Positive Resection Margins Research Articles

A South African central hospital's experience with malignant colorectal obstruction.

The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting. A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded. Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32). One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

The role of image-guided volume-adapted high-dose-rate endorectal brachytherapy boost in total neoadjuvant treatment of distal locally advanced rectal cancer.

3611 Background: Endorectal brachytherapy has been used as palliative or preoperative treatment for advanced or locally advanced rectal cancer, with moderate radiation induced toxicity. This study aimed to explore the efficacy of high-dose-rate 192Ir brachytherapy combined with external beam radiotherapy (EBRT) in total neoajuvant treatment (TNT) of distal rectal cancer. Methods: From January 2017 to December 2022, eligible rectal adenocarcinoma patients were assessed as clinical stage II -III, with primary tumor located in distal rectum (≤5 cm from anal verge). The local staging was determined using endorectal ultrasound and magnetic resonance imaging (MRI). In addition, cases included in this study underwent preoperative semiweekly endorectal brachytherapy of 8-12Gy/2-3F/1-1.5w, followed by EBRT of 45-50.4Gy/25-28F, fluorouracil-based concurrent and consolidation chemotherapy. The brachytherapy was image-guided volume-adapted, and delivered by multi-channel 192Ir source applicators with different diameters. Radiation proctitis was graded from 0 to 4 using Radiation Therapy Oncology Group (RTOG) criteria. Results: A total of 40 cases were enrolled in this retrospective study, biopsy-proven and diagnosed as clinical stage II (n = 8), stage III (n = 32). The rates of T4 and positive circumferential resection margin (CRM) were 35% and 87.5% respectively. The median value of the interval from completion of radiotherapy to operation was 86 days (interquartile range: 75-98 days). After neoadjuvant treatment, 2 cases were undergoing the watch-and-wait strategy with sustained clinical complete response (cCR), 38 patients received operation and R0 resection rate was 97.4%. The pathological complete response (pCR) rate was 28.9%, and major pathological regression rate was 67.5%. The theoretical rate of anus preservation was 62.5%, including 6 of 21 cases underwent abdominoperineal resection but achieved pCR, 17 cases underwent low anterior resection or intersphincteric resection, and 2 cases with sustained cCR. After a median follow-up of 37 months (range 12-68 months), the 3-year disease-free survival, local-regional reccurence-free survival and overall survival was 81.1% (95%CI: 64.3%-91.2%), 94.9% (95%CI: 80.6%-98.5%) and 96.9% (95%CI: 82.1%-99.4%), respectively. No patients experienced Grade ≥3 radiation proctitis. The median Wexner fecal incontinence score of anus-preserving cases was 1 (range 0-8). Subgroup analysis showed that the complete response rate (pCR or sustained cCR) was lower in cases received 2 fractions brachytherapy than those received 3 fractions (27.8% vs 36.4%). Conclusions: The addition of image-guided volume-adapted high-dose-rate 192Ir endorectal brachytherapy boost to TNT could improve the pathological tumor response and anus preservation rate in distal locally advanced rectal cancer.

Impact of positive resection margins on recurrence and survival following resection and adjuvant chemotherapy in pancreatic cancer: Results of the PRODIGE 24-CCTG PA-6 trial.

4160 Background: Pancreatic adenocarcinoma (PDAC) has a poor prognosis. Only 10-15% of patients present with resectable tumors upfront, and most patients develop recurrence and die prematurely. The data are incongruous when considering R1 status, direct invasion is not consistently a significant prognostic factor. It is recommended that 7 margins be identified for surgery: the bile duct, pancreatic neck, proximal and distal duodenum, superior mesenteric vein (SMV), superior mesenteric artery (SMA), and posterior pancreas. By analyzing data from the PRODIGE 24-CCTG PA-6 trial that validated the mFOLFIRINOX regimen in adjuvant setting, our main objective was to analyze the prognostic value of margin involvement on disease-free survival (DFS). Methods: The protocol recommended that the surgeon inked the resection margins. R1 was defined as direct tumor margin infiltration within 1 mm of one or more resection margins. All patient data were re-evaluated centrally by an external review committee including pathologists, surgeons, and medical oncologists to verify key prognostic factors, including inking and filling of resection margins. Results: Among the 400 patients included in the study, the median number of documented margins was 6, IQR (5-7). In 214 patients (53.5%), fewer than 7 margins were reported. The most common margin involvement was on the SMV groove (28.3%), posterior margin (21%), SMA (14.5%), and pancreatic neck transection (5.3%). Margin inking was performed in 64.9% of cases. Misclassification of the R1 status concerned 24.1% of the files after centralized review. When positive, only 3 margins (SMV groove, median and posterior) were significant prognostic factors in unifactorial analysis (all p < 0.01). When combined, one R1 margin among these three had independent prognostic value in multivariable analysis. In multivariate analysis, DFS was significantly different by quality of resection margins in the gemcitabine arm (HR 95% CI 1.97 [1.23;3.16]; p = .005) but not in the mFOLFIRINOX arm (HR 95% CI 1.46 [0.91;2.35]; p = .114). Conclusions: Few studies have examined the prognostic implications of each margin. We consider that every effort should be made to evaluate the 3 best prognostic margins. One finding of this work is the likely effect of mFOLFIRINOX on local invasion in operated patients. It seems that this chemotherapy regimen (unlike gemcitabine) corrects the alteration related to margin involvement, probably explaining all or part of the improved survival. Therefore, the value of additional therapies, such as cloture radiotherapy, should be evaluated in patients with unknown marginal status or in those who did not benefit from mFOLFIRINOX chemotherapy. A patient who received mFOLFIRINOX as adjuvant therapy is more likely to recur with distant metastasis (80%) and with a better survival of 28 months. Clinical trial information: NCT01526135 .

