Higher Risk Of Positive Margins Research Articles

Oncologic Safety of Immediate Oncoplastic Surgery Compared with Standard Breast-Conserving Surgery for Patients with Invasive Lobular Carcinoma.

Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, resulting in a high risk of positive margins at surgical resection. Oncoplastic approaches have been shown to reduce this risk, but concerns persist around the safety of immediate oncoplastic surgery for those with ILC. This study evaluated the short- and long-term oncologic outcomes of immediate oncoplastic surgery for patients with ILC. This study retrospectively analyzed an institutional database of stages I to III ILC patients who underwent breast-conserving surgery (BCS) with or without immediate oncoplastic surgery (oncoplastic closure or oncoplastic reduction mammoplasty [ORM]). The study compared positive margin rates, rates of successful BCS, and recurrence-free survival (RFS) by type of surgery. For 494 patients the findings showed that the use of immediate ORM was associated with significantly lower odds of positive margins (odds ratio [OR], 0.34; 95 % confidence interval [CI], 0.17-0.66; p = 0.002). Both lumpectomy with oncoplastic closure and ORM were significantly associated with higher rates of successful BCS than standard lumpectomy (94.2 %, 87.8 %, and 73.9 %, respectively; p < 0.001). No difference in RFS was observed between those undergoing immediate oncoplastic surgery and those undergoing standard lumpectomy alone. The patients with stages I to III ILC who underwent immediate oncoplastic surgery had significant benefits including lower odds of positive margins and higher rates of successful BCS, with both types of immediate oncoplastic surgery showing similar RFS compared with lumpectomy alone. This supports the oncologic safety of immediate oncoplastic surgery for diffusely growing tumors such as ILC, providing it an ideal option for patients desiring BCS.

A clinical perspective on oncoplastic breast conserving surgery.

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.

Risk Factors for Positive Margins in Breast-Conserving Surgery.

Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomybut is associated with higher rates of local recurrence. Positive surgical margins in BCS are the most important predictor of local recurrence. The aim of our study was to assess the risk factors associated with positive margins in women undergoing BCS for breast cancerin order to inform our clinical practice and minimize re-operation rates. Methods Patients with a diagnosis ofbreast cancer who underwent BCS from January 2013 to January 2021 were identified from our pathology database and included in the study. All patients underwent a lumpectomy with the removal of additional shaved cavity margins. Statistical analysis was used toassess the effect of patient clinical and pathological risk factors on the rate of positive margins. Results One hundred and twenty patients underwent BCS for breast cancer. Twenty-four percent of patients had positive margins. Of the 29 patients that underwent subsequent re-excisions, only 13 (45%) hadresidual disease in the re-excision specimen. In younger patients, tumors localized in lower quadrants and the presence of extensive intraductal component within invasive breast cancer increased the risk of positive margins. In addition, positive margins were encountered more significantly in patients with ductal carcinoma in situ (DCIS) compared to invasive tumors. Multivariate analysis showed that DCIS and young age were the only factors independently associated with positive margins. Conclusion DCIS and younger patients have a higher rate of positive margins during BCS than invasive breast cancer. For such patients at higher risk of positive margins, excision of cavity shave margins and intraoperative inking may be done to lower positive margin rates.Preoperative review of breast imaging, core biopsies, and counseling of patients about the likelihood of positive margins is important.

Margin Free Resection Achieves Excellent Long Term Outcomes in Parathyroid Cancer.

