Infiltrative Margins Research Articles

Abdominoperineal excision or extralevator abdominoperineal excision: which is the best oncological treatment?

Surgery of tumors of the lower third of the rectum is particularly difficult due to the complex anatomy of the pelvis, which can lead to an incomplete radical resection. Abdominoperineal excision (APE) is the operation of choice for tumors of the low rectum that infiltrate levatorani or sphincter muscles. Regardless, APE causes an important morbidity, a higher incidence of circumferential resection margin (CRM) infiltration, iatrogenic tumor perforation incidence and worsens the mesorectum quality due to the conicity induced during surgery while dissection between both distal mesorectum and levatorani planes is performed. An extralevator abdominoperineal excision (ELAPE), which involves a broader resection of the pelvic floor muscles, would theoretically reduce the risk of CRM infiltration and tumor perforation rate, independently from the position (prone vs . supine) or the approach (open vs . laparoscopic). This review is focused on the analysis of the scientific evidence published so far comparing both techniques, APE or ELAPE. In spite of some publications observe a possible benefit in terms of reduction in CRM involvement, iatrogenic perforations or local recurrence, there is not enough evidence to affirm the superiority of ELAPE compared to conventional APE in terms of oncological results. In general, similar rates of postoperative complications are described for both techniques. Further prospective, controlled and randomized studies are needed to conclude which of the two techniques is the best oncological treatment.

Invasive Ductal Carcinoma of the Breast with Medullary Features or Medullary Carcinoma of the Breast: A Challenging Histopathological Case Report with Review of Literature

Medullary Breast carcinoma (MBC) is an infrequent type of breast cancer and is in the differential diagnosis of invasive ductal carcinoma (IDC) with medullary features. We reported a 35-year-old lady with left breast since 6 months ago. CEA tumor marker serum level and CA15-3 were within normal limits. The patient underwent the incomplete left mastectomy. Gross specimen revealed gray-yellow hemorrhagic tumor lesion with pushing border. Histopathology demonstrated highly atypical cells with lymphocytic infiltration and mainly pushing border but with infiltrative margin in few areas. The permanent diagnosis was “invasive ductal carcinoma with medullary features“. We conclude that careful histopathological evaluation and considering strict criteria is necessary for definitive diagnosis and subsequent proper treatment.

Quantitative Cross-Polarization Optical Coherence Tomography Detection of Infiltrative Tumor Margin in a Rat Glioma Model: a Pilot Study

Quantitative Cross-Polarization Optical Coherence Tomography Detection of Infiltrative Tumor Margin in a Rat Glioma Model: a Pilot Study

A retrospective review of the role of B-mode and color Doppler ultrasonography in the investigation of primary hyperparathyroidism: Features that differentiate benign from malignant lesions.

To identify the variant features encountered in parathyroid abnormalities and document those suggesting malignant change. Data were collected from a cohort of patients who underwent investigation for primary hyperparathyroidism over a 10-year period. Ultrasonographic features: shape, presence of calcification, cystic changes, heterogeneous echogenicity, vascularity, capsular thickening, local invasion, and vascularity were reviewed retrospectively and were used to correlate with final histological findings. One hundred forty-seven patients with histology and concurrent ultrasonographic scans were reviewed, and divided into benign parathyroid lesions (nodular hyperplasia (n = 44), adenoma (n = 93)) and parathyroid carcinoma (n = 10). Parathyroid carcinomas were significantly larger than benign parathyroid lesions (P = 0.030). Benign parathyroid lesions showed variant sonographic features: irregular shape (16.8%), heterogenous echogenicity (24.1%), calcification (1.5%), capsular thickening (1.5%), and cystic change (19.7%). A significantly higher proportion of parathyroid carcinomas demonstrated heterogenous echogenicity (P = 0.022), capsular thickening (P = 0.023), and infiltrative margin (P < 0.0001) than benign parathyroid lesions. Of the 137 benign parathyroid lesions, 38 (27.7%), 76 (55.5%), 23 (16.8%) were avascular, vascular, and hypervascular, respectively. Of the 10 parathyroid carcinomas, 4 (40%), 3 (30%), and 3 (30%) of lesions were avascular, vascular, and hypervascular, respectively. The vascularity of the lesions did not differ significantly between the parathyroid carcinoma and benign parathyroid lesions (P = 0.281). Ultrasonographic features such as irregular shape, heterogeneous echogenicity, cystic change, and vascularity are nondiscriminatory features between benign or malignant lesions. Large lesion size together with the presence of calcification, capsular thickening, or infiltrative margin strongly raises the suspicion of a malignant parathyroid lesion, and management should be altered.

