Inadequate Margins Research Articles

The Oncologic Safety and Practicality of Breast Conservation Surgery in Large Breast Tumors 5 Centimeters or More

BackgroundSurgery remains a therapeutic strategy for women with breast cancer, and long-term outcomes for breast conservation surgery (BCS) and radiotherapy are equivalent to those for mastectomy. To date, there are few published data assessing the oncologic safety and practicality of BCS in women with large breast cancers ≥ 5 cm. The current study compares survival outcomes for women with breast cancer ≥ 5 cm undergoing BCS or mastectomy. MethodsAll women undergoing surgery for breast cancer ≥ 5 cm between January 2004 and December 2011 were included in this study. Kaplan–Meier survival curves statistically compared the overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) in the BCS and mastectomy groups. Statistical analysis involved chi-square analysis and t test. The mean length of follow-up was 55.25 months (range, 6-115 months). ResultsA total of 217 women had surgery for tumors ≥ 5 cm (BCS in 51, mastectomy in 166). There was no statistical difference in the OS, DFS, and LRFS between groups (P = .439; 95% confidence interval, 0.114-0.347). The re-excision rate of women undergoing BCS was 45.1%, with 65.2% of women undergoing a completion mastectomy. Extensive ductal carcinoma in situ represented the only significant risk factor associated with inadequate margins (P = .021). Larger tumor size was associated with a greater risk of local recurrence (P = .039). ConclusionsThis study is one of the largest studies to date to report BCS + radiotherapy as a safe oncologic treatment option for women with large breast cancers. However, the higher re-excision rate advocates a need to investigate ways to improve patient selection.

Surgical classification and efficacy of sacral side for primary pelvic malignancies involving the sacrum and its therapeutic effect

Objective To evaluate the surgical margin achievement,perioperative risk management and improvement in oncologic and functional result of a surgical classification on sacral side for primary pelvic malignancies involving the sacrum.Methods The study was conducted in 59 patients according to modified Enneking type Ⅳ surgical classification in our center from February 2003 to February 2013.There were 28 males and 31 females,with an average of 36 years old (range,15-72 years).There were 43 cases conform to subtype Ⅳa,9 to Ⅳb,5 to Ⅳc and 2 to Ⅳd according to the extent of sacrum the tumor invades.Distinctive resection and reconstruction methods were designed for each subtype.Results Adequate margins were acquired in 43 cases (73％),while inadequate margins were inevitable in 16 cases (27％).Average operation time lasted 5 hours (range,2.5-13 h).Average blood loss during operation was 2 157 ml (range,500-6 000 ml).No case died of perioperative complications.53 of 59 patients were followed up with an average follow-up time of 26 months (range,6-88 months).Local recurrence occurred in 20 cases (38％,20/53),and average recurrence time was 12 months (range,1-52 months).Metastasis occurred in 10 cases.20 patients (38％) were still surviving without recurrence.Average Musculoskeletal Tumor Society 93 score reached 58％.Average score after subtype Ⅳa resection reached 57％ (range,10％-100％),Ⅳb 66％ (range,13％-100％),Ⅳc 45％ (range,13％-77％),and Ⅳ d 30％ (range,27％-33％).Conclusion The modified Enneking's type Ⅳ surgical classification,which is classified as four distinct subtypes according to the extent the sacrum invaded,defines the standardized surgical approach and resection plane.It plays an important role in surgical margin achievement,improvement in oncologic and functional result,and perioperative risk management. Key words: Pelvic tumor; Sacrum; Surgical procedure; Limb salvage

Is laparoscopic resection in select T4 colorectal lesions comparable to open resection for achieving adequate margins?