Clinicopathological Factors Influencing Resection Margin Involvement During Mohs Micrographic Surgery for Skin Tumors.

Mohs micrographic surgery (MMS) is a specialized procedure for removing skin tumors. Intraoperative assessment of the resection margin (RM) status using frozen section examination is a crucial component of MMS. This study aimed to identify significant clinicopathological characteristics that could help surgeons determine the optimal surgical extent. One hundred and fifty-one patients with primary skin tumors were included. The relationship between RM involvement and the clinico-pathological characteristics was analyzed for each histological type. Basal cell carcinoma (BCC) was significantly more likely to exhibit positive RMs and required additional excision during MMS compared to squamous cell carcinoma. In addition, the probability of RM involvement was significantly higher in high-risk BCC subtypes. When planning MMS, considering the histological type and presence of high-risk morphology may help surgeons perform more effective procedures.

Extension of resection after positive intraoperative pathology during surgery for gastric and gastroesophageal junction adenocarcinoma - a retrospective cohort study.

Residual tumor at the resection margins after surgery for gastric and gastroesophageal junction (GEJ) adenocarcinoma is a known prognostic factor. In this single-center, retrospective cohort study in a tertiary referral center, we aimed to evaluate the relevance of intraoperative pathology consultation (IOC) and consecutive extension of surgery on patient survival. Of 737 consecutive patients undergoing (sub)total gastrectomy for gastric or GEJ adenocarcinoma, 679 cases with curative intent surgery between 05/1996 and 03/2019 were included. Patients were categorized into: i) R0 without further resection (direct R0), ii) R0 after positive IOC and extension of resection (converted R0) and iii) R1. IOC was performed in 242 (35.6%) patients, in 216 (89.3%) at the proximal resection margin. Direct R0 status was achieved in 598 (88.1%), converted R0 in 26 (3.8%) of 38 (5.6%) patients with positive IOC and R1 in 55 (8.1%) patients. Median follow-up was 29 months for surviving patients. 3-year survival rate (3-YSR) was significantly higher for direct R0 compared to converted R0 with 62.3% compared to 21.8% (hazard ratio (HR)=0.298; 95%CI=0.186-0.477, P<0.001). 3-YSR was similar between converted R0 and R1 (21.8% vs. 13.3%; HR=0.928; 95%CI=0.526-1.636, P=0.792). In multivariate analysis, advanced T (P<0.001), N (P<0.001), R (P=0.003) and M1 status (P<0.001) were associated with worse overall survival (OS). IOC and consecutive extended resection for positive resection margins in gastrectomy for proximal gastric and gastroesophageal junction does not achieve long-term survival benefits in advanced tumor stages.

Real-world data on prostate cancer: the VERSUS trial by d-uo

At the beginning of 2017, the German Society of Uro-Oncologists (d-uo) had the idea of designing a documentation platform that would enable d-uo members to report cancer cases to the cancer registry and transfer data to d-uo's own database - without a double effort. The cancer registry reimburses the first notification of a tumour with €18. As the only provider, d-uo reimburses its members for the documentation effort associated with the additional notification to d-uo with a further €18. In addition to the basic oncological data set, further parameters were defined by d-uo. This data is collected, evaluated and interpreted as part of the VERSUS study. At the end of 2022, 14,834 patients with a newly diagnosed urological tumour were included in the VERSUS study. Almost two thirds of all patients had prostate cancer. About half of all patients with prostate cancer were diagnosed as part of an early detection measure. These patients then also had more favourable tumour stages. Overall, almost every eighth patient already had metastases at the time of initial diagnosis. Data from the VERSUS study are available for 2,167 operations on prostate cancer with tumour category T2 or T3. There were 1,360 operations in patients with a T2 tumour (62.8%) and 807 operations in patients with T3 tumours (37.2%). A positive margin was present in 25.5% of all operated-on patients. In relation to tumour categories T2 and T3, the proportion of a positive resection margin was 14.3% and 44.2%, respectively. The VERSUS study will continue to provide answers to many questions from the uro-oncological field with reference to the "real world" situation in Germany.