Comparative dynamics of microglial and glioma cell motility at the infiltrative margin of brain tumours.

Microglia are a major cellular component of gliomas, and abundant in the centre of the tumour and at the infiltrative margins. While glioma is a notoriously infiltrative disease, the dynamics of microglia and glioma migratory patterns have not been well characterized. To investigate the migratory behaviour of microglia and glioma cells at the infiltrative edge, we performed two-colour time-lapse fluorescence microscopy of brain slices generated from a platelet-derived growth factor-B (PDGFB)-driven rat model of glioma, in which glioma cells and microglia were each labelled with one of two different fluorescent markers. We used mathematical techniques to analyse glioma cells and microglia motility with both single cell tracking and particle image velocimetry (PIV). Our results show microglia motility is strongly correlated with the presence of glioma, while the correlation of the speeds of glioma cells and microglia was variable and weak. Additionally, we showed that microglia and glioma cells exhibit different types of diffusive migratory behaviour. Microglia movement fit a simple random walk, while glioma cell movement fits a super diffusion pattern. These results show that glioma cells stimulate microglia motility at the infiltrative margins, creating a correlation between the spatial distribution of glioma cells and the pattern of microglia motility.

Large sporadic thyroid medullary carcinomas: predictive factors for lymph node involvement.

Lymph node involvement (LNI) is one of the most important prognostic factors for poor survival in medullary thyroid carcinoma (MTC). At diagnosis, LNI is found in over 50% of sporadic MTCs, and especially in large tumours. Cervical lymph node dissection is therefore mandatory during MTC surgery. However, some large tumours (responsible for high preoperative basal calcitonin levels) are found to lack LNI, and can be cured definitely. Preoperative detection of these particular tumours might spare patients from undergoing extensive cervical dissection. The objective of the present retrospective study of a series of large sporadic MTCs was to identify clinical, biological and pathological factors that were predictive of LNI. Consecutive cases of large, sporadic MTCs (measuring at least 1cm in diameter) were retrieved and reviewed. The levels of several mature microRNAs (miRs) in paraffin-embedded samples were assessed using qPCR. Of the 54 MTCs, 26 had LNI and 28 were pN0. Relative to pN0 patients, patients with LNI had a significant higher preoperative basal calcitonin level (p = 0.0074) and a greater prevalence of infiltrative margins (p < 0.0001), lymphovascular invasion (p = 0.0004), extrathyroidal extension (p < 0.0001), a higher pT stage (p = 0.0003) and more abundant desmoplastic stroma (p = 0.0006). Tumour expression levels of miR-21 (p = 0.0008) and miR-183 (p = 0.0096) were higher in the LNI group. The abundance of desmoplastic stroma (p = 0.007) and the miR-21 expression level (p = 0.0026) were independent prognostic factors for LNI. The abundance of desmoplastic stroma and high levels of miR-21 expression were strong indicators of LNI, and may thus help the surgeon to choose the extent of cervical lymph node dissection for large, sporadic MTCs with no preoperatively obvious LNI.

Ten-year survival outcomes of patients with potentially resectable gastric cancer: impact of clinicopathologic and treatment-related risk factors.