e14527 Background: Laparoscopic resection has been considered a relative contraindication for T4 colonic and rectal lesions due to concern over inadequate margins. The objective of this study is to compare planned laparoscopic and open resections of T4 lesions with respect to the positive margin rate. Methods: Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients that underwent a colorectal resection for a primary T4 lesion during 2011 and 2012. Patients were excluded if they had evidence of metastatic disease. A multiple logistic regression analysis was performed to determine the adjusted odds ratio (OR) of positive margins based on surgical approach (i.e. laparoscopic vs. open). Results: The sub-selected population consisted of 304 and 478 patients in the laparoscopic and open group, respectively. There were no statistical differences between the two groups with respect to demographic and clinical variables including age, sex, body mass index, number of emergency cases, and patients with coagulopathy. However, a significantly higher proportion of patients received neoadjuvant therapy in the open group (p <0.01). The laparoscopic group had 66 (22.68%) cases with positive margins and the open group had 126 (27.9%). Among patients with a planned laparoscopic approach, 77 (25%) required conversion to an open procedure with 19 (25%) cases resulting in positive margins. No statistical difference was found between planned laparoscopic and open resections with respect to positive margin status (OR 0.76, p = 0.13, 95% CI [0.54-1.08]). In addition, no significant clinical predictors for positive margin status were identified. Conclusions: Using this large national surgical database, select patients with T4 lesions that underwent planned laparoscopic colorectal resections did not have a significantly higher positive margin rate compared to patients with open operations. Experienced laparoscopic surgeons are able to selectively perform adequate resections for T4 colorectal lesions.

Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)?

The aim of this study is to review the literature to find out the exact etiology of anastomotic cancers of colon post resection and differentiate them between a recurrence, second primary, and metastatic disease (local manifestation of systemic disease). Web-based literature search was done, and datas collected. We searched PubMed for papers using the keywords colon cancer recurrence, anastomotic recurrence, and recurrent colon carcinoma. We also searched for systematic review in the same topic. In addition, we used our personal referrence archive. Anastomotic recurrences of colon are postulated to arise due to inadequate margins, tumor implantation by exfoliated cells, altered biological properties of bowel anastomosis, and missed synchronous lesions. Some tumors are unique with repeated recurrence after repeated resection. Duration after primary surgery plays a major role in differentiating recurrent and second primary lesions. Repeated recurrences after repeated resections have to be considered a manifestation of systemic disease or metastatic disease due to the virulence of the disease. A detailed analysis and study of patients with colonic anastomotic lesion are required to differentiate it between a recurrent, a second primary lesion, and a metastatic disease (local manifestation of a systemic disease). The nomenclature is significant to study the survival of these patients, as a second primary lesion will have different survival compared to that of recurrent lesions.

MRI-Based Assessment of Safe Margins in Tumor Surgery

Introduction. In surgical oncology, histological analysis of excised tumor specimen is the conventional method to assess the safety of the resection margins. We tested the feasibility of using MRI to assess the resection margins of freshly explanted tumor specimens in rats. Materials and Methods. Fourteen specimen of sarcoma were resected in rats and analysed both with MRI and histologically. Slicing of the specimen was identical for the two methods and corresponding slices were paired. 498 margins were measured in length and classified using the UICC classification (R0, R1, and R2). Results. The mean difference between the 498 margins measured both with histology and MRI was 0.3 mm (SD 1.0 mm). The agreement interval of the two measurement methods was [−1.7 mm; 2.2 mm]. In terms of the UICC classification, a strict correlation was observed between MRI- and histology-based classifications (κ = 0.84, P < 0.05). Discussion. This experimental study showed the feasibility to use MRI images of excised tumor specimen to assess the resection margins with the same degree of accuracy as the conventional histopathological analysis. When completed, MRI acquisition of resected tumors may alert the surgeon in case of inadequate margin and help advantageously the histopathological analysis.

Radioguided localisation of impalpable breast lesions using 99m-Technetium macroaggregated albumin: Lessons learnt during introduction of a new technique to guide preoperative localisation.

