Incomplete Surgical Excision Research Articles

Audit of incomplete BCC surgical excisions: How to improve patients’ outcomes and services

Audit of incomplete BCC surgical excisions: How to improve patients’ outcomes and services

Giant cell tumor of tendon sheath: a case series

Giant cell tumor of tendon sheath is a relatively rare non-malignant soft tissue tumor arising from the synovial cells and is associated with high recurrence rate. Many factors are considered for high recurrence including proximity to distal interphalangeal joints, presence of degenerative joint disease, pressure erosions in the radiograph and increased mitotic activity. But the most common cause for recurrence is incomplete surgical excision. However, it is the second most common tumor in hands after ganglion cysts. Here we present a case series comprising of 3 cases for whom marginal excision was done and they were kept on regular follow up without any recurrence.

Sclerosing liposarcoma of the anterior mediastinum: An unusual case.

Liposarcomas are extremely rare in the mediastinum. Patients usually present late due to the compressive effect of the tumor on the adjacent structures. Severity of the symptoms depend mainly on the size of the tumor and the structure it infiltrates. Well differentiated slow growing liposarcomas are the most common ones in the mediastinum followed by dedifferentiated and poorly differentiated ones. These tumors have bad prognosis because of incomplete surgical excision due to its inaccessible location. Hence these patients should be kept under close follow up because of high recurrent rates. Here we are presenting a rare case of anterior mediastinal sclerosing liposarcoma in a 77 year old male.

Imiquimod 5% as Adjuvant Therapy for Incompletely Excised Infiltrative Nodular Basal Cell Carcinoma and Dermoscopy to Monitor Treatment Response

IntroductionA relatively novel application for dermoscopy is its use in the monitoring of topical treatment response for non-melanoma skin cancer. Basal cell carcinoma (BCC) is the most frequent type of skin cancer in humans. Surgical excision is still considered the “gold-standard” of treatment. However, a number of topical therapies are now available for the treatment of different types of basal cell carcinoma.Case ReportThis case report exemplifies the usefulness of dermoscopy in the monitoring of residual disease after incomplete surgical excision and also in the monitoring of topical treatment response. Imiquimod 5% cream acts as a topical immune response modifier promoting a Th-1 immune response enhancing the removal of neoplastic cells and has proven to reduce deregulated Hedgehog (HH)/GLI signal strength independent of Toll-like receptor signaling, which makes it a valuable adjuvant topical therapy for the treatment of basal cell carcinoma.ConclusionImiquimod 5% cream is a valuable adjuvant therapy for the treatment of incompletely excised BCC. This case report adds further evidence to the usefulness of dermoscopy in the assessment and monitoring of treatment outcome.Electronic supplementary materialThe online version of this article (doi:10.1007/s13555-015-0088-z) contains supplementary material, which is available to authorized users.

Treatment of Basal Cell Carcinoma Using a One-Stop-Shop With Reflectance Confocal Microscopy: Study Design and Protocol of a Randomized Controlled Multicenter Trial.

BackgroundBasal cell carcinoma (BCC) is the most common cancer diagnosed in white populations worldwide. The rising incidence of BCC is becoming a major worldwide public health problem. Therefore, there is a need for more efficient management.ObjectiveThe aim of this research is to assess the efficacy and safety of a one-stop-shop (OSS) concept, using real-time in vivo reflectance confocal microscopy (RCM) (Vivascope 1500; Lucid Technologies, Henrietta, NY, USA) as a diagnostic tool, prior to surgical management of new primary BCCs.MethodsThis is a prospective non-inferiority multi-center RCT designed to compare the “OSS concept using RCM” to current standards of care in diagnosing and treating clinically suspected BCC. Patients ≥ 18 years attending our outpatient clinic at the Department of Dermatology, Academic Medical Center, University of Amsterdam, and the Department of Dermatology, the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (Amsterdam, The Netherlands) with a clinically suspected new primary BCC lesion will be considered for enrollment using predefined inclusion and exclusion criteria, and will be randomly allocated to the experimental or control group. The main outcome parameter is the assessment of incomplete surgical excision margins on the final pathology report of confirmed BCC lesions (either by punch biopsy or RCM imaging). Other outcome measures include diagnostic accuracy (sensitivity and specificity) of RCM for diagnosing BCC and dividing between subtypes, and throughput time. Patient satisfaction data will be collected postoperatively after 3 months during routine follow-up.ResultsThis research is investigator-initiated and received ethics approval. Patient recruitment started in February 2015, and we expect all study-related activities to be completed by fall 2015.ConclusionsThis RCT is the first to examine an OSS concept using RCM for diagnosing and treating clinically suspected BCC lesions. Results of this research are expected to have applications in evidence-based practice for the increasing number of patients suffering from BCC and possibly lead to a more efficient disease management strategy.Trial RegistrationClinicalTrials.gov: NCT02285790; https://clinicaltrial.gov/ct2/show/NCT02285790 (Archived by WebCite at http://www.webcitation.org/6b2LfDKWu).

