Inadequate Surgical Margins Research Articles

Oncoplasty’s Contribution in Breast Cancers: About 48 Cases

Introduction: Oncoplasty has developed for 20 years in order to avoid potentially major deformations of conservative treatment. We report the results of our oncoplastic breast operations. Patients and Methods: We conducted a descriptive and retrospective study of 48 patients treated by oncoplastic technique in the national center of burn and plastic surgery in the U.H. IBN-ROCHD of Casablanca between 2011 and 2014. Patient and tumor characteristics, as well as information on the procedures and complications, were collected from clinical records. Results: Forty-eight cases were reviewed. The tumors were processed for the majority of invasive ductal carcinoma pT2. Seven patients had an inadequate surgical margin. About histology, the rate of recovery for non-positive margins was significantly lower in the CCI alone than that in other types. Morbidity was 14.5% and the average delayed to adjuvant treatment of 72 days. The symmetrization rate was 24%. In terms of oncological results, during a median follow-up of 22 months, the rate of local recurrences was 13%. Conclusion: The oncoplastic operations offer tools for breast conservation in patients and otherwise is destined for mastectomy or poor esthetic outcome. This study shows that the goal of surgical therapy is to identify patients who are suitable for oncoplastic surgery. Proper pre-operative evaluation and diagnosis, surgical planning, adequacy of resection, and pathological evaluation are essential.

Risk factors for and consequences of inadequate surgical margins in oral squamous cell carcinoma.

The purpose of this study was to examine which factors are associated with inadequate surgical margins and to assess the postoperative consequences. A retrospective cohort of 110 patients with oral squamous cell carcinoma treated with surgery during a 2-year period was examined. Clinical, histopathologic, and operative variables were related to the surgical margin status. Furthermore postoperative treatment data were compared with margin status. Univariate statistically significant associations were found between the tumor site in the floor of mouth, more advanced T-stage, increasing tumor thickness, and inadequate margins. Of the patients with involved margins, 87% were treated with postoperative radiotherapy or re-resection, but among patients with close margins, only 35% received either radiotherapy or re-resection. Clinical and histopathologic factors were associated with the inadequate margin. Postoperative treatment for patients with close margins is controversial, and more studies are needed to define clear guidelines.

Proximal Tumor Location and Fluid-fluid Levels on MRI Predict Resistance to Chemotherapy in Stage IIB Osteosarcoma

Primary tumor growth during neoadjuvant chemotherapy is believed to be a sign of resistance to chemotherapy (chemoresistance), and often is associated with poor histologic response, local recurrence, and poorer survival. Currently there are no proven indicators to predict poor response to chemotherapy at the time of diagnosis. We asked (1) what clinicopathologic factors present at diagnosis predict primary tumor growth during neoadjuvant chemotherapy, (2) what factors at presentation predict survival, and (3) when the factors at presentation and the treatment-related factors are considered, what factors independently correlate with survival. We studied 567 patients with Stage IIB osteosarcomas. The factors assessed included age, sex, location, pattern on plain radiographs (radiodense, radiolucent, mixed), MRI findings, pathologic subtype, initial tumor volume determined by MRI, tumor volume change after chemotherapy, surgical margin, and histologic response to preoperative chemotherapy. Logistic modeling was used to identify risk factors. Independent risk factors associated with primary tumor growth after neoadjuvant chemotherapy were proximal tumor location (p < 0.01; relative risk [RR], 2.41; 95% CI, 1.5-3.86) and fluid-fluid level on initial MRI (p < 0.01; RR, 5.56; 95% CI, 3.48-8.87). Among factors at presentation, large initial tumor volume (p < 0.01; RR, 1.58; 95% CI, 1.22-2.04), proximal tumor site (p < 0.01; RR, 1.61; 95% CI, 1.19-2.19), and presence of fluid-fluid level (p < 0.01; RR, 1.83; 95% CI, 1.37-2.5) independently predicted reduced event-free survival. When we consider the factors at presentation and treatment-related factors, large initial tumor volume (p < 0.01; RR, 1.54), tumor growth after neoadjuvant chemotherapy (p < 0.01; RR, 3.88), inadequate surgical margin (p < 0.01; RR, 2.42), and poor histologic response (p = 0.03; RR, 1.43) were independent poor prognostic factors of event-free survival. Proximal tumor location and the presence of the fluid-fluid level on initial MRI were predictors of tumor progression and poor survival in patients presenting with Stage IIB osteosarcomas. If confirmed in other studies, patients with these risk factors should be considered for trials of other treatment strategy. Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Clinical and pathological features of patients with resected synovial sarcoma: a multicenter retrospective analysis of the Anatolian Society of Medical Oncology.

