Local Excision Of Tumor Research Articles

Clipping of tumour resection margins allows accurate target volume delineation in head and neck cancer adjuvant radiation therapy

BackgroundAccurate tumour bed localisation is a key requirement for adjuvant radiotherapy. A new procedure is described for head and neck cancer treatment that improves tumour bed localisation using titanium clips. Materials and methodsFollowing complete local excision of the primary tumour, the tumour bed was marked with titanium clips. Preoperative gross target volume (GTV) and postoperative tumour bed were examined and the distances between the centres of gravity were evaluated. Results49 patients with squamous cell carcinoma of the oral cavity were prospectively enrolled in this study. All patients underwent tumour resection, neck lymph node dissection and defect reconstruction in one stage. During surgery, 7–49 clips were placed in the resection cavity. Surgical clip insertion was successful in 88% (n=43). Clip identification and tumour bed delineation was successful in all 43 patients. The overall distance between the centres of gravity of the preoperative tumour extension to the tumour bed was 0.9cm. A significant relationship between the preoperative tumour extension and the postoperative tumour bed volume could be demonstrated. ConclusionWe demonstrate a precise delineation of the former tumour cavity. Improvements in tumour bed delineation allow an increase of accuracy for adjuvant treatment.

MP10-06 SURGICAL TREATMENT OF PRIMARY DISEASE FOR PENILE SQUAMOUS CELL CARCINOMA: A SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS (SEER) DATABASE ANALYSIS