Long-term outcomes of parathyroid cancer remain poorly documented and unsatisfactory. This cohort includes 25 consecutive parathyroid cancer patients with median follow-up of 10.7 years (range 4.1-26.5 years). Pre-operative work-up in the center identified a suspicion of parathyroid cancer in 17 patients. En bloc resection, including the recurrent laryngeal nerve in 4/17 (23.5%), achieved cancer-free resection margins (R0) in 82.4% and lasting loco-regional disease control in 94.1%. Including patients referred after initial surgery elsewhere, R0 resection was achieved in merely 17/25 (68.0%) of patients. Cancer-positive margins (R1) in 8 patients led to local recurrence in 50%. On multivariate analysis, only margin status prevailed as independent predictor of recurrence free survival (χ2 19.5, p &lt; 0.001). Local excision alone carried a 3.5-fold higher risk of positive margins than en bloc resection (CI95: 1.1-11.3; p = 0.03), and a 6.4-fold higher risk of locoregional recurrence (CI95: 0.8-52.1; p = 0.08). R1-status was associated with an 18.0-fold higher risk of recurrence and redo surgery (CI95: 1.1-299.0; p = 0.04), and a 22.0-fold higher probability of radiation (CI95: 1.4-355.5; p = 0.03). In patients at risk, adjuvant radiation reduced the actuarial risk of locoregional recurrence (p = 0.05). When pre-operative scrutiny resulted in upfront oncological surgery achieving cancer free margins, it afforded 100% recurrence free survival at 5- and 10-year follow-up, whilst failure to achieve clear margins caused significant burden by outpatient admissions (176 vs. 4 days; χ2 980, p &lt; 0.001) and exposure to causes for concern (1369 vs. 0 days; χ2 11.3, p = 0.003). Although limited by cohort size, our study emphasizes the paradigm of getting it right the first time as key to improve survivorship in a cancer with excellent long-term prognosis.

Borderline Resectable Pancreatic Cancer: Challenges for Clinical Management.

Pancreatic ductal adenocarcinoma (PDAC) remains a significant worldwide health problem with a poor prognosis. A borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) is a tumor with limited vascular involvement that is technically resectable but with a high risk of positive margins (R1 resection). To identify the current challenges that exist in the management of BR-PDAC. A review of the literature was conducted to identify articles discussing the definitions and management of BR-PDAC. Several anatomic definitions of BR-PDAC exist, and there is significant heterogeneity in their utilization across published trials. To improve the odds of a margin negative (R0) resection, a neoadjuvant treatment approach involving chemotherapy with or without radiation is currently preferred. While supporting the efficacy of a neoadjuvant approach in BR-PDAC, the largest published randomized trials have utilized older gemcitabine-based regimens. Recently published Phase II evidence and meta-analyses have supported the use of modern multi-agent regimens such as FOLFIRINOX. The utility of adding radiation to a chemotherapy backbone remains in question. Due to remnant fibrosis and edema following neoadjuvant therapy, accurately selecting patients for resection based on a restaging CT scan is challenging. Furthermore, the role of adjuvant therapy in BR-PDAC patients receiving neoadjuvant therapy needs to be defined. Though progress has been made, the optimal management of BR-PDAC is uncertain. Phase III trials utilizing modern chemotherapeutic regimens are needed to establish a standard of care.

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

BackgroundAbdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE)MethodsThis multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien–Dindo ≥ 3), histopathology results, and perineal wound healing.ResultsA total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention.ConclusionsTpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.

The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care.

Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.

The potential risk of tumor progression after use of dehydrated human amnion/chorion membrane allograft in a positive margin resection model.

Objective:The objective of this study was to examine the impact of dehydrated human amnion/chorion membrane (dHACM) allografts on prostate and bladder cancer growth in the setting of residual disease and positive surgical margins.Materials and methods:A commercially available version of dHACM was used. Cytokines were identified and quantified, followed by comparative analysis of cell growth in two different human cell lines: prostate cancer (LNCaP) and bladder cancer (UM-UC-3), in vitro and in vivo. Tumor growth between the two groups, membrane versus no membrane implant, was compared and immunohistochemistry studies were conducted to quantify CD-31, Ki-67, and vimentin. A Student’s unpaired t-test was used to determine statistical significance.Results:The UM-UC-3 and LNCaP cells grew quicker in medium plus 10% serum and dHACM extract than in the other media (p = 0.03). A total of 28 distinct cytokines were found in the extract, 11 of which had relatively high concentrations and are associated with prostate and bladder cancer tumor progression. In vivo LNCaP model, after 10 weeks, the median tumor volume in the membrane group was almost threefold larger than the partial resection alone (p = 0.01). Two weeks after resection, in the UM-UC-3 model, the membrane group reached fourfold larger than the partial resection without membrane group (p < 0.01). In both groups, the expression of CD-31 and Ki-67 markers were similar and showed no statistical significance (p > 0.05). It was only in the LNCaP tumors that vimentin expression was significantly higher in the group without membrane compared with the membrane group (p = 0.008).Conclusion:The use of dHACM after partial tumor resection is related to faster tumor relapse and growth in prostate and urothelial cancer in vivo models, showing a potential risk of rapid local recurrence in patients at high risk of positive margins.