IntroductionPreoperative wire-guided localisation (WGL) of impalpable breast lesions is widely used but can be technically difficult. Risks include wire migration, inaccurate placement, and inadequate surgical margins. Research shows that radioguided occult lesion localisation (ROLL) is quicker, easier, and can improve surgical and cosmetic outcomes. An audited introduction of ROLL was conducted to validate the technique as a feasible alternative to WGL.MethodsFifty patients with single impalpable lesions and biopsy proven malignancy or indeterminate histology underwent WGL followed by intralesional radiopharmaceutical injection of 99m-Technetium macroaggregated albumin. Postprocedural mammography was performed to demonstrate wire position, and scintigraphy to evaluate radiopharmaceutical migration. Lymphoscintigraphy and intraoperative sentinel node biopsy were performed if indicated, followed by lesion localisation and excision using a gamma probe. Specimen imaging was performed, with immediate reexcision for visibly inadequate margins.ResultsAccurate localisation was achieved in 86% of patients with ROLL compared to 72% with WGL. All lesions were successfully removed, with clear margins in 71.8% of malignant lesions. Reexcision and intraoperative sentinel node localisation rates were equivalent to preaudit figures for WGL. ROLL was easy to perform and problems were infrequent. Inaccurate radiopharmaceutical placement necessitating WGL occurred in four patients. Minor radiopharmaceutical migration was common, but precluded using ROLL in only two cases.ConclusionsROLL is effective, simple, inexpensive, and easily learnt; however, preoperative confirmation of correct radiopharmaceutical placement using mammography and the gamma probe is important to help ensure successful lesion removal. Insertion of a backup hookwire is recommended during the initial introduction of ROLL.

Preservation of the contralateral sacral nerves during hemisacrectomy for sacral malignancies

This study aimed to evaluate the oncologic and functional outcome of the cases treated with hemisacrectomy through a sagittal plane in the sacrum and simultaneous en bloc resection together with the ipsilateral sacroiliac joint without sacrificing the contralateral sacral nerves and summarize tumor resection techniques and reconstruction strategy. En bloc resection of a sacral malignancy with ipsilateral sacroiliac joint and preservation of the contralateral sacral nerves by sagittal hemisacrectomy had been performed in 15 patients. An intra-abdominal aortic balloon was used in all these cases and a combined posterior-anterior approach was adopted. A modified Galveston technique was used to reestablish spinopelvic stability and a nonvascularized fibula autograft was used in selected cases. Contralateral sacral nerves were preserved in all 15 patients. Adequate margins (wide and marginal margin) were accomplished in 10 patients. Local recurrence occurred in seven (47%) patients, and four of these had an inadequate margin. There was no perioperative death. Four (27%) patients had wound problems. No mechanical breakdown occurred until the last follow-up. All the patients were able to walk without the use of a walking aid. Sphincter function was partially preserved in all these patients. At the last follow-up, seven (47%) patients survived without evidence of disease, two (13%) patients lived with disease, and six (40%) patients had died of disease. This procedure has an oncologic outcome that is similar to that of other high sacrectomy and a much better function outcome. Although demanding, it is indicated in selected patients.

Abstract P5-15-02: Beyond the learning curve: Surgical judgment in the approach to breast conserving surgery

