Radical Local Excision Research Articles

Total mesorectal excision compared to local excision in locally advanced rectal cancer achieving complete pathological response with neoadjuvant therapy: A National Cancer Database Analysis.

4107 Background: Total mesorectal excision (TME) is the standard surgical intervention for patients with locally advanced rectal cancer (LARC) regardless of response to neoadjuvant therapy. In this study, we perform a comprehensive review of the National Cancer Database (NCDP) to compare the clinical and surgical outcomes of TME to local excision (LE) in patients with LARC. Methods: NCDP was systematically researched to abstract all patients with stage II and III rectal adenocarcinoma between the years 2004 and 2015. We subsequently excluded all the patients who did not achieve complete pathological response (pT0) after neoadjuvant therapy. The patients were then divided into two groups; those who underwent TME and those who underwent LE. Data were analyzed using SPSS v. 26.0, SAS v. 9.4. Results: A total of 4,705 were included in the study; 4,589 in the TME group and 116 in the LE group. Baseline characteristics were similar between the groups except for age. A total of 81(1.8%) of patients in the TME group and 8(6.9%) of patients in the LE group did not receive radiation (p=0.006) and 19(0.4%) of patients the TME group and 4(3.4%) of patients in the LE group did not receive chemotherapy. There was no difference in median overall survival between TME and LE groups. The median length of hospital stay was remarkably shorter in the LE group compared to the TME group (1 day vs 6 days, p<0.0001). The rate of 30-day and 90-day postoperative mortality were similar between the two groups (p-value=0.334 and 0.06, respectively). In the LE group, 4 (3.4%) of patients were readmitted within 30 days of the resection compared to 374 (8.5%) in the TME group but was not a statistically significant difference (p=0.059). Conclusions: In this study, TME and LE had similar overall survival and time to 25% mortality in patients with LARC who achieved complete pathological response after neoadjuvant therapy. Also, LE had a shorter hospital stay compared to the TME group. This study is limited by its retrospective nature, however these interesting observations warrant further investigation in randomized clinical trials. [Table: see text]

Malignant melanoma of the breast: controversies in the diagnosis and therapeutic management of a rare nosologic entity.

Melanoma of the breast is an infrequent entity, presenting as either primary or metastatic from extramammary solid neoplasms. Depending on the involvement of the skin, primary malignant melanoma of the breast (PMMB) can be classified as cutaneous or noncutaneous. Cutaneous PMMB accounts for <5% of all melanomas and only 0.5% of all breast cancers. Furthermore, despite the rarity of metastatic breast neoplasms, melanoma comprises a frequent source of metastases. Metastatic potential of melanoma is associated with poor prognosis, and the majority of patients present more than one metastatic foci at the time of diagnosis. Diagnostic approach for both primary and metastatic melanomas of the breast is substantiated by fine needle aspiration (FNA) cytology along with immunohistochemistry. Nevertheless, verification of a metastatic mammary melanoma requires the discovery of a primary lesion. The mainstay of treatment for primary tumors is surgery, with radical local excision and axillary lymph node dissection or, on occasion, axillary sentinel node resection, while for metastatic tumors it depends on the specificities of the melanoma. Adjuvant therapy is always implemented. The aim of this survey is to meticulously review the literature of primary and metastatic malignant melanomas of the breast and report epidemiologic and clinicopathologic data for this rare entity. Clinical features, histogenesis, morphological, and immunochemical findings are discussed, while the role of current diagnostic and therapeutic management of this uncommon entity is emphasized.

