Margin Recurrence Research Articles

Re-irradiation of recurrent IDH-wildtype glioblastoma in the bevacizumab and immunotherapy era: Target delineation, outcomes and patterns of recurrence

Introduction and backgroundWhile recurrent glioblastoma patients are often treated with re-irradiation, there is limited data on the use of re-irradiation in the setting of bevacizumab (BEV), temozolomide (TMZ) re-challenge, or immune checkpoint inhibition (ICI). We describe target delineation in patients with prior anti-angiogenic therapy, assess safety and efficacy of re-irradiation, and evaluate patterns of recurrence. Materials and methodsPatients with a histologically confirmed diagnosis of glioblastoma treated at a single institution between 2013 and 2021 with re-irradiation were included. Tumor, treatment and clinical data were collected. Logistic and Cox regression analysis were used for statistical analysis. ResultsOne hundred and seventeen recurrent glioblastoma patients were identified, receiving 129 courses of re-irradiation. In 66 % (85/129) of cases, patients had prior BEV. In the 80 patients (62 %) with available re-irradiation plans, 20 (25 %) had all T2/FLAIR abnormality included in the gross tumor volume (GTV). Median overall survival (OS) for the cohort was 7.3 months, and median progression-free survival (PFS) was 3.6 months. Acute CTCAE grade ≥ 3 toxicity occurred in 8 % of cases. Concurrent use of TMZ or ICI was not associated with improved OS nor PFS. On multivariable analysis, higher KPS was significantly associated with longer OS (p < 0.01). On subgroup analysis, patients with prior BEV had significantly more marginal recurrences than those without (26 % vs. 13 %, p < 0.01). ConclusionRe-irradiation can be safely employed in recurrent glioblastoma patients. Marginal recurrence was more frequent in patients with prior BEV, suggesting a need to consider more inclusive treatment volumes incorporating T2/FLAIR abnormality.

Scalp Volumetric Modulated Arc Therapy Using 3D Milled Bolus: Dosimetry, Toxicity and Outcome.

Radiotherapy for scalp lesions is frequently challenging due to the competing needs for target volume coverage, sparing of numerous critical nearby OARs, and reproducible bolus setup despite the irregular and highly convex scalp geometry. Here, we evaluate the use of 3D milled bolus in treating such tumors. A retrospective analysis of scalp patients (pts) treated between 2016-2022 using 3D milled bolus and VMAT. All pts were treated with 6 MV photon beams, IGRT via daily CBCT, and 6-degree of Freedom (6-DOF) couch tops. Pts demographics, tumor characteristics, DVHs, toxicities and outcomes were evaluated. Regional control (RC) defined as control of the disease in the rest of the scalp/neck and local control (LC) defined as disease control within the PTV. A total of 23 pts were identified. Median age 74 (46-85), ECOG performance status was 0-1 in 20 pts (87%) and 92% were males. The histopathologies were squamous cell carcinoma (SCC) (61%), angiosarcoma (AS) (35%) and melanoma (4%). 35% of pts were treated with definitive intent to gross disease; the remaining 65% were treated post-operatively, 22% with microscopically positive margins and 43% with negative margins. 21% had perineural invasion (PNI), and none had lymphovascular invasion (LVI). 78% had T3/T4 and 13% had N+ disease. Median radiation dose was 66 Gy (60-69.96Gy). 44% received concurrent systemic therapy (Paclitaxel 22%, Cemiplimab 12%, Temozolomide 5%, Nivolumab 5%). In 40% of pts, the whole scalp was treated; in the remaining 60%, the median ratio of PTV volume to scalp volume was 35% (25-90%). 22% of pts (n = 5) had neck irradiation for prophylactic (3pts)/ neck lymph node involvement (2 pts). The median brain Dmax was 65 Gy (52.5-71.9), median brain mean dose was 15.4Gy (1.4-38.4), median eye Dmax was 10.9Gy (0.23-49), median cochlea mean was 8.4Gy (0.1-20.4), median lacrimal gland mean dose was 6.8Gy (0.11-38), median hippocampus Dmin was 5.9Gy (0.1-14.9) and Dmax was 10Gy (0.3-23). Most common acute side effects were grade 1-2 fatigue (100%), grade 1-2 pain (78%), grade 1 dysgeusia (22%), grade 1-2 dermatitis (74%). The only grade > = 3 adverse event was grade 3 dermatitis in 26%. Regarding long-term side effects, one pt had grade 2 osteoradionecrosis and other one developed grade 2 skin ulcer. 17% developed grade 1 memory impairment. 17% had grade 1 eye dryness. None developed brain radionecrosis. At a median follow-up was 14.4 months (1-73.5), the 1-yr LC was 96%. The 1-yr RC was 75% overall, 100% in angiosarcoma vs 62% in SCC (p = 0.18). Of the 4 regional recurrences, 1 pt had marginal recurrence along V1, 2 had neck nodal recurrence, and 1 had recurrence elsewhere in the scalp. 1-yr DMFS was 62% overall. 1-yr OS was 78% overall, 100% for AS vs 64% for SCC (P = 0.097). VMAT planning with 3D milled bolus permits technically sound radiotherapy for scalp targets with an acceptable toxicity profile and relatively favorable clinical outcomes. This approach warrants further evaluation in a larger prospective study.

