Higher Rate Of Positive Margins Research Articles

The Evolving Role of Neoadjuvant Radiation Therapy in Pancreatic Adenocarcinoma

Background/Objectives: Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers. Surgical resection is the most reliable chance for cure, but high rates of positive margins and local failure persist. Neoadjuvant therapies (NAT), including chemotherapy and radiation therapy (RT), are being explored to improve surgical outcomes, particularly in borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC). This review aims to summarize the current landscape and future directions for neoadjuvant RT (NART) in PDAC. Methods: The review includes a detailed analysis of past and ongoing clinical trials investigating various NART approaches in PDAC, with an emphasis on different RT techniques, fractionation schemes, and their integration into multimodal treatment strategies. Results: Early evidence suggests that NART can improve resection margins and local control. However, recent trials, including the Alliance A021501 and LAP-07 trials, have failed to demonstrate significant survival benefits with the addition of RT to NAT. Nevertheless, nuances in trial design and execution continue to keep the question of NART open. Newer approaches, such as stereotactic magnetic resonance-guided adaptive radiation therapy (SMART), show promise in improving local control and survival, but further phase 3 trials are needed. Conclusions: While NART has shown potential in improving local control in PDAC, its impact on overall survival remains unclear. Ongoing trials, particularly those utilizing advanced techniques like SMART, are critical in defining the role of RT in the neoadjuvant setting for PDAC. Collaboration across multidisciplinary teams is essential to optimize treatment strategies and trial outcomes.

Racial Disparities in Preoperative Breast MRI Use and Surgical Margin Outcomes among Patients with Recently Diagnosed Breast Cancer.

Purpose To evaluate racial disparities in preoperative breast MRI use and surgical margin outcomes among patients with recently diagnosed breast cancer. Materials and Methods This retrospective study included patients with breast cancer who presented to a single cancer center between 2008 and 2020, underwent breast surgery, and self-identified as White or Black. Patients were divided into MRI or no-MRI cohorts based on preoperative MRI use. MRI use and positive surgical margin rates were determined for all patients and racial subgroups. Data were collected from the electronic medical record and analyzed using the χ2 test for significance. Results The study included 28 384 female patients (mean age, 56 years ± 13 [SD]) with recently diagnosed breast cancer who self-identified as White (90.36%, n = 25 647) or Black (9.64%, n = 2737). Of the entire cohort, 32.78% (9305 of 28 384) underwent preoperative MRI. Black patients had a lower rate of preoperative MRI use than White patients (29.85% [817 of 2737] vs 33.10% [8488 of 25 647], respectively; P < .001). The MRI cohort had a lower positive margin rate compared with the no-MRI cohort (2.90% [133 of 4592] vs 4.78% [539 of 11 271], respectively; P = .03). In the no-MRI cohort, Black patients had a higher positive margin rate than White patients (6.17% [68 of 1103] vs 4.63% [471 of 10 168], respectively; P = .03). In the MRI cohort, there was no evidence of a difference in positive margin rates between Black and White patients (3.17% [12 of 379] vs 2.87% [121 of 4213], respectively; P = .90). Conclusion Compared with White patients, Black patients with breast cancer were less likely to undergo preoperative MRI and had a higher positive surgical margin rate. Keywords: MR Imaging, Breast Cancer, Breast MRI © RSNA, 2024 See also the commentary by Tran and Miles in this issue.

Primary site surgical resection in cM1 oral cavity squamous cell carcinoma.