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Penis/Testis/Urethra: Malignant Disease1 Apr 2015MP10-06 SURGICAL TREATMENT OF PRIMARY DISEASE FOR PENILE SQUAMOUS CELL CARCINOMA: A SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS (SEER) DATABASE ANALYSIS Gu Weijie, Zhu Yao, and Ye Dingwei Gu WeijieGu Weijie More articles by this author , Zhu YaoZhu Yao More articles by this author , and Ye DingweiYe Dingwei More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.407AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Current guidelines recommend penile sparing surgery (PSS) for select penile cancer. This study describes the use of PSS in a population-based cohort, and also examines the role of PSS on penile cancer specific mortality (PCSM). METHODS Surveillance, Epidemiology, and End Results (SEER) data were used to identify individuals who were diagnosed with penile squamous cell carcinoma from 1998 to 2009 and treated with surgery. Patients were sorted into 2 groups: local tumor excision (LTE), and partial/total penectomy (PE). We examined factors associated with the receipt of LTE and PCSM after LTE. Comparison of PCSM was made between LTE and PE after propensity score matching. RESULTS Of 1292 eligible subjects, 24.2% underwent LTE. For stage T1 disease, the rates of LTE increased moderately from 29% to 40% over last decade. After adjustment, young age, black race, tumor size of <3cm, and stage T1 disease positively influenced the receipt of LTE. With a median follow-up of 55 months, the 4-year PCSM was 9.8% in patients treated with LTE. Older age, tumor size of 3 to 4cm and spread disease in SEER stage were significant predictors of PCSM. In matched cohort with stage T1 disease, the 4-year PCSM were 8.9% and 10.0% for patients received LTE or PE, respectively (p=0.93). CONCLUSIONS Underuse of PSS is pronounced in the general community with significant age and race disparities. The population-based study provides evidence supporting the oncological safety of PSS as compared with PE in early stage disease. Multivariate analyses of predictors for the receipt of local tumor excision in patients with penile squamous cell carcinoma (n=1292) Variables Odds ratio (95% CI) p value Age 0.99 (0.98-1.00) <0.01 Race (ref= White) Black 1.72 (1.07-2.75) 0.02 Other 0.9 (0.46-1.75) 0.75 Marrital status (ref= Married) Unmarried 1.30 (0.97-1.75) 0.08 Primary tumor size (ref=< 1) 1-1.9 1.20 (0.74-1.96) 0.46 2-2.9 0.70 (0.43-1.14) 0.15 3-3.9 0.44 (0.25-0.75) <0.01 >4 0.37 (0.21-0.63) <0.01 T-stage (ref=T1) T2 0.18 (0.10-0.31) <0.01 T3-T4 0.16 (0.08-0.31) <0.01 SEER stage (ref=Localized) Regional 1.09 (0.68-1.74) 0.71 Distant 1.16 (0.40-3.37) 0.78 Grade (ref=Grade I) Grade II 0.92 (0.67-1.26) 0.60 Grade III-IV 0.77 (0.50-1.17) 0.21 Year of diagnosis (ref=1988-2000) 2001-2003 1.31 (0.81-2.14) 0.28 2004-2006 1.46 (0.90-2.37) 0.12 2007-2009 1.38 (0.86-2.21) 0.18 CI, confidence interval; SEER, Surveillance Epidemiology and End Results Program. Propensity score matching of surgical procedures in patients with stage T1 disease Variables Local tumor excision Before matching Penectomy p-value After matching Penectomy p-value n 265 434 265 Age <0.01 0.84 Mean 64.7 67.7 65.0 Race 0.48 0.21 White 222 375 229 Black 30 37 19 Other 13 22 17 Marrital status 0.53 0.23 Married 167 285 181 Unmarried 98 149 84 Grade 0.42 0.33 Grade I 100 143 85 Grade II 122 219 138 Grade III-IV 43 72 42 Primary tumor size <0.01 0.92 <1 38 48 44 1-1.9 97 94 88 2-2.9 67 109 68 3-3.9 33 91 33 >4 30 92 32 SEER Stage 0.29 0.66 Localized 242 384 238 Regional/Distant 23 50 27 Propensity Score <0.01 0.55 Mean 0.59 0.64 0.59 SEER, Surveillance Epidemiology and End Results Program. Multivariate analyses of predictors of penile cancer specific mortality in patients treated with local tumor excision (n=313) Variables Odds ratio (95% CI) p value Age 1.03 (1.00-1.05) 0.03 Race (ref=White) Black/Other 0.15 (0.02-1.21) 0.08 Marrital status (ref=Married) Unmarried 0.75 (0.31-1.80) 0.52 Primary tumor size (ref=< 1) 1-1.9 1.00 (0.19-5.17) 1.00 2-2.9 2.41 (0.50-11.52) 0.27 3-3.9 6.79 (1.32-35.07) 0.02 >4 1.99 (0.35-11.32) 0.44 T-stage (ref=T1) T2-T4 0.49 (0.15-1.55) 0.22 SEER stage (ref=Localized) Regional/Distant 4.83 (1.74-13.38) <0.01 Grade (ref=Grade I) Grade II 0.76 (0.29-2.00) 0.58 Grade III-IV 0.94 (0.27-3.23) 0.92 CI, confidence interval; SEER, Surveillance Epidemiology and End Results Program. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e112-e113 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gu Weijie More articles by this author Zhu Yao More articles by this author Ye Dingwei More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Marking of tumor resection borders for improved radiation planning facilitates reduction of radiation dose to free flap reconstruction in head and neck cancer surgery

Accurate localization of tumor resection borders is crucial for adjuvant radiotherapy. An improvement to adjuvant radiotherapy with the reduction of radiation doses to free flap reconstruction by virtual navigation procedures and titanium clips was evaluated.Thirty-three patients with oral cancer were prospectively included in the study. Following complete local excision of the primary tumor, resection borders were marked virtually using a navigation pointer and with titanium ligature clips. Postoperative delineation of tumor resection borders was examined. In five patients with microvascular free flap reconstruction a reduction of the radiation dose to the free flap reconstruction was achieved. The tumor resection borders in 30 patients were marked with titanium ligature clips. Surgical clip insertion was successful in 91%. We demonstrate a significant relationship between the reconstruction volume and the part of the target volume which will receive a reduced radiation dose. A cumulative dose of 60 Gy was administered to the target volume and a significant reduction of the administered radiation dose to the center of the flap could be demonstrated. We demonstrate an accurate delineation of the tumor resection margins. These improvements in tumor resection margin delineation allow for increased accuracy in adjuvant treatment and a reduction of radiation dose to the vascular free flap reconstruction.

Merkel cell carcinoma of the upper eyelid: when reconstruction becomes a challenge.

Merkel cell carcinoma of the upper eyelid: when reconstruction becomes a challenge.