Management of Squamous Cell Carcinoma Involving the Temporal Bone

To examine contemporary management of squamous cell carcinoma (SCC) involving the temporal bone. The modified Pittsburgh criteria have gained acceptance by many institutions for staging, planning treatment and comparing outcomes. Often primary SCC as well as secondary cutaneous SCC involving the temporal bone can be managed in a similar fashion. T1 tumours should undergo lateral temporal bone resection (LTBR) due to the higher risk of positive margins and recurrence rates with lesser surgical procedures. T2 tumours require LTBR and superficial parotidectomy. T3 and T4 tumours often require a subtotal resection of the temporal bone (STBR), parotidectomy and cutaneous soft tissues as an en bloc excision. Advanced lesions are associated with a diminished survival especially if margins are involved. Patient outcomes are improved by a combination of surgery and postoperative radiotherapy. Preoperative imaging with high resolution CT and MRI is useful, particularly if there is evidence of large nerve perineural spread and nodal disease.

Metabolic syndrome and low high-density lipoprotein cholesterol are associated with adverse pathological features in patients with prostate cancer treated by radical prostatectomy

BackgroundPrevious studies have suggested a link between metabolic syndrome (MetS) and prostate cancer (PCa). In the present study, we aimed to assess the association between MetS and markers of PCa aggressiveness on radical prostatectomy (RP). MethodsAll patients consecutively treated for PCa by RP in 6 academic institutions between August 2013 and July 2016 were included. MetS was defined as at least 3 of 5 components (obesity, elevated blood pressure, diabetes, low high-density lipoprotein (HDL)-cholesterol, and hypertriglyceridemia). Demographic, biological, and clinical parameters were prospectively collected, including: age, biopsy results, preoperative serum prostate-specific antigen, surgical procedure, and pathological data of RP specimen. Locally advanced disease was defined as a pT-stage ≥3. International Society of Urological Pathology (ISUP) groups were used for pathological grading. Qualitative and quantitative variables were compared using chi-square and Wilcoxon tests; logistic regression analyses assessed the association of MetS and its components with pathological data. Statistical significance was defined as a P<0.05. ResultsAmong 567 men, 249 (44%) had MetS. In a multivariate model including preoperative prostate-specific antigen, biopsy ISUP-score, clinical T-stage, age, and ethnicity: we found that MetS was an independent risk factor for positive margins, and ISUP group ≥4 on the RP specimen (odds ratio [OR] = 1.5; 95% CI: 1.1–2.3; P = 0.035; OR = 2.0; 95% CI: 1.1–4.0; P = 0.044, respectively). In addition, low HDL-cholesterol level was associated with locally advanced PCa (OR = 1.6; 95% CI: 1.1–2.4; P = 0.024). Risks of adverse pathological features increased with the number of MetS components: having ≥ 4 MetS components was significantly associated with higher risk of ISUP group ≥ 4 and higher risk of positive margins (OR = 1.9; 95% CI: 1.1–3.3; P = 0.017; OR = 1.8; 95% CI: 1.1–2.8; P = 0.007, respectively). ConclusionMetS was an independent predictive factor for higher ISUP group and positive margins at RP. Low HDL-cholesterol alone, and having 4 and more MetS components were also associated with higher risk of adverse pathological features.