How Does the Oncogene Astrocyte Elevated gene-1 ( AEG-1 ) Augment Glioma Progression?

Gliomas are common primary brain tumors in adults that are for the most part lethal. Recent studies suggest that gliomas can arise from adult neural stem cells or multipotential neural progenitor cells that exist in the subventricular and subgranular zone [1]. According to the WHO, gliomas are classified into four malignancy grades (I–IV) based on their histological features; among these, grade I and II are considered low-grade gliomas with better prognosis, while glioblastoma multiforme ([GBM], malignant glioma, grade IV) has the worst prognosis. Patients diagnosed with malignant glioma display a median survival of approximately 12–15 months even with multimodal therapeutic approaches including maximal tolerated surgery, chemotherapy and radiotherapy [2]. Gliomas exhibit a strong propensity to invade healthy brain tissue by migrating through the convoluted extracellular spaces of the brain parenchyma, and eventually develop tumors at distant locations. Due to this invasive nature of the human malignant glioma, it is difficult to define borders between normal brain tissue and the tumor, which leads to incomplete surgical excision of the tumors. As such, radiotherapy or chemotherapy following surgery as combination therapies are standard of care for malignant glioma management [2]. Malignant gliomas are highly heterogeneous both genetically and pathologically, which makes the selection of diagnostic markers or targeted therapies challenging. The Cancer Genome Atlas (TCGA) network has established three essential signaling pathways that are important for malignant glioma progression including RTK/RAS/PI3K, p53 and Rb pathways [3]. Additionally, several hallmark tumorigenesis features are relevant for glioma progression, including uncontrolled proliferation, invasion, angiogenesis and chemo-radio resistance. Consequently, it is imperative to define and understand the Luni Emdad‡,1,2,3, Bin Hu1, Timothy P Kegelman1, Swadesh K Das1,2,3, Devanand Sarkar1,2,3 & Paul B Fisher*,‡,1,2,3 “The multifaceted role of AEG-1 on glioma progression implies that AEG-1 inhibition would be an appropriate end point to counter the pathogenesis of this dismal disease, particularly in conjunction with other current treatment modalities.”

Neoadjuvant FOLFOX 4 versus FOLFOX 4 with Cetuximab versus immediate surgery for high-risk stage II and III colon cancers: a multicentre randomised controlled phase II trial – the PRODIGE 22 - ECKINOXE trial

