Incomplete Tumor Resection Research Articles

Vestibular Schwannomas in Young Patients: A 12-Year Experience in a Single Center

This study evaluated the characteristics of vestibular schwannomas (VS) in young patients, including clinical features, treatment, prognosis, and histopathologic characteristics. We retrospectively reviewed medical records and follow-up data for 36 pediatric patients <21 years of age who were surgically treated for VS in the Chinese PLA General Hospital between 2008 and2019. Mean patient age was 17.4 years. Mean tumor size was 2.8 cm. Hearing loss (n= 32, 88.9%) and tinnitus (n= 20, 55.6%) were the most common symptoms. Ten patients (27.8%) had impaired facial nerve function after surgery. Gross total resection (GTR) was achieved in 26 cases (72.2%). The median tumor Ki-67 level was 5%. Tumor size was related to incomplete tumor resection (odds ratio, 0.2; 95% confidence interval, 0.1-0.9) and postoperative facial nerve dysfunction (odds ratio, 24.9; 95% confidence interval, 1.2-539.1). Tumor size was nonlinearly associated with prognosis and 2.2 cm corresponded to the inflection point at which the probability of tumor remnant and postoperative facial nerve dysfunction significantly increased. The GTR and low Ki-67 groups achieved better 3-year tumor control rate. Histopathologic findings confirmed the presence of cellular schwannoma subtype in young patients. Tumor size is an important factor affecting the prognosis of VS in young patients. For large VS, surgical treatment should be the first choice, rather than wait-and-scan. VS in young patients shows high tumor proliferation and a tendency to relapse. The cellular schwannoma subtype requires special attention; an accurate histopathologic diagnosis is necessary for young patients with VS, and a closer follow-up strategy should be adopted for cellular VS.

Treatment Discontinuation in Patients With Muscle-Invasive Bladder Cancer Undergoing Chemoradiation

PurposeChemoradiation (CRT) is a definitive treatment option for muscle-invasive bladder cancer (MIBC). Despite its effectiveness, CRT is underused, in part owing to concerns of tolerability and the need for integrated multidisciplinary care. We investigated factors associated with and the impact of treatment discontinuation in patients with MIBC treated with CRT. Methods and MaterialsIn the US Veterans Affairs’ national database, we identified patients with urothelial histology, MIBC (T2-4a/N0-3/M0) diagnosed between 2000 and 2018 and treated with definitive-intent CRT. The primary endpoint of discontinued radiation was evaluated in a multivariable logistic regression. Secondary endpoints of 30-day and 90-day mortality, overall mortality, and nonbladder cancer mortality were evaluated in multivariable models. ResultsOf 369 veterans with MIBC who underwent CRT, 30 patients (8.1%) did not complete radiation. The most common reasons for treatment discontinuation included comorbidities or infections necessitating hospital admission (63.3%) and treatment intolerance or declining performance status (26.7%). In multivariable logistic regression, variables associated with radiation discontinuation were creatinine clearance ≤ 50 (odds ratio [OR], 3.93; 95% CI, 1.63-9.50; P = .002), incomplete transurethral resection of bladder tumor (TURBT) (OR, 3.16; 95% CI, 1.15-8.63; P = .02), and nonpreferred chemotherapy (OR, 3.31; 95% CI, 1.31-8.36; P = .01). In the cohort that discontinued radiation, 30-day mortality was 33.3% and 90-day mortality was 50.0%, with the majority of deaths attributed to nonbladder cancer causes. No patient or tumor variables were associated with either endpoint. In the cohort that completed radiation, 30-day mortality was 2.7% and 90-day mortality was 6.8%. In multivariable analysis, radiation discontinuation was associated with worse overall mortality (hazard ratio [HR], 2.48; 95% CI, 1.36-4.50; P = .003) and worse nonbladder cancer mortality (HR, 2.32; 95% CI, 1.24-4.34; P = .008). ConclusionsWith a low rate of treatment discontinuation, CRT is an effective and feasible treatment option for the typically elderly and comorbid population of patients with MIBC. In addition to identified predictors of treatment discontinuation (poor renal function, incomplete TURBT, etc.), further research is required to develop evidence-based guidelines for optimal patient selection.