Five-Fraction Stereotactic Radiation for Head and Neck Paragangliomas

Paragangliomas of the head and neck (HN) are benign, slow-growing neoplasms that are rarely functional. Treatment is often indicated for patients presenting with mass effect, cranial neuropathies, or pulsatile tinnitus. Radiotherapy, traditionally conventionally fractionated, is often used for primary, post-operative, and salvage therapy, given its excellent control rates and reduced risks to adjacent neurovascular structures. Stereotactic ablative radiation (SAbR) offers shorter treatment time, and modern techniques eliminate margins to improve organ-at-risk avoidance. SAbR may offer additional radiobiological sparing of normal structures over single-fraction SAbR. We aimed to evaluate tumor and symptom response, acute and late toxicity rates, and recurrence patterns in HN paraganglioma patients treated with 25 Gy in 5 fractions. Retrospective chart review collected baseline patient and tumor information, treatment and dosimetry details, acute and long-term toxicity grades (per the CTCAE v. 5.0), symptom and tumor response, and survival. Local control was defined as the absence of local enlargement (per RECIST v. 1.1) or marginal failure and was estimated using the Kaplan-Meier method. Between December 2009-March 2020, 39 patients received 25 Gy in 5 fractions to 43 HN paragangliomas, of which 17 were treated in 11 patients with hereditary paraganglioma-pheochromocytoma syndrome. Fifteen targets were post-operative recurrent or residual tumors. There were 27 jugulotympanic tumors, 4 jugular, 1 tympanic, 8 vagal, 5 carotid body, and 2 jugulotympanic or vagal. Median follow-up time was 3.3 years (range 0-11.4 years), and 21 targets had at least 4 years of follow-up. Tumor volume decreased by a median of 37%. Three-year local control was 100%. One patient, known to harbor an SDHD mutation, had 2 out-of-field recurrences within the post-operative bed at 7.1 years. Two patients experienced 2 marginal recurrences within the post-operative bed at 6.1 and 8.4 years: one had an SDHB mutation and developed metastatic disease, and the other did not have genetic testing. The most common grade 1-2 acute toxicities were headache and fatigue; the most common grade 1-2 late toxicities were dysphagia and otalgia. There were no grade >2 acute toxicities. A late grade 3 aspiration event was seen in 1 patient who presented with paralyzed vocal cord requiring multiple medialization laryngoplasties. Within 6 months of SAbR, 18% of symptoms or toxicities improved or resolved; 34% improved or resolved more than 6 months after SAbR. This is the largest series of HN paragangliomas treated with SAbR, detailing a 10-year experience with a 5-fraction regimen that is well-tolerated and achieves excellent local control. Post-SAbR recurrences occurred outside of the radiation field but within the post-operative bed, suggesting that some post-operative patients may benefit from expanded radiation volumes or close surveillance for salvage therapy.

Assessment of Local and Regional Control in Atypical (WHO Grade 2) Meningiomas Receiving Fractioned Stereotactic Radiotherapy

The optimal delivery of postoperative radiotherapy to WHO grade 2 or atypical meningiomas (AM) is controversial. The historical standard of care has been high dose fractionated radiation to the resection bed and a 2 cm CTV as in RTOG 0539. Single fraction radiosurgery offers a more conformal alternative with demonstrated local control for smaller AM in less sensitive areas. Though less studied, fractionated stereotactic radiosurgery (FSRT) promises safer treatment of larger AM in more sensitive locations while minimizing the treated volume. This single institution retrospective review examines the hypothesis that local and marginal failure patterns in AM treated with five fraction FSRT remain unacceptably high. Thirty-nine patients received 27.5 - 30 Gy in 5 fractions to their AM from 2009 to 2022 with grading based on the WHO criteria active at the time of treatment. All treatments were frameless VMAT deliveries with no PTV margin. Histological diagnosis of AM, gross disease at time of FSRT, five fraction FSRT, and lack of prior local radiation were required for inclusion. Single fraction treatments were excluded. Local recurrence was defined similar to RECIST criteria as an increase of 20% in the greatest cross-sectional diameter on MRI (or CT if MRI contraindicated) with at least one voxel touching the prescription volume. To examine the role of CTV margin, marginal recurrence was defined as any new lesion outside of the prescription volume but within 2 cm of the resection cavity. High grade toxicity per CTCAE v5 was an irreversible grade 3 or any grade 4 toxicity. Resection for radionecrosis was considered a local failure if any viable tumor was seen on pathology. Median follow up was 32.5 months (range 3.2-147.5 months). The number of AM treated post STR, post GTR recurrence, and definitively were 26, 16, and 5 respectively. 3-year local tumor control was estimated to be 84%. As expected, larger tumors were more likely to fail locally (p >.001). Two (5%) patients experienced high grade toxicity - both symptomatic radionecrosis requiring resection. Three-year marginal control was estimated to be 92.3%. Of the 5 tumors treated to the entire resection cavity, none experienced a marginal failure. Interestingly, recurrent tumors s/p GTR were more likely to recur marginally than tumors treated after STR (p = .009). Only 1 (4%) tumor treated after STR failed marginally while 4 (33%) tumors treated after GTR recurrence failed. The rate of high-grade toxicity in AM receiving FSRT was low. Local control appeared comparable to historical rates which may suggest the need for dose escalation with longer term follow-up. Recurrent tumors appear more prone to marginal failures, however more work is needed to determine which patients may benefit from additional CTV margin and more prolonged fractionated dose schedules. Improved targeting with newer imaging studies (e.g., DOTATATE PET) should be examined to determine if more accurate targeting will improve outcomes.