Plaque radiotherapy for anterior uveal melanomas

To determine the effectiveness of plaque radiation therapy for anterior uveal melanomas and to evaluate the risk and frequency of complications at different time intervals after the treatment. During 2010-2013 a total of 30 patients (10 male, 20 female) aged 11-73 (50 years on the average) with iris or iridociliary melanomas were treated with Ru-106 and Sr-90 ophthalmic plaques. In 8 patients the brachytherapy was preceded by local tumor excision. Morphological diagnosis was verified in 10 patients (8 iridectomies, 2 enucleations), of them 8 cases turned out to be spindle cell melanomas and the other 2--mixed cell melanomas. Follow-up period ranged from 1 to 54 months with the median of 13,5 months. Tumor regression was achieved in all cases. Enucleation had to be performed in 2 patients due to cornea and sclera necrosis. In the early post-brachytherapy period (up to 1 month) the most frequent radiation-related complications were keratopathy and uveitis (8 and 6 patients correspondingly). In patients observed for up to 3 months (28 patients) these were keratopathy and cataract (8 and 5 patients correspondingly). In the long-term (over 6 months) cataract predominated (17 patients). At the end of the study all patients were alive. Metastatic disease was diagnosed in one patient 30 months after the treatment. The results of the present clinical study confirm the effectiveness of brachytherapy for iris and iridociliary melanomas, which implies that tumor is well locally controlled and radiation-related complications are moderate and curable. This method of local tumor destruction can be another alternative to enucleation in cases when local tumor excision cannot be performed.

Long-Term Outcomes of Surgical and Nonsurgical Management of Stage IV Thymoma: A Population-Based Analysis of 282 Patients

The outcomes of patients with stage IV thymoma are derived largely from small patient cohort studies from single institutions. Although surgery is a pillar in the management of early-stage and locally advanced thymoma, resection is more controversial for patients with stage IVA thymoma. Using a large national population database, we set out to define the long-term outcomes of patients treated surgically and nonsurgically for stage IV thymoma. The Surveillance, Epidemiology, and End Results (SEER) database was examined to identify patients with stage IV thymoma (SEER historic stage IV with extension by discontinuous metastases) between 1988 and 2010. By this definition, stage IV included both stage IVA and stage IVB diseases. Surgical management was defined by grouping SEER categories of “radical surgery,” “debulking surgery,” “total surgical removal,” “simple or partial removal,” “surgery not otherwise specified,” “local tumor excision,” and “surgery of regional, distant site.” Nonsurgical management was defined by “no surgery,” “excisional biopsy,” and “incisional biopsy.” Overall survival (OS) and cancer-specific survival (CSS) were calculated from the time of diagnosis with KaplanMeier methods and compared with log-rank tests. For those managed surgically, age, sex, race, radiotherapy, type of procedure, and World Health Organization histology were investigated as prognostic factors with Cox proportional hazard models. P values were considered significant if o0.05. Overall, 110 patients (39.0%) underwent surgical resection and 172 (61.0%) were managed nonsurgically for stage IV thymoma (Table). The follow-up

The Pedicled Lateral Arm Flap for Oncologic Reconstruction Near the Shoulder

Oncologic resections near the shoulder create challenging reconstructive problems. In addition to severe contour defects and the risk for functional deficits resulting from contractures, there may be exposed bone and peripheral nerves rendering simple skin graft closures suboptimal long term. The lateral arm flap is a versatile septofasciocutaneous flap based on the posterior branch of the radial collateral artery in the lateral intermuscular septum of the upper arm. This paper details our experience with 3 patients who underwent wide local excision or radical resection of soft tissue tumors of the upper arm and closure with pedicled lateral arm fasciocutaneous flaps. Flap size ranged from 6 × 10 cm to 5 × 15 cm. Two flaps were transferred as 180-degree pivotal flaps; 1 flap was transferred as an advancement flap. There were no immediate postoperative complications or long-term functional deficits. The pedicled lateral arm flap is a safe and reliable option for soft tissue coverage of anterolateral shoulder defects. The vascular pedicle lies deep within the mid-upper arm and is rarely at risk during extensive tumor extirpation. The adjacent donor site allows for a single operative field without the need for repositioning and furthermore results in a skin paddle requirement that is one half the width of the original defect.