Differences in clinical presentation and management between pre- and postsurgical diagnoses of urinary bladder paraganglioma: is there clinical relevance? A systematic review

PurposeParaganglioma of the urinary bladder (UBPGL) is a rare neuroendocrine tumor diagnosed in many patients only after surgery. We, therefore, assessed clinical clues relevant to presurgical diagnosis and clinical consequences in patients with a missed presurgical diagnosis of UBPGL.Materials and methodsCase reports describing a UBPGL (published from 1–1–2001 and 31–12–2020) were identified in Pubmed. Two authors independently performed data extraction and assessed data quality according to the PRISMA guideline. Patients were divided into two groups: UBPGL diagnosis before and after surgery.ResultsWe included 177 articles reporting 194 cases. In 90 (46.4%) patients, the UBPGL was diagnosed before and in 104 (53.6%) after surgery. In presurgically diagnosed UBPGL, hypertension and catecholamine-associated symptoms were 2- to 3-fold (p < 0.001) more frequent than in postsurgically diagnosed patients whereas hematuria was twofold (p = 0.003) more prevalent in those with postsurgical diagnosis. Hypertension was an independent factor for presurgical biochemical testing (OR 4.45, 95% CI 1.66–11.94) while hematuria (OR 0.23, 95% CI 0.09–0.60) was an independent factor for not performing presurgical biochemical testing. Most patients diagnosed after surgery were not pretreated with alpha-adrenoceptor blockade (95.2%), underwent more frequently transurethral resection instead of cystectomy (70.2% vs. 23.1%) and had more frequent peroperative complications and residual tumor mass.ConclusionsIn nearly half of all patients with a UBPGL, the diagnosis was not established before surgery. Hypertension and hematuria contributed independently to a presurgical diagnosis. Postsurgical diagnosis, which was associated with suboptimal presurgical and surgical management, resulted in more peroperative complications and incomplete tumor resections.

ENDOBRONCHIAL GLOMUS TUMOR: AN UNUSUAL LOCATION FOR A RARE MALIGNANCY

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Glomus tumors are rare neoplasms which usually arise from the glomus bodies in the subungual dermis of the hands and feet. Cases of endobronchial glomus tumors present an already rare malignancy in an exceedingly rare location. CASE PRESENTATION: A 76 year-old female who presented with productive cough and progressive dyspnea underwent a CT chest which indicated a 16x14x17 mm right lower-lobe endobronchial mass. Bronchoscopy demonstrated a completely obstructing and vascular appearing mass in right lower lobe which was followed by endobronchial biopsy and incomplete tumor resection. Histological examination confirmed the diagnosis of glomus tumor. Patient was evaluated by radiation oncology and approved for radiation therapy but declined, given symptomatic improvement following partial resection. DISCUSSION: Glomus tumors are rare, typically benign, malignancies that arise from neuromyoarterial glomus bodies, which have a strong predilection for subungual location. These malignancies account for 2% of soft tissue tumors. Rarely, these tumors can occur in extra-cutaneous sites such as bone, gastrointestinal tract and lungs. Most cases of endobronchial glomus tumors are asymptomatic but depending on size and location of tumor, patients may present with dyspnea, wheeze, or other respiratory complaints. Most glomus tumors are benign but malignant characteristics include: >2cm in size, visceral in location, and containing atypical mitotic figures. Glomus tumors are slow growing neoplasms that are characterized as small, uniform, and containing round nuclei with each cell surrounded by basal lamina. CONCLUSIONS: Due to the rarity of extracutaneous glomus tumors reported in the literature their clinical course and prognosis are unknown. Most clinicians recommend surgical resection as definitive treatment but endobronchial therapy such as ablation can be considered. If lesion is intrapulmonary, a sub-lobar resection may be sufficient but lobectomy may be required for large masses that are centrally located. In our case, the patient forwent further treatment given the asymptomatic nature of her post-operative course and opted for serial monitoring for tumor recurrence. This case highlights an exceedingly rare location for a fortunately benign malignancy. REFERENCE #1: Chou T, Pan SC, Shieh SJ, Lee JW, Chiu HY, Ho CL. Glomus Tumor: Twenty-Year Experience and Literature Review. Ann Plast Surg. 2016 Mar;76 Suppl 1:S35-40. doi: 10.1097/SAP.0000000000000684. PMID: 26808758. REFERENCE #2: Valle, Javier Alonso Baena-Del, et al. "Glomus Tumour of the Lung: A Case Report and Literature Review." Cirugía y Cirujanos (English Edition), Elsevier, 20 Apr. 2016, www.sciencedirect.com/science/article/pii/S2444050715000650. REFERENCE #3: Yun, Ju Sik, et al. "Synchronous Primary Glomus Tumor in a Patient with Adenocarcinoma of the Ipsilateral Lung." Thoracic Cancer, John Wiley & Sons Australia, Ltd, May 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6501053/. DISCLOSURES: No relevant relationships by Joseph Flynn, source=Web Response No relevant relationships by Stephen Mitchell, source=Web Response No relevant relationships by John Wynne, source=Web Response