Organ preservation with chemoradiotherapy plus local excision for rectal cancer: 5-year results of the GRECCAR 2 randomised trial

GRECCAR 2 was the first multicentre, randomised trial to compare local excision with total mesorectal excision in downstaged low rectal cancer. Encouraging oncological results were noted at 3 years' follow-up but needed to be corroborated with longer follow-up. In this study, we aimed to report the 5-year oncological outcomes, including local recurrence, metastatic disease, and survival. Patients age 18 years and older with T2T3 low rectal cancer, of maximum size 4 cm, who were clinically good responders after chemoradiotherapy (residual tumour ≤2 cm) were randomly assigned before surgery to either local excision or total mesorectal excision. Randomisation was centralised and not stratified and used permuted blocks of size eight. In the local excision group, a completion total mesorectal excision was performed if pathological tumour stage was ypT2-3. The primary objective of this study was to assess the 5-year oncological outcomes of local recurrence, metastatic disease, disease-free survival, overall survival, and cancer-specific mortality, which were the secondary endpoints of GRECCAR 2. We used Kaplan-Meier estimates and Cox modelling to estimate and compare recurrence and survival in modified intention-to-treat and as-treated populations. This trial was registered with ClinicalTrials.gov, number NCT00427375. Between March 1, 2007, and Sept 24, 2012, 148 patients who were good clinical responders were randomly assigned to treatment, three patients were excluded after randomisation (because they had metastatic disease, tumour >8 cm from anal verge, or withdrew consent), leaving 145 for analysis: 74 in the local excision group and 71 in the total mesorectal excision group. Median follow-up was 60 months (IQR 58-60) in the local excision group and 60 months (57-60) in the total mesorectal excision group. 23 patients died and five were lost to follow-up. In the local excision group, 26 had a completion total mesorectal excision for ypT2-3 tumour. In the modified intention-to-treat analysis, there was no difference between the local excision and total mesorectal excision groups in 5-year local recurrence (7% [95% CI 3-16] vs 7% [3-16]; adjusted hazard ratio [HR] 0·71 [95% CI 0·19-2·58]; p=0·60), metastatic disease (18% [CI 11-30] vs 19% [11-31]; 0·86 [0·36-2·06]; p=0·73), overall survival (84% [73-91] vs 82% [71-90]; 0·92 [0·38-2·22]; p=0·85), disease-free survival (70% [58-79] vs 72% [60-82]; 0·87 [0·44-1·72]; p=0·68), or cancer-specific mortality (7% [3-17] vs 10% [5-20]; 0·65 [0·17-2·49]; p=0·53). The 5-year results of this multicentre randomised trial corroborate the 3-year results, providing no evidence of difference in oncological outcomes between local excision and total mesorectal excision. Local excision can be proposed in selected patients having a small T2T3 low rectal cancer with a good clinical response after chemoradiotherapy. National Cancer Institute of France.

Local versus Radical Excision of Early Distal Rectal Cancers: A National Cancer Database Analysis.

Local excision (LE) has been proposed as an alternative to radical resection for early distal rectal cancer, for which the optimal oncologic treatment remains unclear. The goal of this study was to compare the overall survival of rectal cancer patients with early distal tumors who underwent LE versus abdominoperineal resection (APR) using a large contemporary database. The National Cancer Database (2004-2013) was used to identify patients with early T-stage rectal adenocarcinoma who underwent LE or APR. Patients were split into groups based on T stage and type of surgery (LE vs. APR). The primary outcome measure was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. Overall, there were 2084 patients with T1 tumors and 912 patients with T2 tumors. For patients with T1 disease, after adjusting for age, sex, income level, race, Charlson score, insurance payor, and tumor size, there was no significant difference in survival between the LE and APR groups (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.65-1.22; P = 0.49). For patients with T2 disease, after adjusting for age, Charlson score, and tumor size, there was no significant difference in survival between patients undergoing LE + chemoradiation therapy (CRT) and APR (HR 1.11, 95% CI 0.84-1.45; P = 0.47). Patients with early distal rectal adenocarcinoma who underwent LE had similar survival to patients who underwent APR. LE is an acceptable oncologic treatment strategy for patients with T1 rectal cancers, and LE with CRT is an acceptable oncologic treatment for patients with T2 distal rectal cancers.