Pancreatic Cancer Outcome: Local Treatment with Radiation Using MRI-Linac

Stereotactic MR-guided on-table adaptive radiotherapy (SMART) is a surging modality in radiotherapy, delivering high dose radiation to the tumor in great proximity to susceptible organs. The aim of this study is to evaluate the clinical outcome in locally advanced or recurrent pancreatic tumors with or without prior irradiation. All consecutive patients were treated in our center for pancreatic cancer (PC) using SMART technology to a prescription of 50Gy (BED10 100 Gy1o) in 5 fractions, with daily on-table adaptation of treatment plan. Endpoints for this retrospective, single center, IRB approved study were local control, overall survival, local disease-free period, acute and late toxicities. Fifty-four PC patients were treated between 8.2019-9.2022, with median follow-up of 8.9 months from SMART (0.8-34 months). Forty patients had upfront inoperable PC (45% were metastatic at RT, five treated to liver metastatic lesions concomitantly) and fourteen patients had local recurrence following prior pancreatectomy, six of them had prior adjuvant RT. 87% received at least one round of chemotherapy (Oxaliplatin based- 72%), 25% received ≥2 regimens. Mean age was 68.9 (45-86) years. There was no significant difference in baseline parameters between prior pancreatectomy and inoperable groups. On-table adaptive replanning was performed for 100% of all (269) fractions (one patient received 4 fractions). No patient reported grade ≥2 acute GI toxicity. Six patients reported fatigue at the end of RT, four of them had prior radiation. Forty-eight patients were available for evaluation. Complete local control was achieved in 21.7% (10 patients) for median of 9 months (2.8-28.8 months), three had later local progression. Eight patients had regional or marginal recurrence following treatment. 6-months and 12-months OS was 75% and 52%, respectively. There was no significant difference in toxicity and outcome between post-pancreatectomy and inoperable groups. Pancreatic cancer local ablative SMART is safe, with minimal treatment-related toxicity, even in previously irradiated patients. Local control with complete response was achieved by 20% of patients. Further studies are needed to evaluate long-term outcome and late toxicity.

A Novel Technique of Renorrhaphy in Difficult Partial Nephrectomies by Single-Layered Parenchymal Imbrication.

Background In partial nephrectomies, achieving the trifecta outcome of negative tumor margins, no surgical complications, and minimal decline in renal function depends on various factors, with the complexity of the tumor described by the nephrometry score being chief among them. These factors often motivate surgeons towarda minimally invasive route even if the preferred route is an open approach. We describean innovative renorrhaphytechnique that overcomes the commonly encountered difficulty in reconstructing the renal parenchyma after resecting a complex tumor with a single-layered parenchymal imbrication (SLPI) technique. Methodology We conducted a retrospective review of case records of the patients who had undergone partial nephrectomies in our center from March 2017 toMarch 2021. The patients who underwent the SLPI technique were chosen, and data were extracted. Data collected included patients' preoperative imaging findings; intraoperative parameters such as ischemia time, blood loss, and number of renal arteries; and postoperative factors such as margin positivity rate, urine leak, secondary bleeding, follow-up imaging, and recurrence rates. Results A total of 28 patients were included in our study. The estimated blood loss was 234 mL (standard deviation [SD] = 55 mL), warm ischemia time was 31 minutes (SD 4 minutes), a hospital stay of 3 days (SD 2 days), two minor complications, two intraoperative complications, and one margin positivity. There were no major complications or recurrences. Conclusions The novel technique of SLPI renorrhaphy can help deal with complex renal masses and is an easily reproducible technique both in open and minimally invasive approaches.

Comparison of Open versus Laparoscopic Approaches in Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation.