Acute hindlimb paresis caused by extension of a peripheral nerve sheath tumour into the spinal canal of a horse

SummaryA 10‐year‐old Quarter Horse gelding presented for a large, slowly growing mass in the right thoracic region caudal to the withers (approximately at the level of thoracic vertebrae 10 to 16). The mass was surgically removed, the horse returned to normal riding activity, and no external regrowth was observed. Two years after surgery, the horse developed progressive signs of hindlimb weakness, ataxia and adopting a dog‐sitting stance. Post‐mortem examination confirmed spinal canal infiltration and spinal cord compression (at the level of the 12th thoracic vertebra) by a similar soft tissue sarcoma as diagnosed previously. Immunohistochemistry confirmed the tumour as a peripheral nerve sheath tumour (PNST) likely originating from the twelfth thoracic spinal nerve. This report demonstrates that with incomplete tumour resection, local recurrence and extension of a PNST into the central nervous system can occur even years after initial tumour removal. Immunohistochemistry to differentiate the type of soft tissue sarcoma in cases with close association to the nervous system may prove beneficial to anticipate this uncommon complication. Early surgical resection with adjunctive therapies should be considered in these cases.

Indocyanine Green-Guided Pediatric Tumor Resection: Approach, Utility, and Challenges.

Incomplete tumor resection increases the risk of local recurrence. However, the standard of care approach to distinguishing tumor tissue is less than optimal, as it depends on a conglomeration of preoperative imaging and visual and tactile indicators in real time. This approach is associated with a significant risk of inadequate resection; therefore, a novel approach that delineates the accurate intraoperative definition of pediatric tumors is urgently needed. To date, there is no reliable method for the intraoperative assessment of tumor extent and real-time differentiation between tumor- involved tissues and tumor-free tissues. Use of intraoperative frozen sections is challenging, time consuming, and covers a small surface area. Increased vascular permeability and impaired lymphatic drainage in the tumor microenvironment leads to an enhanced permeability and retention effect of small molecules. ICG is a fluorescent dye that when administered intravenously accumulates passively in the tumor because of EPR, thereby providing some tumor contrast for intraoperative real-time tumor recognition. Preclinical and clinical studies suggest that the tumor-to-background fluorescence ratio is optimized when imaging is obtained 24 h after dye injection, and many studies suggest using a high dose of ICG to optimize dye retention in the tumor tissue. However, in childhood cancers, little is known about the ideal dosing, applications, and challenges of ICG-guided tumor resection. This retrospective study examines the feasibility of ICG-guided tumor resection in common childhood solid tumors such as neuroblastoma, sarcomas, hepatic tumors, pulmonary metastases, and other rare tumors. Pediatric dosing and challenges related to the optimization of tumor-to-background ratio are also examined.

Portable air-fed cold atmospheric plasma device for postsurgical cancer treatment.

Surgery represents the major option for treating most solid tumors. Despite continuous improvements in surgical techniques, cancer recurrence after surgical resection remains the most common cause of treatment failure. Here, we report cold atmospheric plasma (CAP)–mediated postsurgical cancer treatment, using a portable air-fed CAP (aCAP) device. The aCAP device we developed uses the local ambient air as the source gas to generate cold plasma discharge with only joule energy level electrical input, thus providing a device that is simple and highly tunable for a wide range of biomedical applications. We demonstrate that local aCAP treatment on residual tumor cells at the surgical cavities effectively induces cancer immunogenic cell death in situ and evokes strong T cell–mediated immune responses to combat the residual tumor cells. In both 4T1 breast tumor and B16F10 melanoma models, aCAP treatment after incomplete tumor resection contributes to inhibiting tumor growth and prolonging survival.