To investigate primary site surgical resection and overall survival (OS) in clinically distantly metastatic (cM1) oral cavity squamous cell carcinoma (OCSCC). The 2006-2018 National Cancer Database was queried for patients presenting with cM1 OCSCC who underwent chemotherapy. Binary logistic, Kaplan-Meier, and multivariable Cox proportional hazards regression models were implemented. Of 278 patients satisfying inclusion criteria, 139 (50.0%) underwent chemotherapy alone, 80 (28.8%) underwent chemoradiotherapy, 25 (9.0%) underwent surgical resection + adjuvant chemotherapy, and 34 (12.2%) underwent surgical resection + adjuvant chemoradiotherapy; 5-year OS was 9.4%, 15.2%, 8.3%, and 23.8%, respectively (p < .001). Compared with those not undergoing surgical resection, patients undergoing surgical resection underwent radiotherapy more frequently (57.6% vs. 36.5%) but multiple-agent chemotherapy less frequently (40.7% vs. 74.4%) (p < .005). Twenty-one (36.2%) patients undergoing surgical resection had positive surgical margins. Academic facility (adjusted odds ratio [aOR] 3.19, 95% CI 1.54-6.62) and Charlson-Deyo comorbidity score ≥1 (aOR 2.82, 95% CI 1.25-6.32, p < .025) were associated with increased odds of undergoing surgical resection. Compared with chemotherapy alone, chemoradiotherapy (adjusted hazard ratio [aHR] 0.56, 95% CI 0.38-0.83) and surgical resection + adjuvant chemoradiotherapy (aHR 0.37, 95% CI 0.21-0.66) were associated with higher OS (p < .005). Immunotherapy (aHR 0.48, 95% CI 0.28-0.81, p = .006) was also independently associated with higher OS. A minority of patients with cM1 OCSCC underwent primary site surgical resection. Despite the high rate of positive surgical margins, surgical resection + adjuvant chemoradiotherapy was associated with higher OS than chemotherapy alone, chemoradiotherapy, or surgical resection + adjuvant chemotherapy. Definitive local therapy may benefit select patients with cM1 OCSCC.Level of evidence: 4.

Variation in surgical treatment by body mass index in patients with invasive lobular carcinoma of the breast

PurposePatients with invasive lobular carcinoma (ILC) face high rates of positive margins and completion mastectomy, which can be improved with the use of specific techniques, such as oncoplastic surgery. However, prior studies have shown that type of breast cancer surgery performed is also associated with patient factors such as elevated body mass index (BMI). Thus, this study investigates whether BMI impacts the type of surgical interventions in patients with ILC.MethodsA retrospective analysis of 705 patients with stage I–III ILC from an institutional database was conducted. Patients were stratified by BMI (underweight, normal weight, overweight, obese). Pearson’s Chi-square, ANOVA, and multivariable logistic regression were used to evaluate the relationship between BMI and surgical procedures.ResultsBreast-conserving surgery (BCS) was the initial operation in 60% of patients, with no significant difference by BMI. Among those undergoing BCS, patients with obese BMI were significantly more likely to undergo oncoplastic surgery (46.9% vs. 7.7%, 37.3%, and 33.6% for underweight, normal, and overweight, respectively, p = 0.032). Obese BMI patients undergoing mastectomy were less likely to have reconstruction compared to those with underweight, normal weight, and overweight BMI (44.2% vs. 50%, 71.1%, and 64.1%, p = 0.002).ConclusionOverweight/obese BMI patients with ILC underwent different surgical interventions compared to those with lower BMI. While initial BCS rates were similar, overweight/obese patients had higher oncoplastic surgery rates in BCS and lower reconstruction rates in mastectomy. Further research is needed to understand BMI’s impact on surgical decisions and outcomes in ILC.

Institution-level Patterns of Care for Early-stage Oropharynx Cancers in the United States.

The adoption of transoral robotic surgery and shifting epidemiology in oropharyngeal squamous cell cancer have stimulated debate over upfront and adjuvant treatment. Institutional variation in practice patterns can be obscured in patient-level analyses. We aimed to characterize institutional patterns of care as well as identify potential associations between patterns of care and survival. This was a retrospective cohort study of patients identified from 2004-2015 in the National Cancer Database. We analyzed 42,803 cases of oropharyngeal squamous cell cancer Stage cT1-2N0-2bM0 (AJCC 7th edition) treated with curative intent surgery and/or radiotherapy. We defined facility-4-year periods to account for changing institutional practice patterns. The 42,803 patients were treated within 2578 facility-4-year periods. We assessed institutional practice patterns, including the ratio of upfront surgery to definitive radiotherapy, case volumes, use of adjuvant therapies (radiotherapy or chemoradiotherapy), and margin positivity rates. Survival associations with institutional practice patterns were estimated with Cox regression. The ratio of upfront surgery to definitive radiotherapy ranged from 80-to-1 to 1-to-23. The institution-level median rate of adjuvant radiotherapy was 69% (IQR 50%-100%), adjuvant chemoradiotherapy was 44% (IQR 0%-67%), and margin-positive resection was 33% (IQR 0%-50%). On patient-level MVA, worse overall survival was not significantly associated with institutional case volume, adjuvant radiotherapy, or adjuvant chemoradiotherapy utilization. High rates of multimodal therapy and positive margins underscore the importance of multidisciplinary care and highlight variable patterns of care across institutions. Further work is warranted to explore indicators of high-quality care and to optimize adjuvant therapy in the HPV era.

