Intraoperative Pathological Diagnosis Research Articles

GCT-55. INTRACRANIAL GERMINOMA ORIGINATING FROM ATYPICAL LOCATION WITH SUBCLINICAL ADH INSUFFICIENCY

INTRODUCTIONIntracranial germinomas are rare tumors which usually develop in the midline structures and affect in 90% of cases the pineal gland and suprasellar regions. Sometimes they involve basal ganglia, septum pellucidum, and other regions. We report a very unusual presentation of an intracranial germinoma originating from the lateral ventricle.METHODSA 10-year-old boy presented with a 1-year history of polydipsia and polyuria. During the hypertonic saline test, a low ADH was detected and established the diagnosis of subclinical ADH insufficiency. MRI showed a heterogeneously enhancing periventricular lesion in the lateral ventricle, but no other abnormal findings, including hypophyseal stalk. Initially, the correlation of imaging findings and clinical symptoms were not clear. With suspected subependymoma, tumor removal was performed by small craniotomy. Since the intra-operative pathological diagnosis was germinoma, we performed only partial removal of the tumor. After establishing the histological diagnosis of germinoma, the patient received chemotherapy using carboplatin and etoposide, followed by radiation therapy. MRI showed no recurrence for five years after treatment. RESULTS/CONCLUSIONOur case presents two atypical features. First, intracranial germinoma originating from the lateral ventricle is quite rare. Though the cases with intracranial germinoma originating from septum pellucidum and corpus callosum have been reported, this case is even different. Second, imaging findings did not match clinical symptoms. The cause of subclinical ADH deficiency may be the occult hypophyseal germinoma. In conclusion, we report a 10-year-old case with a very unusual presentation of an intracranial germinoma originating from the lateral ventricle.

Evaluation Study of Intraoperative Cytology Smear and Frozen Section of Glioma.

Objective:Glioma is the commonest primary malignant brain tumour. Diagnosis is made based on cytology smear, frozen section and histopathological examination. Intraoperative pathological diagnosis using either cytology smear, frozen section or combination of both, plays a crucial role in patient’s future management and prognosis. This study aims to determine the accuracy of cytology smear and frozen section in glioma, and to compare the difference between both techniques. Methods:A cross-sectional study was conducted involving 22 cases of glioma diagnosed intraoperatively from January 2013 until August 2019 in Hospital Universiti Sains Malaysia. The selected tissues were processed for cytology smear and frozen section. The remaining tissues were proceeded for paraffin section. The diagnosis was categorized as either low-grade or high-grade glioma based on cellularity, nuclear pleomorphism, mitotic count, microvascular proliferation and necrosis. The sensitivity and specificity of frozen section and cytology smears were determined based on paraffin section being as the gold standard. The accuracy of both techniques was compared using statistical analysis. Results:The overall sensitivity and specificity of cytology smear were 100% and 76.9%, respectively. Meanwhile, the sensitivity and specificity of frozen section were 100% and 84.6%. There was no significant difference in diagnostic accuracy between cytology smear and frozen section in glioma (p>0.05). Conclusion:Cytology smears provides an alternative method for frozen section due to good cellularity and morphology on smear. Cytology smear is rapid, inexpensive, small amount of tissue requirement and less technical demand. This finding may benefit to the hospital or treatment centres where frozen section facility is unavailable.

Ciliated Muconodular Papillary Tumor of the Lung: a Surgical Case Report

We describe a surgical case of ciliated muconodular papillary tumor (CMPT) of the lung. A 48-year-old man presented to our hospital complaining of right chest pain. Computed tomography (CT) revealed a part-solid grand glass nodule (GGN) in the superior segment of the lower lobe (S6) of the right lung. The maximum diameter of the GGN was 7 mm, with the solid portion having a 5 mm diameter. On follow-up CT, performed 14 months after the first examination, the size of the mass was stable, with almost the same extent of pleural indentation. A CT scan obtained 12 years previously had shown no evidence of a tumor. Considering the continued growth of the lesion, an adenocarcinoma was suspected, and a wedge resection of the right lower lobe was performed. The intra-operative pathological diagnosis by frozen section revealed a dysplastic epithelium. Thus, we did not proceed with lobectomy and lymph node dissection. Postoperative pathological diagnosis of CMPT was confirmed. For comparison, we included an overview of 41 cases of CMPT previously published in 17 studies. In these cases, computed tomography was performed over the follow-up period in 13 cases (31.7%). Tumor growth, which mimicked malignancy, was observed in 9 of 13 cases (69.2%). Since it is usually difficult to make a diagnosis pre- and intra-operatively, most cases of CMPT are pathologically diagnosed postoperatively. During surgery for small peripheral pulmonary tumor like lung cancer, which is not definitive in intra-operative pathological diagnosis, CMPT should be considered as one of differential diagnoses.