MP16-09 SAFETY AND EFFICACY OF TRANSURETHRAL RESECTION OF BLADDER TUMOUR COMPARING SPINAL ANAESTHESIA TO SPINAL ANAESTHESIA WITH AN OBTURATOR NERVE BLOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyBladder Cancer: Non-invasive II (MP16)1 Sep 2021MP16-09 SAFETY AND EFFICACY OF TRANSURETHRAL RESECTION OF BLADDER TUMOUR COMPARING SPINAL ANAESTHESIA TO SPINAL ANAESTHESIA WITH AN OBTURATOR NERVE BLOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS Anil Krishan, Angus Bruce, Shehab Khashaba, Mohamed Abouelela, and Syed Ali Ehsanullah Anil KrishanAnil Krishan More articles by this author , Angus BruceAngus Bruce More articles by this author , Shehab KhashabaShehab Khashaba More articles by this author , Mohamed AbouelelaMohamed Abouelela More articles by this author , and Syed Ali EhsanullahSyed Ali Ehsanullah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002001.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To investigate whether spinal anaesthesia with an obturator nerve block (SA+ONB) can be effectively employed for transurethral resection of bladder tumours (TURBT) during the COVID-19 pandemic to improve patient outcomes whilst also avoiding aerosol-generating procedures. We aimed to compare outcomes of TURBT using spinal anaesthesia (SA) alone versus SA+ONB in terms of rates of obturator reflex, bladder perforation, incomplete tumour resection, tumour recurrence and local anaesthetic toxicity. METHODS: We conducted a comprehensive search of electronic databases (MEDLINE, PUBMED, EMBASE, CINAHL, CENTRAL, SCOPUS, Google Scholar and Web of Science), identifying studies comparing the outcomes of TURBT using spinal anaesthesia versus spinal with an obturator nerve block. The Cochrane risk-of-bias tool for RCTs and the Newcastle-Ottawa scale for observational studies were used to assess the included studies. Random effects modelling was used to calculate pooled outcome data. RESULTS: Searches of electronic databases resulted in 107 articles, from which four randomised control trials (RCTs) and three cohort studies met the eligibility criteria, enrolling a total of 448 patients. The use of spinal anaesthesia with an obturator nerve block was associated with a significantly reduced risk of obturator reflex (p <0.00001), bladder perforation (p=0.02), incomplete resection (p <0.0001) and 12-month tumour recurrence (p=0.005). Obturator nerve block was not associated with an increased risk of local anaesthetic toxicity (0/159). CONCLUSIONS: Our meta-analysis suggests that TURBT employing spinal anaesthesia with an obturator nerve block is superior to the use of spinal anaesthesia alone. During the COVID-19 pandemic, where avoidance of aerosol-generating procedures (AGPs) such as a general anaesthesia is paramount, the use of an obturator nerve block with spinal anaesthesia is essential for the safety of both patients and staff without compromising care. Further high-quality RCTs with adequate sample sizes are required to compare the different techniques of obturator nerve block as well as comparing this method to general anaesthesia with complete neuromuscular blockade. Source of Funding: Nil © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e299-e300 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anil Krishan More articles by this author Angus Bruce More articles by this author Shehab Khashaba More articles by this author Mohamed Abouelela More articles by this author Syed Ali Ehsanullah More articles by this author Expand All Advertisement Loading ...

Blood-Based Liquid Biopsy for Comprehensive Cancer Genomic Profiling Using Next-Generation Sequencing: An Emerging Paradigm for Non-invasive Cancer Detection and Management in Dogs.

This proof-of-concept study demonstrates that blood-based liquid biopsy using next generation sequencing of cell-free DNA can non-invasively detect multiple classes of genomic alterations in dogs with cancer, including alterations that originate from spatially separated tumor sites. Eleven dogs with a variety of confirmed cancer diagnoses (including localized and disseminated disease) who were scheduled for surgical resection, and five presumably cancer-free dogs, were enrolled. Blood was collected from each subject, and multiple spatially separated tumor tissue samples were collected during surgery from 9 of the cancer subjects. All samples were analyzed using an advanced prototype of a novel liquid biopsy test designed to non-invasively interrogate multiple classes of genomic alterations for the detection, characterization, and management of cancer in dogs. In five of the nine cancer patients with matched tumor and plasma samples, pre-surgical liquid biopsy testing identified genomic alterations, including single nucleotide variants and copy number variants, that matched alterations independently detected in corresponding tumor tissue samples. Importantly, the pre-surgical liquid biopsy test detected alterations observed in spatially separated tissue samples from the same subject, demonstrating the potential of blood-based testing for comprehensive genomic profiling of heterogeneous tumors. Among the three patients with post-surgical blood samples, genomic alterations remained detectable in one patient with incomplete tumor resection, suggesting utility for non-invasive detection of minimal residual disease following curative-intent treatment. Liquid biopsy allows for non-invasive profiling of cancer-associated genomic alterations with a simple blood draw and has potential to overcome the limitations of tissue-based testing posed by tissue-level genomic heterogeneity.