Abstract PO5-26-07: Surgery for Invasive Lobular Carcinoma: A Patient Experience Survey from the Lobular Breast Cancer Alliance

Abstract The Lobular Breast Cancer Alliance (LBCA) is a nonprofit, patient advocacy organization committed to raising awareness and promoting research into invasive lobular carcinoma (ILC). While ILC accounts for 15% of breast cancers, knowledge about ILC remains limited. ILC’s hallmark is lack of E-cadherin, which results in non-cohesive formation and impacts accuracy of imaging tests and staging. Consequently, patients with ILC have higher rates of positive surgical margins, mastectomies, and axillary lymph node (LN) dissections. To understand the surgery experience of individuals with ILC, LBCA conducted an anonymous online survey from 6/21-7/2/23, distributed via the LBCA newsletter, social media, and partner organizations. Questions addressed pre-operative imaging, type of surgery, surgical margins, LN status, decision making about and patient experience with surgery. Analyses were limited to those respondents who had surgery. Study limitations include potential recall and selection bias. Results 1,482 individuals with a diagnosis of ILC completed the survey and 1,426 had undergone surgery. 76% were from North America, 11% from England, and 4% from Australia. Average age at diagnosis was 56 (range 31-86). At diagnosis, 38% were clinically stage 1; 37% stage 2; 17% stage 3; and 4% de novo metastatic. 75% had a mammogram that indicated dense breasts. Of 1,426 surgery respondents (SR), 95% reported that ILC was identified in only one breast at diagnosis. 80% had a pre-surgical MRI. MRI revealed larger tumors than seen on other imaging for 43% and revealed previously unseen contralateral ILC for 3%. 375 (26%) of SRs were diagnosed with ipsilateral disease and had a pre-surgical MRI that did not reveal new information about their ILC. Of these, post-surgical pathology reports indicated 16% had additional ipsilateral foci, 2% contralateral disease, and 40% had larger tumors than seen on pre-surgical imaging. 614 (43%) of SRs had one or more lumpectomy (L), 560 (39%) of SRs had a double mastectomy (DM), and 451 (32%) of SRs had a single mastectomy (SM). 123 (20%) of SRs who had one or more Ls, had a subsequent SM or DM. For those undergoing L (614), reasons for this choice included: recommendation from their care team (83%), wanted to keep their breast (25%), thought it was better for their overall survival (OS) (14%), and 13% indicated they wanted breasts but did not want reconstruction. Of the 560 women who had a DM, 60% indicated that they thought a DM would improve their OS, 50% were concerned about the risk of local recurrence, 47% doubted that imaging would detect future ILC tumors, and 45% noted concern that ILC is more likely to be bilateral. Of note, only 9% had ILC or ILC and another invasive breast cancer in both breasts at initial diagnosis and 31% who had a pre-surgical MRI changed their initial surgical treatment plan. Post surgery, pathology for DM group revealed larger tumors than seen on imaging (57%), and 6% had tumors found in a second breast that were not seen on imaging. For those 451 who had an SM, reasons for this choice included: 75% said it was what their care team recommended, 35% thought it would improve OS, 20% feared risk for local recurrence, and 15% doubted imaging would detect future ILC. Of 614 respondents who had L, 33% had positive margins at first surgery. Of those, 17% reported multiple Ls and M; and 24% reported clear margins were never achieved. Of the 1011 SM or DMs reported, 10% did not achieve clear margins after these surgeries. Conclusion The survey demonstrates the experience of a large cohort of women with ILC, reporting high rates of uncertainty about accuracy of imaging, high rates of repeat surgery, bilateral mastectomies, and positive margins. Patients are factoring concerns about potential extent of disease and future recurrence in their surgical decision making. These results support the need for improved pre-operative staging and imaging modalities specific to ILC. Citation Format: Laurie Hutcheson, Janice Axelrod, Tracy Cushing, Colleen Fitzwater, Rinath Jeselsohn, Gitte Joergensen, Maria Karsten, Miranda Kimm, Megan Kruse, Theresa Langdon, Julia Levine, Mason Mitchell-Daniels, Rita Mukhtar, Barbara Neilsen, Shani Paluch-Shimon, Therese Pross. Surgery for Invasive Lobular Carcinoma: A Patient Experience Survey from the Lobular Breast Cancer Alliance [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-26-07.

