Inadequate Margins Research Articles

Improving Interdisciplinary Communication and Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation.

Surgical pathology reports play an integral role in postoperative management of head and neck cancer patients. Pathology reports of complex head and neck resections must convey critical information to all involved clinicians. Previously, we demonstrated the utility of 3D specimen and defect scanning for communicating margin status and documenting the location of supplemental margins. We introduce a newly designed permanent pathology report which improves documentation of intraoperative margin mapping and extent of corresponding supplemental margins harvested. We test the hypothesis that gaps in understanding exist for head and neck resection pathology reports across providers. A cross-sectional exploratory study using human-centered design was implemented to evaluate the existing permanent pathology report with respect to understanding margin status. Pathologists, surgeons, radiation oncologists, and medical oncologists from United States-based medical institutions were surveyed. The results supported a redesign of our surgical pathology template, incorporating 3D specimen / defect scans and annotated radiographic images indicating the location of inadequate margins requiring supplemental margins, or indicating frankly positive margins discovered on permanent section. Forty-seven physicians completed our survey. Analyzing surgical pathology reports, 28/47 (60%) respondents reported confusion whether re-excised supplemental margins reflected clear margins, 20/47 (43%) reported uncertainty regarding final margin status, and 20/47 (43%) reported the need for clarity regarding the extent of supplemental margins harvested intraoperatively. From this feedback, we designed a new pathology report template; 61 permanent pathology reports were compiled with this new template over a 12-month period. Feedback from survey respondents led to a redesigned permanent pathology report that offers detailed visual anatomic information regarding intraoperative margin findings and exact location/size of harvested supplemental margins. This newly designed report reconciles frozen and permanent section results and includes annotated radiographic images such that clinicians can discern precise actions taken by surgeons to address inadequate margins, as well as to understand the location of areas of concern that may influence adjuvant radiation planning.

Adequacy of Surgery of Head and Neck Cancers

Adequacy of Surgery of Head and Neck Cancers

Feasibility of an MR-based digital specimen for tongue cancer resection specimens: a novel approach for margin evaluation.

This study explores the feasibility of ex-vivo high-field magnetic resonance (MR) imaging to create digital a three-dimensional (3D) representations of tongue cancer specimens, referred to as the "MR-based digital specimen" (MR-DS). The aim was to create a method to assist surgeons in identifying and localizing inadequate resection margins during surgery, a critical factor in achieving locoregional control. Fresh resection specimens of nine tongue cancer patients were imaged in a 7 Tesla small-bore MR, using a high-resolution multislice and 3D T2-weighted Turbo Spin Echo. Two independent radiologists (R1 and R2) outlined the tumor and mucosa on the MR-images whereafter the outlines were configured to an MR-DS. A color map was projected on the MR-DS, mapping the inadequate margins according to R1 and R2. We compared the hematoxylin-eosin-based digital specimen (HE-DS), which is a histopathological 3D representation derived from HE stained sections, with its corresponding MR-images. In line with conventional histopathological assessment, all digital specimens were divided into five anatomical regions (anterior, posterior, craniomedial, caudolateral and deep central). Over- and underestimation 95th-percentile Hausdorff-distances were calculated between the radiologist- and histopathologist-determined tumor outlines. The MR-DS' diagnostic accuracy for inadequate margin detection (i.e. sensitivity and specificity) was determined in two ways: with conventional histopathology and HE-DS as reference. Using conventional histopathology as a reference, R1 achieved 77% sensitivity and 50% specificity, while R2 achieved 65% sensitivity and 57% specificity. When referencing to the HE-DS, R1 achieved 94% sensitivity and 61% specificity, while R2 achieved 88% sensitivity and 71% specificity. Range of over- and underestimation 95HD was 0.9mm - 11.8mm and 0.0mm - 5.3mm, respectively. This proof of concept for volumetric assessment of resection margins using MR-DSs, demonstrates promising potential for further development. Overall, sensitivity is higher than specificity for inadequate margin detection, because of the radiologist's tendency to overestimate tumor size.