Synovial sarcoma (SS) is a rare disease and compared with other soft-tissue sarcomas has a relatively high mortality rate. The optimal management of this disease and prognostic factors associated with patient outcome remains controversial. We aimed to evaluate the factors affecting the outcomes of SS patients in the adjuvant setting. In this Turkish multicenter study, we assessed the data of 69 SS patients regarding prognostic factors for SS patients retrospectively. Our study included 69 localized SS patients (38 males and 31 females) with a median age of 34.5 years (minimum-maximum: 14-68 years). Overall survival (OS) and disease free survival (DFS) rates for 5 years were 64% and 25%, respectively. All patients under went surgical treatment; 64 patients were treated with a wide excision and 5 patients had an amputation. According to the univariate analysis, adverse prognostic factors for OS were male sex, higher mitotic activity, high Ki-67 levels, trunk localization and inadequate surgical margins. In multivariate analysis, none of these factors had independent significant association with OS. Prognostic factors for DFS; in the univariate analysis were higher mitotic activity, high Ki-67 levels and inadequate surgical margins. Only higher mitotic activity (≥10 high-power field) was significantly associated with worse DFS in the multivariate analysis (hazard ratio: 0.30, % confidence interval: 0.11-0.80, P = 0.017). Our study confirms that high mitotic activity is significantly associated with decreased DFS. The question of whether the chemotherapy provides a survival advantage in patients having adverse prognostic factors requires confirmation in randomized trials.

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.

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.

Prognostic factors and clinical outcomes in synovial sarcoma of the extremities

To evaluate the clinical outcomes and identify which prognostic factors influence the clinical outcomes of synovial sarcoma patients at a tertiary university hospital in Thailand. Patients with synovial sarcoma of the extremities between 1997 and 2007 were reviewed from the database of the Musculoskeletal Oncology Unit, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand. Of 41 patients, 23 males (56%) and 18 females (44%) with a median age of 39 (range, 1-78 years), 18 (44%) had metastasis at the first diagnosis and 23 (56%) had only a localized tumor. The 5-year overall survival of all the patients was 36%; 64% in patients with localized disease and 0% in patients with metastasis at first diagnosis. In all 23 patients (56%) died of the disease at a median duration of 11 months (range 3-47 months). All patients with metastases died at a median 9 months (range 1-41 months). Metastasis at first diagnosis influenced overall survival for patients with synovial sarcoma (P < 0.001). According to a univariate analysis, the significant adverse factors were biphasic histological subtype and an inadequate surgical margin of the definitive surgery (P < 0.05). Synovial sarcoma is still a disease with a poor prognosis. Distant metastasis at initial diagnosis is a significant adverse prognostic factor for overall survival. A biphasic histological subtype and an inadequate surgical margin are significant adverse prognostic factors in localized synovial sarcoma.

Stereotactic radiosurgery for primary and metastatic sarcomas involving the spine

The treatment for spinal sarcomas is difficult due to inadequate surgical margin and an inability to deliver high dose radiation. Advanced technology of stereotactic radiosurgery (SRS) enabled higher biological effective doses of radiation to be delivered to spinal sarcomas by hypofractionation method. The authors evaluated local control rate following SRS for primary and metastatic spinal sarcomas. Thirty-two spinal sarcomas (10 primary tumors, 22 metastatic tumors) in 27 patients were treated by SRS from November 2002 to September 2009. Patients were assessed for pain status, neurological status and radiological response by regular follow-up. Overall survival and local progression-free survival were calculated and prognostic factors were sought. Median tumor volume was 18.6 ml. Radiation doses to the tumor margins ranged from 16 to 45 Gy in one to three fractions, and the median single session equivalent dose was 21.8 Gy. Follow-up ranged from 4 to 68 months (median, 22 months). Overall median survival was 29 months and no related prognostic factors were identified. During follow-up, pain was controlled in 89.3% (25/28) lesions at 6 months, in 68.2% (15/22) at 1 year, and in 61.5% (8/13) at 2 years. Tumor volume was found to be significantly related to post-SRS pain control rate. Radiological evaluation showed that local control was maintained in 96.7% (29/30) lesions at 6 months, in 78.3% (18/23) at 1 year, and in 76.9% (10/13) at 2 years. Radiation dose and tumor volume were found to be related to radiological control at 24 months following SRS. Nine cases developed recurrence between 2 and 33 months, median local progression-free survival was 23 months. Age was found to be predictive of local progression-free survival (P = 0.009). SRS proved to be an effective modality for the local control of primary and metastatic spinal sarcomas, and age was significantly related to local recurrence.