An effective inflation treatment for frozen section diagnosis of small-sized lesions of the lung.

BackgroundThe accuracy of intraoperative pathological diagnosis of small-sized pulmonary nodules including ground-glass opacity (GGO) is important for the surgeon to choose a suitable surgical procedure. Diagnosis of the small-sized lesions of the lung by frozen section (FS) is very difficult for the pathologist because of limited FS technology. Here we tested an effective inflation treatment for FS to improve the diagnostic accuracy of small-sized lung lesions.MethodsThe lung specimens were derived from 113 patients who underwent the surgery at Shanghai Chest Hospital in 2018–2019. The specimens were randomly divided into two groups—uninflated or inflated with diluted embedding medium (Tissue-Tek OCT; Sakura Finetek-USA, CA). The qualities of the FSs were compared with that of corresponding permanent paraffin sections. The FS diagnoses were compared with the final pathologic diagnoses of corresponding permanent sections.ResultsOur results showed that the quality of FS of lung tissue was excellent after inflation with diluted embedding medium (1:1). The total consistency between diagnosis of inflated FS and final pathological diagnosis was 85.7%. In control group, however, the consistency was only 70.2%. When the lesions were less than 1cm, the consistency between diagnosis of inflated FS and final pathological diagnosis was 90.3%, compared to 64.9% consistency in uninflated group (P=0.014, <0.05). When the lesions’ computed tomography (CT) measurement threshold ≤−350 HU, the consistency between diagnosis of inflated FS and final pathological diagnosis was 88% compared to 73.2% consistency in uninflated group (P=0.071, >0.05). Accuracy, sensitivity and specificity were observed about 90% for adenocarcinoma in situ (AIS), whereas it is drop to more than 80% for minimally invasive adenocarcinoma (MIA) in inflated FS.ConclusionsInflation with diluted embedding medium (1:1) could make lung tissue expand well during FS. By using this method, small-sized lesions (especially less than 1 cm) could be correctly diagnosed to enable adequate surgical procedure, and evaluation of which can be easily based on the intraoperative pathological diagnosis. The small lesions especially AIS could be readily identified on FS. Therefore, this method improves the diagnostic accuracy of FSs for small-sized lung lesions, and has important practical consequences for further therapy.

Hexaphenyl-1,3-butadiene derivative: a novel “turn-on” rapid fluorescent probe for intraoperative pathological diagnosis of hepatocellular carcinoma

The staining method based on AIE-active ZZ-HPB-NC can simple distinguish the hepatocellular carcinoma from liver noncancerous tissue, which overcomes the drawbacks of the poor anti-interference ability of the authoritative clinical H&amp;E technique.

Individualization of the surgical procedure in response to overdiagnosis and overtreatment in differentiated thyroid carcinomas

Advances in diagnostic methods have led to an early detection of thyroid nodules with debatable malignant potential in numerous cases. This can result in a potential overtreatment of thyroid lesions with very good prognosis. To avoid surgical overtreatment, an individualized, risk-adapted management is required that respects the different tumor biology of the underlying histological entities. The current guidelines of the leading professional societies, the American Thyroid Association (ATA) and the German Association of Endocrine Surgeons (CAEK), were compared and critically studied, to describe risk-adapted, more conservative treatment options for certain types of thyroid neoplasms according to the 2017 WHO definition. The German CAEK recommends thyroidectomy as a routine operation in the case of thyroid carcinoma. Exceptions are papillary thyroid microcarcinoma and minimally invasive follicular thyroid carcinoma, which can be treated by lobectomy. The ATA proposes an "active surveillance" for papillary thyroid microcarcinoma and lobectomy in cases of differentiated thyroid carcinoma <4 cm in diameter in the absence of clearly predefined risk factors. The pre- or intraoperative pathological diagnosis of the underlying tumor entity is the key point, which allows for an adaption of the resection strategy for thyroid malignancy. Depending on the type of carcinoma, the current guidelines of international expert societies allow for parenchyma-sparing operations and, according to the ATA, even an "active surveillance."