Abstract Background: Inadequate lumpectomy margins are associated with an increased risk of ipsilateral breast tumor recurrence in patients undergoing breast conserving surgery for malignant disease. Second surgical procedures are often required to achieve acceptable margins. The purpose of this study was to examine the practice of breast conserving surgery by experienced practitioners, focusing on the approach to margins at the time of primary lumpectomy procedure. Methods: The NYU Langone Medical Center Breast Cancer Database was queried for patients who underwent breast conserving surgery from 1/2010-1/2013 by experienced breast surgeons. Variables of interest, segregated by surgeon, included: characteristics of additional margins taken at primary lumpectomy surgery, re-excision rates, and rates of conversion to mastectomy. Statistical analyses were performed using Pearson's Chi-Square Test, Spearman's correlation, and descriptive analyses. Results: During the study period, 988 patients opted for breast conserving surgery for invasive and intraductal breast cancer, including 260 patients who underwent at least 1 re-excision procedure. We excluded 31 patients who had initial surgery outside of NYU, yielding a study cohort of 229 patients. Stage 0 disease was associated with an increased frequency of re-excision procedures (p&amp;lt;0.0001). Re-excision rates differed widely among surgeons (10-36%). The average number of additional margins excised did not correlate with surgeons’ re-excision rates (p = 0.18). Additional margins taken at primary lumpectomy surgery included both false positives and true positives (Table 1). Of note, the number of false positive margin excisions was double the number of true positives. Patients who went on to mastectomy after unsuccessful primary lumpectomy surgery (45 of a total of 59 who converted to mastectomy) frequently did so based on their preference (19/45 = 42%). However, patients who converted to mastectomy after multiple excisions generally did so out of concern for extent of disease. Conclusions: In our study, patients with pure intraductal carcinoma represented a particular challenge as surgeons’ margin assessment was less accurate than in cases of invasive cancer. Re-excision rates varied by surgeon, and did not correlate with the average number of additional margins taken at the primary lumpectomy procedure. The rate of false positive margins excised exceeded the true positive rate, reflecting the limitations of surgeons’ ability to assess margins intraoperatively. We documented a significant number of patients who opted for conversion to mastectomy after a single unsuccessful lumpectomy procedure, underscoring the need for better methods of intraoperative margin assessment to support the practice of breast conserving surgery. Table 1: Re-excision rates and approach to margins at primary lumpectomy surgerySurgeonPatients undergoing Re-excision - N (%)Avg Additional Margins Taken (per patient) in Primary LumpectomyFalse Positives - N (%)True Positives - N (%)A67 (23%)139 (10%)26 (6%)B53 (10%)4147 (45%)60 (18%)C14 (19%)217 (20%)6 (7%)D11 (31%)01 (1%)3 (5%)E8 (36%)15 (10%)3 (6%)F27 (11%)118 (11%)10 (6%)G20 (15%)335 (29%)26 (22%)H29 (32%)237 (21%)24 (14%)Total229 (16%)2299 (22%)158 (11%) Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-15-02.

Improving breast-conserving surgery: A focus on margins.

127 Background: Inadequate lumpectomy margins are associated with an increased risk of ipsilateral recurrence in patients undergoing breast conserving surgery for cancer. Multiple procedures are often required to achieve acceptable margins, increasing the burden to the patient and the health care system, and potentially delaying other adjuvant treatments. A novel device for intraoperative assessment of lumpectomy margins (MarginProbe) has been associated with a 25% reduction in the rate of positive margins at the conclusion of primary lumpectomy surgery. Our aim was to establish a baseline re-excision rate among surgeons and to initiate a follow up study to assess the impact of incorporating this new technology for intraoperative margin assessment. Methods: The NYU Langone Medical Center Breast Cancer Database was queried for patients who underwent breast conserving surgery including ≥ 1 re-excision procedure from 1/2010-1/2013. Variables of interest included re-excision rates, stage of disease, and additional margins taken at primary lumpectomy surgery. Statistical analyses included descriptive analyses and Pearson’s Chi-Square. Results: During the study period 957 patients had breast conserving surgery and 229 required ≥ 1 re-excision procedures (24%). Re-excision rates varied widely among surgeons (10-36%). Stage 0 disease (ductal carcinoma in situ) was associated with an increased frequency of re-excisions (p&lt;0.0001). These parameters will be re-evaluated in patients undergoing breast conserving surgery with adjunctive intraoperative use of the MarginProbe device. Re-excision rates and the accuracy of intraoperative assessment of lumpectomy margins will be compared with the historical cohort. Conclusions: The necessity for multiple surgical procedures to complete breast conserving surgery results in an added burden to the patient and the health care system. Improved intraoperative assessment of lumpectomy margins represents an opportunity to improve the quality of breast cancer surgery. A critical analysis of the impact of a new device on re-excision rates will be important to understand its potential benefit to the conduct of breast conserving surgery.