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.

Primary (De Novo) Dedifferentiated Liposarcoma in the Extremities: A Multi-Institution Tohoku Musculoskeletal Tumor Society Study of 18 Cases in Northern Japan

Dedifferentiated liposarcomas usually occur in the retroperitoneal space and relatively rarely in the extremities. We identified 18 patients with primary dedifferentiated liposarcoma in the extremities from the files of Tohoku Musculoskeletal Tumor Society and analyzed demographics, histologic findings, treatments and prognostic factors. The average follow-up period was 58 months. The subjects were 12 men and 6 women with a mean age of 65 years. All tumors were in the thigh. Nine patients noticed a rapid enlargement of the long-standing tumor. Histologic subtypes of the dedifferentiated area were undifferentiated pleomorphic sarcoma (n = 12), osteosarcoma (n = 2), rhabdomyosarcoma (n = 2), leiomyosarcoma (n = 1) and malignant peripheral nerve sheath tumor (n = 1). In the patient with rhabdomyosarcoma-like dedifferentiated area, extensive necrosis was observed after the preoperative chemotherapy. One patient who underwent marginal excision developed a local recurrence, but inadequate surgical margin was not associated with a risk of local recurrence. Three patients had lung metastasis at initial presentation, and four other patients developed lung metastases during the follow-up period. The overall survival rate was 61.1% at 5 years. On univariate analyses, large size of the dedifferentiated area (>8 cm), high MIB-1-labeling index (>30%) for the dedifferentiated area and lung metastasis at initial presentation were significantly associated with poor prognosis. Primary dedifferentiated liposarcoma in the extremities predominantly occurred in the thigh and a rapid enlargement of long-standing tumors was a characteristic symptom. Although the local behavior of these tumors was less aggressive than that of retroperitoneal dedifferentiated liposarcomas, they had a relatively high metastatic potential.

Bone and/or joint attachment is a risk factor for local recurrence of myxofibrosarcoma

BackgroundMyxofibrosarcoma is characterized by a high local recurrence rate despite optimal surgical treatment. The definition of prognostic factors for recurrence offers high-risk patients a closer follow-up and a multi-disciplinary therapeutic approach. MethodsA cohort of 23 patients treated for primary myxofibrosarcoma was retrospectively analyzed. The patients (sex and age), tumors (size, stage, tumor location, bone and/or joint attachment), radiological findings (abnormal signal extension in MRI), histological findings (FNCLCC grade and microscopic extension along the muscle fascia), and treatment (surgical margin) characteristics were included in univariate prognostic factor analysis. ResultsAfter a median follow-up of 63.3 months (range 15–191), the overall recurrence rate was 34.7%. Median time between initial surgery and recurrence was 24.8 months (range 8–52). Inadequate surgical margins (p = 0.026) and bone and/or joint attachment (p = 0.001) were associated with an increased recurrence rate. ConclusionFor the further improvement of local recurrence-free survival of patients with myxofibrosarcoma, accurate diagnosis of the tumor extension and adequate planning for the surgical margin should be focused on in cases with bone and/or joint attachment.

Optimal use of adjuvant chemotherapy in stage II colorectal cancer

The prognosis of stage II colorectal cancer varies. Whether or not to perform adjuvant chemotherapy on patients with stage II colorectal cancer is a controversial issue. The aims of this study were to identify relevant risk factors for the prognosis of stage II colorectal cancer and to evaluate the need for adjuvant chemotherapy. Between January 2000 and January 2005, 443 patients with stage II colorectal cancer who had received radical surgery at the Sun Yat-sen University Cancer Center were retrospectively analyzed. The overall survival rates and survival curves were analyzed using the Kaplan-Meier method and log-rank test. Univariate and multivariate prognostic analyses were performed using the Cox regression model. Patients with certain important risk factors were analyzed according to whether they received adjuvant chemotherapy, and four chemotherapeutic regimens were classified into sub-groups and analyzed. Univariate analyses showed that intestinal obstruction or perforation, type 2 diabetes mellitus, an inadequate surgical margin, and sampling of less than 12 lymph nodes were risk factors that correlated with poor prognosis. Patients with an intestinal obstruction or perforation and insufficient lymph node samples achieved higher 5-year survival rates with adjuvant chemotherapy than with surgery alone. Intestinal obstruction or perforation, sampling of less than 12 lymph nodes, and inadequate surgical margins were identified as risk factors for poor survival, and patients with either of the first two factors benefited from adjuvant chemotherapy. Moreover, the use of capecitabine alone may be insufficient for patients with an intestinal obstruction or perforation.