Comparing oncologic and surgical outcomes of robotic and laparoscopic pancreatoduodenectomy in patients with pancreatic cancer: a propensity-matched analysis.

Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied. The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles. A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50-0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92-1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68-1.71), 30-day (HR = 0.78, 95% CI = 0.39-1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42-1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92-1.44), nodal harvest (HR = 1.01, 95%CI = 0.94-1.09) or positive margins (HR = 1.19, 95% CI = 0.89-1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033). LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases.

Fluorescence guided surgery imaging systems for breast cancer identification: a systematic review.

Breast-conserving surgery (BCS) is limited by high rates of positive margins and re-operative interventions. Fluorescence-guided surgery seeks to detect the entire lesion in real time, thus guiding the surgeons to remove all the tumor at the index procedure. Our aim was to identify the optimal combination of a camera system and fluorophore for fluorescence-guided BCS. A systematic review of medical databases using the terms "fluorescence," "breast cancer," "surgery," and "fluorescence imaging" was performed. Cameras were compared using the ratio between the fluorescent signal from the tumor compared to background fluorescence, as well as diagnostic accuracy measures, such as sensitivity, specificity, and positive predictive value. Twenty-one studies identified 14 camera systems using nine different fluorophores. Twelve cameras worked in the infrared spectrum. Ten studies reported on the difference in strength of the fluorescence signal between cancer and normal tissue, with results ranging from 1.72 to 4.7. In addition, nine studies reported on whether any tumor remained in the resection cavity (5.4% to 32.5%). To date, only three studies used the fluorescent signal for guidance during real BCS. Diagnostic accuracy ranged from 63% to 98% sensitivity, 32% to 97% specificity, and 75% to 100% positive predictive value. In this systematic review, all the studies reported a clinically significant difference in signal between the tumor and normal tissue using various camera/fluorophore combinations. However, given the heterogeneity in protocols, including camera setup, fluorophore studied, data acquisition, and reporting structure, it was impossible to determine the optimal camera and fluorophore combination for use in BCS. It would be beneficial to develop a standardized reporting structure using similar metrics to provide necessary data for a comparison between camera systems.

Prognostic significance of the PI-RADS score in men with prostate cancer undergoing radical prostatectomy.

MRI-targeted biopsy (T-Bx) for which Prostate Imaging Reporting and Data System (PI-RADS) assessment categories are useful has been shown to more accurately detect clinically significant prostate cancer. However, the prognostic significance of the PI-RADS in prostate cancer patients needs further investigation. In the present study, we compared radical prostatectomy findings and postoperative oncologic outcomes in men with prostate cancer initially undergoing T-Bx for PI-RADS 3 vs. 4 vs. 5 lesions. We assessed consecutive patients undergoing T-Bx with concurrent systematic biopsy (S-Bx), followed by radical prostatectomy. Within our Surgical Pathology database, we identified a total of 207 men where prostatic adenocarcinoma was detected on either S-Bx or T-Bx, or both. Prostate cancer was detected on S-Bx only (n = 32; 15%), T-Bx only (n = 39; 19%), or both S-Bx and T-Bx (n = 136; 66%). These patients had PI-RADS 3 (n = 42; 20%), 4 (n = 86; 42%), or 5 (n = 79; 38%) lesions, while T-Bx detected cancer in 31 (74%) of PI-RADS 3 cases, 72 (84%) of PI-RADS 4 cases, and 72 (91%) of PI-RADS 5 cases. There were no significant differences in any of the clinicopathologic features examined, including tumor grade on biopsy or prostatectomy and pT or pN stage, among the PI-RADS 3 vs. 4 vs. 5 groups, except a significantly higher rate of positive margin and significantly larger tumor volume in PI-RADS 5 cases than in PI-RADS 3 cases. Univariate and multivariable analyses revealed significantly higher risks of biochemical recurrence after prostatectomy in patients with PI-RADS 5 lesion than in those with PI-RADS 3 or 4 lesion. Additionally, compared with respective controls, detection of any grade cancer (P = 0.046) or Grade Group 2 or higher cancer (P = 0.005) on T-Bx was associated with a significantly higher risk of recurrence in patients with PI-RADS 5 lesion, but not in those with PI-RADS 3 or 4 lesion. PI-RADS 5 lesions were thus found to independently predict a significantly poorer postoperative prognosis. Moreover, the failure of detection of any grade cancer or clinically significant cancer on T-Bx of PI-RADS 5 lesion may particularly indicate favorable outcomes in radical prostatectomy cases.