A path toward the clinical translation of nano-based imaging contrast agents.

Recently, nanoparticles have evolved ubiquitously in therapeutic applications to treat a range of diseases. Despite their regular use as therapeutic agents in the clinic, we have yet to see much progress in their clinical translation as diagnostic imaging agents. Several clinical and preclinical studies support their use as imaging contrast agents, but their use in the clinical setting has been limited to off-label imaging procedures (i.e., Feraheme). Since diagnostic imaging has been historically used as an exploratory tool to rule out disease or to screen patients for various cancers, nanoparticle toxicity remains a concern, especially when introducing exogenous contrast agents into a potentially healthy patient population, perhaps rationalizing why several nano-based therapeutic agents have been clinically translated before nano-based imaging agents. Another potential hindrance toward their clinical translation could be their market potential, as most therapeutic drugs have higher earning potential than small-molecule imaging contrast agents. With these considerations in mind, perhaps a clinical path forward for nano-based imaging contrast agents is to help guide/manage therapy. Several studies have demonstrated the ability of nanoparticles to produce more accurate imaging preoperatively, intraoperatively, and postoperatively. These applications illustrate a more reliable method of cancer detection and treatment that can prevent incomplete tumor resection and incorrect assessment of tumor progression following treatment. The aim of this review is to highlight the research that supports the use of nanoparticles in biomedical imaging applications and offer a new perspective to illustrate how nano-based imaging agents have the potential to better inform therapeutic decisions. This article is categorized under: Diagnostic Tools > In Vivo Nanodiagnostics and Imaging.

Delayed variations in the diagnostic accuracy of intraoperative neuromonitoring in the resection of intramedullary spinal cord tumors.

The use of intraoperative neuromonitoring (IONM) has become an imperative adjunct to the resection of intramedullary spinal cord tumors (IMSCTs). While the diagnostic utility of IONM during the immediate postoperative period has been previously studied, its long-term diagnostic accuracy has seldom been thoroughly assessed. The aim of this study was to evaluate long-term variations in the diagnostic accuracy of transcranial motor evoked potentials (tcMEPs), somatosensory evoked potentials (SSEPs), and D-wave recordings during IMSCT excision. The authors performed a retrospective evaluation of imaging studies, patient charts, operative reports, and IONM recordings of patients who were operated on for gross-total or subtotal resection of IMSCTs at a single institution between 2012 and 2018. Variations in the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) for postoperative functional outcome (McCormick Scale) were analyzed at postoperative day 1 (POD1), 6 weeks postoperatively (PO-6 weeks), and at the latest follow-up. Overall, 28 patients were included. The mean length of follow-up was 19 ± 23.4 months. Persistent motor attenuations occurred in 71.4% of the cohort. MEP was the most sensitive modality (78.6%, 87.5%, and 85.7% sensitivity at POD1, PO-6 weeks, and last follow-up, respectively). The specificity of the D-wave was the most consistent over time (100%, 83.35%, and 90% specificity at the aforementioned time points). The PPV of motor recordings decreased over time (58% vs 33% and 100% vs 0 for tcMEP and D-wave at POD1 and last follow-up, respectively), while their NPV consistently increased (67% vs 89% and 70% vs 100% for tcMEP and D-wave at POD1 and last follow-up, respectively). The diagnostic accuracy of IONM in the resection of IMSCTs varies during the postoperative period. The decrease in the PPV of motor recordings over time suggests that this method is more predictive of short-term rather than long-term neurological deficits. The increasing NPV of motor recordings indicates a higher diagnostic accuracy in the identification of patients who preserve neurological function, albeit with an increased proportion of false-negative alarms for the immediate postoperative period. These variations should be considered in the surgical decision-making process when weighing the risk of resection-associated neurological injury against the implications of incomplete tumor resection.

Cerebellar liponeurocytoma, a rare tumor: Case report and review of the literature.

IntroductionCerebellar liponeurocytoma is a rare tumor of the central nervous system occurring mainly in the posterior fossa, which shows neuronal and variable astrocytic differentiation, along with foci of lipomatous differentiation.Case presentationHerein, we describe a 50-year-old female patient who presented to the hospital complaining of headache, tinnitus, and vertigo with positive cerebellar signs. MRI revealed a left cerebellar tumor. After tumor resection, histological examination and immunohistochemistry were done and the diagnosis of cerebellar liponeurocytoma was confirmed.DiscussionLiponeurocytoma may be mistaken as a medulloblastoma with lipidized cells or a lipomatous ependymoma. Histopathological examination, reinforced by immunohistochemistry and electron microscopy, are required to distinguish between these entities. The rarity of this tumor and paucity of pertinent information regarding its biological potential and natural history have resulted in the application of various treatment modalities.ConclusionLiponeurocytoma is a rare benign tumor with cerebellum is the typical site for it. Although surgery is the treatment of choice; however, postoperative radiotherapy may have a role in case of incomplete tumor resection or recurrence.