Prediction of prognosis in oral squamous cell carcinoma using infrared microspectroscopy.

Estimation of prognosis of oral squamous cell carcinoma (OSCC) is inaccurate prior to surgery, only being effected following subsequent pathological analysis of the primary tumour and excised lymph nodes. Consequently, a proportion of patients are overtreated, with an increase in morbidity, or undertreated, with inadequate margins and risk of recurrence. We hypothesise that it is possible to accurately characterise clinical outcomes from infrared spectra arising from diagnostic biopsies. In this first step, we correlate survival with IR spectra derived from the primary tumour. Infrared spectra were collected from tumour tissue from 29 patients with OSCC and subject to classification modelling. The model had a median AUROC of 0.89 with regard to prognosis, a median specificity of 0.83, and a hazard ratio of 6.29 in univariate Cox proportional hazard modelling. The data suggest that FTIR spectra may be a useful early biomarker of prognosis in OSCC.

Improved intraoperative identification of close margins in oral squamous cell carcinoma resections using a dual aperture fluorescence ratio approach: first in-human results.

Surgical excision is the main treatment for solid tumors in oral squamous cell carcinomas, where wide local excision (achieving a healthy tissue margin of around the excised tumor) is the goal as it results in reduced local recurrence rates and improved overall survival. No clinical methods are available to assess the complete surgical margin intraoperatively while the patient is still on the operating table; and while recent intraoperative back-bench fluorescence-guided surgery approaches have shown promise for detecting "positive" inadequate margins (), they have had limited success in the detection of "close" inadequate margins (1 to 5mm). Here, a dual aperture fluorescence ratio (dAFR) approach was evaluated as a means of improving detection of close margins. The approach was evaluated on surgical specimens from patients who were administered a tumor-specific fluorescent imaging agent (cetuximab-800CW) prior to surgery. The dAFR approach was compared directly against standard wide-field fluorescence imaging and pathology measurements of margin thickness in specimens from three patients and a total of 12 margin locations (1 positive, 5 close, and 6 clear margins). The area under the receiver operating characteristic curve, representing the ability to detect close compared to clear margins () was found to be 1.0 and 0.57 for dAFR and sAF, respectively. Improvements in dAFR were found to be statistically significant (). These results provide evidence that the dAFR approach potentially improves detection of close surgical margins.

Care Pathway Analysis to Inform the Earliest Stages of Technology Development: Scoping Oncological Indications in Need of Innovation

ObjectivesIdentifying unmet needs for innovative solutions across disease contexts is challenging but important for directing funding and research efforts and informing early-stage decisions during the innovation process. Our aim was to study the merits of care pathway analysis to scope disease contexts and guide the development of innovative devices. We used oncologic surgery as a case study, for which many intraoperative imaging techniques are under development. MethodsCare pathway analysis is a mapping process, which produces graphical maps of clinical pathways using important outcomes and subsequent consequences. We performed care pathway analyses for glioblastoma, breast, bladder, prostate, renal, pancreatic, and oral cavity cancer. Differences between a “perfect” care pathway and the current care pathway in terms of percentage of inadequate margins, associated recurrences, quality of life, and 5-year overall survival were calculated to determine unmet needs. Data from The Netherlands Cancer Registry and literature were used. ResultsCare pathway analysis showed that highest percentages of inadequate margins were found in oral cavity cancer (72.5%), glioblastoma (48.7%), and pancreatic cancer (43.9%). Inadequate margins showed the strongest increase in recurrences in cancer of oral cavity, and bladder (absolute increases of 43.5% and 41.2%, respectively). Impact on survival was largest for bladder and oral cavity cancer with positive margins. ConclusionsCare pathway analysis provides overviews of current clinical paths in multiple indications. Disease contexts can be compared via effectiveness gaps that show the potential need for innovative solutions. This information can be used as basis for stakeholder involvement processes to prioritize care pathways in need of innovation.

Is the Thickness of the Margin Associated With Local Recurrence and Survival in Patients With Myxofibrosarcoma?