BackgroundIn patients with high risk stage II and stage III colon cancer (CC), curative surgery followed by adjuvant FOLFOX-4 chemotherapy has become the standard of care. However, for 20 to 30 % of these patients, the current curative treatment strategy of surgical excision followed by adjuvant chemotherapy fails either to clear locoregional spread or to eradicate distant micrometastases, leading to disease recurrence. Preoperative chemotherapy is an attractive concept for these CCs and has the potential to impact upon both of these causes of failure. Optimum systemic therapy at the earliest possible opportunity may be more effective at eradicating distant metastases than the same treatment given after the delay and immunological stress of surgery. Added to this, shrinking the primary tumor before surgery may reduce the risk of incomplete surgical excision, and the risk of tumor cell shedding during surgery.Methods/DesignPRODIGE 22 - ECKINOXE is a multicenter randomized phase II trial designed to evaluate efficacy and feasibility of two chemotherapy regimens (FOLFOX-4 alone and FOLFOX-4 + Cetuximab) in a peri-operative strategy in patients with bulky CCs. Patients with CC deemed as high risk T3, T4 and/or N2 on initial abdominopelvic CT scan are randomized to either colectomy and adjuvant chemotherapy (control arm), or 4 cycles of neoadjuvant chemotherapy with FOLFOX-4 (for RAS mutated patients). In RAS wild-type patients a third arm testing FOLFOX+ cetuximab has been added prior to colectomy. Patients in the neoadjuvant chemotherapy arms will receive postoperative treatment for 4 months (8 cycles) to complete their therapeutic schedule. The primary endpoint of the study is the histological Tumor Regression Grade (TRG) as defined by Ryan. The secondary endpoints are: treatment strategy safety (toxicity, primary tumor related complications under chemotherapy, peri-operative morbidity), disease-free and recurrence free survivals at 3 years, quality of life, carcinologic quality and completeness of the surgery, initial radiological staging and radiological response to neoadjuvant chemotherapy, and the correlation between histopathological and radiological response. Taking into account a 50 % prevalence of CC without RAS mutation, accrual of 165 patients is needed for this Phase II trial.Trial RegistrationNCT01675999 (ClinicalTrials.gov)

A retrospective international study on primary extranodal marginal zone lymphoma of the lung (BALT lymphoma) on behalf of International Extranodal Lymphoma Study Group (IELSG).

Primary lymphoma of the lung is a rare entity. Clinical features, optimal treatment, role of surgery and outcomes are not well defined, and the follow-up is variable in published data. Clinical data of 205 patients who were confirmed to have bronchus mucosa-associated lymphoid tissue lymphoma from December 1986 to December 2011 in 17 different centres worldwide were evaluated. Fifty-five per cent of the patients were female. The median age at diagnosis was 62 (range 28-88) years. Only 9% had a history of exposure to toxic substances, while about 45% of the patients had a history of smoking. Ten per cent of the patients had autoimmune disease at presentation, and 19% patients had a reported preexisting lung disease. Treatment modalities included surgery alone in 63 patients (30%), radiotherapy in 3 (2%), antibiotics in 1 (1%) and systemic treatment in 128 (62%). Patients receiving a local approach, mainly surgical resection, experienced significantly improved progression-free survival (p = 0.003) versus those receiving a systemic treatment. There were no other significant differences among treatment modalities. The survival data confirm the indolent nature of the disease. Local therapy (surgery or radiotherapy) results in long-term disease-free survival for patients with localized disease. Systemic treatment, including alkylating-containing regimens, can be reserved to patients in relapse after incomplete surgical excision or for patients with advanced disease. Copyright © 2015 John Wiley & Sons, Ltd.

Amelanotic Melanoma in the Rabbit: A Case Report With an Overview of Immunohistochemical Characterization

An adult spayed female New Zealand white mix-breed rabbit was presented for an abnormal cutaneous pigmentation of the left nasal canthus. Biopsy samples were collected when the rabbit was under general anesthesia. Using the results of the biopsy, an initial diagnosis of carcinoma was made. The patient was referred for surgical excision followed by local radiation therapy using strontium-90. The histological appearance was most consistent with an amelanotic melanoma. Neoplastic cells strongly expressed melan-A and vimentin and failed to express pancytokeratin markers. The immunohistochemical findings supported the presumptive diagnosis of amelanotic melanoma. Owing to the high mitotic index, presence of neoplastic cells within the vessels, and incomplete surgical excision, the prognosis was poor. The owner refused further treatment and diagnostic evaluation of the patient. The rabbit was found dead in its enclosure approximately 6 months after the diagnosis. A postmortem examination was not performed. Although melanomas have been reported in rabbits, this condition appears to be underreported in pet rabbits. This case report describes the clinical presentation and diagnosis of amelanotic melanoma, histological evaluation of affected tissue, and immunohistochemistry in a rabbit.

Inhibition of adhesion, proliferation, and invasion of primary endometriosis and endometrial stromal and ovarian carcinoma cells by a nonhyaluronan adhesion barrier gel.