BackgroundDespite therapeutic advancements, gastric cancer (GC) remains a leading cause of death worldwide.MethodsThis retrospective cohort study statistically analyzed the clinicopathologic characteristics, treatments and outcomes of patients with potentially resectable GC managed at our institution between 2006 and 2010. The STROBE checklist was applied.ResultsPreoperative assessment of 164 GC patients (male: female ratio 1.87, median age 65 years) assigned 132 (80.5%) to total (56; 42.4%) or subtotal (76; 57.6%) gastrectomy. Resection margins were microscopically tumor-free (R0) in 100 (75.8%), microscopically infiltrated (R1) in 25 (18.9%) and macroscopically infiltrated (R2) in 7 (5.3%) patients. Nodal plane dissection was D0 in 34 (25.8%), D1 in 62 (47.0%) and D2 in 36 (27.3%) patients. Early GC was diagnosed in 19 patients (14.4%). Fluorouracil-based chemotherapy was administered in 69.7% and chemoradiation in 18.2% of patients. The 5- and 10-year survival rates of patients with R0 resection were 74% and 65.4%, respectively. The 2-year survival rates for R1 and R2 resection were 28.9% and 0% respectively. The 5- and 10-year survival rates according to nodal plane dissection were 55.6% and 41.4% for D2, and 53.2% and 49.7% for D1, respectively. On multivariate analysis, T4, N3 and R1/R2 remained independent negative prognostic factors for overall survival. Microscopic or macroscopic infiltration of surgical margins was the worst adverse prognostic factor for survival.ConclusionThese results are equivalent to those from centers of excellence and indicate the urgent need for improvements in the field, particularly in the development of predictive models to guide personalized therapy.

The Effectiveness of Intraoperative Frozen Section Analysis of Safety Margins in Breast Conserving Surgery and the Role of Surgeon in Decreasing the Rate of Positive Margins

Introduction: Nowadays the more accepted surgical option for treating early breast cancer is breast conserving surgery. The main challenge in this type of surgery is to get free safety margins without need of second surgical operation, so many breast surgeons have started to depend on intraoperative frozen sections to ensure free safety margins. Aim of work: To assess our policy that we prefer to depend on intraoperative frozen section analysis to get free safety margin in breast conserving surgery from the 1st surgery, and its oncologic outcome. Patients and Methods: This is a retrospective study conducted in Oncology Center—Mansoura University (OCMU), where the data of 219 patients with breast cancer, who were managed by breast conserving surgery with intraoperative frozen section analysis of the safety margins, was analyzed. Results: The intraoperative frozen section analysis of safety margin was negative from the start in 183 (83.6%) patients, while it was positive in 36 patients (16.4%). Intraoperative decision of margin re-excision was applied for 29 patients (13.2%) in order to reach negative margin, modified radical mastectomy was offered for 4 patients (1.8%), while nipple sparing mastectomy with immediate breast reconstruction using latissimus dorsi flap was offered for 3 patients (1.4%). The postoperative paraffin results were typical with intraoperative frozen section analysis results in 216 patients (98.6%) and different results were obtained in only 3 patients (1.4%) who were managed by modified radical mastectomy in a second operation. Only 4 patients had local recurrence (1.8%) during the period of follow-up duration which was ranged from 1 to 86 months with mean ± SD (22.3 ± 14.1). Conclusion: The intraoperative frozen section analysis of safety margins in breast conserving surgery has very high-rate typical results with the paraffin section analysis and it is very helpful in decreasing the rate of second surgical operation in cases of infiltrated margins. It should be used routinely in all cases of breast conserving surgery.

Retrospective analysis of surgery for cervical stump carcinoma at early stage.

Cervical stump cancer is a rare type of disease as total hysterectomies are performed infrequently. The purpose of this retrospective study was to assess the diagnosis, treatment, follow-up methods and complications of 10 patients with cervical stump carcinoma treated with surgery in Anhui Provincial Hospital affiliated to Anhui Medical University (Hefei, China). From January 2006 to October 2016 a total of 10 patients underwent surgery for carcinoma of the cervical stump. The pathological reports revealed 80% of cases were squamous cell carcinoma and 20% of cases were adenocarcinoma. The FIGO stage distribution was as follows: Carcinoma in situ (10%); IB1 (70%); IIA (20%). The patients received a transvaginal trachelectomy or a radical trachelectomy and pelvic lymphadenectomy (either laparoscopic or laparotomic abdominal); four of the patients were treated with adjuvant chemotherapy, and two with concurrent chemoradiotherapy. The parametrial and resection margin infiltration, lymph node metastasis and lymph vascular space invasion (LVSI) were negative in all patients, and the deep stromal invasion rate was 66.7% (6/9). No incidences of recurrence or mortality were recorded during the follow-up interval of 6-120 months. Compared with the four patients who received laparotomic abdominal surgery, significantly less blood loss was recorded for the five patients who underwent laparoscopic surgery (P<0.01). There was no significant difference observed in the surgery time (P>0.01) or in the hospital stay duration (P>0.01) for the patients treated with laparotomic abdominal surgery and laparoscopic surgery. One patient experienced bladder fistula due to bladder over-dilation, but recovered quickly after the catheter was reinserted. Surgery for cervical stump cancer at an early-stage is a viable and safer procedure, particularly the laparoscopic approach.

