Free Margin Rate Research Articles

Oropharyngeal free flap reconstruction: Transoral robotic surgery versus open approach.

Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used. Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups. Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival. Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis. 4.

Comparison of ultrasound guided surgery and radio-guided occult lesions localization (ROLL) for nonpalpable breast cancer excision.

There is little literature comparing intraoperative ultrasound (IOUS) with radio-guided occult lesions localization (ROLL) in nonpalpable invasive tumors in breast conserving surgery (BCS). There is a need to compare these two methods in terms of safety and efficacy. This is an observational cohort study. All patients treated with BCS for nonpalpable invasive breast cancer using IOUS from March 2016 to March 2020 were included and compared with a historical reference control group operated on using ROLL from March 2013 to March 2017. For each detection method, the ability to locate tumors intraoperatively, tumor and surgical specimen sizes, total resection volume (TRV), optimal resection volume, excess of healthy tissue resected (ETR), margin status, re-excision rate, surgical time, complications and costs were studied. One hundred and fifty-eight were included, 83 with IOUS and 75 with ROLL. The mean tumor size is equivalent in both groups (11.88 mm IOUS vs. 12.29 mm ROLL, P=0.668). TRV is significantly lower with IOUS (24.92 vs. 60.32 cm3, P<0.001), and the ETR is also significantly lower in the IOUS group (21.74 vs. 58.37 cm3, P<0.001). The rate of positive margins did not differ (10.98% vs. 12.16%, P=1), nor did re-excision rate (10.98% vs. 8.11%, P=0.597). Complication rate did not differ (12.2% IOUS vs. 10.81% ROLL, P=0.808). Surgical time was shorter in IOUS (45.5 vs. 57 min, P>0.05). IOUS in BCS for nonpalpable invasive breast cancer is more accurate than ROLL because it decreases excision volumes with the same rate of free margins and re-excision. Also, IOUS is a more efficient and comfortable technique, and just as safe as ROLL.

Targeted breast surgery: Non-direct approach.

e12602 Background: Breast conserving surgery is the standard in T1-T3 primary breast cancer. The cosmetic result is very much depending upon the surgeon ́s experience, the tumor-size/breast ratio and the technique applied. We have proposed a nomogram earlier (1) which has been cited earlier by the American Society of Breast Surgeons Consensus Conference as a concept for avoidance of re-excisions and achievement of a favorable aesthetic result. Our nomogram proposed 5 simple oncoplastic techniques to handle the vast majority of breast cancer cases, with high rates of free margins. However, these techniques all used direct access to the mammary gland through the skin above the tumor, leaving permanent scars in the visible skin of the breast. To avoid this, we now have chosen a more natural access to the mammary gland along natural transitions and Langerhans´s skin lines in this prospective open-label study. Methods: We conducted a prospective open-arm study including all primary invasive and non-invasive breast cancer cases of tumor stages AJCC 0-III A (Version 8.0). Non-palbable tumors and those undergoing neoadjuvant chemotherapy had to be marked by a wire and clipped before. Intraoperative ultrasound was applied before skin incision and after removal of the tumor including ultrasound of the specimen to confirm clear margins). Resection was performed as a segmentectomy and SLN biopsy and axillary clearance was done according to national guidelines. Access to the tumor was chosen in a non-direct approach according to the proximity of the tumor to one of the following natural transitions: 1. areola 2. axillary line 3. inframammary fold. Results: 84 patients with breast conserving targeted breast surgery with a "non-direct to the tumor approach" have been enrolled so far. 76 patients had primary surgery with stage distribution as follows: Tis (1), T1a (3), T1b (8), T1c (30), T2 (30), T3 (4) and T4b(1). 8 patients had neoadjuvant chemotherapy with stage distribution as follows: ypT0 (3), ypT1a (2), ypT1c (1) and ypT2 (2). Histopathology was predominantly invasive-ductal breast cancer (70), followed by invasive-lobular (6), ductulo-lobular (5), invasive- ductal and pure DCIS (1), invasive-ductal and mucinous (1) and mucinous only (1). After first surgery according to our nomogram 77 patients had a tumor resection with free margins and 7 with involved margins, thus 91,6 % tumors were resected with free margins at first surgery. The remaining 8,4 % of cases were margin-free after second surgery. Conclusions: Scars were not visible on the surface of the breast outside of natural transitions and rate of free margins was high with targeted breast surgery at a rate of 91,6 % without any cosmetic impairment due to the remote natural access to the mammary gland. Patient-reported outcome in detail has been evaluated by validated questionnaires and demonstrated a high satisfaction with scar pattern, volume and symmetry.