Background and Objectives: Although radiofrequency ablation (RFA) is widely used as an effective local treatment for hepatocellular carcinoma (HCC), evidence on salvage hepatectomy for local recurrence after RFA is limited. This study aims to compare open and laparoscopic approaches in salvage hepatectomy for recurrent HCC after RFA. Materials and Methods: Among patients who underwent hepatectomy between January 2004 and August 2022 at a single tertiary referral center, 55 patients who underwent salvage hepatectomy for marginal recurrence after RFA were selected. An open approach was used in 23 (41.8%) patients, while 32 (58.2%) patients underwent laparoscopic surgery. Short-term and long-term outcomes were compared between the two groups. Results: Major hepatectomy was more often performed in the open group (9 [39.1%] vs. 4 [12.5%], p = 0.022). Intraoperative blood loss was also greater in the open group (450 (325-750) vs. 300 (200-600), p = 0.034). Operation time (p = 0.144) and postoperative morbidity rates (p = 0.639) were similar, and there was no postoperative mortality in either group. Postoperative hospital stay was significantly longer in the open group compared to the laparoscopy group (8 (6-11) days vs. 5 (4-7) days, p = 0.028). The 1-, 3-, and 5-year disease-free survival rates showed no difference between the two groups (44.6% vs. 62.5%, 16.5% vs. 13.5%, and 8.3% vs. 13.5%, respectively; p = 0.154). The 1-, 3-, and 5-year overall survival rates between the two groups were also similar (85.7% vs. 96.8%, 79.6% vs. 86.0%, and 79.6% vs. 79.4%, respectively; p = 0.480). Conclusions: Laparoscopic salvage hepatectomy shows oncologic outcomes comparable to the open approach with faster postoperative recovery rates. Considering that recurrence rates are high after RFA, the laparoscopic approach should be considered as a first-line option in selected patients.

Laparoscopic Groin Hernia Repair Using the Totally Extraperitoneal Approach: A Retrospective Study and Our Experience.

Background Recently, laparoscopic totally extraperitoneal (TEP) inguinal hernia repair has been considered one of the most effective and widely performed techniques for repairing inguinal hernias by avoiding entry into the peritoneal cavity. Its indications have evolved and expanded to almost encompass the entire range of groin hernias. This retrospective study aims to determine the outcomes and postoperative complications in patients undergoing TEP inguinal hernia repairperformed by a single surgeon for groin hernias at a single center. Methodology We retrospectively evaluated the prospectively collected data of 900 patients who underwent elective TEP repair over 18 years at a single center performed by a single surgeon from April 2004 to February 2023. Patients were evaluated for age, sex, type of hernia, time taken for surgery, open from laparoscopy, intra and postoperative complications, hospital stay, and days taken to resume regular activity. Results The mean age of the 900 patients was 59 years (range = 21-83 years). The mean age of males and females was 59 and 56 years, respectively. The mean operative time was 40 and 55 minutes for a unilateral and bilateral hernia, respectively. In total, 369 (41%) patients had a right-sided groin hernia, 382 (42%) patients had a left-sided groin hernia, and 149 (16.5%) patients had bilateral groin hernias. A total of 121 (13%) patients had occult hernias, and 17 patients underwent concurrent TEP and transurethral resection of the prostate. Of the 900 patients, 20 (2.2%) had a recurrent hernia after a previous open inguinal hernia repair. Seven (0.8%) patients had a recurrence of hernias post-TEP and subsequently underwent open inguinal hernia repair. Seven (0.7%) patients needed conversion from TEP to the transabdominal pre-peritoneal approach. Only minor complications were noted intra and postoperatively. The average time of hospitalization was 24 hours. The time to resume normal activities was five (±1) days. Conclusions Our experience suggests that TEP repair with mesh fixation is a safe and effective procedure with a marginal recurrence rate. Apart from the obvious cosmetic benefits of minimal tissue invasion, a significant advantage of TEP is the visualization of the contralateral groin along with the surgical repair of a hernia, if required, in the same sitting and without the insertion of any extra trocars.

Beyond the Surgical Margin: Patterns of Recurrence in World Health Organization Grade 2 Intracranial Meningiomas

To characterize and classify the location of recurrence in surgically resected WHO grade 2 intracranial meningiomas that did not receive adjuvant radiation, and compare the recurrence pattern of those that underwent gross total versus subtotal resection. We performed a retrospective review of patients who underwent surgical resection of a newly diagnosed WHO grade 2 meningioma at our institution between 1996 and 2019. Patients that were observed postoperatively without adjuvant radiation and subsequently developed a recurrence were included in the study. All patients who received adjuvant therapy were excluded. Recurrence was defined as any evidence of radiographic progression on postoperative surveillance MRI. Location of recurrence were categorized as follows: (1) central - growth observed inside the area of the previously resected tumor more than 1 cm inside the original tumor margin; (2) marginal - growth observed within 1 cm (inside or outside) of the original tumor margin; and (3) remote - growth observed more than 1 cm outside of the original tumor margin. Patterns of recurrence were evaluated by two observers after co-registering pre- and post-operative MRIs, and any differences were reconciled by discussion. A total of 22 patients matched the inclusion criteria. Twelve (55%) underwent GTR while ten (45%) underwent STR. In 12 patients in whom GTR was achieved, mean preoperative tumor volume was 50.6 cm3 with 5 (41.7%) in a skull base location. The average time to recurrence for these tumors was 22.7 months, with a mean recurrent tumor volume of 9.0 cm3. Ten (83.3%) patients had central recurrence, 11 (91.7%) patients had marginal recurrence, and only 4 (33.3%) patients had remote recurrence. In 10 patients in whom STR was achieved, mean preoperative tumor volume was 44.8 cm3, with 7 (70.0%) in a skull base location. The average time to recurrence for these tumors was 23.0 months, with a mean recurrent tumor volume of 21.8 cm3. Of these 10 patients, 9 (90.0%) had central recurrence, all 10 (100.0%) had marginal recurrence, and only 4 (40.0%) patients had remote recurrence. The present study evaluating patterns of recurrence for WHO grade 2 meningiomas after surgical resection (GTR or STR) showed that recurrence occurred centrally and/or at the original tumor margin, with only a minority recurring >1cm outside the original tumor margin. The results of this study suggest that treatment, whether initial surgical resection or adjuvant radiation, may benefit from including at least a 1cm dural margin when safe, to optimize tumor control, but further clinical study is needed.