The impact of total neo-adjuvant treatment on nonoperative management in patients with locally advanced rectal cancer: The evaluation of 66 cases

BackgroundThe study aimed to assess if adherence to a total-neoadjuvant-treatment (TNT) protocol followed by observation(watch-and-wait) led to the successful nonoperative-management of low-rectal-cancer. MethodsIn this study, patients with primary, resectable-T3-T4, N0–N1 distal-rectal-adenocarcinoma underwent-chemoradiotherapy + consolidation-chemotherapy (TNT). During the-TNT-period, endoscopy, MRI, and FDG-PET/CT were performed. We allocated patients with complete-clinical-tumor-regression, who underwent endoscopy every two months, MRI every-four-months, and PET/CT every-six-months-after-treatment, to the observation-group(OG). All other patients were referred for surgery. The OG was followed-up. The primary endpoint was local tumor-ecurrence after allocation to the OG. ResultsBetween 2015 and 2018, we enrolled 66-patients. Of 60-patients who were eligible to participate, 39 had complete-clinical-response(cCR) and were allocated to the OG, six underwent local-excision (LE), and 15 underwent total-mesorectal-excision (TME). The median follow-up duration was 22 (9–42) months. The local-recurrence-rate in the OG was 15.3%, and the LE and TME rates were 16.6% and 0%, respectively. All recurrence cases were salvaged through either LE or TME. The-distant-metastasis rate was 5.1%, 16.6%, and 12.5% in the OG, LE, and TME groups, respectively. The endoscopic negative-predictive-value(NPV) was 50%, and the positive-predictive-value(PPV) was 76.9% in the surgery group (LE + TME). MRI; NPV-50%, PPV-76.9%. PET/CT; NPV-100%, PPV-93.3%. Six patients(28.57%) from surgery group achieved complete pathological response (cPR). ConclusionOur results indicated a high proportion of selected-rectal-cancers with-cCR after neo-adjuvant-therapy could potentially be managed non-operatively, and major surgery may be avoided.

Mucosal melanoma of the female genital tract: Operation modalities.

e21060 Background: Primary melanomas originating from the female genital tract are rare and aggressive. There are still no established guidelines for its primary surgery , so we analyzed the effect of the surgical approach on its relapse free survival (RFS) and overall survival (OS ) based on a phase 3 randomized trial (NCT03435302). Methods: Mucosal melanoma patients with female genital tract primary which were stageⅠ-Ⅲ and completely resected were enrolled as part of the multicenter, randomized, controlled, phase 3 trial for the comparison of adjuvant chemotherapy (TMZ plus DDP 6 cycles) vs. High-dose interferon group (HDI, 1 year).The RFS and OS was compared between local and extensive excision group. Results: Seventy eight female genital tract primary melanoma patients were enrolled from Feb 2014 to Jun 2016, Surgical approach was chosen by the surgeon, 39.2% (29/74) took local excision and 60.8% (45/74) extensive excision. The average age was 52.3 years. Of all these patients 46.2% were vulvar primary, 53.8% vaginal, and 85.3%stage I/II, 14.7% stage III. Primary ulceration was found in 68.1% lesions, 7 cases harbored with BRAF mutation. 57.7% patients randomized to adjuvant chemotherapy and 42.3% in HDI group. All these factors showed no difference in local excision and extensive excision group. At a median follow-up of 31.2 months (range: 5.3-60.0m), 64.4% got metastases and 23.1% showed local recurrence. RFS (8.0m vs. 11.4m, p = 0.523) and local recurrence rate (13.8% vs.31.1%, p = 0.105 ) did not show significant difference between local excision group and extensive excision group. OS in whole cohort was 28.9 months, it also did not show significant difference between two groups(local 25.5m vs. extensive 40.1m, p = 0.653). In univariate analysis there was also no relation between surgical approach and OS in this cohort. Conclusions: Based on this trial, for resectable female genital tract primary mucosal melanoma, there was no difference of local control rate, RFS and OS between local excision and extensive excision group. Local excision might be adequate for the primary leision. Still more prospective data are needed for this subtype of melanoma. Clinical trial information: NCT03435302.