P1.17-43 Sublober Resection for Adenocarcinoma in Situ Diagnosed by Intraoperative Frozen Sections

The establishment of sublobar resection procedures for non-small cell lung cancer is expected. Many groups have suggested adenocarcinoma in situ (AIS) to be a potential indication for sublobar resection. From 2012 to 2016, 80 patients (23 men and 57 women; median age, 70 years; range 40-86) diagnosed with adenocarcinoma in situ from intraoperative frozen sections, and underwent sublobar resection or lobectomy at our institution. Of these, 74 patients received sublobar resection and 6 patients underwent lobectomy. for adenocarcinoma in situ. We evaluate the predictive value of the intraoperative pathologic examination for AIS diagnosis, and overall survival, disease-free survival, and cancer-specific survival. Permanent pathologic examination revealed 61patients had AIS, 17 patients had minimally invasive adnocarcinoma and 2 patients had invasive adnocarcinoma. The predictive value of intraoperative pathologic examination for AIS diagnosis was 79.3%. During a median 48-month follow-up, there were 1 cancer unrelated deaths. The 5-year overall survival rate was 98.8%. The disease-free survival rate and the 5-year cancer-specific survival rate were 100%. The results of our retrospective study indicate that an intraoperative pathologic diagnosis of AIS is strongly predictive and allows for an intraoperative decision to perform a sublobar resection in these patients.

Difficult intraoperative pathological diagnosis of malignancy due to presence of collision tumor

症例は71歳男性．胸部CTで左S6の結節を認めた．気管支鏡で診断がつかず，胸腔鏡下左肺部分切除術を施行した．術中迅速病理検査では良性の炎症性病変とのことであったが，臨床的には悪性の可能性が高いと考え，マージンの確保のためS6区域切除術を施行した．術後の病理検査では，肺扁平上皮癌と炎症性筋線維芽細胞腫の衝突腫瘍と診断された．迅速病理検査は炎症性筋線維芽細胞腫側で行われていた．低悪性度の腫瘍の場合は，迅速病理では良性腫瘍との鑑別が難しいことがあり，本症例のような稀な病態もありえるため注意が必要である．

Central pancreatectomy in portal annular pancreas for metastatic renal cell carcinoma: a case report

BackgroundPortal annular pancreas (PAP) is a rare congenital anatomical abnormality of the pancreas in which the portal vein is encircled by aberrant parenchyma, and special attention is needed for pancreatic resections. This is the first report of central pancreatectomy (CP) in a PAP for metastatic renal cell carcinoma (RCC).Case presentationA 76-year-old man who had a history of left nephrectomy for renal cancer not otherwise specified 36 years earlier and radical cystectomy for bladder cancer 4 years earlier was incidentally found to have a pancreatic tumor and a liver tumor. The pancreatic tumor was diagnosed as metastasis of clear cell RCC, and the liver tumor was diagnosed as moderately differentiated hepatocellular carcinoma (HCC) on preoperative histological evaluation. Preoperative computed tomography imaging showed a type 3A PAP, in which the main pancreatic duct (MPD) ran ventral to the portal vein (anteportal type), and the aberrant parenchyma was located cranial to the confluence of the portal vein and splenic vein (suprasplenic type). After adhesiotomy and partial liver resection, CP was performed. With intraoperative ultrasound guidance, the aberrant parenchyma of the PAP could be preserved, avoiding additional resection. Thus, two pancreatic transections were performed, creating a single-cut margin that contained the MPD in the distal pancreas. Oncologically safe margins were confirmed by intraoperative pathological diagnosis. The distal pancreas was reconstructed by pancreatojejunostomy in the routine procedures. The pathological diagnosis of the surgical specimens was identical to the preoperative diagnosis. A postoperative pancreatic fistula (POPF) developed from the proximal stump of the head of the pancreas, necessitating no specific treatment other than drainage. The patient showed no signs or symptoms of recurrent RCC or abnormal pancreatic function for 2 years after the operation, although a histologically proven new HCC lesion developed distant from the initial site 8 months after the operation.ConclusionsPrecise preoperative evaluation of the tumor features and PAP allowed adequate surgical strategies to be planned. Intraoperative ultrasound was useful to minimize parenchymal resections of the PAP. CP is still a challenging procedure in terms of the development of POPF.