Myxofibrosarcoma (MFS) is a spectrum of aggressive soft tissue fibroblastic neoplasms characterized by variable myxoid stroma, pleomorphism, and a distinctive curved vascular pattern; these tumors are associated with a high likelihood of recurrence. Better local tumor control (a tumor-free margin) is believed to be important to minimize the risk of recurrence, but the effect of surgical resection margin status on local recurrence and survival in MFS is not as well-characterized as it might be. (1) Is margin width associated with local recurrence? (2) Is there a relationship between greater margin thickness and improved overall and disease-free survival (DFS)? (3) Is worsening French Federation of Cancer Centers grade associated with local recurrence and poorer overall survival? Using a database of patients with bone and soft tissue tumors at a tertiary university hospital, we retrospectively reviewed the medical records of 282 patients who had soft tissue sarcomas and who had been surgically treated by a multidisciplinary bone and soft tissue tumor care team between January 2010 and December 2021. Of these 282 patients, 38 were identified as having MFS. Patients who received surgical care for MFS outside our institution (unplanned resection) (four patients) and whose surgical margins were not reported as microscopic numerical data (10) were excluded from the analysis. We estimated survival and local recurrence and examined factors potentially influencing these outcomes. Patient demographics, tumor characteristics, surgical margin distance (in mm), and disease-related outcomes were recorded. The minimum follow-up was 3 months (median 41.5 months, range 3 to 128 months). Overall 1-year local recurrence-free rates were 66.7% (95% CI 50% to 88%). Patients with positive margins were more likely to have local recurrence than patients with negative margins (HR 10.91 [95% CI 2.61 to 45.66]; p = 0.001). Patients with an inadequate margin (positive margin or a negative margin of 1 mm or less) had a greater risk of local recurrence (HR 9.96 [95% CI 1.22 to 81.44]; p = 0.032). Patients with positive margins or margins less than or equal to 1 mm had worse 2-year local recurrence-free survival than did those with margins of greater than 1 mm (46.9% [95% CI 16% to 76%] versus 91.7% [95% CI 75% to 100%]; p = 0.005). The mean overall survival was 98 months (95% CI 77.2 to 118.8). The Kaplan-Meier overall 1-, 2- and 5-year estimated rates of survival were 88% (95% CI 75% to 100%), 79.2% (95% CI 64.5% to 97.2%), and 73.5% (95% CI 57.2 % to 94.5%), respectively. Positive surgical margins were associated with decreased overall survival (HR 6.96 [95% CI 1.39 to 34.89]; p = 0.018). There was a mean DFS time of 4.25 months (95% CI 0.92 to 7.59) in microscopically positive patients, 75.5 months (95% CI 37.47 to 113.53) in patients with margins 1 mm or less, and 118 months (95% CI 99.23 to 136.77) in patients with margins over 1 mm. There was a statistical difference between DFS times according to surgical margin classification (p < 0.001). With the numbers we had, we could not detect any difference between the histologic grades determined by the French Federation of Cancer Centers grading system in terms of local recurrence (HR 3.80 [95% CI 0.76 to 18.94]; p = 0.103) and overall survival (HR 6.91 [95% CI 0.79 to 60.13]; p = 0.080). Tumor size was the prognostic factor associated with a higher local recurrence rate among all factors analyzed as univariate (HR 1.18 [95% CI 1.05 to 1.32]; p = 0.004). A surgical procedure with a sufficient negative surgical margin distance appears to be associated with a lower proportion of patients who experience a local recurrence and is associated with overall patient survival. It is difficult to define what a sufficient margin is, but in our patients, it appears to be greater than 1 mm.Level of Evidence Level III, therapeutic study.

Pre-resection Intraoperative Core Biopsies in Oral Tongue Cancer-A Pilot Study.