Oncologic Outcomes of Organ Preserving Approaches in Patients With Rectal Cancer Treated With Preoperative Chemoradiotherapy.

PurposeWe evaluated the oncologic outcomes of organ-preserving strategies in patients with rectal cancer treated with preoperative chemoradiotherapy (PCRT).MethodsBetween January 2008 and January 2013, 74 patients who underwent wait-and-watch (WW) (n = 42) and local excision (LE) (n = 32) were enrolled. Organ-preserving strategies were determined based on a combination of magnetic resonance imaging, sigmoidoscopy, and physical examination 4–6 weeks after completion of PCRT. The rectum sparing rate, 5-year recurrence-free survival (RFS), and overall survival (OS) were evaluated.ResultsThe rectum was more frequently spared in the LE (100% vs. 87.5%, P = 0.018) at last follow-up. Recurrence occurred in 9 (28.1%) WW and 7 (16.7%) LE (P = 0.169). In the WW, 7 patients had only luminal regrowth and 2 had combined lung metastasis. In the LE, 2 (4.8%) had local recurrence only, 4 patients had distant metastasis, and 1 patient had local and distant metastasis. Among 13 patients who indicated salvage surgery (WW, n = 7; LE, n = 11), all in the WW received but all of LE refused salvage surgery (P = 0.048). The 5-year OS and 5-year RFS in overall patients was 92.7% and 76.9%, respectively, and were not different between WW and LE (P = 0.725, P = 0.129).ConclusionWW and LE were comparable in terms of 5-year OS and RFS. In the LE group, salvage treatment was performed much less among indicated patients. Therefore, methods to improve the oncologic outcomes of patients indicated for salvage treatment should be considered before local excision.

Surgical treatment of low-grade chondrosarcoma involving the appendicular skeleton: long-term functional and oncological outcomes.

The traditional treatment for chondrosarcoma is wide local excision (WLE), as these tumors are resistant to chemotherapy and radiation treatment. While achieving negative margins has traditionally been the goal of chondrosarcoma resection, multiple studies have demonstrated good short-term results after intralesional procedures for low-grade chondrosarcomas (LGCS) with curettage and adjuvant treatments (phenol application, cauterization or cryotherapy) followed by either cementation or bone grafting. Due to the rarity of this diagnosis and the recent application of this surgical treatment modality to chondrosarcoma, most of the information regarding treatment outcomes is retrospective, with short or intermediate-term follow-up. The aim of this study was to assess the long-term results of patients with LGCS of bone treated with intralesional curettage (IC) treatment versus WLE. This retrospective analysis aims to characterize the oncologic outcomes (local recurrence, metastases) and functional outcomes in these two treatment groups at a single institution. Using an institutional musculoskeletal oncologic database, we retrospectively reviewed medical records of all patients with LGCS of the appendicular skeleton that underwent surgical treatment between 1985 and 2007. Thirty-two patients (33 tumors) were identified with LGCS; 17 treated with IC and 15 with WLE. Seventeen patients (18 tumors) with a minimum clinical and radiologic follow-up of 10years were included. Nine patients were treated with IC (four with no adjuvant, three with additional phenol, one with liquid nitrogen and one with H2O2) with either bone graft or cement augmentation, and nine others were treated with WLE and reconstruction with intercalary/osteoarticular allograft or megaprosthesis. The mean age at surgery was 41years (range 14-66years) with no difference (p = 0.51) between treatment cohorts. There was a mean follow-up of 13.5years in the intralesional cohort (range 10-19years) and 15.9years in the WLE cohort (range 10-28years, p = 0.36). Tumor size varied significantly between groups and was larger in patients treated with WLE (8.2 ± 3.1cm versus 5.4 ± 1.2cm, at the greatest dimension, p = 0.021). There were two local recurrences (LR), one in the intralesional group and one in the wide local excision group, occurring at 3.5months and 2.9years, respectively, and both required revision. No further LR could be detected with long-term follow-up. The MSTS score at final follow-up was significantly higher for patients managed with intralesional procedures (28.7 ± 1.7 versus 25.7 ± 3.4, p = 0.033). There were less complications requiring reoperation in the intralesional group compared with the wide local excision group, although this difference was not found to be statistically significant (one versus four patients, respectively; p = 0.3). This series of low-grade chondrosarcoma, surgically treated with an intralesional procedures, with 10-year follow-up, demonstrates excellent local control (88.9%). Complications were infrequent and minor and MSTS functional scores were excellent. Wide resection of LGCS was associated with lower MSTS score and more complications. In our series, the LR in both groups were detected within the first 3.5years following the index procedure, and none were detected in the late surveillance period.