Abstract P2-14-18: Achiveing rapid intrao-operative diagnosis during breast cancer surgery using high-reloution full-field optical coherence imaging and dynamic cell imaging

Abstract Background: Intraoperative pathological diagnosis such as frozen section and imprint cytology is not routinely recommended in clinical practice because of time and accuracy concerns. Full-field optical coherence tomography (FF-OCT) is a new optical imaging technique that could generate sectioning tomogram from fresh tissue and provide depiction of the morphological structure and pathological changes in minutes without conventional tissue preparation, slicing, and staining, and dynamic cell imaging (DCI) added the viability information of cells/tissue, which could be more important in cancer diagnosis. This study was to evaluate the feasibility and diagnostic value of FF-OCT and DCI in breast lesions and lymph node specimens during breast cancer surgery. Methods: We evaluated normal breast tissue, benign breast lesions, breast cancer and axillary lymph node specimens from 107 patients using FF-OCT and DCI. After the optical assessment, the tissue was paraffin embedded and sent to conventional H&amp;E diagnosis. The similar layer of OCT and H&amp;E images were compared and diagnostic criteria were generated. The diagnostic sensitivity and specificity by two trained surgeons without pathology diagnosis experience were evaluated. Results: A total of 194 specimens were examined, including 143 breast tissue(101 malignant and 42 benign/normal) and 51 lymph nodes(26 metastatic and 25 non-metastatic). On FF-OCT and DCI, normal morphological structures such as adipose, collagen, mammary ducts, and lobules in breast tissue and lymphoid follicle and hilum in lymph nodes were easily recognized. Breast cancer characteristics on H&amp;E imaging correspond to collagen distortion, focal hypointensity, micro-calcification, clustered or linear lively cells et etc on FF-OCT or DCI, which could also be easily distinguished. We included the previously mentioned features to build diagnosis criteria for cancer on FF-OCT and DCI. The average acquisition time is 14±11 minutes. The sensitivity and specificity for breast cancer diagnosis were 92.1% and 94.3% respectively. The sensitivity and specificity for lymph node involvement were 92.3% and 84% respectively. Conclusion: The time- and tissue-saving optical imaging technique yielded high accuracy that was comparable to that of traditional intraoperative and postoperative pathological diagnosis in breast cancer and lymph node metastasis. These results implied the promising application in the intraoperative evaluation and possible decrease of the re-excision rate for breast cancer surgery. Citation Format: Yang H, Zhang S, Guo J, Xie F, Tong F, Cao Y, Liu P, Zhou B, Cheng L, Liu M, Wang S, Peng Y, Wang C, Yang Y, Ma Y, Chen D, Shen D, Wang S. Achiveing rapid intrao-operative diagnosis during breast cancer surgery using high-reloution full-field optical coherence imaging and dynamic cell imaging [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-18.

