margin status and patterns of local recurrence. When feasible, visibly intra-operative negative margins are an excellent predictor of low risk for LR, and, in cases of CIS or focally positive margins, further resection to achieve negative margins is unlikely to reduce the risk of clinically significant LR. Additionally, in cases of bulky disease, the goals of resection should be focused toward palliation and next line therapy.

The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment.

Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety. This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution. The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires. Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%. The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

Margin Assessment Methods in Oral Cavity Squamous Cell Carcinoma and Recurrence

Positive margins and margin clearance are risk factors for recurrence in oral cavity squamous cell carcinoma (OCSCC), and these features are used to guide decisions regarding adjuvant radiation treatment. However, the prognostic value of intraoperative tumor bed vs resection specimen sampling is not well defined. To determine the prognostic implications of intraoperative margin assessment methods (tumor bed vs resection specimen sampling) with recurrence among patients who undergo surgical resection for OCSCC. This was a retrospective study of patients who had undergone surgical resection of OCSCC between January 1, 2000, and December 31, 2021, at a tertiary-level academic institution. Patients were grouped by margin assessment method (tumor bed [defect] or resection specimen sampling). Of 223 patients with OCSCC, 109 patients had localized tumors (pT1-T2, cN0), 154 had advanced tumors, and 40 were included in both cohorts. Disease recurrence after surgery was estimated by the cumulative incidence method and compared between cohorts using hazard ratios (HRs). Data analyses were performed from January 5, 2023, to April 30, 2023. Recurrence-free survival (RFS). The study population comprised 223 patients (mean [SD] age, 62.7 [12.0] years; 88 (39.5%) female and 200 [90.0%] White individuals) of whom 158 (70.9%) had defect-driven and 65 (29.1%) had specimen-driven margin sampling. Among the 109 patients with localized cancer, intraoperative positive margins were found in 5 of 67 (7.5%) vs 8 of 42 (19.0%) for defect- vs specimen-driven sampling, respectively. Final positive margins were 3.0% for defect- (2 of 67) and 2.4% for specimen-driven (1 of 42) margin assessment. Among the 154 patients with advanced cancer, intraoperative positive margins were found in 29 of 114 (25.4%) vs 13 of 40 (32.5%) for defect- and specimen-driven margins, respectively. Final positive margins were higher in the defect-driven group (9 of 114 [7.9%] vs 1 of 40 [2.5%]). When stratified by margin assessment method, the 3-year rates of local recurrence (9.7% vs 5.1%; HR, 1.37; 95% CI, 0.51-3.66), regional recurrence (11.0% vs 10.4%; HR, 0.85; 95% CI, 0.37-1.94), and distant recurrence (6.4% vs 5.0%; HR, 1.10; 95% CI, 0.36-3.35) were not different for defect- vs specimen-driven sampling cohorts, respectively. The 3-year rate of any recurrence was 18.9% in the defect- and 15.2% in the specimen-driven cohort (HR, 0.93; 95% CI, 0.48-1.81). There were no differences in cumulative incidence of disease recurrence when comparing defect- vs specimen-driven cases. The findings of this retrospective cohort study indicate that margin assessment methods using either defect- or specimen-driven sampling did not demonstrate a clear association with the risk of recurrence after OCSCC resection. Specimen-driven sampling may be associated with reduced surgical margin positivity rates, which often necessitate concurrent chemotherapy with adjuvant radiation therapy.

How Often is Cancer Present in Oral Cavity Re-resections After Initial Positive Margins?