To assess a novel intraoperative core biopsy technique to provide enhanced guidance in partial glossectomies. All patients diagnosed with squamous cell carcinoma of the oral tongue were eligible for study participation. Following anesthesia, the planned resection and three points midway between the gross tumor and the intended ablation were marked. A core biopsy was performed with a needle spring on each point and sent for frozen sections. The initially planned resection was executed if the cores returned free of tumor. In case of a positive core biopsy, a new 1-1.5 cm margin was marked around that point. The main outcome measure was the closest final margin diameter, especially the deep ones. Other outcome measures were the core biopsies' sensitivity, specificity, and negative predictive value. Complications were recorded. The final margins of 10 patients undergoing intraoperative core biopsies and 20 matched controls were analyzed. One patient had two positive cores and final negative margins after modifying the resection accordingly. Another patient had a positive biopsy diagnosed only on final pathology, and one close final margin. Patients that were operated with the new technique had larger margins compared to the controls: median (interquartile range) closest margin 5.95 (3.97; 9.63) mm versus 4 (2.25; 5) mm (p =0.074) and median deep margin 8.6 (6.16; 10) mm versus 5 (3;10) mm (p =0.411), respectively. There were no complications. A novel pre-resection intraoperative biopsy technique is presented. Core biopsies taken during glossectomies have the potential to prevent inadequate margins. 3 Laryngoscope, 133:2232-2236, 2023.

Dissecting Diagnostic Discrepancies between Intraoperative and Permanent Head and Neck Pathology Sections at a Large University Medical Center

Abstract Introduction/Objective Accurate correlation between intraoperative frozen section (FS) and subsequent permanent section (PS) diagnoses is essential for quality patient care. Intraoperative FS is used for confirmation of diagnoses and margin status (MS) evaluation in head and neck (H&amp;N) pathology. Reported FS-PS discrepancy rates for H&amp;N cases range between 1.42% to 1.80%, mostly due to sampling and interpretation errors. We sought to review our experience with FS and concordant PS from H&amp;N pathology cases diagnosed at a high volume, university medical center. Methods/Case Report Correlation was performed between intraoperative FS and paraffin-embedded PS of H&amp;N surgical resections between January 2019 to December 2021. FS-PS discrepancies were classified due to “sampling” or “interpretation”. Recurrence rates based on a 2 year follow up period of 2019 cases was also recorded. Results (if a Case Study enter NA) 2337 H&amp;N cases yielded 11108 intraoperative FS diagnoses. FS-PS correlation identified 142 (1.27%) discrepancies. Of these, 85 (60%) were for MS control, comprised of 45 (53%) due to “sampling” and 40 (47%) to “interpretation”. FS slides generally represented a single top section taken from the tissue, with “sampling” discrepancies due to discordant diagnoses identified on a deeper cut of tissue on the PS slides. Common “interpretative” discrepancies included overlooking high-grade dysplasia. For patients diagnosed in 2019, we found that 6% of discrepant cases of locoregional disease over a 2 year follow up period were due to inadequate margin control. Conclusion Our institutional intraoperative FS-PS discrepancy rate for H&amp;N pathology cases is 1.27%, and within the national quality standards. Our FS-PS discrepancy rate for H&amp;N cases related to MS control were mostly due to “sampling". Intraoperative review of deeper cuts of FS tissue and in service instruction for pathologists regarding intraoperative reporting of high-grade dysplasia will be the subject of a prospective study for potential improvement of “sampling” and “interpretative” discrepancies, respectively. Future studies hope to minimize the cases of locoregional occurence due to inadequate margin status.

Comparison of narrow band and fluorescence molecular imaging to improve intraoperative tumour margin assessment in oral cancer surgery