5-Aminolevulinic Acid Guided Sampling of Glioblastoma Microenvironments Identifies Pro-Survival Signaling at Infiltrative Margins

Glioblastoma (GBM) contains diverse microenvironments with uneven distributions of oncogenic alterations and signaling networks. The diffusely infiltrative properties of GBM result in residual tumor at neurosurgical resection margins, representing the source of relapse in nearly all cases and suggesting that therapeutic efforts should be focused there. To identify signaling networks and potential druggable targets across tumor microenvironments (TMEs), we utilized 5-ALA fluorescence-guided neurosurgical resection and sampling, followed by proteomic analysis of specific TMEs. Reverse phase protein array (RPPA) was performed on 205 proteins isolated from the tumor margin, tumor bulk, and perinecrotic regions of 13 previously untreated, clinically-annotated and genetically-defined high grade gliomas. Differential protein and pathway signatures were established and then validated using western blotting, immunohistochemistry, and comparable TCGA RPPA datasets. We identified 37 proteins differentially expressed across high-grade glioma TMEs. We demonstrate that tumor margins were characterized by pro-survival and anti-apoptotic proteins, whereas perinecrotic regions were enriched for pro-coagulant and DNA damage response proteins. In both our patient cohort and TCGA cases, the data suggest that TMEs possess distinct protein expression profiles that are biologically and therapeutically relevant.

Subventricular Zone Involvement Characterized by Diffusion Tensor Imaging in Glioblastoma.

Glioblastomas have a poor prognosis, possibly because of a subpopulation of therapy-resistant stem cells within the heterogeneous glioblastoma. Because the subventricular zone is the main source of neural stem cells, we aimed at characterizing the subventricular zone using diffusion tensor imaging (DTI) to show subventricular zone involvement in glioblastoma. We prospectively included 93 patients with primary glioblastomas who underwent preoperative DTI. The nonenhancing high fluid-attenuated inversion recovery (FLAIR) signal was used to describe the infiltrative tumor margin. We used a 5-mm margin surrounding the lateral ventricles to define the subventricular zone. The subventricular zone with high FLAIR was compared with the subventricular zone without high FLAIR, control high FLAIR outside the subventricular zone and control contralateral normal-appearing white matter. Normalized DTI parameters were calculated and compared between the different regions. The subventricular zone with high FLAIR showed increased isotropic p values compared with thesubventricular zone without high FLAIR (t126= 3.9; P<0.001) and control regions (t179= 1.9; P= 0.046). Anisotropic q and fractional anisotropy values were lower in regions with high FLAIR compared with the subventricular zone without high FLAIR (t181= 11.6, P < 0.001 and t184=12.4, P < 0.001, respectively). DTI data showed that the subventricular zone is involved in glioblastoma with increased isotropic pvalues in the subventricular zone with high FLAIR, indicating tumor infiltration.

Tumor-infiltrating B cells producing antitumor active immunoglobulins in resected HCC prolong patient survival.

Background & AimsThe immunological microenvironment of HCC influences patient outcome, however, the role of B cells remains unclear. This study investigated effects of local B-cell infiltration in HCC cohorts on patient survival and immunological and molecular tumor microenvironment.ResultsUnsupervised gene expression analysis of full cancer transcriptomes (N=2158) revealed a highly co-regulated immunological cluster in HCC that mainly contained immunoglobulin fragments. More specifically, in an independent patient cohort (N=242) that compares HCC with non tumorous liver tissue high expression of these B-cell associated genes was associated with better patient outcome (P=0.0149). Conclusively, the immunohistochemical analysis of another independent cohort of resected HCCs (N=119) demonstrated that infiltration of HCCs by CD20+ cells (P=0.004) and CD79a+ cells (P=0.038) at the infiltrative margin were associated with prolonged patient survival. Further, the immunoglobulin fragments that were identified in the gene expression analysis were detected at high levels in patients with dense B-cell infiltration.MethodsGene expression of 2 independent HCC tissue databases was compared using microarrays. Additionally, tissue of resected HCCs was stained for CD20, CD79a and immunoglobulins and analysed for the respective cell numbers separately for tumor, infiltrative margin and distant liver stroma. These findings were correlated with clinical data and patient outcome.ConclusionsInfiltration of HCCs by B cells is associated with prolonged patient survival. Further, a distinct B-cell like immunoglobulin profile of HCCs was identified that goes along with better patient outcome. We suggest that B cells contribute to local tumor control by secreting increased levels of immunoglobulins with antitumor activity.