To evaluate the rate at which carcinoma is present in the re-resection specimen following initial positive margins during head and neck cancer surgery and its impact on oncologic outcomes. Retrospective chart review. A single institution retrospective chart review of patients that underwent curative-intent surgery for oral cavity cancer was performed. Final pathology reports were reviewed to identify patients with initial positive margins who underwent re-resection during the same operation. Initial positive margin was defined as severe dysplasia, carcinoma in situ (CIS), or carcinoma. Cox proportional hazards and Kaplan-Meier analyses were used to assess for associations with survival outcomes. Among 1873 total patients, 190 patients (10.1%) had initial positive margins and underwent re-resection during the same surgery. Additional carcinoma, CIS, or severe dysplasia was found in 29% of re-resections, and 31% of patients with initial positive margins had final positive margins. Half of the patients with a final positive margin had a positive margin at an anatomic site different than the initial positive margin that was re-resected. The median follow-up was 636 days (range 230-1537). Re-resection with cancer and final positive margin status was associated with worse overall survival (OS; p = 0.044 and p = 0.05, respectively). However, only age, T4 disease, and surgery for recurrent oral cavity cancer were independently associated with OS (p < 0.001, p = 0.005, and p = 0.001, respectively). Fewer than a third of oral cavity re-resections contain further malignancy, which may suggest that surgeons have difficulty relocating the site of initial positive margin. Final positive margins are often at anatomic sites different than the initial positive margin. 4 Laryngoscope, 134:717-724, 2024.

'Stealth' Prostate Tumors.

The aim of this study was to determine the false negative rates of prebiopsy magnetic resonance imaging (MRI) and MRI-ultrasound (US) 12-core systematic prostate biopsy (PBx) by analyzing radical prostatectomy specimens. This retrospective study included 3600 prostate cancer (PCa) patients who underwent robot-assisted laparoscopic radical prostatectomy. Based on comparison of lobe-specific data on final pathology with preoperative biopsy and imaging data, the study population was subdivided into group I-contralateral (CL) benign PBx (n = 983), group II-CL and/or bilateral (BL) non-suspicious mpMRI (n = 2223) and group III-CL benign PBx + non-suspicious mpMRI (n = 688). This population was studied for the presence of PCa, clinically significant PCa (csPCa), extracapsular extension (ECE) (pathological stage pT3), positive frozen section and final positive surgical margin (PSM) in the CL lobe. Descriptive statistics were performed. In subgroups I, II and III, PCa was respectively detected in 21.5%, 37.7% and 19.5% of cases, and csPCa in 11.3%, 16.3% and 10.3% of cases. CL pT3 disease was seen in 4.5%, 4% and 5.5%, and CL surgical margins and/or frozen section analysis were positive in 6%, 7% and 5% of cases in subgroups I, II and III, respectively. There are still significant rates of false negatives in the standard care diagnostics of PCa. Further strategies are required to improve the accuracy of diagnosis and determination of tumor location.

Frequency and accuracy of intraoperative bone margin sampling for T4a cancers of the head and neck at the QEII Health Sciences Centre: a retrospective chart review

BackgroundStage T4a cancers are associated with a 5-year survival of 21.6–59.0%. Adequate resection of these tumors is a critical factor in maximizing survival. Tumors invading bone pose a unique challenge to intraoperative bone margin assessment. Due to processing limitations, there had been no formal standardized protocol for intraoperative bone sampling at the QEII Health Sciences Centre. These resections often involve extensive reconstruction, making salvage surgery difficult if positive margins are detected post-surgically. The purpose of this study was to assess the accuracy and frequency of intraoperative bone margin assessment during the study period and to determine survival and recurrence rates associated with positive final bone margins.MethodsA retrospective chart review was conducted including patients with stage T4a head and neck cancer involving bone that underwent primary surgical resection in Nova Scotia between 2009 and 2019. Eligible patients were identified through the Cancer Care Nova Scotia registry. Exclusion criteria included patients with stage T4a tumors involving bone that did not receive primary surgical treatment with curative intent and patients with stage T4a tumors that did not invade bone.ResultsOf 67 patients included, 50 were amenable to intraoperative bone margin sampling while 18 had intraoperative sampling. Four patients had positive intraoperative margins and one had final positive bone margins. The incidence of final bone margin positivity was 7.5%. Median survival following surgery was 4.56 years for patients with final negative bone margins (n = 62) and 3.98 years for patients with positive final bone margins (n = 5). All patients with final positive bone margins received adjuvant radiation therapy. Of patients with negative final bone margins, 16.1% received no adjuvant therapy, 61.3% received adjuvant radiation therapy and 21.0% received adjuvant chemoradiation therapy.ConclusionIntraoperative bone margin sampling occurred in 26.8% of all cases and 36.0% of amenable cases. Median survival of patients with positive final bone margins was 0.58 years lower than those with negative final bone margins, although this difference did not reach statistical significance. This will provide baseline data for comparison of the standardized intraoperative bone margin sampling protocol implemented at the QEII Health Sciences Centre.Graphical