Extramammary Paget’s disease: Our 15-year experience in a Southeast Asian population

The treatment of choice for Extramammary Paget's disease (EMPD) is wide excision. However, owing to the tendency of microscopic spread and multi-centricity of the disease, resection margins are hard to determine. Despite the use of adjunctive methods such as mapping biopsy and Moh's micrographic surgery, recurrence rates remain high. We aim to establish treatment guidelines by determining the variables associated with recurrence and the optimal resection margin size. We reviewed 52 patients who underwent wide excision in our institution between 2002 and 2017. A retrospective review of patient demographics, disease characteristics, and resection margins was performed. Most patients were Chinese (n=39, 75%) male (n=38, 73.1%). The mean tumor size was 6.73cm (SD=4.10; range, 1.50-21.0cm). The mean resection margin was 2.5cm (SD=1.21; range, 0.20-5.50cm). Eleven patients (21.2%) had disease recurrence. Nodal involvement significantly correlated with disease recurrence or mortality related to disease (HR=4.645; 95% CI=1.539,14.018; p=0.0064). Subgroup analysis showed a significant correlation between resection margin size and recurrence rates (p=0.047). We observed that a smaller resection margin (<2cm) is acceptable for smaller tumor sizes (<6cm) to achieve the lowest possible recurrence rates (20%), whereas a larger resection margin (>2cm) is required for larger tumor sizes (>6cm) (p=0.012). Our results suggest that a resection margin recommendation can be made in correlation to the tumor size. This serves as a guideline for surgeons to predict the defect size and provide options for reconstructive surgery while achieving low recurrence rates.

Prognostic impact of R1 resection margin in synchronous and simultaneous colorectal liver metastasis resection: a retrospective cohort study

BackgroundA margin ≥ 1 mm is considered a standard resection margin for colorectal liver metastasis (CRLM). However, microscopic incomplete resection (R1) is not rare since aggressive surgical resection has been attempted in multiple and bilobar CRLM. This study aimed to investigate the prognostic impact of resection margins and perioperative chemotherapy in patients with CRLM.MethodsA total of 368 of 371 patients who underwent simultaneous colorectal and liver resection for synchronous CRLM between 2006 and June 2017, excluding three R2 resections, were included in this study. R1 resection was defined as either abutting tumor on the resection line or involved margin in the pathological report. The patients were divided into R0 (n = 304) and R1 (n = 64) groups. The clinicopathological characteristics, overall survival, and intrahepatic recurrence-free survival were compared between the two groups using propensity score matching.ResultsThe R1 group had more patients with ≥ 4 liver lesions (27.3 vs. 50.0%, P < 0.001), higher mean tumor burden score (4.4 vs. 5.8%, P = 0.003), and more bilobar disease (38.8 vs. 67.2%, P < 0.001) than the R0 group. Both R0 and R1 groups showed similar long-term outcomes in the total cohort (OS, P = 0.149; RFS, P = 0.414) and after matching (OS, P = 0.097, RFS: P = 0.924). However, the marginal recurrence rate was higher in the R1 group than in the R0 group (26.6 vs. 16.1%, P = 0.048). Furthermore, the resection margin did not have a significant impact on OS and RFS, regardless of preoperative chemotherapy. Poorly differentiated, N-positive stage colorectal cancer, liver lesion number ≥ 4, and size ≥ 5 cm were poor prognostic factors, and adjuvant chemotherapy had a positive impact on survival.ConclusionsThe R1 group was associated with aggressive tumor characteristics; however, no effect on the OS and intrahepatic RFS with or without preoperative chemotherapy was observed in this study. Tumor biological characteristics, rather than resection margin status, determine long-term prognosis. Therefore, aggressive surgical resection should be considered in patients with CRLM expected to undergo R1 resection in this multidisciplinary approach era.