Clinicopathological analysis of 80 patients with duodenum gastrointestinal stromal tumors

To explore the clinicopathological characteristics, efficacy, and prognostic factors for patients with duodenum gastrointestinal stromal tumor(GIST). Clinicopathological and follow-up data of 80 patients with duodenum GIST in the Zhongshan Hospital from January 2000 to December 2013 were analyzed retrospectively. There were 38 male and 42 female patients with a median age of 54 years. The major symptoms were upper alimentary tract hemorrhage and abdominal pain. Thirty-nine patients received local tumor excision, 18 patients underwent segmental duodenectomy, 23 patients were subjected to pancreaticoduodenectomy, all these operations were R0 resection. Thirty patients received imatinib treatment after operation, and 11 among them had metastasis relapse. Recurrence-free survival rates of 1-, 3-, and 5-years were 96.2%, 90.6%and 78.6% retrospectively. Overall survival rates of 1-, 3-, and 5-years were 100%, 98.3% and 96.1%. Multivariate Cox analysis showed tumor size >5 cm, mitotic count >5 mitosis/50 HPF and intermediate/high NIH risk classification were associated with an increased risk of recurrence. The significant difference was not detected between the limited resection group and pancreaticoduodenectomy group in OS and RFS. Surgery is still the main treatment for duodenum GIST. The surgical program is mainly determined by the location and size of tumor. Imatinib therapy should be used if necessary.

Clinical outcome of advanced squamous cell carcinoma of the conjunctiva.

BackgroundTo evaluate the outcome of surgical management of advanced squamous cell carcinoma (SCC) of the conjunctiva (American Joint Committee Cancer—classification >III) and the rate of recurrences after treatment during follow-up. Second, to investigate the incidence of orbital exenteration during follow-up.MethodsThirty-eight cases with SCC >grade T3 AJCC were retrospectively analysed at a University Eye Hospital Munich. Tumour stage, type of treatment, follow-up time, risk factors and—if present—recurrence were documented.ResultsThe mean follow-up was 24.2 months (22.3–71 months). The most frequent surgical procedure was local tumour excision (n=25 patients, 71%). Orbital exenteration was performed in 10 patients (28%). Twenty patients (57%) did not show a progressive disease during follow-up. Of the patients with primary local excision, 13 (52%) had recurrence. Average time to recurrence for all treated patients was 24 months in the mean (minimum 4 months, maximum 68 months, SD, 22). Patients following orbital exenteration had recurrence of disease in 20% (n=2). None of the patients with primarily local tumour excision required an orbital exenteration.ConclusionAdvanced-stage SCC can be treated surgically. An extensive surgical approach is sometimes inevitable. Patients with surgical excision of advanced-stage disease should be reviewed closely as recurrences may occur and even after more than 5 years. However, on early detection, most of these recurrences can be handled by local excision.

Mo1609 Treatment and Survival Disparities of Locoregional Gastroesophageal Cancer in Whites, Blacks and Asian Americans: A SEER-Database Analysis