Specimen-Based Resection Margins and Local Control during Transoral Robotic Surgery for Oropharyngeal HPV-Mediated Squamous Cell Carcinoma

Objectives: The aim of the study was to investigate the association of surgical margin conditions, including positive specimen margins revised to negative relative to local recurrence, disease-free survival, and overall survival (OS) within a cohort of HPV-mediated oropharyngeal squamous cell carcinoma (OPSCC) who underwent en bloc resection via transoral robotic surgery (TORS). Materials and Methods: Retrospective cohort of patients with untreated HPV-mediated OPSCC cT1 or T2 undergoing TORS resection between October 2014 and March 2020. The methodologic description of our interdisciplinary institutional approach, number of cut-through margins (CTMs) during intraoperative consultation, percentage of final positive margin cases, and disease-free survival and OS stratified by margin status and margin tumor-free distance is identified. Results: 135 patients with primary cT1/T2 HPV-mediated OPSCC met inclusion criteria. Twenty-eight of 135 (20.7%) specimens revealed CTM and were revised during the same operative setting. Three of 135 (2.2%) surgical cases had positive final margin status. Local control rate was 97%. On univariate analysis, margin distance did not impact OS. CTM and final positive margins had lower OS than initially negative margins (p = 0.044). Pathologic N-stage significantly impacted OS (p < 0.001). Conclusions: High local control rate and low final positive margin status confound the study of specimen margin-based techniques in HPV-mediated OPSCC resected en bloc with TORS. Pathologic N-stage may impact OS more than margin status. Larger numbers are needed to confirm differences.

The Accuracy of Sequential Urethral Frozen Section and its Impact on Urethral Recurrence After Radical Cystectomy.

To assess the accuracy of frozen section analysis (FSA) for detecting and eliminating malignant urethral margins during radical cystectomy (RC) for bladder cancer (BC) and its impact on urethral recurrence. Urethral margins were initially examined by FSA in 217 patients at RC. When positive, additional resections were performed. Subsequently, all specimens were re-examined on formalin-fixed, paraffin-embedded sections (FFPE). Malignancy was defined as either the presence of carcinoma in situ, high-grade or invasive tumor cells at the urethral margin. Kaplan-Meier analysis was used to assess the impact of the final urethral margin status on urethral recurrence. Multinomial logistic regression addressed independent risk factors for a positive final urethral margin. At initial examination, urethral margins were positive on FSA and FFPE in 21 (9.7%) and 17 (7.8) patients, respectively. The corresponding sensitivity, specificity, positive and negative predictive values were 88.2%, 97.0%, 71.4% and 99.0% (overall accuracy: 96.3%). After initial FSA, 23 patients (including 2 with equivocal histological findings) received re-resections (median: 1, total range: 1-3). Persistent positive margins were detected on FSA in 10 (43.5%) while none of these margins were positive on FFPE (overall accuracy: 52.2%). A positive urethral FSA at initial assessment was the only independent risk for a positive final urethral margin. The 3-year urethral recurrence-free survival was 99.1% for patients with negative margins on initial assessment (I), 100% for those with negative final margins after re-resection (II) and 83.3% for patients with positive final margins (III; P= .013 for I/II vs. III). The accuracy of FSA for detecting malignant urethral margins is high on initial examination but drops considerably in case of re-resection while most positive margins at initial FSA are converted to negative final ones on FFPE. Conversion of a positive to a negative margin was associated with a lower risk of urethral recurrence.

Impact of Histologic Risk Factors on Recurrence Rates for Oral Cavity Squamous Cell Carcinoma.