Endometriosis is a chronic disease of women in the reproductive age, defined as endometrial cells growing outside of the uterine cavity and associated with relapses. Relapses are hypothesized to correlate with incomplete surgical excision or result from nonrandom implantation of new endometrial implants in adjacent peritoneum. Thus, surgical excision could lead to free endometriotic cells or tissue residues, which readhere, grow, and invade into recurrent lesions. Barrier agents are frequently used to prevent postoperative adhesions. We tested if the absorbable cell adhesion barrier gel Intercoat consisting of polyethylene oxide and sodium carboxymethyl cellulose could inhibit cellular adhesion, proliferation, and invasion of primary endometriosis and endometrial cells. Due to an association of endometriosis with ovarian carcinoma, we tested two ovarian carcinoma cell lines. Prior to cell seeding, a drop of the barrier gel was placed in cell culture wells in order to test inhibition of adherence and proliferation or coated over a polymerized collagen gel to assay for prevention of invasion. Results showed that the barrier gel significantly inhibited cell adherence, proliferation, and invasion of endometriosis and endometrial stromal cells as well as ovarian carcinoma cells in culture. Our findings could help to prevent local cell growth/invasion and possible consequent recurrences.

A Rare Case of Tumoral Calcium Pyrophosphate Dihydrate Crystal Deposition Disease of the Wrist Joint.

Introduction. Tumoral calcium pyrophosphate dihydrate (CPPD) crystal deposition disease (CPPDCD), also known as tophaceous calcium pyrophosphate deposition disease (CPDD), is a tumorlike lesion, and it should be distinguished from usual CPDD that causes severe joint inflammation and arthralgia. A case of tumoral CPPDCD of the wrist joint that required differentiation from synovial osteochondromatosis is described. Case Presentation. The patient was a 78-year-old woman with a 5-year history of nodular lesions at the right wrist that had gradually increased in size. An excisional biopsy and a histological examination of the excised nodular lesions by hematoxylin and eosin (H&E) staining were performed, demonstrating numerous polarizable, rhabdoid, and rectangular crystals, surrounded by fibroblasts, macrophages, and foreign body-type giant cells, consistent with tumoral CPPDCD. Conclusion. Tumoral CPPDCD, especially at the wrist joint, is rare, and, to the best of our knowledge, only 2 articles have been published. This case seems to need further follow-up for recurrence, because tumoral CPPDCD may recur after complete or incomplete surgical excision.

Proton beam therapy for presumed and confirmed iris melanomas: a review of 36 cases

To report the clinical features and outcomes of iris melanomas treated by proton beam therapy. A retrospective study was conducted at the Croix-Rousse University Hospital of Lyon, Department of Ophthalmology, in 36 patients treated by proton beam therapy for presumed (n = 29) and confirmed (n = 7) iris melanomas between July 1997 and October 2010. Ciliary body melanomas with iris involvement were excluded. The patients' mean age was 54.4 years (range, 22-82 years). The average tumor diameter was 3.8 mm (range, 2.5-8.0). The iridocorneal angle was invaded by the tumor in 47% of cases (n = 17), the ciliary body in 17% of cases (n = 6), and the sclera in 3% (n = 1). Raised intraocular pressure was present before treatment in 11.1 % of cases (n = 4). Tumor biopsy was performed in 19% of cases (n = 7). Four patients had undergone an initial incomplete surgical excision of tumor before radiotherapy. Surgical preparation of the eye with tantalum ring positioning had been performed in all cases 3-4 weeks before irradiation. The prescribed dose was 60 Cobalt Gray Equivalent (CGE) of proton beam radiotherapy delivered in four fractions on four consecutive days. The median follow-up was 50 months (mean 60.5, range 15-136). One patient (2.7%) was lost to follow-up. None of the patients showed tumor progression, local recurrence, or metastasis. None of the patients required secondary enucleation. Cataract was developed in 62% of patients, glaucoma in two cases (6%) after irradiation, and hyphema with the aggravation of pre-existing glaucoma in one patient. No patients developed neovascular glaucoma. Proton beam therapy appears to be the treatment of choice for the conservative treatment of iris melanomas with excellent tumor control and an acceptable rate of complications. Longer follow-up studies on a larger series is necessary to consolidate these results.