Background: Cancers that arise from the lower esophagus, esophagogastric junction and gastric cardia, so-called gastroesophageal cancers (GEC), predominantly adenocarcinomas, have trended up rapidly in incidence since the mid-1970s. Despite advances in multimodal therapies for GEC, the overall survival remains poor. African Americans have known worse outcome of GEC, however the reasons are still elusive. Studies on the outcome of GEC in the Asian Americans are sparse. Methods: In this study, we examined the racial differences in receipt of surgery and survival of locoregional GEC among whites, blacks and Asian Americans, using the latest Surveillance Epidemiology and End Results database. Subjects diagnosed with a primary GEC between 1998 and 2010 were extracted along with their demographics, tumorand therapy-related variables. Multivariate logistic regression, KaplanMeier and Cox proportional hazards regression analyses were performed to identify the factors influencing the receipt of surgery and cancer-specific survival using STATA. Results: 12,543 patients, diagnosed with primary GEC, consisting of 11,043 whites, 830 blacks and 526 Asian Americans were included. The Asian Americans had a similar surgical rate as the whites, while the black patients had lower surgical rate than whites [59% vs 80%; OR= 0.53; p<0.001], after controlling for all potential covariates. Specifically, blacks had 39% lower rate of local tumor excision, 32% less partial esophagectomy or gastrectomy, and 62% less total esophagectomy/gastrectomy compared to whites (p<0.05). Additionally, blacks were 2-fold more likely to refuse recommended surgery, and to have unknown or undocumented reasons for not receiving recommended surgery than whites (p < 0.001). The median survivals were 19, 33 and 35 months for blacks, whites and Asian Americans, respectively. Being black was associated with a HR of 1.41 for cancer-specific mortality of GEC compared to white (p < 0.001). After controlling for patient and tumor characteristics, the HR for black vs white was 1.20 (p < 0.001); further adjustment for surgery reduced the difference in hazards to a statistically insignificant value (HR=1.11, p=0.06). Surgery reduced HR of cancers at the midesophagus and lower more pronouncedly than at the cardia for blacks vs whites. In contrast, there was no difference in the survival of GEC between Asian Americans and whites. Conclusions: Blacks had markedly lower rate of surgical intervention and worse survival of locoregional GEC than whites and Asian Americans. The black-white survival differences were more profound for cancers of the midor lower esophagus than that of the cardia. Surgery diminished the survival disadvantages in blacks. More efforts are needed to promote patient education, surgeon-patient communication and close follow up for black patients to improve their survival of GEC.

Validation of the effects of TGF-β1 on tumor recurrence and prognosis through tumor retrieval and cell mechanical properties

BackgroundIn vivo, the transforming growth factor-beta1 (TGF-β1)-induced epithelial to mesenchymal transition (EMT) occurs in seconds during cancer cells intravasation and extravasation. Although it has been established that cellular stiffness can change as a cancer cell transformed, the precise relationship between TGF-β1-induced mesenchymal stem cell mechanics and cancer prognosis remains unclear. Accordingly, it is hard to define the effects of EMT on cell mechanical properties (CMs), tumor recurrence and metastasis risks. This study bridges physical and pathological disciplines to reconcile single-cell mechanical measurements of tumor cells.Methods and resultsWe developed a microplate measurement system (MMS) and revealed the intrinsic divergent tumor composition of retrieval cells by cell stiffness and adhesion force and flow cytometry analysis. After flow cytometry sorting, we could measure the differences in CMs of the Sca-1+-CD44+ (mesenchymal-stem-cell-type) and the other subgroups. As well as the stiffer and heterogeneous compositions among tumor tissues with higher recurrence risk were depicted by MMS and atomic force microscopy (AFM). An in vitro experiment validated that Lewis lung carcinoma (LLC) cells acquired higher CMs and motility after EMT, but abrogated by SB-505124 inhibition. Concomitantly, the CD31, MMP13 and TGF-β1 enriched micro-environment in the tumor was associated with higher recurrence and distal lung metastasis risks. Furthermore, we report a comprehensive effort to correlate CMs to tumor-prognosis indicators, in which a decreased body weight gain ratio (BWG) and increased tumor weight (TW) were correlated with increased CMs.ConclusionsTogether, we determined that TGF-β1 was significantly associated with malignant tumor progressing. In terms of clinical applications, local tumor excision followed by MMS analysis offers an opportunity to predict tumor recurrence and metastasis risks.

Abstract P2-18-18: Improving training in breast surgical oncology: The development and preliminary validation of a simulator for wide local excision