This study assesses the impact of adverse histologic risk factors including worst pattern of invasion (WPOI), predominant pattern of invasion (PPOI), tumor budding, and tumor infiltrating lymphocytes (TILS), on risk of recurrence in patients with early-stage Oral Cavity Squamous Cell Carcinoma (OCSCC). Retrospective chart review was performed at a single institution to identify patients with OCSCC who underwent surgical excision. Inclusion criteria included T1-T2 stage disease based on AJCC seventh edition guidelines, no cervical lymph node involvement, no perineural invasion (PNI), no lymphovascular invasion (LVI), no post-operative adjuvant radiation therapy, and cancer involving only the oral tongue or floor of mouth. Patients were excluded if they had positive final margins. A subset of 35 patients were selected for additional histologic review to determine WPOI, PPOI, TB, and TILS. Bivariable and multivariable cox analysis were performed to determine variables associated with recurrence. One hundred and sixty-one patients met criteria and were included in the analysis. Variables that were significantly associated with recurrence on bivariable analysis included tumors with high risk PPOI (groups 4 and 5; P = .021), TB with 10 or more buds (P = .021), T-stage (P = .001), neck dissection (P = .03), and depth of invasion (DOI) >4 mm (P = .044). Multivariable cox proportional hazards found T-stage (HR: 6.40; 95% CI 1.67, 24.50; P = .007), neck dissection (HR: 0.23; 95% CI 0.07, 0.82; P = .023), and TBs (HR: 1.17; 95% CI 1.05, 1.30; P = .006) to be most predictive of recurrence. TB is a strong predictor of recurrence. WPOI, PPOI, and TILS were not statistically significant risk factors for recurrence.

Exploring the accuracy of multiparametric MRI in prostate cancer staging: An institutional retrospective study.

e17056 Background: Multiparametric Magnetic Resonance Imaging (mpMRI) has been increasingly utilized in prostate cancer (PCa) diagnosis and staging. While there is Level 1 data supporting MRI utility in identifying clinically significant PCa and guiding PCa diagnosis, there is little data on its ability to predict surgical outcomes and its utility as a staging study. We aimed to evaluate the accuracy of mpMRI in predicting common surgical pathology outcomes in patients who underwent radical prostatectomy (RP). Methods: Men who underwent either open radical prostatectomy (ORP) or robotic assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma from January-December 2021 at a single tertiary level care academic medical center were identified. Chart review for relevant patient demographics, mpMRI related variables and final surgical pathology was completed. In patients who had pre-operative mpMRI, we evaluated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mpMRI in predicting relevant surgical outcomes, including presence of pT2N0 organ confined disease (OCD), extracapsular extension (ECE), seminal vesicle invasion (SVI), lymph node involvement (LNI), and bladder neck invasion (BNI). Results: 168 eligible patients were identified in a 12-month period. The mean age was 63.5±6.24 years and mean Prostate Specific Antigen (PSA) was 11.4±23.7, with 166 (98.8%) patients undergoing RALP and 115 (68.5%) having pre-operative mpMRI. Median GGG was 2 in both MRI and CT subsets (p = 0.580), and patients who had pre-op MRI were more likely to have higher PSA (12.7 ±28.1 vs 8.38± 6.32, p = 0.073) and clinically node positive disease (p &lt; 0.001) than those with CT. However, there was no significant difference in final surgical pathology or positive surgical margin rates between these two groups. On subset analysis of the MRI subset, Table summarizes the sensitivity, specificity, PPV, and NPV of pre-op MRI to predict OCD, ECE, SVI, LNI, and BNI. While specificity of pre-op MRI was adequate for all outcomes (89.1-100%), sensitivity (2.9-49.2%), PPV (40-100%), and NPV (56.3-94.3%) were poor. Conclusions: At present, pre-op MRI of the prostate does not appear to be accurate in its ability to predict important pathologic outcomes at the time of radical prostatectomy and should be used cautiously as a local staging tool. More work is needed before MRI can be used as a reliable staging tool for PCa.[Table: see text]