ObjectiveNew techniques have emerged to aid in preventing inadequate margins in oral squamous cell carcinoma (OSCC) surgery, but studies comparing different techniques are lacking. Here, we compared narrow band imaging (NBI) with fluorescence molecular imaging (FMI), to study which intraoperative technique best assesses the mucosal tumour margins. Materials and MethodsNBI was performed in vivo and borders were marked with three sutures. For FMI, patients received 75 mg of unlabelled cetuximab followed by 15 mg cetuximab-800CW intravenously-two days prior to surgery. The FMI borders were defined on the excised specimen. The NBI borders were correlated with the FMI outline and histopathology. ResultsSixteen patients were included, resulting in 31 NBI and 30 FMI measurements. The mucosal border was delineated within 1 mm of the tumour border in 4/31 (13 %) of NBI and in 16/30 (53 %) FMI cases (p = 0.0008), and within 5 mm in 23/31 (74 %) of NBI and in 29/30 (97 %) of FMI cases (p = 0.0048). The median distance between the tumour border and the imaging border was significantly greater for NBI (3.2 mm, range −6.1 to 12.8 mm) than for FMI (0.9 mm, range −3.0 to 7.4 mm; p = 0.028). Submucosal extension and previous irradiation reduced NBI accuracy. ConclusionEx vivo FMI performed more accurately than in vivo NBI in mucosal margin assessment, mainly because NBI cannot detect submucosal extension. NBI adequately identified the mucosal margin especially in early-stage and not previously irradiated tumours, and may therefore be preferable in these tumours for practical and cost-related reasons.

Recurrent Dermatofibrosarcoma Protuberans of the Head and Neck: a Case Series.

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma that develops from dermal fibroblasts and spreads within the dermis and subcutaneous fat. It is locally aggressive, with a high local recurrence rate after excision but has extremely low metastatic potential. In the case of recurrent tumors, surgical excision with adequate margins is the gold standard treatment and may require adjuvant radiotherapy or chemotherapy in some cases. We conducted a retrospective analysis of individuals with dermatofibrosarcoma protuberance of the head and neck region that had treatment at our facility between 2016 and 2021. We gathered the data on the surgical techniques, reconstructive techniques used, histopathological features, adjuvant therapy, and outcomes. We treated three patients with head and neck dermatofibrosarcoma protuberance: one scalp lesion and two on the cheek. All three patients had recurrent tumors, two of whom were treated elsewhere for the primary lesion. One patient underwent surgery for a benign spindle cell tumor of the right cheek, but a final histopathological examination revealed dermatofibrosarcoma protuberance, and the tumor recurred within 3months. The duration of recurrence is between 3 and 24months. The size of the tumor ranges from 7.2 to 10.5cm. The wide local excision margins range from 2 to 4cm. Reconstruction ranges from split skin graft to regional flap. Inadequate margins raise the possibility of local recurrence in dermatofibrosarcoma protuberance.

Application and accuracy of ultrasound-guided resections of tongue cancer

ObjectivesSurgical removal of squamous cell carcinoma of the tongue (SCCT) with tumour-free margin status (≥5 mm) is essential for loco-regional control. Inadequate margins (<5 mm) often indicate adjuvant treatment, which results in increased morbidity. Ultrasound (US)-guided SCCT resection may be a useful technique to achieve more adequate resection margins compared to conventional surgery. This study evaluates the application and accuracy of this technique. MethodsForty patients with SCCT were included in a consecutive US cohort. During surgery, the surgeon aimed for a 10-mm echographic resection margin, while the tumour border and resection plane were captured in one image. Ex-vivo US measurements of the resection specimen determined whether there was a need for an immediate re-resection. The margin status and the administration of adjuvant treatment were compared those of with a consecutive cohort of 96 tongue cancer patients who had undergone conventional surgery. A receiver operating characteristic analysis was done to assess the optimal margin of ex-vivo US measurements to detect histopathologically inadequate margins. ResultsIn the US cohort, the frequency of free margin status was higher than in the conventional cohort (55% vs. 16%, p < 0.001), and the frequency of positive margins status (<1 mm) was lower (5% vs. 15%, respectively, p < 0.001). Adjuvant radiotherapy was halved (10% vs. 21%), and the need for re-resection was comparable (10% vs. 9%). A cut-off value of 8 mm for ex-vivo measurements prevented histopathologically inadequate margins in 76%. ConclusionUS-guided SCCT resections improve margin status and reduce the frequency of adjuvant radiotherapy.

Intralesional margin after excision of a high-grade osteosarcoma: Is it a catastrophe?