Non-operative treatment outcome for rectal cancer patient with clinical complete response after neoadjuvant chemoradiotherapy

Among rectal cancer patients, some of good responders after neoadjuvant chemoradiotherapy (nCRT) are considered for non-operative treatments to avoid postoperative morbidities and permanent stoma. However, oncologic feasibility of non-operative treatment has not been fully understood. From 2008 to 2017, we retrospectively reviewed patient's records who had lower or mid rectal cancer and diagnosed to clinical complete response by magnetic resonance imaging after nCRT. Clinical differences and oncologic outcomes were compared among Radical surgery (RS), Local excision (LE) and Wait-and-see (WS) group. Number of 129, 25, 15 patients included to RS, LE, WS groups. Local recurrence was frequent type of recurrence in both of LE and WS group (RS; 31.3%, LE; 80%, WS; 66.7%), and many patients in WS group omitted salvage treatment (RS; 75%, LE; 100%, WS; 33.3%). 5-years local-recurrence/disease-free survival rate (LRFS, DFS) between RS and LE were similar between each group, but WS showed significantly inferior outcomes than that of RS (LRFS; p=0.001, DFS; p=0.001). In multivariate analysis, WS protocol (OR; 7.163, 95% CI; 1.995-25.715) and cT4 stage (OR; 8.206, 95% CI; 1.596-42.198) were independent factors for LRFS. Wait-and-see group showed high rate of rejection of salvage treatments for recurrence, and poor oncologic outcomes. However, recent low-level evidences reported favorable outcome of WS protocol when salvage treatment was followed after recurrence. It seems that the application of WS protocol should be postponed until the results of randomized-controlled trials are available. Local excision seems to be good alternative option to radical surgery when salvage treatment is followed.

Local Excision Versus Radical Resection for 1- to 2-cm Neuroendocrine Tumors of the Rectum: A National Cancer Database Analysis

The optimal surgical management for 1- to 2-cm, nonmetastatic rectal neuroendocrine tumors remains unknown. We sought to determine overall survival and operative outcomes in patients who underwent local excision versus radical resection of rectal neuroendocrine tumors. The National Cancer Database (2004-2013) was queried to identify patients with nonmetastatic rectal neuroendocrine tumors who underwent local excision or radical resection. The study included national data. There were 274 patients in the local excision group and 47 patients in the radical resection group. The primary outcome was overall survival. Secondary outcomes included 30-day mortality, hospital length of stay, and procedural outcomes. There were no differences in demographics between the 2 groups. Patients who underwent radical resection had slightly larger tumors with higher stage and grade. Patients undergoing local excision had higher rates of positive margins (8.23% vs 0%; p = 0.04). There were no deaths within 30 days in either group, but patients who had radical resection had longer median hospital length of stay (0 vs 3 d; p < 0.01). After adjusting with a Cox proportional hazards model, no difference was seen in survival between the 2 patient groups (HR = 2.39 (95% CI, 0.85-6.70); p = 0.10). There are several limitations, which include that this work is a retrospective review; the data set does not include variables such as depth of tumor invasion, which may influence surgical treatment or local recurrence rates; and patients were not randomly assigned to treatment groups. There is no survival benefit to radical resection of 1- to 2-cm, nonmetastatic rectal neuroendocrine tumors. This suggests that local excision may be a feasible and less morbid option for intermediate-sized rectal neuroendocrine tumors. See Video Abstract at http://links.lww.com/DCR/A744.