Delayed Treatment and Inadequate Surgical Margins for Invasive Melanoma in Elderly Patients

As melanoma incidence and mortality rise and as populationsage indevelopedcountries suchasFranceand theUnited States, it becomesparamount fordermatologists tousediminishing resources judiciously to optimize melanoma management. Well-established guidelines of care, however, neither stratify nor adjust primarymelanoma treatment according to patient age.1,2 The article by Ciocan et al3 describes several patient and tumor characteristics of invasive melanoma in an elderly Frenchpopulationcomparedwithayounger cohort.Thestudy alsohighlights significant practice gaps in themanagement of melanoma in patients 70 years or older that present a challenge for dermatologists to understand and overcome. Age-relatedandsocioeconomic factorsmaycauseexplainabledelays indiagnosis. Prioritizinggeriatricprimarycareover dermatologic specialty care likely contributed to themore frequentlydiagnosedthicker,ulcerated, higher-grade category T3 or T4 tumors. The increased frequencyof nodular andacral lentiginousmelanomas is potentially explainable by impaired vision, selfsurveillance, and immunity in older patients. Despite these patient and tumor variances, a fundamental tenet of oncologic management protocols is their universal application toappropriatecases.Ciocanetaldescribeaclear deviation fromsuchanapproach in2 specific areas.First, older patients experienced a significant delay in treatment. Second, andmore important, definitive surgical excisionwas often inadequate. Although more elderly patients underwent an appropriate initial diagnostic excisional biopsy, almost 1 in 4 of them received no additional definitive excision when indicated, a rate 3-foldhigher than that inyoungerpatients.Thosewhounderwent additionalwide excisionwere alsodisadvantagedby inadequate surgical margins. The 5-fold increased incidence of lentigomalignamelanomaand a relative preponderance of head and neck tumors likely factored intomore conservative surgery to limit complications. Many prospective randomized clinical trials, however, have defined excisional margins that clearly reducemortality.4 The possibility that elderly patients may not receive this established standard of care represents a significant practice gap. Furthermore, regardless of the specific treatment, subsequent care was delayed beyond 6 weeks in almost a third of elderly patients. Optimal timing of definitivemelanomaexcisionhasnotbeenas rigorously studiedas surgicalmargins and represents a valuable research opportunity. Prolonged delays in treatment,however, clearly constitute anotherpracticegap. This importantstudybyCiocanetal should increaseawareness that agebias can influencedecisions inpotentially harmful ways. We do not know the dialogue exchanged between physician and patient thatmay have colored these decisions. Perhaps recovery from an illness, use of anticoagulation therapy, lack of desire for sentinel lymph node prognostic information, or the need to care for a disabled spouse strongly influenced the timing, prioritization, and/or aggressiveness of primaryoradjuvant treatment.This studyalsoneitherasksnor answers whether these older patients were satisfied with the quality of their care. The true challenge in bridging these specific melanoma managementpracticegaps in theelderlymirrorsamuchgreater challenge in modern medicine: How do we reconcile outcomes research that defines population-based best practices with our duty to provide humanistic, artful care of individual patients in the context of their age, comorbidities, and socioeconomic situation?

Gross examination by the surgeon as an alternative to frozen section for assessment of adequacy of surgical margin in head and neck squamous cell carcinoma

The cost-effectiveness of the frozen section for assessment of margin in head and neck squamous cell carcinoma (HNSCC) is still contentious. The purpose of this study was to evaluate whether gross examination of margin is an alternative to frozen section. It was a prospective observational study in 145 consecutive patients undergoing surgery for HNSCC. Surgical margins were first assessed by the surgeons with a metallic scale. All specimens were then examined using frozen section and permanent section. Overall, 83% of inadequate margins were detected by frozen section. The chances of inadequate margin were very low if gross surgical margin were 7 mm or more. Gross examination alone (with 7 mm as cutoff) predicted 88% of the inadequate surgical margin. There was no difference in precision of frozen section vis-à-vis gross examination with 7 mm cut off (p ≤ .8). Achievement of 7 mm surgical margin measured by a surgeon obviates the need for frozen section.