Compartmental resection of peripheral nerve tumours with limb preservation in 16 dogs (1995–2011)

Peripheral nerve tumours (PNTs) affecting the limbs may lead to chronic pain, lameness and/or monoparesis that is refractory to medical treatment. The most common radical therapy for PNTs has been surgical excision with limb amputation. However, compartmental resection with preservation of the limb has been performed by the authors with favourable clinical results and therefore this bi-institutional retrospective study was undertaken to assess limb function, survival and recurrence.Sixteen dogs that had been diagnosed with PNTs between 1995 and 2011 met the inclusion criteria for this study. In the majority of the cases, good to excellent limb function was achieved. The overall median survival time (MST) was 1303days (42.8 months; range, 14 days–4639 days, [0.5–152.4 months]), with two dogs still alive at time of evaluation. Non-infiltrated margins were the best prognostic indicator; dogs with non-infiltrated margins had a MST of 2227days (P<0.001) compared to dogs with infiltrated margins (MST of 487 days). The 1-year calculated survival rate was 68.8% and the 2- and 3-year calculated survival rates were 62.5%. Surgical treatment with tumour removal and limb spare for proximal and distal PNTs can be successful. Compartmental excision can lead to good limb function, producing survival comparable to limb amputation, and should therefore be considered as an alternative to limb amputation in canine PNTs.

Inflammatory Myofibroblastic Tumors of the Female Genital Tract Are Under-recognized: A Low Threshold for ALK Immunohistochemistry Is Required.

Inflammatory myofibroblastic tumor (IMT) of the female genital tract is under-recognized. We investigated the prevalence of ALK-positive IMT in lesions previously diagnosed as gynecologic smooth muscle tumors. Immunohistochemistry (IHC) for ALK was performed on tissue microarrays of unselected tumors resected from 2009 to 2013. Three of 1176 (0.26%) “leiomyomas” and 1 of 44 (2.3%) “leiomyosarcomas” were ALK IHC positive, confirmed translocated by fluorescence in situ hybridization (FISH) and therefore more appropriately classified as IMT. On review significant areas of all 4 tumors closely mimicked smooth muscle tumors morphologically, but all showed at least subtle/focal features suggesting IMT. Recognizing that the distinction between IMT and leiomyoma/leiomyosarcoma can be subtle, we then reviewed 1 hematoxylin and eosin slide from each patient undergoing surgery for “leiomyoma” from 2014 to 2017 and selected cases for ALK IHC with a low threshold. Of these, 30 of 571 (5.3%) underwent IHC. Two were confirmed to be IHC positive and FISH rearranged. Of the 6 IMTs, only 1 tumor with a previous diagnosis of leiomyosarcoma, an infiltrative margin and equivocal necrosis, metastasized. Of note it demonstrated a less aggressive clinical course compared with most metastatic leiomyosarcomas (alive with disease at 6 y). The patient was subsequently offered crizotinib to which she responded rapidly. In conclusion, IMTs may closely mimic gynecologic smooth muscle tumors. IMTs account for at least 5 of 1747 (0.3%) tumors previously diagnosed as leiomyoma and 1 of 44 (2.3%) as leiomyosarcoma. These tumors may be recognized prospectively with awareness of subtle/focal histologic clues, coupled with a low threshold for ALK IHC.