Abstract P3-18-10: Current options and future perspectives for breast margin assessment in clinical practice

Abstract Background: Ensuring negative margins at the time of breast conserving surgery for invasive breast cancer or ductal carcinoma in situ is necessary to minimize the chance of local recurrence and avoid re-excisions that cause patient concern and may delay adjuvant therapy. However, about 25% of women who have lumpectomy have a second surgery to remove residual disease, suggesting an ongoing need for improved methods of intraoperative margin assessment. This study aimed to perform a contemporary review of methods of intraoperative margin assessment during breast conservation surgery. Methods: A review of the scientific literature from 2009 to 2021 comprising 62 manuscripts of the current and proposed. intraoperative techniques for breast margin assessment during breast conservation surgery was conducted via PubMed and Google Scholar. The methods assessed were grouped into 10 categories based on the technology employed: bioimpedance/radiofrequency, high-resolution imaging, optical imaging, mass spectrometry, magnetic-resonance imaging, 2D/3D specimen CT, X-ray, multimodal optical microscopy, pharmacologic and pathological margin assessment. All technologies were reviewed for overall effectiveness in lowering re-excision rates derived from their respective advantages, limitations, sensitivity, and specificity. Results: Overall, 8 current and 7 technologies under development were assessed (Table 1). Frozen section and cytology yielded the highest diagnostic accuracy; however, these can be time-consuming, resource-intensive, and have limited sampling points. Conversely, 2D specimen CT provides rapid results but is limited by relatively low sensitivity. Future technologies such as optical coherence tomography showed promising results in demonstrating higher diagnostic accuracy for lumpectomy and margin shaves, but remain to be proven in clinical practice. Conclusion: Intraoperative margin assessments can lower final positive margins and subsequent re-excisions rates. A number of current and upcoming technologies that assess margin status range in their respective efficacies and limitations. There remains demand for improved margin assessment at the time of breast conserving surgery, but which technologies will become standard of care remains, at present, unclear. Table 1.Methods of intraoperative margin assessmentMethod:Brand:Sensitivity:Specificity:Source:Bioimpedence• ClearEdge™87.3%75.6%Dixon et al. 2016• MarginProbe75.2%70-87%Schanabel et al., 2014Cytology:• Imprint72%97%Esbona &amp; Zhanhai 2012; Qui et al., 2018Frozen Section–83%95%Schmidt et al, 2020; Schwarz &amp; Schmidt, 2020Mass Spectrometry• iKnife93.4-94.7%94.7-96.2%St. John et al., 2017• MasSpec Pen83-95%95-100%Garza et al., 2020Multimodal optical microscopy• fluorescence imaging combination withRCM/OCT subsystemTBDTBDScimone et al., 2021MRI• ClearSight™93%92%Moshe et al., 2016Optical Coherence Tomography (OCT)• OTIS™96%92%Mojahed et al., 2020; Schmidt et al. 2020Pharmacology• Bevacizumab98%79%Koch et al., 2017• Lumicell2-3D specimen CT• Mozart®93%78%Black et al., [poster]• Faxitron78.6-85.6%100%Emmadi &amp; Wiley 2012; Bathla et al. 2011• MicroCT56%100%Qiu et al. 2018X-ray• XPCI83%83%Massimi et al. 2021 Citation Format: Huma Javaid, Ivan Marin, Jessica Montalvan, Logan Healy, Brian Menegaz, Cary Hsu, Eric Silberfein, Elizabeth Bonefas, Stacey A. Carter, Alastair M. Thompson. Current options and future perspectives for breast margin assessment in clinical practice [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-10.

Clinicopathologic Characteristics and Patient Outcomes of Phyllodes Tumors: A Single Institution Experience.