Retrospective analysis of local recurrence pattern by computed tomography image-guided intracavitary and interstitial brachytherapy for locally advanced cervical cancer in a single Japanese institution

PURPOSEThe purpose of this study was to investigate the treatment results with focus on local control (LC) by computed tomography (CT)-guided intracavity brachytherapy and interstitial brachytherapy (ICBT/ISBT) for locally advanced cervical cancer (LACC). METHODS AND MATERIALSPatients with LACC undergoing ICBT/ISBT at least once in our institution between January 2017 and June 2019 were analyzed retrospectively. The primary endpoint was local control (LC), and the secondary endpoints were progression-free survival (PFS), overall survival (OS), and late toxicities. Differences between patient subgroups for prognostic factors in LC, PFS, and OS were analyzed using the log-rank test. The recurrence patterns of LC were also investigated. RESULTSForty-four patients were included in the present study. The median high-risk clinical target volume (HR-CTV) at the initial brachytherapy was 48.2 cc. The median total dose of HR-CTV D90 (EQD2) was 70.7 Gy. The median followup period was 39.4 months. The 3-year LC, PFS and OS rates in all patients were 88.2%, 56.6%, and 65.4% (95% CI 50.3–78.0%), respectively. Corpus invasion and large HR-CTV (70 cc or more) were significant prognostic factors in LC, PFS, and OS. Marginal recurrences at the fundus of the uterus were detected in 3 of 5 patients in whom local recurrence was observed. Late toxicities of Grade 3 or higher were detected in 3 patients (6.8%). CONCLUSIONSFavorable LC was achieved by performing CT-guided ICBT/ISBT for LACC. The brachytherapy strategy for patients with corpus invasion or large HR-CTV may need to be reconsidered.

Effect of body habitus on surgical outcomes following bilateral axillo-breast approach robotic thyroidectomy: a retrospective cohort study.

BMI has been shown to predict perioperative outcomes in patients undergoing surgery. Most studies assessing the role of body habitus in thyroid surgery have focused on open surgery, with few studies assessing patients undergoing robotic surgery. The present study evaluated the effects of BMI on surgical outcomes in patients undergoing bilateral axillo-breast approach (BABA) robotic thyroidectomy. This study included patients who underwent BABA robotic thyroidectomy between January 2013 and September 2021 at Seoul National University Bundang Hospital. Patients were categorized into six groups based on the WHO classification of overweight and obesity. Clinicopathological characteristics, postoperative complications, and surgical outcomes were evaluated. A total of 1921 patients were included. Comparisons of the six BMI groups showed no statistically significant differences in postoperative stay, resection margin involvement, postoperative complications, and recurrence. Subgroup analysis showed that hypocalcemia rates differed among BMI groups in patients who underwent lobectomy, with underweight and class II obese patients being at the highest risk ( P =0.006). However, the actual number of complications was relatively small and similar among the groups. In patients who underwent total thyroidectomy and isthmectomy, BMI was not correlated with postoperative complications, including hypocalcemia, recurrent laryngeal nerve palsy, postoperative bleeding, and chyle leakage. Body habitus was not significantly associated with operative time and postoperative complications in patients undergoing BABA robotic thyroidectomy, indicating that this approach is safe and feasible in obese patients.

Open, Laparoscopic, and Robot-Assisted Radical Prostatectomy Oncological Results: A Reverse Systematic Review.

Context: Systematic reviews (SR) have always been used as the best evidence to compare three radical prostatectomy (RP) techniques: retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic radical prostatectomy (RARP). Despite the superiority of minimally invasive surgery in relation to perioperative outcomes, the literature still cannot establish which technique is superior in relation to oncological outcomes. A new methodology called Reverse Systematic Review (RSR) was created to gather the best evidence in the literature based on a heterogeneous sample, allowing the comparison of oncological outcomes from a population point of view. Objective: To apply the RSR to compare RP techniques in relation to oncological outcomes: positive surgical margin (PSM) and biochemical recurrence rate (BCR). Evidence Acquisition: A search was carried out in eight databases between 2000 and 2020 through SR studies referring RRP, LRP, or RARP (80 SR). All references used in these SR were captured referring to 1724 reports. Preoperative and oncological outcomes were compared and correlated among RRP, LRP, and RARP. Evidence Synthesis: Five hundred fifty-nine (32.4%) reports for RRP, 413 (23.9%) for LRP, and 752 (43.7%) for RARP, and a total of 1,353,485 patients were found. Regarding PSM, 284 reports were collected for RRP, 324 for LRP, and 499 for RARP, with rates of 23.6%, 20.7%, and 19.2%, respectively, and only the RRP with statistical difference (p < 0.001). Using a nonlinear regression model, the BCR was correlated with follow-up time at 1, 2, 3, 5, 7, and 10 years: 10%, 15%, 18%, 20%, 23%, and 38% for RRP; 6%, 9%, 13%, 20%, 23%, and 10% for LRP; and 8%, 12%, 16%, 23%, 27%, and 19% for RARP. The absence of long-term work for RARP prevented more accurate projections of BCR. Conclusions: RSR proved to be effective in generating a population and heterogeneous sample capable of demonstrating better oncological results for minimally invasive surgery (LRP and RARP) compared to RRP. It demonstrated the maturity of temporal follow-up data for RRP and LRP and the impact of absence of late follow-up from RARP studies on the long-term rate of BCR. Patient Summary: After 20 years of coexistence of the three main radical prostatectomy techniques, the RSR was able to detect better results from minimally invasive surgery in relation to PSMs and long-term BCRs.