Abstract Background Simulation training has the potential to increase resident confidence in basic procedural tasks prior to operating room (OR) refinements, offsets a reduction in mentoring opportunities, avoids the use of patients for skills practice, and facilitates objective assessment of technical skills. Despite a multitude of benefits, adoption of simulation training and assessment in breast surgical oncology has not been forthcoming. Aims To develop and validate a high-fidelity surgical simulator for the practice, training and assessment of technical skills in wide local excision (WLE) of a palpable breast tumour. Methods Subjects (attendings and residents with an interest in breast surgery, and novice trainees) were invited to perform a WLE of 25mm palpable breast lesion located 30mm from the nipple areolar complex in the 3o clock position, on a synthetic breast simulator developed at Imperial College London as part of the London Deanery Skills Programme. Procedures were videotaped (blind) and were retrospectively reviewed and independently rated against procedure-specific ratings of performance (VAS 0-100) by two expert breast surgeons (&amp;gt;10 years experience). Specimen radiographs were performed (BioVision, Faxitron, USA) and margin of clearance (mm) were calculated from the edge of the “tumour” to the limits of surrounding breast tissue excised in 4 cardinal directions (i.e. N, S, E W). Specimen weights were recorded (g). Subjects completed a comprehensive questionnaire to determine simulator content and face validity. Results 21 subjects participated (5 attendings, 13 registrars, and 3 junior trainees). Data was analysed according to experience (high = &amp;gt;100 independent wide local procedures; low = no independent wide local procedures). Statistically significant (p ≤ 0.05) differences in performance were observed between high and low experience surgeons [for each category data are VAS score medians±IQR; ‘exposure’: low = 70.0±50.0, high = 80.0±20.0; ‘skin flap development’: low = 70.0±50.0, high = 80.0±40.0; ‘resection skills’: low = 60.0±55.0, high = 80.0±45.0; ‘glandular remodelling’: low = 70.0±25.0; high = 80.0±50.0, ‘skin closure’: low = 70.0±25.0, high = 90.0±20.0]. Resection margin width and specimen weight (MWU = 52.5, p = 1.0) did not discriminate high-low experience surgeons. The majority of participants believed that training on the model simulated the same steps as a real WLE (94.7%) and was useful for real practice (84.2%). Discussion Preliminary data on a WLE simulator suggests that the model is face and construct valid, and may be useful to supplement early stage practice prior to skills development in the OR. Video performance ratings whilst time consuming appear to distinguish high-low experience surgeons better than do specimen weight or radiographic margin width. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-18.

Margin negative, breast conserving resection: adequate for benign phyllodes tumors, but inadequate therapy for borderline and malignant phyllodes tumors

(1) Phyllodes tumors are uncommon breast tumors, but are not rare Over a 10-year period 3 % of the breast neoplasms were phyllodes tumors. Benign phyllodes tumors were about ten times more common than malignant, and about five times more common than borderline. In a busy surgical practice of 400 cases per year one could expect to see 12 patients with phyllodes tumors: nine benign, two borderline, and one malignant. (2) Margin negative resection of benign phyllodes tumors is associated with a very low incidence of local recurrence Many previous studies have described the result of local excision or wide local excision of benign phyllodes tumors, without clearly delineating the margin status. In a review of several of these studies in 1999, we found that benign phyllodes tumors recurred after local excision in 21 % of cases and after wide local excision in 8 % [2]. Since one may have a positive margin even after an attempted wide local excision, the key variable is the margin status. Kim et al. have now described 114 patients who underwent margin negative, breast conserving resections of benign phyllodes tumors with only four local recurrences (3.5 %). Achieving a margin negative resection, while optimizing cosmesis by excising a minimal amount of surrounding breast tissue is optimal treatment for patients with benign phyllodes tumors. (3) The histologic grade of phyllodes tumor (benign vs borderline vs malignant) predicts the likelihood of local recurrence after margin negative resection Kim et al. report that the chance of a local recurrence after breast conserving, margin negative resection of benign, borderline, and malignant phyllodes tumors is 4/114 (3.5 %), 4/23 (17.4 %), and 5/10 (50 %), respectively. (4) The risk of local recurrence after margin negative resection of borderline or malignant phyllodes tumors is substantial We have previously reviewed the literature on the incidence of local recurrence after margin negative breast conserving resection of borderline and malignant phyllodes tumors [3]. In that review, 12/50 (24 %) patients with borderline phyllodes tumors and 25/124 (20 %) patients with malignant phyllodes tumors locally recurred. Adding the data from Kim et al., the risk of local recurrence after margin negative breast conserving resection of borderline and malignant phyllodes tumors is 16/73 (22 %), and 30/134 (22 %), respectively. The similarity in rates of local recurrence of borderline and malignant phyllodes tumors may be explained by recent molecular evidence that these tumor grades share similar genetic profiles. Comparative genomic hybridization analyses, which quantify chromosomal copy number gains and losses, indicate that phyllodes tumors segregate into two groups, with the borderline and malignant group having much This is an invited commentary to article doi: 10.1007/s10549-0132684-x.