Clear cell sarcoma

Clear cell sarcoma (CCS), also referred as to melanoma of soft tissues, is a rare malignant tumour of soft tissues. This tumour harbors the characteristic features of soft tissue sarcoma (STS) and is a slowly growing, painless tumour, which then acquires an aggressive course. CCS is characterized by a translocation t(12; 22)(q13; q12), which in addition to the diagnostic implications may be important for targeted treatment in the future. CCS occurs mainly on the limbs, most often shin (in feet and ankle area) in the tendons and aponeurosis, often at a young age. CCS is characterized by high potential to develop metastases in regional lymph nodes (about 30% of cases). In the diagnostic process one should consider performing a sentinel node biopsy with possible subsequent radical lymphadenectomy in the case of metastases detection. Treatment of localized disease is limited to radical local excision with complementary radiotherapy. Due to the resistance to classical chemotherapy and the presence of characteristic molecular abnormalities, trials of molecular targeted therapies in this group of cancers are ongoing. In clinical trials, MET inhibitors, tyrosine kinase inhibitors (TKI) — sunitinib and pazopanib were evaluated. CCS was also one of the subtypes of tumours evaluated in the CREATE clinical trial with crizotinib.

Sentinel lymph node biopsy in vulvar cancer: A series of 19 cases

Introduction: Vulvar cancer is a relatively rare gynaecologic malignancy that represents less than 5% of gynaecological cancers and is primarily seen in postmenopausal women. The classical approach for the surgical management of vulvar cancer was radical vulvectomy with en-bloc inguinofemoral lymphadenectomy. In current practice, radical local excision and sentinel lymph node biopsy (SLNB) is the best surgical option for selected patients, with comparable efficacy, less morbidity and disfigurement.

MRI evaluation of vulvar squamous-cell carcinoma in fresh radical local excision specimens for cancer localization and prediction of surgical tumor-free margins.

In the surgical treatment of vulvar squamous‐cell carcinoma (VSCC), tumor‐free margins of 8 mm or more are considered adequate. However, limited perioperative information on the tumor‐free margins other than the surgeon's own estimation is available. The purpose of this study was therefore to investigate the feasibility of ex vivo MRI in localizing VSCC and to assess the surgical tumor‐free margins in fresh radical local excision (RLE) specimens to guide the surgeon during resections. Nine patients with biopsy‐proven VSCC scheduled for RLE were prospectively included. Intact fresh specimens were scanned using a 7 T preclinical MR‐scanner. Whole mount H&E‐stained slides were obtained every 3 mm and correlated with ex vivo MRI. A pathologist annotated VSCC and minimal tumor‐free margins (3 o'clock, 9 o'clock, basal) on the digitalized histological slides. An observer with knowledge of histology (the non‐blinded annotation) and a radiologist blinded to histology (the blinded annotation) separately performed annotation of the same features on ex vivo MRI. Linear correlation and agreement of the ex vivo MRI measurements with histology were assessed. Diagnostic performance for VSCC localization and identification of margins less than 8 mm was expressed as positive and negative predictive values (PPV, NPV). In 153 matched ex vivo MRI slices, the observer correctly identified 79/91 margins as less than 8 mm (PPV 87%) and 110/124 margins as 8 mm or greater (NPV 89%). The radiologist correctly annotated absence of VSCC in 73/81 (NPV 90%) and presence in 65/72 (PPV 90%) slices. Sixty‐four of 90 margins were correctly identified as less than 8 mm (PPV 71%) and 83/102 margins as 8 mm or greater (NPV 81%). Both non‐blinded and blinded annotations were linearly correlated and demonstrated good agreement with histology. Accurate localization of VSCC and measurements of the surgical tumor‐free margins in fresh RLE specimens using ex vivo MRI seems feasible. High diagnostic performance in VSCC localization and identification of margins less than 8 mm suggest ex vivo MRI to be clinically applicable.