Feeding and Draining Vessel Ligation with Sclerotherapy of High Flow Arteriovenous Malformations in the Head and Neck

Feeding and Draining Vessel Ligation with Sclerotherapy of High Flow Arteriovenous Malformations in the Head and Neck

Additional Local Therapy With Primary Re‐Excision or Radiation Therapy Improves Survival and Local Control After Incomplete or Close Surgical Excision of Mast Cell Tumors in Dogs

To compare survival and local recurrence outcomes in dogs with mast cell tumors with incomplete or close margins treated with primary re-excision or radiation therapy of the primary site versus no additional local therapy. Retrospective case series. Dogs (n = 64). Outcomes of canine mast cell tumor cases that had incomplete or close surgical resection and presented to the Ontario Veterinary College Health Sciences Centre (2001-2010) were evaluated after additional local therapy (primary re-excision or radiation therapy) or no additional local therapy (comparison). Follow-up was performed through evaluation of medical records and telephone contact with referring veterinarians and owners. Tumors (n = 70) in 64 dogs were studied. Median survival times for the primary re-excision (2930 days) and radiation therapy (2194 days) groups were significantly longer than for the comparison (710 days) group. Local recurrence occurred in 13% of the re-excision group, 8% of the radiation therapy group, and 38% of the comparison group. Although local recurrence rate was not statistically significant for the re-excision group, time to local recurrence was statistically longer for both the re-excision and radiation groups. Adjunctive chemotherapy was not associated with improved survival or local control. There is significant improvement in survival and duration of local control when additional local therapy is performed after incomplete or close resection of mast cell tumors. These follow-up therapies should be recommended to owners when mast cell tumors are incompletely or closely resected.

Epithelial lacrimal gland tumors: A comprehensive clinicopathologic review of 26 lesions with radiologic correlation

AimTo study the prevalence, clinicopathological and radiological correlations of epithelial lacrimal gland tumors and compare these with similar published literature. The study was also designed to look at the natural history of benign mixed tumors (BMT) in regard to recurrence and malignant degeneration. MethodsThis was a retrospective study of all suspected epithelial tumors of the lacrimal gland surgically excised at King Khaled Eye Specialist Hospital (KKESH) for the period: 1983–2008. Exclusion criteria included structural lesions (dacryops) and inflammatory lesions. We included 26 cases of epithelial lacrimal gland tumors (from 24 patients). The histopathologic slides and the radiologic findings were reviewed. The corresponding demographic and clinical data were obtained by chart review using a data sheet. ResultsBMT accounted for 12/26 of the lesions while malignant lesions including adenoid cystic carcinoma (ACC) were more common (14/26). The mean age was 44.27years (range 12–75). Commonest clinical presentation was proptosis. Median duration of symptoms in the BMT cases was 30months and 7months in the ACC group. The 12 BMT cases were primary in 9 and recurrent in 3 patients. The 11 ACC cases showed mostly cribriform pattern and low histopathologic grade. We had 2 cases of malignant mixed tumor (MMT) one of which arising in a recurrent tumor. One case of primary mucoepidermoid carcinoma with histopathologic grade 2 was noted. Radiologically, a well-defined appearance with bone remodeling was observed in BMT in contrast to invasive appearance with destruction in malignant lesions. ConclusionOur series information indicated a different distribution of benign and malignant epithelial lesions with a slightly higher rate of malignancy. BMT was the commonest benign tumor where recurrence was a squeal of incomplete surgical excision. ACC was the commonest malignant tumor with shorter duration of symptoms and radiologic evidence of invasiveness that correlated with the histopathologic features.