Single‐incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum

We report a case involving a minimally invasive single-incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59-year-old man presented with a 35-mm lesion located in the second portion of the duodenum. A local resection was performed via single-incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single-incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.

Survival Outcome of Local Excision versus Radical Resection of Colon or Rectal Carcinoma

To compare cancer-specific results of local excision with major resection. Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical surgery. Patients with stage 0 (carcinoma in situ) or stage I (T1/2N0M0) adenocarcinoma of the colon or rectum undergoing surgery between 1998 and 2009 were included from the SEER (Surveillance, Epidemiology, and End Results) database. Local excision (endoscopic or surgical) was compared with major surgical resection using adjusted hazard ratios (HRs) for 5-year cancer-specific survival (CSS). This study included 7378 local excisions and 36,116 major resections. There were 3553 patients with carcinoma in situ and 39,941 with clinical stage I cancer. Local tumor excision for carcinoma in situ was associated with equivalent CSS compared to major resection (HRs = 1.06, P = 0.814, for colon and 0.78, P = 0.494, for rectum). Local excision of T1 and T2 colon cancer was associated with reduced CSS (HR = 1.31, P = 0.020, and 2.89, P < 0.001, respectively). Local excision of T1 rectal cancer did not affect CSS (HR = 1.16, P = 0.236), but it significantly reduced CSS for T2 cancer (HR = 1.71, P < 0.001). Subgroup analysis of T1 and T2 rectal cancer after neoadjuvant therapy and local excision showed oncological equivalence to major resection (HR = 1.12, P = 0.802, and 1.23, P = 0.802). Local excision for early colorectal cancer was oncologically equivalent to major surgery for carcinoma in situ and T1 rectal cancer, but inferior for T1-2 colon and T2 rectal cancer. Exploratory data suggest local excision of T1-2 rectal cancer after neoadjuvant therapy may be safe.

Novel risk factors for lymph node metastasis in early invasive colorectal cancer: a multi-institution pathology review

Novel risk factors for lymph node metastasis (LNM) in T1 colorectal cancer (CRC) have been recently proposed, but most have not been implemented because of the lack of validation. Here we determined the value of poorly differentiated clusters (PDCs) in a multi-institutional cohort of T1 CRC cases. A pathology review involving 30 institutions was conducted for 3556 T1 CRCs. PDC was defined as malignant clusters comprising ≥5 cells and lacking a glandular formation. The ability to identify LNM risk was compared using Akaike's information criterion (AIC). PDC was observed in 1401 tumors (39.4 %), including 94 (17.8 %) with <1000 µm submucosal invasion and 1307 (43.2 %) with ≥1000 µm submucosal invasion (P < 0.0001). The incidence of LNM was higher in PDC-positive tumors (17.4 %) than in PDC-negative tumors (6.9 %; P < 0.0001), and PDCs had an adverse impact on LNM irrespective of the degree of submucosal invasion. Grade 3, vascular invasion, budding, and submucosal invasion depth were also significant factors (all, P < 0.0001). AIC of risk factor to identify LNM risk was most favorable for vascular invasion (2273.4), followed by PDC (2357.4); submucosal invasion depth (2429.1) was the most unfavorable. Interinstitutional judgment disparities were smaller in PDC (kappa, 0.51) than vascular invasion (0.33) or tumor grade (0.48). PDC is a promising new parameter with good ability to identify LNM risk. Use of its appropriate judgment criteria will enable us determine whether an observational policy can be safely applied following local tumor excision in T1 CRC cases.

Transanal minimally invasive surgery (TAMIS) for local excision of rectal tumors

Transanal excision is a possible approach to rectal lesion. In TAMIS (Trans Anal Minimally Invasive Surgery) a single-incision laparoscopic access port (SILS Port) is used to allow precise dissection and radical removal of rectal neoplasms, both benign and, in selected cases, malignant.