Echocardiographic parameters to predict inadequate defibrillation safety margin in patients receiving implantable cardioverter defibrillators for primary prevention

Implantable cardioverter defibrillators (ICDs) have become an important part of the management of patients with congestive heart failure. At the time of ICD implantation, ventricular fibrillation (VF) is induced to assess adequate energy required for defibrillation. There are multiple parameters which influence the defibrillation safety margin (DSM); however, these factors are not well-established when ICDs are implanted for the primary prevention of sudden cardiac death (SCD) in patients with severe systolic dysfunction. We evaluated multiple clinical and echocardiographic parameters as predictors of adequate DSM in patients referred for ICD implantation for the primary prevention of SCD. We prospectively enrolled 41 patients for ICD implantation with clinical indications for the primary prevention of SCD. Two blinded independent readers evaluated the prespecified echocardiographic parameters. These included left ventricular (LV) mass, indices of right ventricular and LV systolic and diastolic functions, and LV geometric dimensions. Basic clinical demographics, including age, gender, comorbidities, and etiology of cardiomyopathy, were also evaluated. DSM was established using our standard protocol for defibrillation testing which includes VF with successful first shock terminating VF at a value at least 10J below the maximum output of the implanted device. High defibrillation thresholds (DFT) were defined as >21J. The mean age is 61.8 ± 14.7years, with men comprising the majority of the patients (73%). The only clinical variables which predicted the high DFT were age (in years) (54.5 ± 17.5 vs. 65.7 ± 11.3, p = 0.044), QRS duration (in milliseconds) (116.0 ± 29.5 vs. 110.5 ± 21.8, p = 0.03), LV mass (in grams) (241.0 ± 77.9 vs. 181.9 ± 52.3, p = 0.006), and LV mass index (in grams per square meter) (111.1 ± 38.2 vs. 86.4 ± 21.1, p = 0.02). On multivariate logistic regression analysis, LV mass was the only independent predictor of low DFT (≤22J) in patients with ICD implanted for the primary prevention of SCD. LV mass may help predict an adequate DSM in patients who are referred for ICD implantation for the primary prevention of SCD. These results may help distinguish the patients who may require high-energy devices prior to the implantation procedure. These results may help distinguish patients requiring high-energy devices, coils, or advanced programming prior to implantation and appropriate referral to electrophysiologists.

Computer-assisted surgery for allograft shaping in hemicortical resection

Hemicortical resection was first described by Campanacci et al. (1982). Several studies have shown the technique to be a safe alternative to larger segmental resections for low-grade chondrosarcoma (Deijkers et al. 2002), pareostal osteosarcoma (Lewis et al. 2000, Pezzillo et al. 2008), and adamantinoma (Agarwal et al. 2007). However, several complications have been reported with this resection and reconstruction, the most important being fractures of the host bone, inadequate margins, and infection. The resections and reconstructions are usually done without objective 3D measurements. Computer-assisted surgery (CAS) offers objective measurements in 3D with high accuracy. It can be used to produce an exact copy of the resected part of the host bone by using the same resection planes in both tumor and allograft resection. In this technical note we describe the technique, report results, and identify shortcomings and possibilities.

Modular hemipelvic endoprosthesis reconstruction–Experience in 100 patients with mid-term follow-up results

IntroductionPelvic endoprostheses are becoming more commonly used in recent years. In 2007, we reported the early results of modular hemipelvic endoprosthesis. In order to provide longer follow-up results, we conducted the current study. ObjectiveTo explore overall survival, local recurrence rate, metastasis rate, function score and survivorship of the prosthesis and related complications. MethodsWe retrospectively reviewed one hundred consecutive patients who received reconstruction with modular hemipelvic endoprostheses from June 2001 to March 2010. The living patients were followed for an average of 52.9 (range, 24–103) months. There were 85 primary tumors and 15 isolated metastases. ResultsAt the time of last follow-up, fifty-eight patients were alive with no evidence of disease and thirty-six patients died of disease. Twenty patients experienced a local recurrence and twenty-eight patients developed distant metastasis. Patients with wide surgical margins had a significantly lower local recurrence rate than those with inadequate margins (p = 0.03). The mean MSTS (Musculoskeletal Tumor Society) 93 score was 57.2% (range, 16.7–86.7%). The mean Karnofsky Performance Score (KPS) was 64.4 (range, 30–90). Postoperative complications occurred in 45% of the patients. Wound healing disturbance (18%) and deep infection (15%) were the most predominant. Less frequent complications included dislocation, which occurred in nine patients and mechanical complications including 5 breakages and 2 aseptic loosening. ConclusionThe modular hemipelvic endoprosthesis can provide a versatile reconstruction option for a variety of pelvic defects with an acceptable rate of complication. Wide margins whenever possible should be the goal for these complex patients.