Background and ObjectivesTreatment of high‐grade osteosarcoma (OS) relies on a combination of systemic chemotherapy and radical surgical excision of the tumor. Little is known on what happens in case of an irrefutably inadequate (intralesional) margin. We aimed to describe the outcome of patients with high‐grade OSs of the trunk and the extremities where planned wide resection resulted in an intralesional margin.MethodsA retrospective study from the Scandinavian Sarcoma Group registry and the Royal Orthopaedic Hospital databases including data from 53 patients surgically treated between the years 1990 and 2017.ResultsLocal recurrence was observed in 13/53 patients. All patients with local recurrence where the neoadjuvant chemotherapy response could be retrieved (n = 9) were shown to be poor responders. None of the patients with good response to chemotherapy relapsed. Postoperative radiotherapy was not associated with improved local control of the disease. Re‐excision surgery was performed in only seven patients, and two of them had tumor relapse.ConclusionsGood response to chemotherapy salvages the outcome of surgical excision with a poor margin in patients with high‐grade OSs and a watchful waiting strategy may be justified in these cases. Poor responders have a higher recurrence risk and their approach should be individualized.

Reoperation rate of ductal carcinoma in situ: impact of tomosynthesis (3D) and spot magnification.

Surgical planning depends on precise preoperative assessment of the radiological extent of ductal carcinoma in situ (DCIS). Despite different modalities used, reoperation rates for DCIS due to involved margins are high. To evaluate the impact of additional imaging views (spot magnification, tomosynthesis) on surgical reoperation rate of DCIS. The retrospective single institute study includes 157 patients with biopsy-proven pure DCIS seen on mammogram as microcalcifications and treated with breast-conserving surgery. Patients have been divided into three groups according to additional imaging performed: spot magnification, tomosynthesis, and none. All breast images (mammograms, spot magnification, tomosynthesis) were reviewed and the maximum extent of pathological microcalcifications was recorded. Radiological size was compared to final histopathological size. Reoperation rate due to inadequate margins was recorded. Reoperation rates (25%) due to inadequate margins were as follows: spot (18%), tomosynthesis (27%), none (31%); P = 0.488. Spot magnification, tomosynthesis, and digital zoom of full-field digital mammography predicted similarly the final histopathological size. Reoperation group had a significantly greater preoperative radiological median size (26 mm vs. 20 mm; P = 0.014) as well as median size of disease on final histopathological report (29 mm vs. 14 mm; P < 0.001). Discrepancy between radiological and final histopathological size became greater with increasing DCIS extent. The main factors for reoperations are DCIS size and discordance between radiological and histopathological sizes. The use of additional imaging views (spot magnification, tomosynthesis) did not reduce reoperation rate.

Impact of Surgical Margins on Overall Survival after Gastrectomy for Gastric Cancer: A Validation of Japanese Gastric Cancer Association Guidelines on a Western Series

PurposeNo consensus exists on the resection extent needed to ensure oncological safety in gastrectomy for gastric adenocarcinoma (GAC). This study aims to assess the impact of margin adequacy according to Japanese Gastric Cancer Association (JGCA) guidelines on overall survival (OS).Patients and MethodsPatients who underwent surgery for stage I–III GAC at our institution between 2010 and 2017 were included. Margin adequacy according to JGCA, National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) guidelines was assessed, and their predictive value on OS was evaluated with Harrell’s C-index. Patients were analyzed according to their margins’ adherence to JGCA guidelines, and a propensity score matching (PSM) was run. Indication to either total gastrectomy (TG) or distal gastrectomy (DG) according to each guideline was also assessed.ResultsA total of 279 patients were included, of whom 220 (79%) underwent DG. Adequate margins according to JGCA were obtained in 209 patients (75%). On multivariate analysis, JGCA margin adequacy was independently associated with OS, together with American Society of Anesthesiologist class, neoadjuvant chemotherapy, lymphadenectomy extent, R0 resection, and postoperative N stage. After PSM, patients with JGCA adequate margins showed better OS, recurrence-free survival (RFS), and local RFS than patients with JGCA inadequate margins. For 220 DG, JGCA guidelines would have recommended TG in 25 patients (11%), NCCN in 30 (14%), and ESMO in 90 (41%) (p < 0.001).ConclusionAdequacy of surgical resection margins to JGCA guidelines leads to improved survival outcomes and allows for a more organ-preserving approach than Western guidelines.