Observation of the delineation of the target volume of radiotherapy in adult-type diffuse gliomas after temozolomide-based chemoradiotherapy: analysis of recurrence patterns and predictive factors

BackgroundRadiation therapy is the cornerstone of treatment for adult-type diffuse gliomas, but recurrences are inevitable. Our study assessed the prognosis and recurrence pattern of different radiotherapy volumes after temozolomide-based chemoradiation in our institution.MethodsThe treatment plans were classified into two groups, the plan 1 intentionally involved the entire edema area while plan 2 did not. Retrospectively investigate the differences in outcomes of 118 adult-type diffuse gliomas patients between these two treatment plans. Then, patients who underwent relapse were selected to analyze their recurrence patterns. Continuous dynamic magnetic resonance images (MRI) were collected to categorized the recurrence patterns into central, in-field, marginal, distant, and cerebrospinal fluid dissemination (CSF-d) recurrence. Finally, the clinical and molecular characteristics which influenced progression were analyzed.ResultsPlan 1 (n = 63) showed a median progression-free survival (PFS) and overall survival (OS) of 9.5 and 26.4 months while plan 2 (n = 55) showed a median PFS and OS of 9.4 and 36.5 months (p = 0.418; p = 0.388). Treatment target volume had no effect on the outcome in patients with adult-type diffuse gliomas. And there was no difference in radiation toxicity (p = 0.388). Among the 90 relapsed patients, a total of 58 (64.4%) patients had central recurrence, 10 (11.1%) patients had in-field recurrence, 3 (3.3%) patients had marginal recurrence, 11 (12.2.%) patients had distant recurrence, and 8 (8.9%) patients had CSF-d recurrence. By treatment plans, the recurrence patterns were similar and there was no significant difference in survival. Reclassifying the progression pattern into local and non-local groups, we observed that oligodendroglioma (n = 10) all relapsed in local and no difference in PFS and OS between the two groups (p > 0.05). Multivariable analysis showed that subventricular zone (SVZ) involvement was the independent risk factor for non-local recurrence in patients with GBM (p < 0.05).ConclusionIn our study, deliberately including or not the entire edema had no impact on prognosis and recurrence. Patients with varied recurrence patterns had diverse clinical and genetic features.

Prognostic Impact of Surgical Margin Width in Hepatectomy for Colorectal Liver Metastasis.

As for resection for colorectal liver metastasis (CRLM), securing an adequate surgical margin is important for achieving a better prognosis. However, it is often difficult to achieve adequate margins for the resection of CRLM. So the current survival impact of sub-centi/millimeter surgical margins in hepatectomy for CRLM should be evaluated. In the current era of multidisciplinary treatment options, this review focused on the prognostic impact of a sub-centi/millimeter surgical margin width in hepatectomy for CRLM. We systematically reviewed retrospective studies that clearly described the surgical margin width for hepatectomy for CRLM. We selected studies conducted since 2000 that involved patients diagnosed as having CRLM. We focused on studies that investigated not only surgical margins, but also microscopic surgical curability such as R0 (microscopically complete resection) or R1 (microscopically incomplete resection), which clearly describe their definitions. Based on our literature review, 1, 2, or 5 mm was considered the minimum surgical margin width for hepatectomy for CRLM. Although a surgical margin width of 1 mm is acceptable for hepatectomy for CRLM, submillimeter margins, which are defined as R1 in many reports, are only acceptable for limited patients such as those who have undergone preoperative chemotherapy. Zero-mm margins are also acceptable in limited patients such as those who show a good response to preoperative chemotherapy. New chemotherapy agents have been reported to reduce the prognostic impact of a narrow surgical margin width. The incidence of margin recurrence, which is a major concern regarding R1 resection of CRLM, is about 20-30% according to the majority of earlier reports. As evaluations of the actual prognostic impact of the surgical margin remain difficult, further study is warranted.

Treatment results with 5-mm surgical excision in nonmelanoma skin cancers: Analysis of 234 cases

Background: Basal cell carcinoma and squamous cell carcinoma constitute the majority of nonmelanoma skin cancers. In our study, we analyzed our results of nonmelanoma skin cancer treatment with 5-mm surgical excision and compared them with the literature. Material and Methods: Patients treated at Ankara City Hospital Plastic, Reconstructive, and Aesthetic Surgery Clinic between February 2019 and March 2022 were included in this study. Demographic data, anatomical region, tumor subtype/differentiation, surgical margins, reconstruction method, and recurrence parameters were recorded. IBM SPSS Statistics (version 26.0) was used for the data analysis. Results: Of the 234 cases, 163 were reported as basal cell and 71 as squamous cell cancer. Margin positivity with 5-mm surgical excision was 14.1% and 16.9% in basal and squamous cell cancer, respectively. Nineth-month recurrence rates were 4.2% and 19.7% in basal and squamous cell cancer, respectively. Conclusions: All surgical margin positivity and recurrences were located in the head and neck regions, revealing the importance of developing treatment references according to the anatomical region.