SEOM Clinical Guideline for the treatment of pancreatic cancer (2016).

Pancreatic cancer remains an aggressive disease with a 5 year survival rate of 5%. Only 15% of patients with pancreatic cancer are eligible for radical surgery. Evidence suggests a benefit on survival with adjuvant chemotherapy (gemcitabine o fluourouracil) after R1/R0 resection. Adjuvant chemoradiotherapy is also a valid option in patients with positive margins. Borderline resectable pancreatic cancer is defined as the involvement of the mesenteric vasculature with a limited extension. These tumors are technically resectable, but with a high risk of positive margins. Neoadjuvant treatment represents the best option for achieving an R0 resection. In advanced disease, two new chemotherapy treatment schemes (Folfirinox or Gemcitabine plus nab-paclitaxel) have showed improvements in overall survival compared with gemcitabine alone. Progress in pancreatic cancer treatment will require a better knowledge of the molecular biology of this disease, focusing on personalized cancer therapies in the near future.

Positive Margins After Oncoplastic Surgery for Breast Cancer.

Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'. A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

Retroperitoneal Sarcoma (RPS) Target Volume and Organ at Risk (OAR) Contour Delineation Agreement Among RTOG Sarcoma Radiation Oncologists

Purpose/Objective(s)To evaluate the variability in target volume and OAR contour delineation for RPS by Radiation Therapy Oncology Group (RTOG) sarcoma radiation oncologists (ROs).Materials/MethodsRadiation planning computed tomography (CT) scans for 2 RPS cases were distributed to 12 sarcoma ROs with instructions for contouring gross tumor volume (GTV), clinical target volume (CTV), high risk CTV (HR CTV: area judged to be at high risk of positive margins after resection), and OARs: bowel bag, small bowel, large bowel, stomach, and duodenum. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics.ResultsEach case was contoured by 11 ROs. The first case (RPS 1) was a patient with well-differentiated (WD) liposarcoma (LPS) with a de-differentiated (DD) component, and the second case (RPS 2) was a patient with DD LPS. Contouring agreement for all volumes is shown in the Table. Agreement for GTV and CTV contours was high. However, the agreement for HR CTVs was only moderate. For OARs, agreement for stomach, bowel bag, large and small bowel was high, but agreement for duodenum was fair to moderate.ConclusionsOral Scientific Abstract 253; TableKappa Statistic Agreement for RPS Target and OAR VolumesRPS 1RPS 2Kappa Level of AgreementKappa Level of AgreementGTV0.84 Almost Perfect0.92 Almost PerfectCTV0.79 Substantial0.86 Almost PerfectHR CTV0.50 Moderate0.57 ModerateBowel Bag0.82 Almost Perfect0.79 SubstantialSmall Bowel0.73 Substantial0.78 SubstantialLarge Bowel0.73 Substantial0.82 Almost PerfectStomach0.77 Substantial0.83 Almost PerfectDuodenum0.41 Moderate0.36 Fair Open table in a new tab Purpose/Objective(s)To evaluate the variability in target volume and OAR contour delineation for RPS by Radiation Therapy Oncology Group (RTOG) sarcoma radiation oncologists (ROs). To evaluate the variability in target volume and OAR contour delineation for RPS by Radiation Therapy Oncology Group (RTOG) sarcoma radiation oncologists (ROs). Materials/MethodsRadiation planning computed tomography (CT) scans for 2 RPS cases were distributed to 12 sarcoma ROs with instructions for contouring gross tumor volume (GTV), clinical target volume (CTV), high risk CTV (HR CTV: area judged to be at high risk of positive margins after resection), and OARs: bowel bag, small bowel, large bowel, stomach, and duodenum. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics. Radiation planning computed tomography (CT) scans for 2 RPS cases were distributed to 12 sarcoma ROs with instructions for contouring gross tumor volume (GTV), clinical target volume (CTV), high risk CTV (HR CTV: area judged to be at high risk of positive margins after resection), and OARs: bowel bag, small bowel, large bowel, stomach, and duodenum. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics. ResultsEach case was contoured by 11 ROs. The first case (RPS 1) was a patient with well-differentiated (WD) liposarcoma (LPS) with a de-differentiated (DD) component, and the second case (RPS 2) was a patient with DD LPS. Contouring agreement for all volumes is shown in the Table. Agreement for GTV and CTV contours was high. However, the agreement for HR CTVs was only moderate. For OARs, agreement for stomach, bowel bag, large and small bowel was high, but agreement for duodenum was fair to moderate. Each case was contoured by 11 ROs. The first case (RPS 1) was a patient with well-differentiated (WD) liposarcoma (LPS) with a de-differentiated (DD) component, and the second case (RPS 2) was a patient with DD LPS. Contouring agreement for all volumes is shown in the Table. Agreement for GTV and CTV contours was high. However, the agreement for HR CTVs was only moderate. For OARs, agreement for stomach, bowel bag, large and small bowel was high, but agreement for duodenum was fair to moderate. ConclusionsOral Scientific Abstract 253; TableKappa Statistic Agreement for RPS Target and OAR VolumesRPS 1RPS 2Kappa Level of AgreementKappa Level of AgreementGTV0.84 Almost Perfect0.92 Almost PerfectCTV0.79 Substantial0.86 Almost PerfectHR CTV0.50 Moderate0.57 ModerateBowel Bag0.82 Almost Perfect0.79 SubstantialSmall Bowel0.73 Substantial0.78 SubstantialLarge Bowel0.73 Substantial0.82 Almost PerfectStomach0.77 Substantial0.83 Almost PerfectDuodenum0.41 Moderate0.36 Fair Open table in a new tab