Phyllodes tumors (PT) are rare fibroepithelial neoplasms that are classified as benign, borderline, or malignant. Patients with PT diagnosed between 2009 and 2019 were identified from a prospectively maintained single institutional database. 76 patients with PT were included; 47 (61.8%) were benign, 9 (11.8%) were borderline, and 20 (26.3%) were malignant. The mean age at diagnosis was 52. Surgical treatment of benign PT included excisional biopsy in 31 (66.0%) patients, segmental mastectomy in 15 (31.9%), and mastectomy in 1 (2.1%). Among patients with borderline PT, operative management was excisional biopsy in 4 (44.4%) and segmental mastectomy in 5 (55.6%). Of those with malignant PT, 7 (35.0%) were treated with excisional biopsy alone, 9 (45.0%) had lumpectomy (segmental mastectomy), and 4 (20.0%) underwent mastectomy. Malignant PT had a higher rate of necrosis compared to borderline or benign PT (25.0% vs 0% vs 4.3%, P = .016). Four patients had recurrent PT. Final positive margins were associated with recurrence (P = .044). The median overall follow-up time was 86.3months (range 1.5-1414.1months), and no deaths occurred among patients with malignant PT. Overall, recurrence rates of PT are low but may be increased by presence of positive margins.

Outcomes of mohs microgrpahic resection for cutaneous malignancy involving the scrotum

IntroductionSquamous cell carcinoma (SCC) and extramammary Paget's Disease (EMPD) of the scrotum are exceedingly rare. Given their propensity for local invasion and treatment with wide local excision, they can be highly morbid conditions. Outcomes of Mohs Micrographic Surgery (MMS) for scrotal cutaneous malignancy is not well described in current literature. We hypothesized that MMS for scrotal cutaneous malignancy would provide equivalent or improved oncologic outcomes while limiting the morbidity associated with wide excision. Materials/MethodsThis is a retrospective review and analysis of a prospectively maintained database spanning entries from 2005 to 2019. Collected data included general patient characteristics and surgical characteristics reported on a per lesion basis. MMS was performed by our institution's department of dermatology using their standard technique. ResultsOverall, a total of 26 consecutive patients with 28 lesions (SCC or EMPD) were analyzed. Out of our cohort of 15 patients with 16 scrotal SCC lesions, 10 (66%) patients were current or former smokers, 4 (26%) were immunosuppressed, and 2 (13%) had HPV infections. The median preoperative and postoperative size of SCC lesions were 5.7cm [2] and 20.2cm [2] respectively. There was one (6%) oncologic recurrence of SCC of the scrotum and one (6%) local wound complication. Our cohort also included 11 patients with 12 scrotal EMPD lesions. One patient (9%) had an underlying associated malignancy (prostate cancer). The preoperative and postoperative area of lesions were 50.6cm [2] and 96.4cm [2] respectively. One (9%) EMPD lesion had a positive final margin at resection requiring reoperation. After achieving negative surgical margins, no patients in this cohort had an oncologic recurrence. 3 (26%) scrotal EMPD cases had local wound postoperative complications, only one required reoperation. ConclusionTo our knowledge, this is the first case series focused on MMS for both SCC and EMPD with scrotal involvement. Our data suggests that MMS for scrotal cutaneous malignancy may improve oncologic outcomes and may decreases local post-operative reconstructive issues when compared to reported outcomes of treatment with wide local excision. When able, scrotal cutaneous malignancy patients should be referred to urologists at centers with MMS capabilities as it likely will improve their outcomes. The urologist should maintain active involvement with these patients to coordinate this complex and advanced pattern of care.

Intraoperative pathology consultation during urological surgery: Impact on final margin status and pitfalls of frozen section diagnosis.

Despite recent improvements in diagnostic and surgical techniques in urological oncology, positive resection margin remains a significant concern for surgeons. Meanwhile, intraoperative pathology consultation with frozen section assessment (FSA), particularly for histological diagnosis of the lesions incidentally found or enlarged or sentinel lymph nodes, generally provides critical information which enables immediate decision making for optimal patient care. The intraoperative evaluation of surgical margins is also often requested, although there are some differences in its application between institutions and surgeons. Importantly, it remains to be determined whether intraoperative FSA indeed contributes to reducing the risk of final positive margins and thereby improving long-term patient outcomes. This review summarizes available data indicating the potential impact of FSA at the surgical margins during urological surgeries, including radical or partial cystectomy, partial nephrectomy, radical prostatectomy, penectomy, and orchiectomy. The accuracy and pitfalls of the intraoperative consultation/FSA diagnosis are also discussed.