Complex nasal reconstruction for skin cancer and posttraumatic deformity using a modified frontonasal flap - Case report.

Introduction and importanceReconstruction of the nasal tip is challenging, especially when large defects are associated with compromised nasal soft tissues and framework. The frontonasal flap is an axial-pattern myocutaneous flap from the glabella and nasal dorsum that allows for various modifications in flap design to cover medium sized defects of the nasal tip.Case presentationA 66-year-old male patient presented with a large and ulcerated squamous cell carcinoma of the nasal tip that was associated with substantial posttraumatic damage of the nasal soft tissue envelope and cartilaginous vault of the dorsum. Considering patient comorbidity, risk factors, and specific nasal condition, a single-stage tumor resection and reconstruction using a modified frontonasal flap was intended. While tumor excision resulting in a tip defect of 1.5 × 1.5 cm and flap coverage were initially achieved in a single stage, histologically incomplete tumor resection and individual patient requests mandated further surgery, including re-excision, cartilage grafting, and soft tissue contouring.Clinical discussionThe frontonasal flap allows for single-stage reconstruction of moderate size tip defects. Even in the case of prior soft tissue damage and scarring, the flap may be used safely pending individual adjustments in flap design. However, additional measures may be employed as needed to optimize the functional and aesthetic outcome in cases of complex nasal pathology.ConclusionIn a case with a combined tumor and posttraumatic nasal deformity, an individualized surgical concept incorporating a modified frontonasal flap with adjunct cartilage grafting and soft tissue contouring achieved an excellent functional and cosmetic outcome.

Fluorophores Use in Pituitary Surgery: A Pharmacokinetics and Pharmacodynamics Appraisal.

(1) Background: Despite many surgical and technological advances, pituitary adenoma surgery is still burdened by non-negligible rates of incomplete tumor resection, mainly due to difficulties in differentiating pathology from normal pituitary tissue. Some fluorescent agents have been recently investigated as intraoperative contrast agents in pituitary surgery. The aim of this study is to evaluate the actual knowledge about the usefulness of such fluorophores with a particular focus on both the pharmacokinetics and pharmacodynamics issues of the pituitary gland. (2) Methods: We reviewed the current literature about fluorophores use in pituitary surgery and reported the first fully endoscopic experience with fluorescein. (3) Results: The studies investigating 5-ALA use reported contrasting results. ICG showed encouraging results, although with some specificity issues in identifying pathological tissue. Low-dose fluorescein showed promising results in differentiating pathology from normal pituitary tissue. Apart from the dose and timing of administration, both the fluorophores’ volume of distribution and the histological variability of the interstitial space and vascular density played a crucial role in optimizing intraoperative contrast enhancement. (4) Conclusions: Both pharmacokinetics and pharmacodynamics issues determine the potential usefulness of fluorophores in pituitary surgery. ICG and fluorescein showed the most promising results, although further studies are needed.

Follow-up care of sinonasal papillomas - risk factors for recurrence and malignant progression

Sinonasal papillomas are tumors of the nasal cavity and paranasal sinuses. They are treated through complete resection under oncologic conditions. Two characteristics complicate follow-up: 1) frequent tumor recurrences (even many years after initial diagnosis), 2) possibility for malignant progression. This review elucidates risk factors for these two characteristics to depict "high-risk patients" for whom a closer follow-up is mandatory. Literature was searched in Pubmed (NCBI). The most important risk factor for recurrence is incomplete tumor resection. This comprises several more factors: inappropriate surgical procedure, large tumors, difficult surgical conditions due to tumor localization or to prior surgery. Young age and tobacco smoking are risk factors for frequent recurrences. In regard to malignant progression, extended tumors, smoking, senior age, female sex, bone invasion, and lack of inflammatory polyps have been identified as risk factors. Histopathological factors for both - recurrences and malignant progression - are epithelial dysplasia, hyperkeratosis, squamous hyperplasia, as well as (if known) increased proliferation, aneuploidy, and infection with human papillomaviruses. Complete resection of sinunasal papillomas under oncologic conditions is of utmost importance. A careful postoperative follow-up is mandatory. Most authors suggest at least a five-year, some a lifelong follow-up. Patients with one or more risk factors should be monitored more closely.