Abstract PS1-11: Natural transition targeted surgery

Abstract Background: Breast conserving surgery is the standard in T1-T3 primary breast cancer. The cosmetic result is very much depending on the surgeon´s experience, the tumor-size/breast ratio and the technique applied. To improve cosmetic outcome and reduce repeated surgery, we have proposed a nomogram earlier (1) which has been cited by the American Society of Breast Surgeons Consensus Conference (2). In this nomogram, we proposed 5 simple oncoplastic techniques to handle the vast majority of breast cancer cases with a good cosmetic result. However, these techniques used direct access to the mammary gland, leaving scars in the visible skin of the breast. To avoid this, we chose a more natural access to the mammary gland at the natural transitions. Methods: We conducted a prospective open-arm study including all primary invasive and non-invasive breast cancer cases of tumor stages AJCC 0-III A (Version 8.0). Access to the tumor was chosen according to the proximity of the tumor to one of the following natural transitions (Areola, Lateral Insertion of the breast, inframmary fold): Non-palpable tumors and those undergoing neoadjuvant chemotherapy had to be marked by a wireand clippes before. Intraoperative ultrasound was applied before skin incision and after removal of the tumour (ultrasound of the specimen to confirm clear margins). Resection was performed as a segmentectomy and SLN biopsy and axillary clearance was done according to current guidelines.Results: 84 patients with breast conserving NTT-surgery have been enrolled so far. 76 patients had primary surgery with stage distribution as follows: Tis (1), T1a (3), T1b (8), T1c (30), T2 (30), T3 (4) and T4b(1). 8 patients had neoadjuvant chemotherapy with stage distribution as follows: ypT0 (3), ypT1a(2), ypT1c(1) and ypT2 (2). Histopathology was predominantly invasive-ductal breast cancer (70), followed by invasive-lobular (6), ductulo-lobular (5), invasive-ductal and DCIS (1),invasive-ductal and mucinous (1) and mucinous only (1). After first surgery 77 patients had a tumor resection according to the nomogramm of NTT-surgery with free margins and 7 with involved margins, thus 91,6 % tumors were resected with free margins at first surgery. The remaining 8,4 % were margin-free after second surgery. Conclusion: Scars were not visible on the surface of the breast outside of natural transitions and rate of free margins was high at 91,6 % without impairment due to the remote access to the mammary gland. We report a high patient satisfaction. Patient-reported outcome in detail has been evaluated by validated questionnaires and will be presented onsite.

Haemostasis control during laparoscopic partial nephrectomy without parenchymal renorrhaphy: The Vivostat® experience

ObjectiveTo present our experience using an autologous fibrin sealant prepared with the Vivostat system® to control haemostasis without any renal parenchymal reconstruction. Material and methodsWe performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, and application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding. ResultsMean age was 63.9 years (33–80); mean tumor size was 2.5cm (1.5–4); mean operative time was 136.1min (90–180). Mean warm ischemia time was 19.2min (10–30). Mean blood loss was 97ml (50–300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not record any case of postoperative bleeding or renal failure. One patient required transfusion due to a big hematoma on the abdominal wall. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2–6). Mean follow-up was 14 months (5–45). ConclusionsExcluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy.

Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat®

ObjectiveTo present our experience using an autologous fibrin sealant prepared with the Vivostat system® to control haemostasis without any renal parenchymal reconstruction. Material and methodsWe performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding. ResultsMean age was 63.9 years (33-80); mean tumor size was 2.5cm (1.5-4); mean operative time was 136.1min (90-180). Mean warm ischemia time was 19.2min (10-30). Mean blood loss was 97ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45). ConclusionsExcluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy

Oncoplastic surgery for breast cancer: an alternative to mastectomy?.

Abstract Abstract #5154 Background:&amp;#x2028; The phrase “Oncoplastic breast surgery” originated with the concept of avoiding mastectomy by means of wide tumour excision coupled with breast reconstruction. Oncoplastic procedures (OP) have been standardised in our institution. The surgical technique was defined according to the quadrant and the breast consistence of the patient, the pathological conditioning associated specimen orientation and inked breast margins.&amp;#x2028; Material and methods:&amp;#x2028; Each woman with a potentially large partial breast removal and a consequent risk of mastectomy has an OP proposed. Pre operative explanations underlined the oncological problem, the technical procedure, the post operative potential morbidity, the necessity to obtain definitive pathologic reports, the timing of controlateral surgery for symmetrization. An independent phone questionnaire was made in order to evaluate the main disorders felt by the patients, the quality of pre operative explanations and the cosmetic and psychological impact.&amp;#x2028; 133 women were operated between 2001 and 2007, the mean age was 51, the mean Bra size 95, the initial TNM staging noticed 40% T0 – 17% T1 – 30% T2 – 13% T3. 40% of tumors were pure DCIS, 40% of patients have had preoperative chemotherapy.&amp;#x2028; Results:&amp;#x2028; The operative technique was an OP alone in 54%. For the external quadrants, we performed mainly a Durfourmentel technique (54%), for the upper quadrants the batwing procedure (10%) and for the inferior quadrants a classic mammoplastic surgery (36%). The mean weight of the specimen was 166 g (20-530), the mean operative time 84' for unilateral surgery, 130' for bilateral, the mean hospital stay 3.8 d. 20% of patients needed a second surgery, twice for post operative morbidity, 25 times for R1 resection. In these cases, 14 second mastectomies were performed, 6 tumorectomies and 2 second OP.&amp;#x2028; The mean diameter of the tumor evaluated on pathology reports was 24.6 mm; the rate of positive margins was 21% for DCIS removal and 28% after neoadjuvant setting. With 33 months FU, we noticed 2 deaths due to the cancer, 5 local recurrences and 12 patients treated for metastases.&amp;#x2028; The independent phone questionnaire revealed a favourable cosmetic result in 70%, bad in 13%. 36% of women wished a second time plastic surgery but relinquished. 48% evaluated the preoperative explanation unsatisfactory. The main reproaches voiced by the patients were the risk of second step surgery according to the final pathological reports and the length of the scars. 75% of women were not afraid to conserve their breast but all were satisfied. 60% were worried due to the follow-up but 83% think that the mastectomy is not less frightening. 17% hesitated to have the same surgical approach.&amp;#x2028; Conclusion&amp;#x2028; OP procedure is a safe alternative to mastectomy in selected cases with acceptable morbidity and good cosmetic results. Pre operative explanations are essential. Since April 2007, we have initiated a prospective multicentric trial in order to evaluate the free margin rate according to the indication and the quality of life of these women. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5154.