Local recurrence after partial mastectomy: Relation to initial surgical margins

Background Local recurrence (LR) after partial mastectomy (PM) has been associated with inadequate surgical margins. We assessed LR association with initial margins after PM in patients receiving postoperative radiation therapy (RT). Methods Initial margins, re-excision status, and ipsilateral LR were identified for all patients having initial PM from 2003 to 2008. Results Seven hundred twelve patients underwent PM as their final procedure, and 598 (84.0%) had adjuvant RT. Initial margins were positive or <1-mm margins in 166 patients (27.8%). Re-excision was performed for all positive and 20.2% of patients with margins <1 mm. We observed 10 LRs (1.7%) at the 3.4-year mean follow-up. For patients with initial margins <1 mm, the LR rate was 4.2% (7/167) and just .7% for margins ≥1 mm ( P = .006). Conclusions We report lower LR rates than traditionally reported. The surgical practice of re-excision to achieve margins of 1 to 5 mm needs closer scrutiny because it may have no impact on LR.

Tumor Volume Increase During Preoperative Chemotherapy as a Novel Predictor of Local Recurrence in Extremity Osteosarcoma

Known risk factors (surgical margin, tumor necrosis) of local recurrence (LR) in osteosarcoma are determined by results available after surgery. However, relations between preoperative characteristics and LR have not been clearly defined. We compared the clinicopathologic characteristics of 36 osteosarcoma patients with LR and 394 patients without LR after surgery. In addition, prognostic variables were evaluated to establish factors could influence LR. Compared to the non-LR group, the LR group showed an increase in tumor volume ratio (TVR) during preoperative chemotherapy (P<0.01), inadequate surgical margin (P<0.01), and poor histologic response (P<0.01). Univariate analysis of data from 430 patients revealed that an increased TVR (P<0.01), inadequate surgical margin (P<0.01), poor histologic response (P<0.01), and nonosteoblastic pathologic subtype (P=0.04) were negatively related to LR-free survival. In multivariate analysis, an elevated TVR (P<0.01, relative risk=10.26) and inadequate surgical margin (P<0.01, relative risk=5.91) emerged as the key prognostic factors for LR. A TVR increase during preoperative chemotherapy could be used to predict patients at high risk of LR. This finding might be useful when considering surgical options to decrease the risk of LR.

Multimodality treatment of locally advanced soft-tissue sarcomas of the extremities

Background Adjuvant radiotherapy (RTE) still has a fundamental role as a post-operative treatment of locally advanced soft tissues sarcomas of the extremities. Moreover the employment of combined modalities in locally advanced soft tissues sarcomas of the extremities allow to maximize the chance of local cure even in difficult presentation cases, and possibly improve survival, especially in high-risk disease patients. In patients with sarcomas of the extremities in which definitive surgery has not been radical (with positive or “close” margins) radiotherapy can improve the results in terms of Disease Free Survival (DFS) and, together with chemotherapy, of Overall Survival (OS). We recommend radiotherapy in case of deep tumor location, inadequate surgical margins and grade 3 tumour; for positive or “marginal (or close)” excision (that means inadequate surgery) or in selected patients with a bad prognosis, we believe that a multidisciplinary approach can be preferable. Introduction Adjuvant radiotherapy (RTE) still has a fundamental role as a post-operative treatment. In patients with sarcomas of the extremities in whom definitive surgery has been or not radical (positive or “close” margins), radiotherapy with chemotherapy can improve the results in terms of Disease Free Survival (DFS) and Overall Survival (OS), while RTE alone seems to improve local control. Materials and methods From 1/2000 to 12/2005 we treated 34 patients affected by locally advanced sarcomas of the upper or lower extremities with radiotherapy (doses ranging from 54 to 66 Gy) and chemotherapy in 18/34 with an adjuvant scheme that consisted in Epirubicine (120 mg/m 2) plus Ifosfamide (7000–9000 mg/m 2). Results Disease Free Survival (DFS) and the Overall Survival (OS) rates were 76% and 82%, respectively. Eighteen patients developed one or more long-term side effects. Most of these complications were mild: all patients experienced only erithema, edema, local sclerosis or moderate pain. Conclusion Radiotherapy has an important role as a post-operative treatment also when surgery was non-radical. It improves local control more in patients with high-grade sarcomas of the extremity with positive or close margins. It is still difficult to assess the role of adjuvant chemotherapy.