이하선에 발생한 악성 고립성 섬유종 1예

Solitary fibrous tumor is an uncommon spindle cell mesenchymal neoplasm with unpredictable behavior, usually arising in the pleura of the thoracic cavity. It is rarely found in the head and neck, and malignant solitary fibrous tumor is even rare. Malignant criteria of solitary fibrous tumor includes increased cellularity, increased mitoses (&gt;4 mitoses/10HPF), cytologic atypia, tumor necrosis and/or infiltrative margin. The treatment of malignant solitary fibrous tumor is complete surgical excision and adjuvant radiotherapy. We report a case of malignant solitary fibrous tumor originating from the parotid gland, relapsed very quickly and grown very rapidly in 6 weeks after surgical resection. (J Clinical Otolaryngol 2017;28-:104-109)

MRI features of pediatric intracranial germ cell tumor subtypes

Intracranial germ cell tumors differ in histology and location, and require different clinical management strategies. We characterized the imaging features that may aid pre-operative differentiation of intracranial germinomas and non-germinomatous germ cell tumors (NGGCTs). This retrospective study analyzed 85 patients with intracranial germ cell tumors and adequate preoperative or pretreatment MRIs between 2000 and 2013 at our institution. Pretreatment MRI characteristics, apparent diffusion coefficient (ADC) values, tumor histopathology, and patient outcomes were compared. NGGCTs occurred in the pineal region and cerebral hemispheres more often than germinomas; all bifocal lesions were germinomas. NGGCTs (36.6 ± 17.0mm) were significantly larger than germinomas (25.7 ± 11.6mm; P = 0.002). The presence of pure solid tumor (45.5 vs. 20.0%, P = 0.033) and an infiltrative margin (20.0 vs. 3.3%, P = 0.035) were significantly more common in germinomas than NGGCTs. The presence of intratumoral T1 hyperintense foci (66.7 vs. 10.9%, P < 0.001) and moderate/marked enhancement (86.7 vs. 50.9%, P < 0.001) were significantly more common in NGGCTs than in germinomas. Mean ADCmean values (×10-3mm2/s) were significantly lower in germinomas (1.113 ± 0.415) than in NGGCTs (2.011 ± 0.694, P = 0.001). Combined a lack of T1 hyperintense foci and an ADCmean threshold value (1.143 × 10-3 mm2/s) had the highest specificity (91.3%) and positive predictive value (92.3%), while the combination of lack of a T1 hyperintensense foci, no/mild enhancement, and an ADCmean threshold value had 100% sensitivity and 100% negative-predictive value for discriminating germinomas from NGGCTs. Pre-operative conventional MRI characteristics and diffusion-weighted MRI help clinicians to assess patients with intracranial germ cell tumors. Tumor size, location, T1 hyperintense foci, intratumoral cystic components, tumor margin and enhancing patterns demonstrate contrast between germinomas and NGGCTs. Serum tumor markers and adjunctive combination with T1 hyperintensity and/or enhancing pattern with ADC offer potential in preoperative differentiating intracranial germinomas and NGGCTs.

Is there a role for adjuvant radiation in T1N0 squamous cell carcinoma tongue with adverse pathological features? Factors affecting local control and the development of a scoring system.

e17565 Background: The patterns of recurrence and the prognostic factors of early tongue lesions have been previously described in literature, often grouping T1 and T2N0 tongue lesions together. Adverse pathological features (APFs) have been used to predict nodal spread, but the prognostic factors predicting local recurrences in T1N0 tongue have seldom been described. We aim to evaluate the APFs associated with poor local control and the possible need for escalation of therapy. Methods: A retrospective analysis of 144 patients of pT1N0 squamous cell carcinoma tongue, extracted from our database of 598 patients of oral cavity who underwent wide local excision with neck dissection in a single institution between 2006-2014 were included in our study. Patients who received any adjuvant therapy were excluded. Results: APFs associated with local control were least margin 5 mm (p=0.004), infiltrative margin (p=0.403), depth ≥ 4mm (p=0.136), lymphovascular invasion (p=0.301) and perineural invasion (p=0.342). We derived a scoring system assigning a score to each of these factors out of a total 10 points, based on the hazard ratio for local failure. Patients with a score ≥ 5 points had a 5-year local control rate of ≤ 60%. Conclusions: Having least margin of 5 mm was the greatest predictor of local failure. This would suggest that all patients having a margin of 5 mm need revision, however if they do not have additional APF (score ≤ 4 points), they still have good local control rates (5-year local control rate of 88%) and may be observed. Those who have margins over 5 mm with a total score ≥ 5 may still benefit from adjuvant therapy for local control. Those with margins over 5mm have improved local control rates (p=0.029). [Table: see text]

Prognostic value of microscopic evaluation of organ infiltration and visceral resection margins (VRM) in patients with retroperitoneal sarcomas (RPS).