Prediction of Large Change in Lung Tumor Motion During Treatment Course: An Ensemble Learning Method With Enhanced Positive Predictive Values

During lung cancer radiotherapy, tumor motion magnitude may change, resulting in either inadequate margins or non-ideal dose conformality (margins are unnecessarily too big). To predict large motion change using only patient-specific clinical information and the simulation 4DCT images, we proposed an ensemble learning model (ELM) with robust feature selection (FS). For this specific study, we minimized the false negative prediction so that we will not miss patients who might have a subsequent large change in tumor motion. Thus, we employed positive predictive values (PPV) as the evaluation metric instead of commonly used accuracy scores.Seventeen features were collected including both clinical factors and imaging features. The motion change is defined by motion difference in SI direction between the simulation 4DCT and mid-course repeat 4DCT with the clinical threshold set as 3 mm. The dataset consisted of 140 patients, where 31 showed large tumor motion change. Four hundred seventy-two sets of 4DCT images were analyzed in this study. The ELM adopts 5 conventional predictive models (logistic regression (LR), decision tree (DT), support vector machine (SVM), random forest (RF), and XGBoost (XGB)) as base predictors. Then, the results are employed as inputs for a two-layer neural network to obtain a final prediction. To enhance the feature sensitivity and to reduce data noise, we developed a robust FS strategy with sequential backward selection. Each criterion score is an average from 5-fold cross-valuation, and the target feature of each round is based on 1000 repeated experiments. The peak of the criterion score after sequential removal of the least sensitive features was used to select the optimal feature set.By employing PPV as the criterion function, all the base predictors ranked initial SI tumor motion as the most important feature. ROC curve with selected sensitive features consistently outperformed the one with all features. For ELM, the AUCs (mean std. ± dev.) were 0.63 ± 0.04 when all features were included and increased to 0.72 ± 0.02 for PPV-based selected features only. The prediction comparisons were performed for all base predictors and ELM with 100 repetitions. The PPV results (Table 1) demonstrated the proposed ELM obtained superior performance than each base predictor.We proposed an ELM to identify patients with potential large tumor motion change using only information prior to the first treatment. The ELM showed superior performance with PPV-driven metrics. We also developed a feature selection strategy for each base predictor, and the consistent superiority was demonstrated by ROC results. In future work, additional information from on-treatment evaluation CTs may further improve the prediction.

Radiological Underestimation of Tumor Size Influences the Success Rate of Re-Excision after Breast-conserving Surgery.

Failure to achieve adequate margins after breast-conserving surgery often leads to re-excision, either by repeat breast-conserving surgery (BCS) or by mastectomy. Despite the high frequency of this problem, the success rate of achieving adequate margins by repeat BCS is not well documented. The objective of this study was to determine the success rate of repeat BCS and identify the factors influencing that rate. A retrospective review was performed of all women undergoing repeat BCS for inadequate margins after initial BCS in our breast unit between 2013 and 2019. Univariate and multivariate analyses were carried out to identify the factors influencing how often adequate margins were achieved after repeat BCS. One hundred fifty-four patients underwent repeat BCS after initially inadequate margins, of which adequate margins were achieved in 82%. Patients with successful repeat BCS had smaller tumors, had less underestimation of tumor size on imaging, and were less likely to have had cavity shaves taken at their initial BCS. A tumor size more than 50% larger than predicted by imaging was independently associated with failure of repeat BCS in multivariate analysis (odds ratio: 3.6, 95% CI: 1.41-9.20, p = 0.007). Underestimation of tumor size by imaging was commoner and more extensive in patients with larger tumors and those with ductal carcinoma in situ. Re-excision by cavity shaves has a high success rate and should be offered to all patients who are deemed suitable for the procedure. Patients whose tumors are more than 50% larger than predicted by imaging should be counseled about the higher risk of failure.