Clinical features and treatment analysis of intracranial extraventricular ependymomas

Objective To study the clinical features, imaging demonstration and treatment outcomes of intracranial extraventricular ependymomas. Methods A total of 17 patients with intracranial extraventricular ependymoma underwent surgical treatment at Department of Neurosurgery, Renmin Hospital of Wuhan University from March of 2010 to June of 2016 and were enrolled into this retrospective study. Pre-operative MR scan showed single lesion located at supratentorial region in all cases. Those lesions were located in occipital lobe (5 cases), occipitoparietal lobe (2 cases), temporal lobe (3 cases), frontal lobe (4 cases) and parietal lobe (3 cases). Among those, 7 were solid and 10 were cystic lesions. Surgical excision was performed for all lesions. Post-operative follow-up was performed for every patient through telephone and outpatient review. Results Of those cases, total resection was achieved in 15 cases, including 10 cases of WHO grade Ⅱ and 5 case of WHO grade Ⅲ, and partial resection in 2 (WHO grade Ⅲ). Intraoperative pathological diagnosis suggested that 10 cases were ependymoma (WHO gradeⅡ) and 7 cases were anaplastic ependymoma (WHO grade Ⅲ). All patients′ clinical symptoms were relieved following surgery. Four cases (grade Ⅲ), including 2 cases undergoing partial resection, received post-operative radiotherapy. The follow-up time of those patient were from 14 to 74 months, with a median of 33.2 months. During the follow-up, no case showed any signs of spinal cord metastasis. Recurrence was reported in 7 cases and 4 of them (grade Ⅲ) received post-operative radiotherapy. Among those, 1 case underwent the second tumor total resection and postoperative radiotherapy, 1 case died 3 months after the second tumor total resection, 2 cases of tumor partial resection rejected the second operation and died after 4 and 6 months, respectively, and the other 3 recurrent cases included 2 (grade Ⅱ) and 1 (grade Ⅲ) undergoing the second tumor total resection without postoperative radiotherapy and 1 (grade Ⅲ) that died of postoperative hemorrhage. Conclusions As intracranial extraventricular ependymoma has non-specific clinical and imaging features, accurate pre-operative diagnosis is difficult. Total tumor resection is the primary method of treatment, if it is possible. The choice of resection type and pathological grading could be predictive factors in postoperative evaluation. Key words: Ependymoma; Neurosurgical procedures; Treatment outcome; Intracranial extraventricular

Analysis of benign gallbladder lesion surgically resected by preoperative diagnosis of gallbladder cancer

Background: We analyzed patients initially diagnosed as gallbladder cancer but resulting in postoperative pathological diagnosis as benign lesions. Patients: This study included 110 patients undergoing operation with preoperative diagnosis of gallbladder cancer in our institution from 1994 to 2017. Among them, 4 cases (3.6%) were diagnosed as benign as a result of postoperative pathological diagnosis. Results: The breakdown of the subjects was 3 males and 1 female, and the average age of the cases was 67.3 years. All cases were diagnosed as advanced gallbladder cancer with varying organ invasions, such as the liver, duodenum or transverse colon. Three patients underwent intraoperative rapid pathologic diagnosis of bile duct or cystic duct stump, and no malignant finding was observed. Two patients underwent surgery with hepatectomy + extrahepatic bile duct resection, one patient underwent pancreaticoduodenectomy + right hemi-colectomy, one patient underwent extended cholecystectomy and extrahepatic bile duct resection. In postoperative pathologic findings, they were diagnosed as Xanthogranulomatous cholecystitis (XGC). Conclusion: Each of the 4 cases could have avoided excessive surgery if we had diagnosed as XGC preoperatively or intraoperatively. In all cases, intraoperative rapid pathologic diagnosis of the excised specimen was not performed, with a possibility that excessive surgery may have been prevented of it had been performed. Even in the case of gallbladder cancer with invasion into surrounding organs, it is better to consider performing careful preoperative examination, and intraoperative rapid pathological diagnosis of the excised specimen, keeping in mind of the possibility of a benign lesion hiding in XGC.

Arterial Spin Labeling Method as a Supplemental Predictor to Distinguish Between High- and Low-Grade Gliomas.