Resultados oncológicos del tratamiento de rescate en pacientes con carcinomas de orofaringe tratados con radioterapia

ObjectiveTo evaluate the possibilities of salvage after local recurrence in patients with oropharyngeal carcinomas treated with radiotherapy, and to analyze the prognostic factors related to the final control of the disease. MethodsRetrospective study of 596 patients with oropharyngeal carcinoma treated with radiotherapy during the period 1991–2018. ResultsOne hundred and eighty-one patients (30.4%) had a local recurrence. Of the patients with a local recurrence, 51 (28.2%) were treated with salvage surgery. Variables that were associated with the patient not receiving salvage surgery were age greater than 75 years, tumor location in the posterior hypopharyngeal wall, an initial tumor extent cT4, and a recurrence-free interval of less than 6 months. Five-year specific survival of patients treated with salvage surgery was 19.1% (95% CI: 7.3%–30.9%). Variables that were related to specific survival were extent of recurrence and status of resection margins. Final tumor control was not achieved in any of the patients with extensive recurrence (rpT3-4, n=25) or positive resection margins (n=22). ConclusionPatients with oropharyngeal carcinomas treated with radiotherapy with local tumor recurrence have a limited prognosis. Most patients (71.8%) were not considered candidates for salvage surgery. The 5-year specific survival of patients treated with salvage surgery was 19.1%.

The Potential Role of Adjuvant Chemoradiotherapy in Patients with Microscopically Positive (R1) Surgical Margins after Resection of Cholangiocarcinoma.

(1) Background: Biliary tract cancers (BTCs) are a heterogeneous group of neoplasms with dismal prognosis and the role of adjuvant chemoradiotherapy in high-risk resected patients is unclear. (2) Methods: We retrospectively analyzed the outcomes of BTC patients who received curative intent surgery with microscopically positive resection margins (R1) and adjuvant chemoradioradiotherapy (CCRT) or chemotherapy (CHT) from January 2001 to December 201. (3) Results: Out of 65 patients who underwent R1 resection, 26 received adjuvant CHT and 39 adjuvant CCRT. The median recurrence-free survival (RFS) in the CHT and CHRT groups was 13.2 and 26.8 months, respectively (p = 0.41). Median overall survival (OS) was higher in the CHRT group (41.9 months) as compared to the CHT group (32.2 months), but the difference was not statistically significant (HR 0.88; p = 0.7). A promising trend in favor of CHRT was observed in N0 patients. Finally, no statistically significant differences were observed between patients undergoing adjuvant CHRT after R1 resection and patients treated with chemotherapy alone after R0 surgery. (4) Conclusions: Our study did not show a significant survival benefit with adjuvant CHRT over CHT alone in BTC patients with positive resection margins, while a promising trend was observed.

Intraoperative evaluation of the resection margin with the usage of digital two-point sectorography (Faxitron PathVision)

Background. Surgery is fundamental in complex and combined approach in the treatment of the early breast cancer. It is a common fact, that absence of tumor cells in the resection margin is the main indicator of oncological safety of the breast-conserving surgery (BCS). The presence of tumor cells in examined margin is the predictor of local recurrence after BCS for breast cancer. Currently the clinical need for precise and fast method of intraoperative assessment of the resection margin status is kept. Intraoperative evaluation of the resection margin with the usage of digital two-point sectorography (Faxitron PathVision) appeared as the alternative to intraoperative histological examination, providing the optimum size of the information about adequacy of the carried out surgical treatment.Aim. To evaluate diagnostic features of the digital two-point sectorography Faxitron PathVision in the intraoperative assessment of the resection margin status after the surgical treatment in comparison with planned histologic examination.Materials and methods. 368 conducted conservative surgeries were analyzed; patients were divided in two groups depending on neoadjuvant chemotherapy. The first group of patients included 236 patients, who didn't receive neoadjuvant chemotherapy before surgery; second group included 132 patients, who received neoadjuvant chemotherapy. Subset analysis of detection rate of the positive resection margin (R1) was carried out with the usage of the intraoperative assessment of the resection margin on the X-ray device Faxitron PathVision or without this method. After each BCS resection margin status was assessed on planned histologic examination for the presence of the tumor cells, with subsequent analysis of the frequency of reoperations when R1 was found.Results. In 368 tested surgical specimens after BCS R1 was found in 25 cases, which is 6.8 %. From 236 patients in the first group after BCS R1 was found in 20 cases, which is 8.5 %; from 132 conducted operations in the second group in 5 (3.8 %) cases the presence of R1 is found. Reoperations were performed in 13 cases and tumor cells were found in 3 cases in the sub-group which didn't receive intraoperative assessment with X-ray device Faxitron PathVision.Conclusions. Assessing the results of our study we can make a conclusion about the positive experience of performing BCS and intraoperative evaluation of the resection margin with the usage of the digital two-point sectorography (Faxitron PathVision) and low frequency of R1 (3.8 %) in comparison with absence of this method (8.5 %).