Comparison of Surgical and Oncological Outcomes between Chest Wall Perforator Flaps and Therapeutic Mammoplasty.

Background:Chest wall perforator flaps (CPF) and therapeutic mammoplasty (TM) are often done in patients with anticipated poor cosmetic outcome with level 1 breast conservation surgery. The aim of this study was to assess the complications and oncological outcomes between CPF and TM.Methods:Prospectively collected data of breast conservation surgery between September 2016 and January 2021 by a single surgeon were reviewed. Specific outcomes included complications needing intervention, re-excision and mastectomy rate, locoregional recurrence, and distant metastasis. Patients were followed up at 3 months and then every 12 months. Statistical analysis included chi-squared test and independent t test, and a P value of less than 0.05 was considered significant.Results:There was no statistically significant difference between CPF and TM with regard to patient characteristics except for BMI and bra cup size, which was significantly higher in the TM group. One patient who had TM returned to the operating room for a hematoma evacuation, and one patient who had CPF had fat grafting, for unsatisfactory cosmetic outcome. Five of the 30 patients having CPF had further re-excision surgery for inadequate margins, but none needed mastectomy, and four of the 43 patients having TM had further surgery (one had re-excision of margins and three had mastectomy) and this was not statistically significant (P = 0.346). There was no locoregional recurrence in CPF and TM groups after a median follow-up of 22 months and 25 months, respectively.Conclusion:There is no significant difference in early complications and oncological outcomes between CPF and TM.

Dermatofibrosarcoma Protuberans Presenting in a Patient With Neurofibromatosis Type 1: Potential Implications on Treatment

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue sarcoma. Neurofibromatosis type 1 (NF1) is a neurocutaneous syndrome that affects multiple organ systems. We present the case of a 47-year-old African American male with a two-year history of a slowly enlarging right lower back lesion. Upon workup, the 3 × 2 cm mass was biopsied confirming a diagnosis of DFSP. This was identified in concert with axillary freckling, café-au-lait spots, and pedunculated plaques evaluated with biopsy. The findings were consistent with neurofibromas, leading to a new diagnosis of NF1. The patient was definitively treated with wide local excision of the DFSP lesion without tumor recurrence over six years. DFSP has a favorable prognosis when treated with wide local excision and negative surgical margins. However, lesions may recur with inadequate margins. Although deferred in our patient, treatment with imatinib mesylate, a tyrosine kinase inhibitor, may be employed in the setting of advanced disease, metastasis, positive surgical margins, or irresectable locations. Imatinib has also been used to treat NF1. Hence, we posit that the concomitant presentation of these two disease entities in our patient highlights a potentially unique treatment with imatinib mesylate. To our knowledge, this is the second reported case of both entities in the same patient.

High-Resolution 18F-FDG PET/CT for Assessing Three-Dimensional Intraoperative Margins Status in Malignancies of the Head and Neck, a Proof-of-Concept.

The surgical treatment of head and neck malignancies relies on the complete removal of tumoral tissue, while inadequate margins necessitate the use of adjuvant therapy. However, most positive margins are identified postoperatively as deep margins, and intraoperative identification of the deep positive margins could help achieve adequate surgical margins and decrease adjuvant therapies. To improve deep-margin identification, we investigated whether the use of high-resolution preclinical PET and CT could increase certainty about the surgical margins in three dimensions. Patients with a malignancy of the head and neck planned for surgical resection were administered a clinical activity of 4MBq/kg 18F-FDG approximately one hour prior to surgical initiation. Subsequently, the resected specimen was scanned with a micro-PET-CT imaging device, followed by histopathological assessment. Eight patients were included in the study and intraoperative PET/CT-imaging of 11 tumoral specimens and lymph nodes of three patients was performed. As a result of the increased resolution, differentiation between inflamed and dysplastic tissue versus malignant tissue was complicated in malignancies with increased peritumoral inflammation. The current technique allowed the three-dimensional delineation of 18F-FDG using submillimetric PET/CT imaging. While further optimization and patient stratification is required, clinical implementation could enable deep margin assessment in head and neck resection specimens.