Preoperative evaluation of malignancy in gliomas is important for surgical planning, particularly to determine whether a 1,3-bis-2-chloroethyl-1-nitrosourea wafer should be placed into the tumor cavity. In some cases, the intraoperative pathologic diagnosis of World Health Organization grade differs from the final diagnosis. Supplemental methods in addition to the routine contrast tomography or magnetic resonance imaging sequences may provide a more accurate preoperative diagnosis. Because tumor vascularity has been useful in distinguishing between low- and high-grade gliomas, we evaluated the accuracy of the arterial spin labeling (ASL) method, which could measure the cerebral blood flow (CBF) without using contrast medium, to determine the malignancy of gliomas. This study included 102 patients with glioma (grade II, n= 40; grade III, n= 18; grade IV, n= 44). All patients underwent ASL to determine the tumor blood flow (TBF) and CBF in the middle cerebral region. The relative tumor vascular index (tVI), which is calculated as TBF divided by CBF in the contralateral middle cerebral region, was used to avoid dispersion of the absolute TBF value. tVI was significantly greater (1.46 ± 0.751) in high-grade gliomas than in low-grade gliomas (1.05±0.343) (P= 0.003). As for each grade, tVI was statistically higher in grade IV than in grade II (P= 0.03) gliomas. The noninvasive ASL method provides additional information to distinguish high-grade glioma from low-grade gliomas without using contrast medium.

Accuracy of intraoperative pathological diagnosis using frozen sections of spinal cord lesions

ObjectivesFrozen sections are used to provide gross and rapid microscopic pathological information for guidance on intraoperative management and therapeutic decision-making. Many studies have shown the accuracy of frozen section diagnosis for intracranial lesions, but there are no studies focusing on spinal cord lesions. The purpose of this study is to evaluate the accuracy of intraoperative rapid diagnosis using frozen sections and to investigate limitations of this approach for spinal cord lesions. Patients and methodsWe performed intraoperative pathological diagnosis using frozen sections in 67 cases in which it was difficult to determine malignancy in preoperative images. The lesions were extradural (ED) in 13 cases, intradural extramedullary (IDEM) in 27 cases, and intramedullary (IM) in 27 cases. Metastatic tumors were excluded. The accuracy of intraoperative pathological diagnosis and the patterns of incorrect diagnosis were examined. ResultsComparison of the intraoperative and final diagnoses gave an overall diagnostic sensitivity of 86.6% (58/67), with 100% (13/13) for ED lesions, 96% (26/27) for IDEM lesions, and 70% (19/27) for IM lesions. The diagnostic accuracy for IM lesions was significantly lower than those for ED and IDEM lesions (p < 0.05). Cases with small specimen sizes were frequently incorrectly diagnosed and inflammatory processes were common incorrect diagnoses using frozen specimens. ConclusionAmong all spinal cord lesions, low diagnostic accuracy in intraoperative diagnosis using frozen sections is most likely for intramedullary lesions. The results of intraoperative rapid diagnosis should be interpreted with understanding of the limitations of this procedure.

Construction of mass spectra database and diagnosis algorithm for head and neck squamous cell carcinoma

ObjectivesIntraoperative identification of tumor margins is essential to achieving complete tumor resection. However, the process of intraoperative pathological diagnosis involves cumbersome procedures, such as preparation of cryosections and microscopic examination, thus requiring more than 30 min. Moreover, intraoperative diagnoses made by examining cryosections are occasionally inconsistent with postoperative diagnoses made by examining paraffin-embedded sections because the former are of poorer quality. We sought to establish a more rapid accurate method of intraoperative assessment. Materials and methodsA diagnostic algorithm of head and neck squamous cell carcinoma (HNSCC) using machine learning was constructed by mass spectra obtained from 15 non-cancerous and 19 HNSCC specimens by probe electrospray ionization mass spectrometry (PESI-MS). The clinical validity of this system was evaluated using intraoperative specimens of HNSCC and normal mucosa. ResultsA total of 114 and 141 mass spectra were acquired from non-cancerous and cancerous specimens, respectively, using both positive- and negative-ion modes of PESI-MS. These data were fed into partial least squares-logistic regression (PLS-LR) to discriminate tumor-specific spectral patterns. Leave-one-patient-out cross validation of this algorithm in positive- and negative-ion modes showed accuracies in HNSCC diagnosis of 90.48% and 95.35%, respectively. In intraoperative specimens of HNSCC, this algorithm precisely defined the borders of the cancerous regions; these corresponded with those determined by examining histologic sections. The procedure took approximately 5 min. ConclusionThis diagnostic system, based on machine learning, enables accurate discrimination of cancerous regions and has the potential to provide rapid intraoperative assessment of HNSCC margins.