Breast lumpectomy margins

There has been considerable literature on breast conservation therapy over the past few years, with an emphasis on cosmesis and less emphasis on the possible disadvantages of excision with inadequate margins at initial surgery. Recent literature1 suggests that 1 in 4 women who have had breast conservation therapy require a second operation to remove residual tumours, an improvement over the last few years, but still substantial. Recent literature1,2 suggests that inadequate margins at initial surgery are disadvantageous for patients from a psychological and economic standpoint. There does not appear to be emphasis that having a positive margin at initial surgery negatively influences the likelihood of remaining disease free, although studies3,4 have demonstrated that local recurrence after breast conservation surgery increases systemic disease, which can lead to increased mortality. It has been stated5 that cancer cells have growth factor receptors that are compatible with growth factors in the wound environment and that cancer cells that shed intraoperatively can contribute to both local recurrence and distant metastases. It is suggested that the cosmetic advantages of removing a specimen 1–2 cm smaller does not warrant the disadvantage of removing a specimen with inadequate margins, particularly since a second procedure negates the cosmetic advantage of removing a smaller specimen. Silverstein and colleagues6 in discussing ductal carcinoma in situ made a comment that should also apply to lumpectomy for neoplasm: “the first excision is the best opportunity to achieve both goals, complete excision and good cosmetic result.”

Sacral chordoma: management of a rare disease in a tertiary hospital

Chordoma is a rare malignant bone tumor. The outcome depends on the adequate surgical treatment with complete excision of the tumor with microscopic clear margins. We performed a retrospective review of 13 cases of chordomas operated in our center between 1988 and 2009. All cases were treated with wide excision. Inadequate margins were found in seven patients. There were complications in ten patients and long-term sequels in 11 patients. Nine had recurrence within the first 2years, six of which had inadequate margins. Five had metastatic disease, three of them with inadequate margins. During the follow-up, four patients died. In a posterior review, three patients survive and all of them had clear margins. In our experience, the best treatment is complete excision of the tumor with clear microscopic margins. When this is not possible, local recurrences increase and survival rate decreases.

610 Skin-sparing Mastectomy and Immediate Breast Reconstruction is a Safe Option in the Management of Early Stage Breast Cancer Patients

had ER positive tumors in 76.5% vs. 47.3% in other group, PR positive tumors in 46.8% vs. 52.3% in other, HER 2/neu negative tumors in 76.9% vs. 56.2% in other. Patients with a positive margins at the initial resection showed higher lobular histology rate (15.3% vs. 6.4%), incidence of multiple ipsilateral tumors (23.1% vs. 15.4%), presens of intraductal component (76.9% vs. 65.1%), but these differences between two groups were no statistically significant. 73.1% of all patients were tested for the two common founder mutaions in BRCA1(4153delA and 5382insC). There was 1 BRCA1(5382insC) mutation-positive patient in the other group and no mutation-positive patients in the positive margin group. Mean follow-up time was 19.9(11−37) months, and there were no local recurrences during the follow-up period in the tumor positive margin group. Conclusion: The overall percentage of positive margins in the Pauls Stradins Clinical University Hospital Breast Unit is within the predefined targets. Lobular histology, multiple ipsilateral tumors and presens of intraductal component have shown a tendency of higher risk for inadequate margins of excision.