Parenchymal-sparing hepatectomy is associated with a higher rate of positive margins than single-stage major hepatectomy but not higher recurrence rate in patients with five or more bilateral colorectal liver metastases

Parenchymal-sparing hepatectomy is associated with a higher rate of positive margins than single-stage major hepatectomy but not higher recurrence rate in patients with five or more bilateral colorectal liver metastases

Quality of emergency oncological surgery: time for advanced oncological life support.

In the emergency care of cancer patients, in addition to cancer-related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery. The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course. Review of articles on the topic. Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer-specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario. Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

Incidence and Impact of Preoperative Hiatal Hernia in Patients with Esophageal Carcinoma Undergoing Curative Surgical Resection.

Hiatal hernia (HH) and gastroesophageal reflux disease (GERD) are risk factors for esophageal adenocarcinoma. High positive margin rates and poor survival were described among HH patients undergoing esophagectomy. We sought to describe incidence and impact of HH on outcomes following esophagectomy. Patients who underwent esophagectomy 2012-2019 for esophago-junctional carcinoma were included. CT studies were blindly reviewed by two radiologists. A third radiologist reviewed cases of disagreement. Hernias ≥ 3 cm were included in the HH group. Overall, 66 patients (33%) had HH ≥ 3 cm. The no hernia group included 12 patients (6%) with < 3 cm HH and 106 (53%) without HH. Preoperative variables were comparable among groups. Location of anastomosis was similar among cohorts and predominantly cervical (n = 97, 82.2% vs 61, 92.4%, p = 0.113). Postoperatively, HH patients had higher incidence of atrial dysrhythmia (n = 11, 16.7% vs n = 6, 5.1% p = 0.015). Rates of R0 resections were similar (n = 62, 93.9%, vs n = 113, 95.8%, p = 0.724). HH patients had higher rates of signet ring cell histology (n = 14, 21.2% vs n = 9, 7.6% p = 0.025); this was confirmed on subgroup analysis including only adenocarcinoma patients (n = 14, 28.6% vs n = 8, 12.3%, p = 0.042). On Cox regression analysis, HH was not associated with disease-free or overall survival (HR 1.308, p = 0.274 and HR .905, p = 0.722). Patients with preoperative HH had higher rates of postoperative atrial dysrhythmias and signet ring cell features on pathology. In a population with predominant cervical anastomosis, positive margin rates were low and survival comparable among cohorts.

Borrmann Type IV Gastric Cancer: Computed Tomography Features and Corresponding Pathological Findings.

We aimed to analyze the association between computed tomography (CT) features and the corresponding pathological findings in Borrmann type IV (BT-4) gastric cancers and explore the pathological basis of the characteristic CT features. This retrospective study included 84 patients with BT-4 gastric cancers who underwent contrast-enhanced CT and surgical resection. Preoperative CT features were evaluated, including the major location, range, circumferential invasion, perigastric fat infiltration, enlarged lymph nodes, layered enhancement, degree of enhancement, and peak enhanced phase. Postoperative pathological findings were also recorded. Differences in CT features according to different World Health Organization types, surgical margin, adjacent organ invasion, and peritoneal status were assessed using the χ 2 or Fisher exact test (n < 5). The most common World Health Organization type of BT-4 gastric cancer was poorly cohesive carcinoma (65.5%), which tended to show circumferential invasion, fewer enlarged lymph nodes, and layered enhancement. Although 82 patients with BT-4 gastric cancer (97.6%) had positive lymph nodes, only 26 (31.0%) had enlarged lymph nodes. Lesions originating from the gastroesophageal junction had a higher rate of positive margins ( P < 0.05). Adjacent organ invasion was more likely to occur in lesions with perigastric fat infiltration ( P < 0.05). Patients with circumferential invasion tended to show peritoneal metastasis ( P < 0.05). The characteristic CT features of BT-4 gastric cancer may be attributed to the corresponding pathological findings. Recognizing the association between CT features and pathological findings may help evaluate the aggressiveness of BT-4 gastric cancers.