Right technique and sufficient dose equal effective radiation to the groins in vulvar cancer

The management of vulvar cancer has significantly evolved from radical en bloc vulvectomy and bilateral inguinal lymphadenectomy to a more nuanced approach. Current management, for example, can involve radical local excision and sentinel lymph node biopsy. These advances have significantly reduced the morbidity associated with the surgical management of this disease. However, there remain unanswered questions regarding the treatment of vulvar cancer, including the ideal management of gross groin lymphadenopathy. Surgery remains the standard of care, but a risk of chronic lymphedema and poor wound healing are potential complications. These can have long term impacts on quality of life and so efforts are warranted to explore ways to minimize these risks.

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.

Contemporary Surgical Management and Outcomes for Anal Melanoma: A National Cancer Database Analysis.

Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma. The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival. The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65years; p < 0.001) and had larger tumors (40 vs 25mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001). The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival.

Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database

BackgroundMajor resection (MR) is recommended for cases with T2 finding after local excision (LE) of early rectal cancer, but the revision procedure is accompanied with high morbidity. We evaluated the oncological safety of LE followed by adjuvant radiotherapy as a rectum-preserving alternative to MR for T2 early rectal cancer. MethodsA total of 3786 patients with T2N0M0 rectal adenocarcinoma between 1998 and 2013 were included from the SEER database. Survival rates were compared using the Kaplan-Meier method with a log-rank test, and multivariate analyses were performed using Cox proportional regression models. ResultsOf these patients included, 429 (11.3%) treated with LE alone (LE group), 3067 (81.0%) treated with MR (MR group), and 290 (7.7%) treated with LE followed by adjuvant radiotherapy (LE + adjuvant RT group). The 5-year cancer specific survival (CSS) rate and 5-year overall survival (OS) rate were significantly lower in LE patients group than those in MR patients group (70.5% vs. 81.8%, P < 0.001; 57.3% vs. 72.3%, P < 0.001). The 5-year CSS rate and 5-year OS rate were similar between LE + adjuvant RT and MR groups (78.4% vs. 81.8%, P = 0.975, and 70.7% vs. 72.3%, P = 0.311, respectively). Multivariate Cox regression revealed that treatment strategies, age and CEA status were independently associated with CSS and OS. After age adjustment, LE was associated with reduced CSS (using MR as a reference, HR, 1.784; P < 0.001) and reduced OS (HR, 1.739; P < 0.001). However, CSS and OS related to LE + adjuvant RT of T2 rectal cancer group weren't be affected (HR, 0.994; P = 0.962 and HR, 0.904; P = 0.302, respectively). ConclusionsWhen MR is inappropriate for T2 early rectal cancer patients because of patients refusal or co-morbidities, LE + adjuvant RT can provide acceptable levels of long-term survival.

Treatment Outcomes of Patients with Squamous Cell Carcinoma of the Vulva: The Largest Series from a Tertiary Care Hospital.