P-0296 Could Pre-Treatment Cea be an Effective Predictor of Relapse in High Risk Rectal Cancer?

ABSTRACT Introduction Over 14,000 cases of rectal cancer occur per year in the UK. Radical surgery with total mesorectal excision (TME) is the main curative treatment for disease localised to the pelvis. Some cases are judged on pelvic MRI to be at high risk of positive margins from surgery alone. They are offered pre-operative chemo-radiotherapy (CRT) before surgery with TME. This hopes to downsize and downstage tumors to provide clear circumferential resection margins and reduce the likelihood of relapse. Good pathological responses to CRT are associated with improved cancer outcomes. We investigated whether carcinoembryonic antigen (CEA) levels at presentation could act as a simple predictor of relapse when using CRT followed by TME for patients with high-risk rectal cancers. Methods Retrospective data was collected on high-risk rectal cancer patients treated radically with pre-op CRT and TME surgery at Ipswich Hospital between March 2005 and Jan 2012. All received at least 45 Gy in 25 fractions of radiotherapy using a three-field CT plan and 5 weeks of oral capecitabine chemotherapy. CEA levels were obtained prior to radiotherapy. Following surgery, rectal specimens were assessed by our pathologists to evaluate response to treatment and whether complete pathological response (pCR) was achieved. Follow-up was by our oncology department and colorectal surgeons with annual CT scanning, 1-3 yearly colonoscopies and clinical surveillance for 5 years. Results 56 patients met inclusion criteria. Male to female ratio: 1.8:1. 96% (n=54) patients received pre-op chemotherapy alongside radiotherapy: 2 patients were considered too high-risk for this component of treatment. Mean follow-up from commencing radiotherapy was 33 months (range 7-69). Mean time from last dose of radiotherapy to surgery was 11 weeks (range 5-18). 93% (n=52) had (R0) resection margins following surgery. 7.1% (n=4) had (R1) incomplete resection margins following surgery; 2 of these 4 suffered local relapse in the pelvis. 30% (n=17) achieved a pCR following CRT, none of the patients who achieved a pCR have relapsed. 77% (n=43) presented with a normal CEA (≤5, range 5, range 6-54). Normal CEA group: 35%, (n=15) achieved pCR following CRT and 14% (n=6) relapsed. High CEA group: 15% (n=2) achieved pCR following CRT and 46%, (n=6) relapsed. There was a significant between group difference in relapse (Fisher's exact test p=0.02). Further survival analysis for relapse revealed a statistically significant hazard ratio of 4.5 (95% CI 1.04 to 19.4). Conclusion 1. High CEA on presentation was associated with an estimated relative risk of relapse 4.5 times greater than presenting with a normal CEA. 2. Therefore high CEA at presentation could be a useful biomarker to identify patients with the highest risk of relapse who may benefit from more intensive treatment. 3. Our high rates of R0 resection margin (93%) and pCR (30%) could be due to a relatively prolonged time from radiotherapy to surgery in our cohort.