Resection margin status at the portomesenteric axis may not determine oncologic outcome after pancreaticoduodenectomy for lymph node-positive pancreatic ductal adenocarcinoma

Lymph node and resection margin status are associated with oncologic outcomes after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. However, surgical radicality at the portomesenteric axis in case of suspected infiltration remains controversial. Clinicopathological data of patients who underwent a partial or total pancreaticoduodenectomy for PDAC between 2012 to 2019 in 2 major hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We evaluated the impact of positive resection margins at the vascular, parenchymal, and retropancreatic surfaces on overall survival in patients with and without lymph node involvement. Margin-positive vascular resection included both patients with positive margins at the vascular groove and the resected venous wall. During the study period, 217 patients underwent partial/total pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. After excluding 7 patients suffering postoperative complications resulting in mortality within 90 days after surgery (3%), 169 patients had lymph node involvement (80%). In the entire study cohort, margin-positive resection (33%) was significantly associated with worse overall survival (3-year overall survival: margin-positive resection: 27% vs margin-negative resection: 43%, P= .014). Among patients with positive lymph nodes, margin-positive vascular resection (n= 48, 28%) was not significantly associated with impaired overall survival (3-year overall survival: margin-positive vascular resection: 28% vs margin-negative vascular resection: 36%, P= .065). On the contrary, margin-positive parenchymal resection (n= 7, 4%) (3-year overall survival: margin-positive parenchymal resection: 0% vs margin-negative parenchymal resection: 35%, P < .0001) and margin-positive retropancreatic resection (n= 21, 12%) (3-year overall survival: margin-positive retropancreatic resection: 6% vs margin-negative retropancreatic resection: 39%, P < .0001) significantly diminished overall survival in univariate and multivariate analysis in all patients. Among patients without lymph node involvement (n= 41, 20%), there were no margin-positive parenchymal or margin-positive retropancreatic resections. In contrast, only 5 patients had margin-positive vascular resection (12%), with overall survival compared to those with margin-negative vascular resection. In patients with pancreatic ductal adenocarcinoma and lymph nodal positivity, resection status at the parenchymal and retropancreatic surface but probably not at the portal and/or superior mesenteric vein is a determinant of survival. Therefore, margin-negative resection should be pursued during pancreaticoduodenectomy. However, radical venous resection and/or reconstruction for suspected tumor infiltration may not be necessary for patients with intraoperatively detected lymph node metastases.

Prognostic factors after resection of locally advanced non-functional pancreatic neuroendocrine neoplasm: an analysis from the German Cancer Registry Group of the Society of German Tumor Centers

ObjectiveThe available literature regarding outcome after pancreatic resection in locally advanced non-functional pNEN (LA-pNEN) is sparse. Therefore, this study evaluates the current survival outcomes and prognostic factors in after resection of LA-pNEN.Materials and methodsThis population-based analysis was derived from 17 German cancer registries from 2000 to 2019. Patients with upfront resected non-functional non-metastatic LA-pNEN were included.ResultsOut of 2776 patients with pNEN, 277 met the inclusion criteria. 137 (45%) of the patients were female. The median age was 63 ± 18 years. Lymph node metastasis was present in 45%. G1, G2 and G3 pNEN were found in 39%, 47% and 14% of the patients, respectively. Resection of LA-pNEN resulted in favorable 3-, 5- and 10-year overall survival of 79%, 74%, and 47%. Positive resection margin was the only potentially modifiable independent prognostic factor for overall survival (HR 1.93, 95% CI 1.71–3.69, p value = 0.046), whereas tumor grade G3 (HR 5.26, 95% CI 2.09–13.25, p value < 0.001) and lymphangiosis (HR 2.35, 95% CI 1.20–4.59, p value = 0.012) were the only independent prognostic factors for disease-free survival.ConclusionResection of LA-pNEN is feasible and associated with favorable overall survival. G1 LA-pNEN with negative resection margins and absence of lymph node metastasis and lymphangiosis might be considered as cured, while those not fulfilling these criteria might be considered as a high-risk group for disease progression. Herein, negative resection margins represent the only potentially modifiable prognostic factor in LA-pNEN but seem to be influenced by tumor grade.