Differential proteomic profiling of chordomas and analysis of prognostic factors

The recurrence rate of chordoma is high, and the prognosis is poor. Differential proteomic analysis was performed on chordomas and adjacent normal tissues, with verification by Western blot. Protein expression was evaluated by immunohistochemistry of 37 chordomas. Association of candidate protein expression with clinical parameters, disease-free survival, and overall survival were analyzed. We identified 14 up-regulated and 5 down-regulated proteins in chordomas. Expression of alpha enolase (ENO1), pyruvate kinase M2 (PKM2), and gp96 was higher in recurrences than in primary tumors. Univariate analysis showed that significantly adverse factors for disease-free survival were overexpression of ENO1 and PKM2, involvement of contiguous vertebral levels, and inadequate surgical margin at initial surgery. Inadequate surgical margin without radiotherapy, involvement of contiguous vertebral levels, and cervical spine location were adverse factors for overall survival. By multivariate analysis, independent adverse prognostic factors were inadequate surgical margin and involvement of multiple contiguous vertebral levels for recurrence; upper cervical spine location and involvement of contiguous vertebral levels for tumor-related death. Multivariate analysis failed to show the significance of the proteins. Involvements of multiple contiguous vertebral levels and upper cervical spine, rather than overexpression of ENO1, PKM2, or gp96, are independent prognostic indicators for chordomas.

Outcome of oncoplastic breast surgery in 90 prospective patients

Background Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007. Methods Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines. Results Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases. Conclusions Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.

Factors Associated with Re-Excision in Patients with Early-Stage Breast Cancer Treated with Breast Conservation Therapy

One of the risks of breast conservation surgery is local recurrence, which predominantly occurs as a result of inadequate surgical margins. The purpose of this study was to identify factors associated with close or positive surgical margins leading to reexcision (RE). The charts of 532 consecutive breast cancer patients treated at our center between September 2001 and June 2007 were reviewed to evaluate patients who opted for breast conservation surgery and needed reexcision. A total of 351 patients were treated with breast conservation, of which 118 (34%) had positive or close surgical margins and went on to RE. On univariate analysis, factors that significantly correlated with RE (P < 0.05) were preoperative diagnosis, final pathology, size of tumor, and presentation with nipple discharge. RE was necessary in 53 per cent of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), 57 per cent of patients diagnosed by surgical excision, 86 per cent of patients presenting with nipple discharge, and 87 per cent of patients with DCIS or invasive carcinoma with extensive intraductal component in the final pathology. Additionally, 53 per cent of patients with T3 tumors required RE. Age, race, and grade of tumor had no effect on RE rates. Most (75%) patients were able to ultimately have breast conservation.

Prognostic analysis of 443 cases of stage II colorectal cancer and the value of adjuvant chemotherapy

Prognosis of stage II colorectal cancer varies. Whether or not to perform adjuvant chemotherapy on patients with stage II colorectal cancer is controversial. This study was to explore the prognostic factors for the patients with stage II colorectal cancer and evaluate the effect and the necessity of adjuvant chemotherapy. Between January 2000 and January 2005, 443 patients with stage II colorectal cancer receiving radical surgery at Sun Yat-sen University Cancer Center were retrospectively analyzed. The overall survival rate and survival curve were analyzed using the Kaplan-Meier method and the log-rank test. The univariate and multivariate prognostic analyses were performed by the Cox regression model. Patients with or without chemotherapy (Xelox/Folfox regimen) with high-risk factors were analyzed respectively. The median follow-up time was 59 months, and the 3-and 5-year survival rates were 88.4% and 82.5%, respectively. Univariate analysis showed that intestinal obstruction or perforation, diabetes mellitus, inadequate surgical margin, and the number of sampled nodes < 9 were poor prognostic factors. Patients with intestinal obstruction or perforation, the number of sampled nodes < 9 achieved higher 5-year survival (80% and 86%) undergoing adjuvant chemotherapy than those receiving surgery alone (67% and 64%). The prognosis of colorectal cancer patients with intestinal obstruction or perforation, diabetes mellitus, inadequate surgical margin, and the number of sampled nodes < 9 are relatively poor. Adjuvant chemotherapy is recommended to patients with intestinal obstruction, perforation or sampled nodes < 9.