Adverse pathologic features impact survival outcomes for small renal masses following nephrectomy.

While most small renal masses (SRM) < 4 cm have an excellent prognosis following resection, the impact of adverse T3a pathologic features on oncologic outcomes of SRMs remains unclear. We sought to compare clinical outcomes for surgically resected pT3a versus pT1a SRMs at our institution. We retrospectively reviewed records of patients who underwent radical or partial nephrectomy (RN, PN) for renal tumors <4 cm at our institution between 2010 and 2020. We compared features and outcomes of pT3a vs pT1a SRMs. Continuous and categorical variables were compared using Student's t and Pearson's chi-squared tests, respectively. Postoperative outcomes of interest including overall, cancer-specific, and recurrence-free survival (OS, CSS, and RFS) were analyzed using Kaplan-Meier method, Cox proportional hazard regression, and competing risk analysis. Analyses were performed using R statistical package (R Foundation, v4.0). We identified 1,837 patients with malignant SRMs. Predictors of postoperative pT3a upstaging included higher renal score, larger tumor size, and presence of radiologic features concerning for T3a disease (odds ratio [OR] = 5.45, 95% confidence interval [CI] 3.92-7.59, P < 0.001). On univariable modeling, pT3a SRMs had higher positive margin rates (9.6% vs 4.1%, P < 0.001), worse OS (hazard ratio [HR] = 2.9, 95% CI 1.6-5.3, P = 0.002), RFS (HR 9.32, 95% CI 2-40.1, P = 0.003), and CSS (HR = 3.6, 95% CI 1.5-8.2, P = 0.003). On multivariable modeling, pT3a status remained associated with worse RFS (HR = 2.7, 95% CI 1.04-7, P = 0.04), but not OS (HR 1.6, 95% CI = 0.83-3.1, P = 0.2); multivariable modeling was deferred for CSS due to low event rates. Adverse T3a pathologic features portend worse outcomes for SRMs, highlighting the crucial role of pre-operative planning and case selection. These patients have relatively poor prognosis, and should be monitored more closely and counseled for consideration of adjuvant therapy or clinical trials.

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.

Positive surgical margins after breast-conserving surgery for ductal carcinoma in-situ: does histologic grade or estrogen receptor status matter?

DCIS has been shown to have a higher rate of positive margins following breast-conserving surgery (BCS) than invasive breast cancer. We aim to analyze certain factors of DCIS, specifically histologic grade and estrogen receptor (ER) status, in patients with positive surgical margins following BCS to determine if there is an association. A retrospective review of our institutional patient registry was performed to identify women with DCIS and microinvasive DCIS who underwent BCS by a single surgeon from 1999 to 2021. Demographics and clinicopathologic characteristics between patients with and without positive surgical margins were compared using chi-square or Student's t-test. We assessed factors associated with positive margins using univariate and multivariable logistic regression. Of the 615 patients evaluated, there was no significant difference in demographics between the patients with and without positive surgical margins. Increasing tumor size was an independent risk factor for margin positivity (P = < 0.001). On univariate analysis both high histologic grade (P = 0.009) and negative ER status (P = < 0.001) were significantly associated with positive surgical margins. However, when adjusted in multivariable analysis, only negative ER status remained significantly associated with margin positivity (OR = 0.39 [95% CI 0.20-0.77]; P = 0.006). The study confirms increased tumor size as a risk factor for positive surgical margins. We also demonstrated that ER negative DCIS was independently associated with a higher rate of positive margins after BCS. Given this information, we can modify our surgical approach to reduce rate of positive margins in patients with large-sized ER negative DCIS.