Rapid and accurate intraoperative pathological diagnosis by artificial intelligence with deep learning technology

Frozen section is widely used for intraoperative pathological diagnosis (IOPD), which is essential for intraoperative decision making. However, frozen section suffers from some drawbacks, such as time consuming and high misdiagnosis rate. Recently, artificial intelligence (AI) with deep learning technology has shown bright future in medicine. We hypothesize that AI with deep learning technology could help IOPD, with a computer trained by a dataset of intraoperative lesion images. Evidences supporting our hypothesis included the successful use of AI with deep learning technology in diagnosing skin cancer, and the developed method of deep-learning algorithm. Large size of the training dataset is critical to increase the diagnostic accuracy. The performance of the trained machine could be tested by new images before clinical use. Real-time diagnosis, easy to use and potential high accuracy were the advantages of AI for IOPD. In sum, AI with deep learning technology is a promising method to help rapid and accurate IOPD.

Advantage of Induction Chemoradiotherapy for Lung Cancer in Securing Cancer-Free Bronchial Margin

Bronchoplasty is a useful procedure for preserving pulmonary function. For this procedure, it is critical to secure the negative surgical margin for avoiding local recurrence. In this study, we examined the status of the surgical bronchial margin as well as the clinical outcomes in bronchoplasty with or without induction chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC). The medical records of NSCLC patients who underwent bronchoplasty at our institution between January 1999 and September 2014 were reviewed. We compared the clinical outcomes of bronchoplasty with or without induction CRT. A total of 58 NSCLC patients were included in this study. Among these, 38 patients underwent primary surgical procedure with bronchoplasty and 20 patients underwent bronchoplasty after induction CRT. Intraoperative pathologic diagnosis for the surgical margin of the bronchus revealed that the patients in the primary surgical procedure group had a significantly higher rate of positive surgical margin than the induction CRT group (p= 0.023), requiring an additional bronchial resection to secure the negative margin. After additional resection of positive bronchial stumps, no significant difference was found in the rate of positive margin with postoperative histologic diagnosis between the two groups. In addition, no significant differences in the postoperative complication rate and overall and recurrence-free survivals were observed between the two groups. Our results suggest that induction CRT before surgical procedure may help ensure the intraoperative negative surgical margin of the bronchus. Our study also indicates that bronchoplasty after induction CRT is feasible in comparison with bronchoplasty in primary surgical procedure.

Rapid Immunohistochemistry With Thyroid Transcription Factor-1 for Pulmonary Adenocarcinoma

Intraoperative pathologic diagnosis of solitary pulmonary tumors to differentiate between metastatic and primary lung cancer is extremely important to determine the appropriate range of excision. Accurate intraoperative pathologic evaluation may be often difficult, however, and needs additional immunohistochemical (IHC) evaluation to support the diagnosis. Although conventional IHC is a powerful tool for diagnosis, its clinical use is limited intraoperatively because of time constraints. To address this issue, we developed a device that enables complete and rapid IHC (R-IHC) analyses within 20 minutes. We aimed to evaluate the discriminative ability of the R-IHC with anti-thyroid transcription factor-1 (TTF-1) antibody, which is a highly specific IHC marker for primary lung adenocarcinoma. A total of 61 pulmonary tumors that were resected at our institute from May 2011 to September 2013were retrospectively examined. The samples were sectioned, labeled with anti-TTF-1 antibody using the R-IHC method, and pathologically evaluated. The standard used for evaluation was conventional IHC with TTF-1. With the R-IHC procedure, analyses were completed within 20 minutes, with a diagnostic accuracy of 96.7% (59 of 61). Among the 47 primary lung adenocarcinomas, the R-IHC detected 31 (66%) tumors that were positive for TTF-1, with a positive predictive value of 100% (31 of 31). Our newly developed method of R-IHC with anti-TTF-1 antibody was useful for diagnosing and differentiation of solitary pulmonary tumors. This technology may prove to be an important supplement to standard intraoperative pathologic diagnosis in routine practice.