Objective To evaluate the outcomes of squamous cell carcinoma (SCCA) of the vulva treated at our tertiary care center. Methods The medical records of SCCA patients treated between January 2006 and December 2015 were retrospectively reviewed. Results One hundred forty-five patients met the criteria with the median age of 57 years old, and 58.6% had an underlying disease. The distribution of stages was as follows: IA 6.2%, IB 21.4%, II 26.2%, IIIA 14.5%, IIIB 6.2%, IIIC 9.7%, IVA 9.0%, and IVB 6.9%. One hundred and nine patients underwent surgical intervention and radical local excision with bilateral groin node dissection as the most frequent procedure. Approximately half of the patients received combined treatment with surgery followed by radiation with or without chemotherapy. Recurrence developed in 127 patients after the median follow-up time of one year with the common sites in the groin and vulva region. However, no significant difference in survival occurred in patients with and without groin node recurrence (15 vs. 28 months, P=0.109). The five-year overall survival was 50.8%. Conclusions The survival of patients with SCCA vulvar cancer was modest. The common failure sites were groin and vulva regions with unfavorable outcomes.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT Surgical resection is the primary mode of treatment for primary osseous neoplasms of the spine. While resection type and margin status have been well demonstrated in primary bone tumors of the extremity, the low prevalence of these tumors in the spine makes it difficult to determine the prognostic significance of these factors for spinal tumors. We investigated the largest registry of primary bone tumors, the national cancer database (NCDB). Our hypothesis was negative margin status and radical resection would correlate with increased length of survival (LOS). PURPOSE To determine if achieving a negative margin following resection of a malignant bone tumor of the spine improves 5-year survival. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 759 patients. OUTCOME MEASURES A total of 5-year survival. METHODS We retrospectively analyzed patients in the NCDB from 2004 to 2015 with a histologic diagnosis of primary spinal chordoma, osteosarcoma, chondrosarcoma and Ewing's sarcoma. Only patients who underwent surgical resection were included. Patients were stratified by margin of resection (negative margin vs. positive margin) and type of surgical resection (radical resection vs. local excision). The Kaplan–Meier (KM) method with statistical comparisons based on the log-rank test was used to identify univariate factors associated with LOS. RESULTS A total of 759 patients with primary spinal tumors undergoing surgical resection were identified with diagnoses of chordoma (n=332), chondrosarcoma (n=217), Ewing's sarcoma (n=112) and osteosarcoma (n=98). Following resection, 36.1% had a negative margin (n=274), 20.2% had a positive margin (n=153) and 43.7% were unspecified (n=332). Improved 5-year survival was seen with a negative resection margin (72.5% vs. 58.3%, p=.0032). Patients undergoing radical resection were more likely to have negative margins (79.8%) than those undergoing local or partial excisions (51.1%) (p CONCLUSIONS Surgical resection is the primary mode of treatment for primary osseous neoplasms of the spine, and this study confirms improved 5-year survival rates with surgical resection. Achieving a negative margin following resection improves survival. The type of resection (radical vs. local or partial excision) was not associated with survival; however, a radical tumor excision was more likely to achieve a negative margin. This study confirms the role of tumor excision in bony neoplasms of the spine, and provides evidence towards the importance of achieving a negative margin.

Total Mesorectal Excision Versus Local Excision After Preoperative Chemoradiotherapy in Rectal Cancer With Lymph Node Metastasis: A Propensity Score–Matched Analysis

Todetermine whether local excision (LE) outcomes were comparable to total mesorectal excision (TME) outcomes in node-positive (cN+) rectal cancer patients who were good responders. This retrospective study included clinical T2-3 and cN+low rectal cancer patient who received preoperative chemoradiotherapy (PCRT) followed by TME or LE. Clinical stage T1 or T4 tumors, upper-to-middle rectal tumors (>7cm from anal verge), and synchronous distant metastases were excluded. Lymph nodes ≥5mm in size were defined as tumor-positive, and patients with metastatic lymph nodes >20mm in size were excluded. Preoperative chemoradiotherapy comprised radiation (50-50.4Gy/25-28 fractions over 5weeks) with 2 cycles of 5-fluorouracil or oral capecitabine. Propensity scores were computed from tumor and patient variables and used for 1-to-1 matched analysis. Local recurrence-free survival, disease-free survival, and overall survival were compared between the 2 matched groups. Between January 2007 and December 2013, 563 and 55 patients underwent TME and LE, respectively. The median follow-up period was 54months. In propensity score-matched analysis, 48 patients were included in each group. No statistical differences were observed in 3-year local recurrence-free survival (97.9% vs 97.9%, P=.994), 3-year disease-free survival (91.5% vs 91.4%, P=.968), or 3-year OS (93.7% vs 97.9%, P=.809) between the TME and LE groups. In clinical N+ rectal cancer patients, oncologic outcomes of PCRT followed by LE were comparable to those of TME; this finding might be applicable only to those patients with good response in the primary tumor and small lymph node metastases.