Risk Factors of Positive Resection Margin in Hepatectomy for Resectable Ruptured Hepatocellular Carcinoma: Risk Prediction and Prognosis

Background and AimClinical work has revealed that hepatectomy for resectable ruptured hepatocellular carcinoma (rHCC) has a relatively high percentage of positive resection margins found in postoperative pathology. It is necessary to evaluate the risk factors associated with R1 resection in patients undergoing hepatectomy for rHCC. MethodsA total of 408 patients with resectable rHCC originating from three centers undergoing surgery from January 2012 to January 2020 were consecutively enrolled in the study to study the prognostic impact of R1 resection using Kaplan–Meier plotting of survival curves. One center with 280 served as the training group, and the other two centers served as the validation group. Multivariate logistic regression analysis screened for variables affecting R1 and developed prediction models, and the models were tested in the validation cohort using the receiver operating characteristic curves (ROC) and calibration curves. ResultsThe prognosis of rHCC patients with positive cut margins was worse than that of patients with R0 resection. Risk factors for R1 resection were tumor max length (OR = 2.668 [1.161–6.131]), microvascular invasion (MVI) (OR = 3.655 [1.766–7.566]), times of hepatic inflow occlusion (1/0:OR = 2.213 [1.113–4.399]; 2/0:OR = 5.723 [2.010–8.289]) and timing of hepatectomy (OR = 5.284 [2.394–9.661]), using tumor max length, times of HIO, and timing of hepatectomy to construct the nomogram, the area under the curve of the model was 0.810 (0.781–0.842) and 0.782 (0.752–0.805) in the training and validation groups, respectively, and the calibration curve of the model was basically on the 45° line. ConclusionsThis study constructs a clinical model to predict R1 resection after hepatectomy for resectable rHCC, which can be used to better plan perioperative strategies for the incidence of R1 resection during hepatectomy.

Robotic and laparoscopic colectomy: propensity score-matched outcomes from a national cancer database

Laparoscopic and robotic approaches to colonic cancer surgery appear to provide similar outcomes. The present study aimed to compare short-term and survival outcomes of laparoscopic and robotic colectomy for colonic cancer. This retrospective review of patients with stage I-III colonic cancer who underwent laparoscopic or robotic colonic resection was undertaken using data from the National Cancer Database (2013-2019). Patients were matched using the propensity score matching method. The primary outcome was 5-year overall survival. Secondary outcomes included conversion to open surgery, duration of hospital stay, 30- and 90-day mortality, unplanned readmission, and positive resection margins. The original cohort included 40 457 patients with stage I-III colonic adenocarcinoma, with a mean(s.d.) age of 67.4(12.9) years. Some 33 860 (83.7 per cent) and 6597 (17.3 per cent) patients underwent laparoscopic and robotic colectomy respectively. After matching, 6210 patients were included in each group. Robotic colectomy was associated with marginally longer overall survival for women, and patients with a Charlson score of 0, stage II-III disease or left-sided tumours. The robotic group had a significantly lower rate of conversion (6.6 versus 11 per cent; P < 0.001) and shorter hospital stay (median 3 versus 4 days) than the laparoscopic group. The two groups had similar rates of 30-day mortality (1.3 versus 1 per cent for laparoscopic and robotic procedures respectively), 90-day mortality (2.1 versus 1.8 per cent), 30-day unplanned readmission (3.7 versus 3.8 per cent), and positive resection margins (2.8 versus 2.5 per cent). In this study population, robotic colectomy was associated with less conversion to open surgery and a shorter hospital stay compared with laparoscopic colectomy.

Large (>4 cm) Intrathyroidal Encapsulated Well-Differentiated Follicular Cell-Derived Carcinoma Without Vascular Invasion May Have Negligible Risk of Recurrence Even When Treated with Lobectomy Alone.