Prognostic factors for residual occult disease in shave margins during partial mastectomy.

Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins. Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors. 166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28months (9-50months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS. Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.

Identification of patients at risk for biochemical recurrence after radical prostatectomy with intra-operative frozen section.

To identify patients at risk for biochemical recurrence (BCR) of prostate cancer (PCa) after radical prostatectomy (RP) with intra-operative whole-mount frozen section (FS) of the prostate. We examined differences in BCR between patients with initial negative surgical margins at FS, patients with final negative surgical margins with initial positive margins at FS without residual PCa after secondary tumour resection, and patients with final negative surgical margins with initially positive margins at FS with residual PCa in the secondary tumour resection specimen. Institutional data of 883 consecutive patients undergoing RP were collected. Intra-operative whole-mount FS was routinely used to check for margin status and, if necessary, to resect more periprostatic tissue in order to achieve negative margins. Patients with lymph node-positive disease or final positive surgical margins were excluded from the analysis. Kaplan-Meier curves and multivariable Cox proportional hazards regression analyses adjusting for clinical covariates were employed to examine differences in biochemical recurrence-free survival (BRFS) according to the resection status mentioned above. The median follow-up was 22.4 months. The 1- and 2-year BRFS rates in patients with (81.0% and 72.9%, respectively; P = 0.001) and without residual PCa (90.3% and 82.3%, respectively; P = 0.033) after secondary tumour resection were significantly lower compared to patients with initial R0 status (93.4% and 90.9%, respectively). On multivariable Cox regression only residual PCa in the secondary tumour resection was associated with a higher risk of BCR compared to initial R0 status (hazard ratio 1.99, 95% confidence interval 1.01-3.92; P = 0.046). Despite being classified as having a negative surgical margin, patients with residual PCa in the secondary tumour resection specimen face a high risk of BCR. These findings warrant closer post-RP surveillance of this particular subgroup. Further research of this high-risk subset of patients should focus on examining whether these patients benefit from early salvage therapy and how resection status impacts oncological outcomes in the changing landscape of PCa treatment.

Survival following locoregional recurrence in breast cancer by clinical subtype.

543 Background: We sought to explore the impact of locoregional recurrence (LRR) on survival in breast cancer (BC) patients in British Columbia treated in the modern era. Methods: A retrospective cohort study design identified patients diagnosed with stage I-III BC from 04/2005-12/2013 treated with surgery and who had a subsequent LRR. Exclusions were death or distant metastasis within 120 days of LRR, bilateral previous/synchronous BC, and other invasive cancers. After LRR, overall survival (OS) and factors associated with OS, including clinical subtype and adjuvant therapy (AdTx), were examined. We defined clinical subtypes as: Luminal (Lum) A-estrogen receptor (ER) and progesterone receptor (PR) positive, HER2 negative, and grade 1 or 2; Lum B-as Lum A but grade 3, or as Lum A but only one of ER or PR positive; triple negative (TNBC)-ER and PR and HER2 negative; and HER2 positive (with any ER, PR). In the absence of earlier LRR, we defined adequate AdTx as: (a) TNBC: &gt;=50% of planned chemotherapy (Chx), (b) HER2 positive: &gt;=50% of planned Chx and &gt;=8 cycles of anti-HER2 therapy, (c) Lum A, B: &gt;=4 years of endocrine therapy and (d) after partial mastectomy or positive final margins: &gt;=50% of radiation therapy dosage. Results: The final cohort had 492 patients with a median follow-up of 7.2 years from LRR and 11.8 years from diagnosis. LRR was local in 69.3% (n=341) and regional +/- local in 30.7% (n=151). Compared with local only, regional recurrences were associated with higher T and N stage, grade, and Lum status (p&lt;=0.01). Biomarkers were re-evaluated at LRR in 82% and changed from initial diagnosis in 32% of those tested: ER expression 3.8% gain, 6.1% loss; PR expression 9.1% gain, 15.1% loss; HER2 overexpression 3.7% gain and 4.8% loss. Over half of patients (n=255, 52%) did not receive adequate AdTx, either by choice or recommendation. A similar proportion with local vs. regional recurrence had inadequate AdTx. Time to death from 1st LRR did not vary significantly between local vs. regional recurrences (median 2.7 years). OS after LRR was lowest in TNBC (median 3.1 years, 24.2% 10-year OS) and longest in Lum A (median not reached, 64.7% 10-year OS) (Table). Conclusions: Our data provide rates of OS after LRR in the era of modern adjuvant therapy. OS after LRR varied by clinical subtype, with TNBC faring the worst, and Lum A the best. Over half had not received adequate AdTx. Despite similar treatment options, OS after LRR was significantly longer for Lum A than B subtypes, underscoring the need for therapy tailored to biology. OS was low in all other subtypes, emphasizing the importance of avoiding LRR.[Table: see text]