Intraoperative [18F]FDG flexible autoradiography for tumour margin assessment in breast-conserving surgery: a first-in-human multicentre feasibility study

IntroductionIn women undergoing breast-conserving surgery (BCS), 20–25% require a re-operation as a result of incomplete tumour resection. An intra-operative technique to assess tumour margins accurately would be a major advantage. A novel method for intraoperative margin assessment was developed by applying a thin flexible scintillating film to specimens—flexible autoradiography (FAR) imaging. A single-arm, multi-centre study was conducted to evaluate the feasibility of intraoperative [18F]FDG FAR for the assessment of tumour margins in BCS.MethodsEighty-eight patients with invasive breast cancer undergoing BCS received ≤ 300 MBq of [18F]FDG 60–180 min pre-operatively. Following surgical excision, intraoperative FAR imaging was performed using the LightPath® Imaging System. The first 16 patients were familiarisation patients; the remaining 72 patients were entered into the main study. FAR images were analysed post-operatively by three independent readers. Areas of increased signal intensity were marked, mean normalised radiances and tumour-to-tissue background (TBR) determined, agreement between histopathological margin status and FAR assessed and radiation dose to operating theatre staff measured. Subgroup analyses were performed for various covariates, with thresholds set based on ROC curves.ResultsData analysis was performed on 66 patients. Intraoperative margin assessment using FAR was completed on 385 margins with 46.2% sensitivity, 81.7% specificity, 8.1% PPV, 97.7% NPV and an overall accuracy of 80.5%, detecting both invasive carcinoma and DCIS. A subgroup analysis based on [18F]FDG activity present at time of imaging revealed an increased sensitivity (71.4%), PPV (9.3%) and NPV (98.4%) in the high-activity cohort with mean tumour radiance and TBR of 126.7 ± 45.7 photons/s/cm2/sr/MBq and 2.1 ± 0.5, respectively. Staff radiation exposure was low (38.2 ± 38.1 µSv).Conclusion[18F]FDG FAR is a feasible and safe technique for intraoperative tumour margin assessment. Further improvements in diagnostic performance require optimising the method for scintillator positioning and/or the use of targeted radiopharmaceuticals.Trial registration: Identifier: NCT02666079. Date of registration: 28 January 2016. URL: https://clinicaltrials.gov/ct2/show/NCT02666079.ISRCTN registry: Reference: ISRCTN17778965. Date of registration: 11 February 2016. URL: http://www.isrctn.com/ISRCTN17778965.

En Bloc Tumor Resection, Optical Molecular Imaging, and the Potential Synergy of the Combination of the Two Techniques in Bladder Cancer.

Although transurethral resection of bladder tumor is the golden standard for the treatment of non-muscle invasive bladder cancer, this surgical procedure still has some serious drawbacks. For example, piecemeal resection of tumor tissue results in exfoliated tumor cells dissemination and implantation, and fragmented tumor specimens make it difficult for pathologists to accurately assess the pathological stage and histologic grade. En bloc tumor resection follows the basic principle of oncological surgery and provides an intact tumor specimen containing detrusor muscle for pathologists to make accurate histopathological assessment. However, there is no robust clinical evidence that en bloc tumor resection is superior to conventional resection in terms of oncological outcomes. Considering the high recurrence rate, small or occult tumor lesions may be overlooked and incomplete tumor resection may occur during white light cystoscopy-assisted transurethral resection. Molecular fluorescent tracers have the ability to bind tumor cells with high sensitivity and specificity. Optical molecular imaging mediated by it can detect small or occult malignant lesions while minimizing the occurrence of false-positive results. Meanwhile, optical molecular imaging can provide dynamic and real-time image guidance in the surgical procedure, which helps urologists to accurately determine the boundary and depth of tumor invasion, so as to perform complete and high-quality transurethral tumor resection. Integrating the advantages of these two technologies, optical molecular imaging-assisted en bloc tumor resection shows the potential to improve the positive detection rate of small or occult tumor lesions and the quality of transurethral resection, resulting in high recurrence-free and progression-free survival rates.

Peritumoral Edema Is Associated With Postoperative Hemorrhage and Reoperation Following Vestibular Schwannoma Surgery.