PD07-06 RENAL TUMOR PLANAR EXTENSION IN THREE-DIMENSIONAL MODEL AS A NOVEL TECHNIQUE FOR PREOPERATIVE ASSESSMENT OF ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023PD07-06 RENAL TUMOR PLANAR EXTENSION IN THREE-DIMENSIONAL MODEL AS A NOVEL TECHNIQUE FOR PREOPERATIVE ASSESSMENT OF ROBOTIC PARTIAL NEPHRECTOMY Xinfei Li, Kunlin Yang, Xiaoteng Yu, Zhongyuan Zhang, Cuijian Zhang, Lin Cai, Zheng Zhang, Cheng Shen, Jin Tao, Dapeng Wu, Xuepei Zhang, Hailong Hu, Liqun Zhou, and Xuesong Li Xinfei LiXinfei Li More articles by this author , Kunlin YangKunlin Yang More articles by this author , Xiaoteng YuXiaoteng Yu More articles by this author , Zhongyuan ZhangZhongyuan Zhang More articles by this author , Cuijian ZhangCuijian Zhang More articles by this author , Lin CaiLin Cai More articles by this author , Zheng ZhangZheng Zhang More articles by this author , Cheng ShenCheng Shen More articles by this author , Jin TaoJin Tao More articles by this author , Dapeng WuDapeng Wu More articles by this author , Xuepei ZhangXuepei Zhang More articles by this author , Hailong HuHailong Hu More articles by this author , Liqun ZhouLiqun Zhou More articles by this author , and Xuesong LiXuesong Li More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003231.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To describe a tumor planar extension technique in three-dimensional (3D) model and assess its practicability in robot-assisted partial nephrectomy (RAPN). METHODS: A total of 231 patients with a renal tumor who underwent RAPN between Mar 2019 and Mar 2022 was prospectively enrolled. The 3D model was obtained based on enhanced CT urography. The tumor plane was extended equidistantly (10 mm) according to the original shape. The patients were divided into the collecting system involvement (CSI) group and the collecting system negative (CSN) group based on the relationship between the extended plane and the collecting system. The evaluation indicators included operative time, ischemia time, positive margin, major complication, and trifecta outcome (negative margin, ischemic time ≤25min, no major complication). RESULTS: The tumor diameter was 2.9 (0.8-10.0) cm. Median PADUA score was 8 (6-15). There were 173 and 58 patients in CSN and CSI groups, respectively. The operative time was 110.3±36.2 and 116.9 ± 36.6 min in CSN and CSI groups (p=0.228). The ischemic time in CSI group was significantly longer than that in CSN group (26.7±10.0 vs 21.0 ± 7.8 min, p<0.001). The patients in CSI group had a higher positive margin rate (1.72% vs. 0.58%) and higher risk of complications (8.62% vs 5.78%), but there was no statistical significance. Patients in CSI group whose ischemia time greater than 25 min was significantly more than that in CSN group (44.83% vs 21.39%, p=0.001). The failure rate in trifecta outcome in CSI group was significantly higher (46.55% vs 24.42%, p=0.003). The area under ROC curve in predicting trifecta outcome was 0.599 (p=0.017) based on the relationship between the tumor planar extension and the collecting system. CONCLUSIONS: The 3D tumor planar extension is a novel technique for tumor anatomy assessment and helps predict surgical outcomes of RAPN. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e164 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Xinfei Li More articles by this author Kunlin Yang More articles by this author Xiaoteng Yu More articles by this author Zhongyuan Zhang More articles by this author Cuijian Zhang More articles by this author Lin Cai More articles by this author Zheng Zhang More articles by this author Cheng Shen More articles by this author Jin Tao More articles by this author Dapeng Wu More articles by this author Xuepei Zhang More articles by this author Hailong Hu More articles by this author Liqun Zhou More articles by this author Xuesong Li More articles by this author Expand All Advertisement PDF downloadLoading ...

Cathepsin protease expression in infiltrative soft tissue sarcomas: cathepsin-K correlates with infiltrative tumor growth and clinical outcomes.

Cathepsin proteases, activated in the lysosomes, are upregulated in many cancers. Intraoperative detection systems of microscopic residual tumor using cathepsin-mediated release of fluorescent nanoparticles may guide surgical excisions to improve local control. We sought to define the genetic and proteomic expression of cathepsins and their clinicopathological correlates in myxofibrosarcoma and undifferentiated pleomorphic sarcoma (UPS)-soft tissue sarcomas with high rates of positive resection margins and local recurrence-and to establish a cellular justification for cathepsin-dependent systems to identify residual cancer in the resection bed. Real-time quantitative polymerase chain reaction analysis of 58 fresh-frozen tumor specimens revealed that 56 (97%) had elevated mRNA expression of ≥1 cathepsin, including cathepsin-B (79%), cathepsin-K (59%), cathepsin-L (71%), and -S (71%). Immunohistochemical analysis of these fresh-frozen specimens revealed that 98% of tumors were positive for one or more of cathepsin-B (85%), cathepsin-K (50%), cathepsin-L (63%), and -S (10%). Strong cathepsin-K expression was associated with greater risks of local recurrence (hazard ratio, 3.78; p=0.044) and disease-specific mortality (hazard ratio, 3.70; p=0.025). Immunohistochemical analysis of 33 formalin-fixed paraffin-embedded block samples revealed that 97% were positive for cathepsin-B (88%), cathepsin-K (76%), cathepsin-L (52%), or -S (52%) at the tumor periphery; cathepsin-K positivity correlated with a radiographic tail-like sign (p=0.004) and microscopic infiltrative growth (p=0.020). We conclude that cathepsins are broadly overexpressed in myxofibrosarcoma and UPS, and cathepsin-K may be an immunohistochemical marker of local infiltration and poorer prognosis that could be used to guide precision surgery.