Surgical outcomes of localization using indocyanine green fluorescence in breast conserving surgery: a prospective study

We investigated localization and safe resection margins for breast cancer patients undergoing breast conserving surgery (BCS) using ultrasound-guided indocyanine green fluorescence (ICG-F) marking. From April 2016 to March 2019, we prospectively enrolled 114 patients who underwent BCS using US-guided ICG-F marking and we compared these results with 300 patients who underwent BCS using US-guided skin marking from January 2012 to December 2016. Clinical features, identification rates, status of resection margins, and re-operation rates were analyzed. The ICG-F identification rate was 100% (114/114). The mean approach time for resection of the lesion ICG-F using group was about 13 min. The positive rate of frozen resection margins was 10.5% using ICG-F and 25.0% using sono-guided skin marking (p < 0.01). The rate of additional intraoperative resection was significantly lower in the ICG-F marking group compared to that in the sono-guided skin marking group (8.8% vs. 23.3%, p < 0.01). The rate of final positive resection margins was 3.5% in the ICG-F using group and 14.7% in the sono-guided skin marking group (p < 0.01). The rate of re-operation was 4.4% in the ICG-F using group and 4% in the sono-guided group (p = 0.79). At follow-up after the operation using ICG-F, no complications occurred. Using ICG-F during BCS could be a safe, sophisticated method for localization.

Total Margin-Controlled Excision is Superior to Standard Excision for Keratinocyte Carcinoma on the Nose: A Veterans Affairs Nested Cohort Study

Keratinocyte carcinoma (KC), including basal and squamous cell carcinoma, is the most common human malignancy. Limited real-world data have compared surgical outcome or cost between total margin-controlled excision (TMCE) and standard excision (SE), the two most common treatments for invasive KC. We compared reconstruction, margin status, and cost between TMCE and SE for KC on the nose at a Veterans Affairs (VA) healthcare system. Randomly selected primary KCs on the nose ≤3cm that were confined to soft tissue, without nerve or lymphovascular invasion, and treated with SE or TMCE between 2000 and 2010, were assessed. Utilization of flap or graft reconstruction and margin status following all surgical attempts were recorded. Costs were based on Current Procedural Terminology codes standardized to 2019 Medicare payments. Overall, 148 cases were included in each treatment group. Baseline characteristics were similar between groups, although SE tumor median diameter was 1mm larger. SE was associated with increased utilization of flap or graft reconstruction (odds ratio 2.05, 95% confidence interval 1.16-3.59, p=0.01). Positive margins were present in 24% of SEs initially and remained positive after the final recorded excision in 9% of cases. No positive final margins were noted in TMCE cases. SE cost per tumor was significantly higher than TMCE ($429.03±143.55; p=0.003). Surgical management of KC with SE is associated with increased reconstruction complexity, a significant risk of positive margins, and higher cost compared with TMCE. The 23% risk of positive margins supports National Comprehensive Cancer Network guidelines for the treatment of high-risk KC with TMCE, unless delayed reconstruction is employed.