Background: Thyroid carcinoma >4 cm in size is staged as T3a. The current American Thyroid Association guidelines recommend subtotal/total thyroidectomy and consideration for postoperative radioactive iodine (RAI) treatment for these tumors. In this retrospective cohort study, we aimed to explore the clinical course of large encapsulated thyroid carcinoma without other risk factors. Methods: Eighty-eight patients with large (>4 cm) encapsulated well-differentiated thyroid carcinoma resected between 1995 and 2021 were included in this retrospective cohort study. Exclusion criteria were tall cell variant, any extent of vascular invasion, extrathyroidal extension (microscopic or gross), high-grade histology, noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), infiltrative tumors, positive resection margin, and cases with follow-up <1 year. The primary outcomes are risk of nodal metastasis at the initial resection, disease-free survival (DFS), and disease-specific survival (DSS). Results: The tumor histotype was follicular carcinoma (n = 18, 21%), oncocytic (Hurthle cell) carcinoma (n = 8, 9%), and papillary thyroid carcinoma (PTC; n = 62, 70%). Among PTC, 38 were encapsulated follicular variant, 20 classic type, and 4 solid variant. Four cases had extensive capsular invasion (CI), 61 (69%) had focal CI, whereas 23 did not have CI. Thirty-two cases (36%) were treated with lobectomy/hemithyroidectomy alone, and 55 patients (62%) did not receive RAI. Five patients had nodal metastasis at the time of primary resection, all of whom had classic-type PTC. The median follow-up period was 4.8 years (interquartile range: 3.2-9.7 years). No recurrence, being local, regional, or distant, was observed in the entire cohort, including those patients treated with lobectomy alone without RAI. The 10-year DFS and DSS were 100%, respectively. Conclusion: Large intrathyroidal encapsulated well-differentiated thyroid carcinoma without vascular invasion follow an extremely indolent clinical course with negligible risk of recurrence. Lobectomy alone without RAI may be the appropriate treatment strategy for this selected group of patients.

Salivary Gland Secretory Carcinoma: Clinicopathologic and Genetic Characteristics of 215 Cases and Proposal for a Grading System.

Salivary gland secretory carcinoma (SC), previously mammary analog SC, is a low-grade malignancy characterized by well-defined morphology and an immunohistochemical and genetic profile identical to SC of the breast. Translocation t(12;15)(p13;q25) resulting in the ETV6::NTRK3 gene fusion is a characteristic feature of SC along with S100 protein and mammaglobin immunopositivity. The spectrum of genetic alterations for SC continues to evolve. The aim of this retrospective study was to collect data of salivary gland SCs and to correlate their histologic, immunohistochemical, and molecular genetic data with clinical behavior and long-term follow-up. In this large retrospective study, we aimed to establish a histologic grading scheme and scoring system. A total of 215 cases of salivary gland SCs diagnosed between 1994 and 2021 were obtained from the tumor registries of the authors. Eighty cases were originally diagnosed as something other than SC, most frequently acinic cell carcinoma. Lymph node metastases were identified in 17.1% (20/117 cases with available data), with distant metastasis in 5.1% (6/117). Disease recurrence was seen in 15% (n=17/113 cases with available data). The molecular genetic profile showed ETV6::NTRK3 gene fusion in 95.4%, including 1 case with a dual fusion of ETV6::NTRK3 and MYB::SMR3B. Less frequent fusion transcripts included ETV6::RET (n=12) and VIM::RET (n=1). A 3-tiered grading scheme using 6 pathologic parameters (prevailing architecture, pleomorphism, tumor necrosis, perineural invasion (PNI), lymphovascular invasion (LVI), and mitotic count and/or Ki-67 labeling index) was applied. Grade 1 histology was observed in 44.7% (n=96), grade 2 in 41.9% (n=90), and grade 3 in 13.5% (n=29) of cases. Compared with low-grade and intermediate-grade SC, high-grade tumors were associated with a solid architecture, more prominent hyalinization, infiltrative tumor borders, nuclear pleomorphism, presence of PNI and/or LVI, and Ki-67 proliferative index >30%. High-grade transformation, a subset of grade 2 or 3 tumors, seen in 8.8% (n=19), was defined as an abrupt transformation of conventional SC into high-grade morphology, sheet-like growth, and a tumor lacking distinctive features of SC. Both overall survival and disease-free survival (5 and 10y) were negatively affected by tumor grade, stage, and TNM status (each P<0.0001). SC is a low-grade malignancy with predominantly solid-microcystic growth patterns, driven by a gene fusion, most commonly ETV6::NTRK3. There is a low risk for local recurrence and a good overall long-term survival, with a low risk for distant metastasis but a higher risk for locoregional lymph node metastasis. The presence of tumor necrosis, hyalinization, PNI and/or LVI, and positive resection margins correlate with higher tumor grade, less favorable prognosis, and increased mortality. The statistical results allowed us to design a 3-tiered grading system for salivary SC.