Correlation between the CT features and malignancy risk of small (≤5 cm) gastric stromal tumors

Objective: To evaluate the correlation between computed tomography (CT) features and malignancy risk category of small (≤5 cm) gastric stromal tumors (GST), in order to provide an image reference for preoperative assessment and intraoperative pathological diagnosis. Methods: Eighty-three patients with surgically and pathologically proven GST (≤5 cm) between January 2011 and November 2015 were recruited, and their clinical, pathological and CT data were retrospectively analyzed. According to the pathological results and malignancy risk category, the patients were divided into 2 groups, the benign biological behavior group (very low and low risk) and malignant biological behavior group (intermediate and high risk). The clinical, pathological and CT imaging findings of the two groups were analyzed. Based on the tumor diameter, the receiver operating characteristic curve (ROC) was applied to evaluate the sensitivity, specificity and the best cut-off point for distinguishing the malignancy risk between the two groups. Results: The lobulation and ulceration of the tumors presented statistically significant difference for the malignancy risk between the two groups (χ(2)=6.273 and 4.163, respectively; all P<0.05), but there was no significant difference in the sex, clinical symptoms, serum ferritin, tumor site, growth pattern, cystis degeneration and calcification (all P>0.05). No statistically significant differences were detected for the tumor CT value, arterial CT value, venous CT value, degrees of enhancement in arterial phase (DEAP), enhancement in portal venous phase (DEPP), and patient's age for distinguishing the malignancy risk between the two groups (all P>0.05). On the other hand, significant differences were found in the maximum diameter (Dmax) of tumor and the minimum diameter (Dmin) of tumor (t=-3.256 and -3.466, respectively; all P<0.05). When the cut-off point of Dmax was 1.6 cm, the area under the ROC curve, sensitivity and specificity were 0.704, 92.3% and 75.4%, respectively. When the cut-off point of Dmin was 1.5 cm, the area under the ROC curve, sensitivity and specificity were 0.713, 88.5% and 71.9%, respectively. Conclusion: CT features of the GST (≤5 cm) may predict, before surgery, the malignancy risk of small gastric stromal tumors, and provide the an image reference for preoperative assessment and intraoperative pathological diagnosis of the disease.

Bilateral free profunda artery perforator flaps(PAP) for immediate unilateral breast reconstruction: a case report and review of literature

Objective To investigate the possibility of using the profunda artery perforator flap (PAP) for breast reconstruction cases who are not the good candidates for back and abdominal donor sites. Methods This case was a breast cancer patient who required an i mmediate breast reconstruction with autologous tissue,skinny, bilateral severe breast atrophy and mastoptosis after lactation, twice cesarean delivery and umbilical hernia in August, 2016. Portable Doppler was used to detect the profunda artery perforator. The donor sites were designed according to the tissue defect after the mastectomy. The incisions were designed near to the inferior gluteal folds and medial gluteal areas. The left PAP flap was 20 cm × 5 cm, and the right PAP flap was 18 cm × 5 cm. The pedicles length of the both flaps were about 6.0 cm, and the perforator artery diameter of the both flaps were 2.2 mm. The right PAP vessels were connected to the left thoracodorsal vessels with end-to-end anastomosis. The left PAP vessels were connected to the proximal part of left internal ma mmary vessels with end-to-end anastomosis. The indocyanine green angiography under microscope showed the signs of patency in all the vessel anastomosis. Results The intraoperative patho-logic diagnosis was extensive intraductal carcinoma, and the sentinel lymph nodes biopsy showed negative result. The re-constructive breast has a nice appearance, natural and proper IMF. Both of the PAP flaps survive 100%, and the donor sites healed well and remained inconspicuous. The patient can walk freely on the 5th day postoperative, and back to home on the 7th day. Within the follow-up for one month, the patient was very satisfied with the new breast and a better gluteal appearance. Conclusion The free PAP flaps provide an excellent alternative to an abdominal and back donor sites for achieving the breast reconstruction due to the relaible supplying pedicle vessels and invisible donor scars. Key words: Profunda artery perforator (PAP); Breast reconstruction; Autologous tissue; Perforator flap