11074 Background: Surgery with gross margin clearance (R0 and R1) is the standard treatment for RPS and visceral resection has been proposed even in the absence of macroscopic visceral infiltration. Formal definition and margin sampling procedures for pathological evaluation are lacking for RPS. This study investigated VRM as well as viscera infiltration and their association with patient survival. Methods: Consecutive patients operated on for primary RPS (2009-2014) were extracted from a prospectively maintained database. VRM were sampled for each resected organ and classified as negative and positive. Also, tumor infiltration of resected organs was classified as follow: absence of infiltration, infiltration of perivisceral fat, early infiltration (i.e., renal/adrenal capsule, muscular fascia, contact with muscular tunica of hollow viscera), and infiltration of the viscera. Results: In 207 patients VRM were negative in 182 (88%) and positive 25 (12%). Organ infiltration was absent, perivisceral, early, and visceral in 37 (18%), 13 (6%), 17 (8%), and 140 (68%), respectively. Overall survival analysis showed that patients with negative VRM plus organ infiltration (HR = 3.56; 95%CI 1.15-11.00, P = 0.028) and those with positive VRM irrespective of organ infiltration (HR = 7.76; 95%CI 2.18-27.65, P = 0.002) did worse that patients with negative VRM plus no organ infiltration, after adjustment from known prognostic features. Conclusions: After liberal multivisceral resection for primary RPS, up to 80% of patients have infiltrated organs at some extent, while VRM are positive in up to 10% of cases. Visceral resection is justified even in the absence of macroscopic infiltration. Systematic evaluation of microscopic involvement of adjacent viscera may stratify prognosis.

Imaging Manifestations of Pseudoprogression in Metastatic Melanoma Nodes Injected with Talimogene Laherparepvec: Initial Experience.

Talimogene laherparepvec is an oncolytic virus recently approved for targeted treatment of advanced melanoma. Because of an inflammatory reaction, treated lesions may increase in size and develop infiltrative margins that can be construed as disease progression or extracapsular spread. In this report, we describe our initial experience imaging the response of metastatic nodes injected with talimogene laherparepvec. Six of 12 nodes (50%) showed growth from baseline followed by decreased size, 5 of 12 nodes (42%) showed a downward size trend, and 1 node showed continued increase in size. Seven of 9 nodes (78%) developed infiltrative margins at a median of 79 days, and 6 of 9 (67%) nodes became necrotic at a median of 76 days after injection, all showing decreased size at final follow-up. An increase in the size of nodes injected with talimogene laherparepvec does not necessarily indicate progression. Infiltrative margins are also frequently seen and may be confused with extracapsular disease.

Adenosquamous carcinoma of the gallbladder. Case report and literature review

Objective: To present the case of a patient with initial diagnosis of colelitiasis who underwent an elective procedure with final diagnosis of adenosquamous gallbladder carcinoma and review the literature. Methods: 34 year old woman with no relevant medical history comes to the clinic referring one year with abdominal pain in LUQ of moderate intensity after eating CCK in several occasions. Normal labs, US reports gallbladder 7.8 × 3.1 cm with multiple stones and a 3 mm wall (Fig. 1). An elective laparoscopic cholecystectomy is performed, during which an abdormal induration is noted intraoperatory biopsy is reported as adenosquamous carcinoma (Fig. 2). The surgery is converted to open procedure to complete liver resection and lymphadenectomy (Fig. 3). The patient courses a fair postoperative evolution, during her hospitalization a multi-phase thoracoabdominal CT is done (Fig. 4). Final pathology reports adenosquamous carcinoma of 5.5 ×4 cm with hepatic infiltration and negative margins, no lymph node meta¡stasis T3N0M0 Stage IIIA. Results: Gallbladder cancer is a rare neoplasm with poor prognosis, most cases are diagnosed incidentally during colelitiasis evaluation. Risk factors are similar to those of chronic gallblader inflammation. Adenosquamous carcinoma is a rare subtype (5–10%) with few reported cases. Cholecystectomy alone is adequate for early stages (Tis-T1a), for T2-T3 liver resection until R0 and lymphadenectomy is indicated. Conclusion: Adenosquamous gallbladder carcinoma share similar characteristics with adenocarcinoma, but it shows tendency of hepatic infiltration (68% vs 49%). Generally they all have poor prognosis, but survival can benefit if a curative resection with negative margins is made.