MP42-16 BLADDER PRESERVATION OR COMPLETE CYSTECTOMY DURING PELVIC EXENTERATION OF PATIENTS WITH RECTAL CANCER. WHAT SHOULD WE DO?

You have accessJournal of UrologyCME1 Apr 2023MP42-16 BLADDER PRESERVATION OR COMPLETE CYSTECTOMY DURING PELVIC EXENTERATION OF PATIENTS WITH RECTAL CANCER. WHAT SHOULD WE DO? Catalina Palma, Charlotte Van Kessel, Michael Solomon, Scott Leslie, Nicola Jeffery, Peter Lee, and Kirk Austin Catalina PalmaCatalina Palma More articles by this author , Charlotte Van KesselCharlotte Van Kessel More articles by this author , Michael SolomonMichael Solomon More articles by this author , Scott LeslieScott Leslie More articles by this author , Nicola JefferyNicola Jeffery More articles by this author , Peter LeePeter Lee More articles by this author , and Kirk AustinKirk Austin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In patients with locally advanced (LARC) or recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially be curative. Urinary tract reconstruction involves ileal/colonic conduit for RC, or either primary bladder repair or ureteric reimplantation with Boari flap and psoas hitch for PC. Where PC potentially provides less post-operative morbidity, a radical resection is the most important prognostic factor for survival. The purpose of this study was to compare PC and RC in PE patients in terms of oncological outcome and post-operative complications. METHODS: This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC. Statistical analysis was performed using SPSS. RESULTS: 329 patients were included; 60 patients with PC and 269 with RC. No significant difference in R0 resection was observed between PC and RC groups (81.8% versus 84.7%, p=0.621). 10 patients in PC group had a positive margin; in 3/10 patients this was at the bladder or ureter margin. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (p=0.008). Overall survival (OS) was 88 months versus 58 months in the PC and RC group, respectively (p=0.265). 1-, 3- and 5-year OS were 90.8%, 68.1% and 58.6% in PC group, and 88.7%, 62.2% and 49.5% in the RC group. Factors that were significantly associated with poorer OS included age, positive resection margin and longer duration of surgery. RC patients demonstrated longer operating time, higher intra-operative blood loss, and longer hospital stay. RC patients also experienced significantly higher rates of wound related complications (25.0% vs. 39.8%, p=0.032). Rates of urinary sepsis or urological leaks did not differ between groups. CONCLUSIONS: This study demonstrates that PC as part of a PE can be performed safely without compromising oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e574 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catalina Palma More articles by this author Charlotte Van Kessel More articles by this author Michael Solomon More articles by this author Scott Leslie More articles by this author Nicola Jeffery More articles by this author Peter Lee More articles by this author Kirk Austin More articles by this author Expand All Advertisement PDF downloadLoading ...

Changing trends, clinicopathological characteristics, surgical treatment patterns, and prognosis of schistosomiasis-associated versus non-schistosomiasis-associated colorectal cancer: a large retrospective cohort study of 31153 cases in Shanghai, China (2001-2021).

With the elimination of schistosomiasis in China, its role in the pathogenesis of colorectal cancer (CRC) has decreased. However, the trends, clinicopathological features, surgical treatment patterns, and prognosis of schistosomiasis-associated CRC (SACRC) versus non-schistosomiasis-associated CRC (NSACRC) in China remain unclear. The percentage trend of SACRC in CRC patients in China was analyzed using data retrieved from the Pathology Registry of Changhai Hospital (2001-2021). Clinicopathological characteristics, surgical treatment patterns, and prognosis-related parameters were compared between the two groups. Multivariate Cox regression analyses were performed for disease-free survival (DFS) and overall survival (OS). A total of 31153 CRC cases were included, with 823 (2.6%) cases of SACRC and 30330 (97.4%) cases of NSACRC. The average percentage of SACRC cases has decreased continuously from 3.8 to 1.7% (from 2001 to 2021). Compared with the NSACRC group, the SACRC group had more men, older age at diagnosis, lower BMI, fewer symptoms; higher rates of rectal cancer, comorbidities, KRAS mutation, multiple primary CRC and concomitant polyps; less lymph node metastasis, distant metastasis, vascular invasion, and tumor budding; less preoperative radiotherapy and preoperative chemotherapy; and more positive resection margins and postoperative targeted therapy. There were no significant differences between the two groups regarding laparoscopic surgery, palliative resection, extended radical resection, or ostomy. Moreover, the SACRC group had adverse DFS and similar OS compared with the NSACRC group. In multivariate analyses, schistosomiasis was not an independent predictor of DFS or OS. The percentage of SACRC in CRC (2.6%) in our hospital was very low, and it decreased continuously over the last two decades, indicating that schistosomiasis is no longer an important risk factor for CRC in Shanghai, China. Patients with SACRC have distinct clinicopathological, molecular, and treatment-related features and survival rates similar to those with NSACRC.