State of art imaging of the pituitary tumors

Over the years imaging of the pituitary has passed through different stages of evolution. Currently magnetic resonance imaging (MRI) is the modality most often used in studies of the pituitary gland. The role of computed tomography (CT) scanning is only appropriate to address specific questions in evaluating abnormalities within the pituitary gland. CT is used more often in lesions located in the parasellar and suprasellar regions or in the bones at the base of the skull. There are various issues that need to be addressed when dealing with the possibility of pituitary dysfunction. Biochemical tests and the clinical symptomatology are indispensable in the diagnosis of a hormonal abnormality that may have its origin in the pituitary but such tests are not always conclusive. Adenomas in the pituitary are benign lesions that cause hyper secretion of a hormone. In order of descending frequency we encounter prolactin (PRL), growth hormone (GH), adrenocorticotrophic (ACTH), gonadotrophic (FSH, LH) and thyrotrophic (TSH) secreting adenomas. The role of imaging is not to distinguish one type of adenoma from the other but to document the presence of the lesion, to show its exact location within the gland and to estimate its size. Adenomas can be small lesions imbedded within the pituitary gland or large enough to increase its size. The terms of microadenomas and macroadenomas have been adopted to describe lesions smaller or larger than 10 mm. The diagnostic issues in these two types of adenomas are different. The main problem in the case of small tumors which may measure 2–3 mm in diameter is that of detection. Small adenomas can easily escape detection because they often enhance in a fashion similar to normal pituitary. Also, the appearance of such small tumors is subjected to the effects of averaging in tomographic sections of 3 mm thickness. Depending on the histologic type, adenomas can be treated medically or by surgical excision. Prolactinomas, at least initially, may be treated medically, whereas the treatment for most of the other adenomas is surgical excision. Targeted radiation therapy is also used in cases that cannot be surgically resected or in patients with incomplete resection of the tumor. Pituitary adenomas selected to be treated by surgery are often small when first diagnosed and yet produce profound clinical symptoms. Therefore detection of small adenomas by imaging is critical for surgical planning. It has been shown that when imaging has accurately identified the adenoma within the pituitary the rate of cure is 80–90 %. When the diagnosis of microadenoma is ambivalent or incomplete, the rate of cure after surgery drops to 50–70 % [1–3]. Adenomas are usually round space occupying lesions commonly separated by a pseudo capsule from the normal pituitary. Even when a pseudo capsule is formed, the border of the adenoma and its interface with the pituitary parenchyma may not be well defined by imaging. This leads to underestimation of its size, which in turn, can result in an incomplete surgical excision and recurrent symptoms. Another diagnostic problem is encountered when the adenomatous mass occupies the entire sella without increasing the overall size of the pituitary. Then the adenoma is not clearly separated from the normal pituitary and may be mistaken as a normal gland. In other instances there is no discreet mass within the pituitary but instead there a diffuse infiltration of its parenchyma by hypersecreting cells [4]. Both the above abnormalities are not detected preoperatively by imaging and may not be appreciated even during surgery. The correct diagnosis is N. J. Patronas (&) C.-Y. Liu Bethesda, MD, USA e-mail: npatronas@nih.gov

Chronic acalculous cholecystitis on hida scan: Is laparoscopic cholecystectomy indicated?

Chronic acalculous cholecystitis on hida scan: Is laparoscopic cholecystectomy indicated?

99mTc-Pertechnetate SPECT/CT for Detecting Recurrent Foregut Duplication Cyst in a Case With Negative Planar Scintigraphy

Recurrence can occur after incomplete surgical excision of foregut duplication cysts. We here present (99m)Tc-pertechnetate SPECT/CT images of a 3-year-old girl with recurrence of foregut duplication cyst. (99m)Planar Tc-pertechnetate scintigraphy was negative in this case.

English

Solitary fibrous tumour is a rare spindle cell neoplasm. It was first described by Klemper and Rabin in 1931 . Initially it was assumed that these tumours .The tumour originates from mesenchyme. The diagnosis is confirmed by immunohistochemical confirmation for CD 34. These tumours usually have good prognosis. These tumours are treated with surgical excision with close followup .Local recurrences were seen after incomplete surgical excision

Orthovoltage radiotherapy in the management of medial canthal basal cell carcinoma

AimsTo report the local control and complication rates of orthovoltage radiotherapy in the management of medial canthal basal cell carcinoma (BCC).MethodsThe medical records of all patients treated with medial canthal...