Racial and regional disparities in the management of locally advanced rectal cancer.

14 Background: Surgical margins following rectal cancer resection impact oncologic outcomes and may reflect adequacy of care. We examined the relationship between race, ethnicity, or region of care with margin positivity following rectal cancer resection. Methods: We queried the National Cancer Database (NCDB) for patients diagnosed with stage II-IV rectal cancer between 2004-2018 who underwent surgical resection and excluded patients with missing data for race/ethnicity and radiation therapy/surgery status, and/or who had local excision only. We performed a propensity-score analysis via inverse probability of treatment weighting (IPTW) of margin positivity rate as outcome and race/ethnicity and region as predictors of interest. We controlled for age, sex, Charlson-Deyo Score, pathologic stage, pathologic grade, time from diagnosis to surgical resection, surgery type, sequence of radiation and surgery, facility type, insurance type, level of education, distance between patient and facility, and region of the United States. Results: Our query yielded 73,269 patients. Median patient age was 63 (IQR: 54-72) years and 40% were female. 81%,8%, 6%, and 5% were non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Other, respectively. After IPTW adjustment, non-Hispanic Black patients had 19% higher odds of margin positivity relative to non-Hispanic White patients (OR: 1.185, 95% CI: 1.094-1.284; p&lt;.0001) Patients in the Northeast United States had a 10% lower odds of margin positivity compared to those in the South (OR: 0.900, 95% CI: 0.842-0.962; p=0.0019). Conclusions: Being non-Hispanic Black was significantly associated with a higher likelihood of positive margin following rectal cancer resection when compared to their non-Hispanic White counterparts. Patients in the South also experienced significantly higher rates of positive margin when compared to Northeast patients. Further investigation into potential interactions between racial and regional disparities and other contributors is warranted.[Table: see text]

608. INCIDENCE AND IMPACT OF PREOPERATIVE HIATAL HERNIA IN PATIENTS WITH ESOPHAGEAL CARCINOMA UNDERGOING CURATIVE SURGICAL RESECTION

Abstract Hiatal hernia (HH) and gastroesophageal reflux disease (GERD) are risk factors for esophageal adenocarcinoma. High positive margin rates and poor survival were previously described among HH patients undergoing esophagectomy. We sought to describe incidence and impact of HH on outcomes following esophagectomy in a population of patients undergoing predominantly cervical anastomosis. Patients who underwent esophagectomy 2012-2019 for esophago-junctional carcinoma were included. CT studies were blindly reviewed by two radiologists. A third radiologist reviewed cases of disagreement. Hernias &amp;gt;3 cm were included in the HH group. Overall, 66 patients (33%) had HH &amp;gt;3 cm. The control group included 12 patients (6%) with &amp;lt;3 cm HH and 106 (53%) without HH. Patients with HH had higher Charlson Comorbidity Index (CCI) (p=0.017). Location of anastomosis was similar among cohorts (cervical anastomosis 82.2% vs 92.4%, p=0.113). HH patients had higher incidence of atrial dysrhythmia (16.7% vs 5.1% p=0.015). Rates of R0 resections were similar (95.8% vs 93.9%, p=0.724). Subgroup analysis on adenocarcinoma patients confirmed higher rates of signet ring cell features among HH patients (28.6% vs 12.3%, p=0.034). HH was not associated with poor disease free survival (p=0.274). Patients with preoperative HH had higher CCI, higher rates of postoperative atrial dysrhythmias and signet ring cell features on pathology. In a population with predominant cervical anastomosis, positive margin rates were low and survival comparable among cohorts.