Increased incidence of lobular breast cancer in women treated with hormone replacement therapy: implications for diagnosis, surgical and medical treatment

A growing body of evidence support the association between the use of hormone replacement therapy (HRT) and a higher risk of both invasive lobular carcinoma (ILC) and invasive ductal-lobular mixed carcinoma (IDLC). Overall biological and clinical features of ILC entail a more cautious diagnostic and therapeutic approach as compared with invasive ductal carcinoma (IDC). ILCs are more frequently multifocal, multicentric and/or bilateral. Mammography and ultrasound show, therefore, significant limitations, while the higher sensitivity of magnetic resonance imaging in the detection of multifocal and/or multicentric lesions seems to improve the accuracy of preoperative staging of ILCs. Early diagnosis is even more challenging because the difficult in the localization and the sparse cellularity of lobular tumours may determine a false negative core biopsy. ILC is characterized by low proliferative activity, C-ErbB-2 negativity, bcl-2 positivity, p53 and VEGF negativity, oestrogen and progesterone positive receptors, low grade and low likelihood of lymphatic-vascular invasion. However, this more favourable biological behaviour does not reflect into a better disease-free and overall survival as compared with IDC. Since lobular histology is associated with a higher risk of positive margins, mastectomy is often preferred to breast conservative surgery. Moreover, only few patients with ILC achieve a pathologic response to preoperative chemotherapy and, therefore, in most patients mastectomy can be regarded as the safer surgical treatment. The preoperative staging and the follow-up of patients with ILC are also complicated by the particular metastatic pattern of such histotype. In fact, metastases are more frequently distributed to the gastrointestinal tract, peritoneum/retroperitoneum and gynaecological organs than in IDC.

Laparoscopic Adrenalectomy for Suspected Metastasis of Adrenal Glands: Our Experience

To present our experience in laparoscopic adrenalectomy for isolated adrenal metastasis. A total of 34 adrenalectomies were performed in 32 patients for incidental adrenal masses discovered at primary tumor diagnosis or during follow-up. The primary tumors diagnosed were 13 cases of lung carcinoma, 9 of renal cell carcinoma, 2 of colorectal carcinoma, 2 of bladder carcinoma, and 1 each of ovarian carcinoma, breast cancer, gastric cancer, and melanoma. Two patients had no history of a primary tumor. The mean patient age was 59 years (range 26 to 75). The male/female ratio was 1.9:1. The mean operative time was 87 minutes (range 40 to 240). The average blood loss was 89 mL (range 0 to 1000). No conversions to open surgery were needed. The mean hospital stay was 3 days (range 1 to 5). One intraoperative diaphragmatic lesion developed that was repaired laparoscopically, and 1 patient had a pancreatic fistula that was managed by percutaneous drainage. The mean tumor size was 4.3 cm (range 1.5 to 9). The microscopic analysis revealed 22 malign lesions (64.7%) and 12 cases of benign pathologic features (35.3%). The mean survival time was 26 months (range 4 to 64) for the 22 patients with malign lesions. In 2 patients (9.1%), the surgical margins were positive. Laparoscopic adrenalectomy for small isolated metastases is feasible. However, because of the high risk of positive margins, this procedure should only be done by expert laparoscopists. We did not find a correlation between mass size and malignancy. Nevertheless, we believe that longer follow-up is mandatory before definitive conclusions can be drawn.