Transanal minimally invasive surgery (TAMIS) using a new disposable device: our initial experience

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS). Their advantage, compared to transanal endoscopic microsurgery, is that they do not require special equipment or training. The aim of this study was to assess our initial experience using the single-site laparoscopic (SSL™) access system (Ethicon Endo-Surgery, Cincinnati, OH, USA) for TAMIS. Five patients eligible for local excision of rectal tumors, four males and one female, mean age 58years (range 50-78), underwent surgery using the SSL™device. The average distance from anal verge was 4cm (range 1-6). Four patients had an initial diagnosis of adenoma, and one had a previous endoscopic excision of a T1 adenocarcinoma with positive margins. In one patient, due to the lack of exposure, the procedure was converted to a low anterior resection. In the remaining four patients, average setup time was 7minutes (range 4-15) and average operative time was 52minutes (range 38-72). All resection margins were tumor free. There were no postoperative complications. Two of the presumed adenomas were intramucosal adenocarcinomas, while one patient had a T2 tumor and underwent radical surgery. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique with great potential. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily by surgeons not trained in transanal endoscopic microsurgery.

Vulvar cancer: Presentation and treatment variation among races.

5611 Background: Vulvar cancer is the fourth most common gynecologic malignancy. We analyzed variation among races in treatment, histology and stage at presentation using the National Cancer Database (NCDB). Methods: Between 2000 and 2010, 51,157 women from 1338 hospitals across the US were reported to the NCDB with vulvar cancer. Differences were assessed using Chi square analysis. Results: Caucasian patients with vulvar carcinoma in situ received no first course treatment significantly less than African American or Hispanic patients (3% vs 6% and 7%, p&lt;0.05). No treatment for stage I and II vulvar cancer was also significantly less than African American patients (1.4% vs 2.5%, p&lt;0.05). African Americans overall chose radical surgery less often than Caucasians (13% vs 16%, p&lt;0.05), but local tumor excision more (29% vs 24%, p&lt;0.05). African Americans and Hispanics chose no surgery of primary sites significantly more than Caucasians (14% and 15% vs 9%, p&lt;0.05). As expected, squamous cell carcinoma accounts for over 90% of vulvar cancer cases reported. However, Asian-Pacific Islanders had a significantly higher proportion of Extramammary Paget’s disease when compared to Caucasians, African Americans, or Hispanics (20% vs 4.3%, 0.6%, 3.2%. p&lt;0.05). African Americans had the lowest proportion of Extramammary Paget’s compared to any other race for all stages (0.6%, p&lt;0.05). African Americans presented as vulvar carcinoma in situ more often than any other race (33% vs 25-29%, p&lt;0.05). Conclusions: This is the largest study analyzing racial differences in treatment, histology and stage at presentation in women with vulvar cancer. Caucasians were least likely to opt for no first course treatment overall. African Americans were most likely to choose no treatment and, when having surgery, preferred local excision over radical vulvectomy.

Cytokeratin-positive interstitial reticulum cell sarcoma: Extranodal presentations mimicking carcinoma

Cytokeratin-positive interstitial reticulum cell (CIRC) sarcoma is a rare type of dendritic cell tumor derived from a subset of fibroblastic reticular cells. Expression of cytokeratins and extranodal location of these tumors can lead to a misdiagnosis of carcinoma. We report two cases of CIRC sarcomas primarily involving the scalp and breast. Patients were referred with an initial diagnosis of carcinoma. Case 1 underwent wide local excision of the scalp tumor with left posterolateral neck dissection. Case 2 had modified radical mastectomy for the tumor in left breast. Histopathological examination of both specimens showed an epithelioid to spindle cell malignant tumor that co-expressed CK 8, CK 18, vimentin, and smooth muscle actin. A diagnosis of CIRC sarcoma was made. Pathologists should be aware of this subset of dendritic cell sarcoma. Carcinomas, other sarcomas of the accessory dendritic cell family, and poorly differentiated malignant tumors have to be ruled out by combination of morphology, immunohistochemistry, and electron microscopic studies.