Cathepsin protease expression in infiltrative soft tissue sarcomas: cathepsin-K correlates with infiltrative tumor growth and clinical outcomes.

Cathepsin proteases, activated in the lysosomes, are upregulated in many cancers. Intraoperative detection systems of microscopic residual tumor using cathepsin-mediated release of fluorescent nanoparticles may guide surgical excisions to improve local control. We sought to define the genetic and proteomic expression of cathepsins and their clinicopathological correlates in myxofibrosarcoma and undifferentiated pleomorphic sarcoma (UPS)-soft tissue sarcomas with high rates of positive resection margins and local recurrence-and to establish a cellular justification for cathepsin-dependent systems to identify residual cancer in the resection bed. Real-time quantitative polymerase chain reaction analysis of 58 fresh-frozen tumor specimens revealed that 56 (97%) had elevated mRNA expression of ≥1 cathepsin, including cathepsin-B (79%), cathepsin-K (59%), cathepsin-L (71%), and -S (71%). Immunohistochemical analysis of these fresh-frozen specimens revealed that 98% of tumors were positive for one or more of cathepsin-B (85%), cathepsin-K (50%), cathepsin-L (63%), and -S (10%). Strong cathepsin-K expression was associated with greater risks of local recurrence (hazard ratio, 3.78; p=0.044) and disease-specific mortality (hazard ratio, 3.70; p=0.025). Immunohistochemical analysis of 33 formalin-fixed paraffin-embedded block samples revealed that 97% were positive for cathepsin-B (88%), cathepsin-K (76%), cathepsin-L (52%), or -S (52%) at the tumor periphery; cathepsin-K positivity correlated with a radiographic tail-like sign (p=0.004) and microscopic infiltrative growth (p=0.020). We conclude that cathepsins are broadly overexpressed in myxofibrosarcoma and UPS, and cathepsin-K may be an immunohistochemical marker of local infiltration and poorer prognosis that could be used to guide precision surgery.

Cell-free DNA as a prognostic and predictive biomarker in resectable distal common bile duct cancer.

Cell-free DNA (cfDNA) as an oncological biomarker has drawn much attention in recent years, but very limited effort has been made to investigate the prognostic values of cfDNA in distal common bile duct (CBD) cancer. Plasma cfDNA was measured in 67 patients with resectable distal CBD cancer. Survival outcomes and the correlation of cfDNA with other conventional prognostic factors were determined. cfDNA levels were significantly higher in female patients, and those with poor tumor differentiation, abnormal serum carcinoembryonic antigen (CEA) level, and stage III cancer. The significant prognostic factors included a high cfDNA level (>8955 copies/mL), abnormal serum CEA level, stage III cancer, and positive resection margins. Compared with patients with high cfDNA level, those with lower cfDNA level (≤8955 copies/mL) had significantly better overall survival outcomes (74.4% vs 100% and 19.2% vs 52.6%, for 1- and 5-year survival rates, respectively, p = 0.001). The cfDNA level, perineural invasion, CEA level, and radicality were identified as independent prognostic factors for distal CBD cancer after multivariate analysis. Circulating cfDNA levels play a significant role in predicting the prognosis and survival outcome for resectable distal CBD cancer. Furthermore, acting as a promising liquid biopsy, cfDNA could serve as a prognostic and predictive biomarker in combination with current conventional markers to improve diagnostic and prognostic efficacy.

En bloc resection by polypectomy with over-the-scope clip for a neuroendocrine tumor located in a duodenal bulb pocket.

Neuroendocrine tumors (NETs) are located primarily in the submucosal layer and require careful resection. Conventional endoscopic mucosal resection (EMR) has a risk of positive deep resection margins. En bloc resection is more feasible in endoscopic submucosal dissection (ESD); however, in the duodenum, there is a heightened risk of intraoperative or delayed perforation owing to the thin duodenal wall and effects of inflowing bile and pancreatic juices [1]. The use of an over-the-scope (OTS) clip during polypectomy can greatly reduce the perforation risk [2] and is reportedly safe for duodenal NETs [3]. However, its use during polypectomy to resect NETs located in the pocket of a duodenal ulcer scar has not been reported. We report the use of this method for the safe, rapid, en bloc resection of such tumors located in the anterior wall of the duodenal bulb ([Fig. 1], [Fig. 2], [Video 1]).