Background: Postoperative hemorrhage (POH) is a severe complication following vestibular schwannoma surgery that may require surgical treatment. The purpose of our study is to identify risk factors associated with POH and reoperation following the resection of vestibular schwannoma.Methods: We retrospectively recruited 452 vestibular schwannoma patients treated with retrosigmoid approach. The primary outcome was POH, and the secondary outcome was reoperation for POH. Clinical and radiographic data were compared by performing univariate analysis and logistic regression analysis.Results: Among the 452 patients, 37 patients (8.2%) presented with POH and14 patients (3.1%) required reoperation within a 30-day hospitalization period. The univariate analysis showed that peritumoral edema, tumor diameter >30 mm, severe postoperative hypertension, and length of hospital stay were associated with POH and reoperation for POH. Logistic regression analysis showed that peritumoral edema [odds ratio (OR) 4.042, 95% confident interval (CI) 1.830–8.926, P = 0.001] and tumor diameter >30 mm (OR 3.192, 95% CI 1.421–7.168, P = 0.005) were independent predictive factors for POH. Peritumoral edema (OR 7.071, 95% CI 2.342–21.356, P = 0.001) was an independent predictive factor for reoperation by using logistic regression analysis. Further analysis revealed that larger tumor and incomplete tumor resection were both associated with a higher incidence of peritumoral edema.Conclusion: Peritumoral edema and tumor size are independent risk factors for POH following vestibular schwannoma surgery. And larger hematoma occurs more commonly in tumors with peritumoral edema which may require reoperation. Tumor size and extent of tumor resection are associated with peritumoral edema. Close attention should be paid to high-risk patients especially for those who presented with severe postoperative hypertension.

Prediction of residual tumor and overall survival after first-line surgery in patients with pancreatic ductal adenocarcinoma using preoperative magnetic resonance imaging findings.

Complete resection is the only potentially curative treatment in patients with pancreatic ductal adenocarcinoma (PDA) and is associated with a longer overall survival (OS) than incomplete resection of tumor. Hence, prediction of the resection status after surgery would help predict the prognosis of patients with PDA. To predict residual tumor (R) classification and OS in patients who underwent first-line surgery for PDA using preoperative magnetic resonance imaging (MRI). In this study, 210 patients with PDA who underwent MRI and first-line surgery were randomly categorized into a test group (n=150) and a validation group (n=60). The R classification was divided into R0 (no residual tumor) and R1/R2 (microscopic/macroscopic residual tumor). Preoperative MRI findings associated with R classification and OS were assessed by using logistic regression and Cox proportional hazard models. In addition, the prediction models for the R classification and OS were validated using calibration plots and C statistics. On preoperative MRI, portal vein encasement (odds ratio 4.755) was an independent predictor for R1/R2 resection (P=0.040). Tumor size measured on MRI (hazard ratio [HR] per centimeter 1.539) was a predictor of OS, along with pathologic N1 and N2 stage (HR 1.944 and 3.243, respectively), R1/R2 resection (HR 3.273), and adjuvant chemoradiation therapy (HR 0.250) (P<0.050). Calibration plots demonstrated satisfactory predictive performance. Preoperative MRI was valuable for predicting R1/R2 resection using portal vein encasement. Tumor size measured on MRI was useful for the prediction of OS after first-line surgery for PDA.

A Case Series of Surgically Treated Spinal Dumbbell Tumors of Critical Parent Nerve Roots: To Cut or Not to Cut?

Dumbbell tumors present challenging cases, with either an incomplete tumor resection or a need to sacrifice nerve roots. Published literature suggests encouraging neurological outcomes after nerve root amputation. To determine the incidence of postoperative neurological deficits after amputating the parent nerve root. A retrospective consecutive analysis of all patients treated for dumbbell nerve sheet tumors with a reported amputation of the functional relevant parent nerve roots C5-Th1 and L3-S1. Among 21 evaluated patients, minor postoperative neurological motor function deterioration occurred in 4 patients (19%). Most patients recovered to the preoperative level at the follow-up examination, and only one patient retained a new Medical Research Council (MRC) scale of 4/5 for deltoid weakness. The majority of tumors were resected at the lumbar level (nerve root L3: 28.6%, L5: 19%). Gross total resection was achieved in 90.5% of patients. Neuropathic pain was reported in one third of the patients during the long-term follow-up. Amputating critical parent nerve roots during the dumbbell tumor resections seems to result in a low incidence of postoperative motor deficits and may offer an acceptable sacrifice in otherwise only incompletely resectable dumbbell tumors. The cross-innervation of neighboring nerve roots and its, probably, per-se-reduced functionality may be a possible mechanism for maintaining motor function.