Soft tissue sarcoma – a population-based, nationwide study with special emphasis on local control

Background. A prospective diagnostics and treatment protocol for extremity and trunk wall soft tissue sarcoma (STS) was introduced by the Scandinavian Sarcoma Group in 1986 and it was also widely adopted in Finland. We have updated the protocol and made it more detailed at the Helsinki University Central Hospital. We retrospectively compared diagnostics and treatment of STS in a nationwide population-based material to this protocol with special emphasis on local control. Methods. Data for 219 patients with an STS of extremity or trunk wall diagnosed during 1998–2001 was retrieved from the nationwide Finnish Cancer Registry. Histologic review was performed. Treatment centres were divided into high-, intermediate- and low-volume centres based on the number of patients with final surgery during the study period. Results. Significantly more patients were operated with a preoperative histological or cytological diagnosis at high-volume centres. No preoperative diagnosis was a strong predictor for the patient to undergo more than one operation (p < 0.0001). Wide surgical margin was achieved more often at high-volume centres, but in all centre categories a considerable percentage of patients with inadequate surgical margin did not receive adjuvant radiation therapy. Local control at five years was 82% at high-volume centres, 61% at intermediate-volume centres treating highest percentage of deep tumours and 69% at low-volume centres (p = 0.046). Local control improved as the number of patients operated (surgical volume of the centre) increased. Conclusion. The present quality-control study is the first nationwide population-based study to assess diagnostics and treatment of STS. When referred to a specialised sarcoma centre even patients with inadequate surgery can achieve good local control. STS is a rare cancer and its treatment should be centralised in Finland, which has 5.4 million inhabitants and approximately 100 new STSs of extremities and trunk wall annually.

Pre-discharge defibrillation testing: clinically important or obsolete?

This editorial refers to ‘Pre-hospital discharge testing after implantable cardioverter defibrillator implantation: A measure of safety or out of date? A retrospective analysis of 975 patients’ by M. Guenther et al. , on page 217 One of the most controversial and hotly debated topics in implantable cardioverter-defibrillator (ICD) management is the role of defibrillation testing. As with most areas of clinical controversy, the lack of controlled studies to guide the decision process is largely responsible for the ongoing differences in opinion. In the early period of ICD use, defibrillation testing was mandatory given the frequency of shocks, high defibrillation thresholds (DFTs) with monophasic waveforms and the relatively unsophisticated sensing algorithms for the detection of ventricular fibrillation (VF). An inadequate defibrillation safety margin was associated with worse outcomes.1 In the primary prevention era this mandate is less clear. Most patients will not have an appropriate discharge over the first 3–5 years of follow-up2 and defibrillation systems have improved significantly so that failed shocks are now infrequent events. The use of …

The effect of junior residents on surgical quality: a study of surgical outcomes in breast surgery

Background Patients are often concerned about the participation of junior trainees in their operative treatment. Breast-conserving therapy (BCT) for nonpalpable breast lesions requires the use of localization devices and carries a significant risk for positive margins of excision. It was therefore hypothesized that the participation of junior residents in BCT operations for nonpalpable breast lesions could result in an increased rate of positive margins of excision. Methods Retrospective analysis of a prospective database of all patients with nonpalpable tumors who underwent BCT from August 1999 to August 2009 was performed. Patient and tumor characteristics and factors involved in resection were analyzed. A ≥2-mm margin of normal breast tissue beyond tumor was considered an adequate margin. Chi-square analysis and Student's t test were performed to determine relationships between independent variables and margin status. Results Of 308 BCT procedures for nonpalpable tumors, 241 (78%) were performed by attending surgeons and junior residents (group 1) and 67 (22%) by attending surgeons without resident assistance (group 2). The operations for group 1 took significantly longer than the operations for group 2 (mean, 130 vs 116 min, P = .006). Intraoperative reexcision of margins was performed for 37% of group 1 patients and 31% of group 2 patients ( P = .249), and reoperation for inadequate margins was performed in 11% of group 1 patients and 13% of group 2 patients ( P = .361). Conclusions Junior resident participation in BCT procedures was not associated with higher rates of inadequate margins of excision. Patients can be reassured that junior resident involvement in their BCT operations is safe and effective.