Salvage Retzius-Sparing Radical Prostatectomy: A Review of Complications, Functional Outcomes, and Oncologic Outcomes

(Background) Radiation failure for localized prostate cancer is seen in 20-60% of patients who do not undergo extirpative surgery. Though potentially curative, salvage prostatectomy (SS) has not been frequently performed historically due to high rates of complications and postoperative incontinence. With the advent of robotic-assisted radical prostatectomy, these rates appear to be improved. Retzius-sparing approaches have additionally been shown to improve continence outcomes in the index setting, and may further improve continence outcomes in salvage cases while maintaining oncologic integrity. (Methods) We performed a literature review and qualitative analysis of published papers on salvage Retzius-sparing robotic-assisted radical prostatectomy (SRS). Three studies met criteria and were included in analysis. (Results) There were more patients with Gleason Grade Group 1 disease after initial treatment in the SRS group vs. SS (22% vs. 8%). Patients most frequently underwent external beam radiation therapy in both groups (52% vs. 49%). 30-day complication rates were 10% and 26% for SRS and SS, respectively. Continence outcomes were significantly improved in SRS with 59% of continence (based on study criteria) compared to 38% in SS. Time to continence was similarly improved for SRS. Positive surgical margins and biochemical recurrence were not significantly different between SRS and SS in any study. (Conclusions) SRS is a safe and feasible option for salvage treatment of localized prostate cancer and may improve postoperative continence outcomes. Positive surgical margin and biochemical recurrence rates are similar to those reported in SS.

RADT-26. PATTERNS OF RECURRENCE IN PATIENTS TREATED WITH RE-IRRADIATION FOR RECURRENT HIGH-GRADE GLIOMA

Abstract Purpose/Objective(s) Re-irradiation (ReRT) is often used to treat recurrent high grade glioma (HGG). There is limited literature regarding the patterns of recurrence following ReRT, which was investigated in the current study. Materials/METHODS Patients with available radiation (RT) contours, dosimetry, and imaging-based evidence of recurrence were included in the retrospective study. All patients were treated with fractionated RT using conformal technique. Recurrence was documented as per decision in tumor board based on imaging with magnetic resonance imaging (MRI) or Flouroethyl-L-Tyrosine (FET) positron emission tomography (PET), which was registered with the planning CT. Failure patterns were classified as in-field, marginal, and out-field as decided by &amp;gt;50% recurrence volume within 95%, 20-95%, and outside 20% isodose lines, respectively. RESULTS Study population included 37 patients treated with median dose of 54 Gy (range 50.4-54 Gy). Before ReRT, 92% patients had undergone surgery (biopsy in 3, gross total resection in 9, subtotal resection in 22), 62% received concurrent chemo with ReRT, and 49% received maintenance chemotherapy. Median time to recurrence was 9 months (7-16 months, median 10 and 8 months respectively for in-field and marginal/out-field recurrence). In-field, marginal, and out-field recurrence were seen in 24 (65%), 10 (27%), and 3 (8%), respectively. Recurrence mapping was done using MRI, PET, or both in 27, 3, and 7, respectively. Of 24 patients with in-field recurrence, 8 and 16 had disease volume within gross tumor volume and clinical target volume, respectively. 2 patients had leptomeningeal dissemination (1 with majority of recurrence volume in-field and 1 with marginal failure in addition to metastatic disease). CONCLUSION Following ReRT for HGG, the majority of recurrence was in the high dose region, suggesting the use of conservative target volumes. Future studies are required for feasibility of dose-escalation to improve control rates, particularly in patients with long intervals from first course of RT.

SURG-25. PATTERNS OF RECURRENCES ACCORDING TO THE EXTENT OF RESECTION IN PARIETNS WITH GLIOBLASTOMA, IDH-WILDTYPE: A RETROSPECTIVE STUDY

Abstract OBJECTIVE In glioblastoma (GBM) patients, controlling the microenvironment around the tumor using various treatment modalities, including surgical intervention, is essential in determining the outcome of treatment. This study was conducted to elucidate whether recurrence patterns differ according to the extent of resection (EOR) and whether this difference affects prognosis. METHODS This single-center study included 358 eligible patients with histologically confirmed isocitrate dehydrogenase (IDH)-wild-type GBM from November 1, 2005, to December 31, 2018. Patients were assigned to one of three separate groups according to EOR: supratotal resection (SupTR), gross-total resection (GTR), and subtotal resection (STR) groups. The patterns of recurrence were classified as local, marginal, and distant based on the range of radiation. The relationship between EOR and recurrence pattern was statistically analyzed. RESULTS Observed tumor recurrence rates for each group were as follows: SupTR group, 63.4%; GTR group, 75.3%; and STR group, 80.5% (p = 0.072). Statistically significant differences in patterns of recurrences among groups were observed with respect to local recurrence (SupTR, 57.7%; GTR, 76.0%; STR, 82.8%; p = 0.036) and distant recurrence (SupTR, 50.0%; GTR, 30.1%; STR, 23.2%; p = 0.028). Marginal recurrence showed no statistical difference between groups. Both overall survival and progression-free survival were significantly increased in the SupTR group compared with the STR and GTR groups (p &amp;lt; 0.0001). CONCLUSIONS In this study, the authors investigated the association between EOR and patterns of recurrence in patients with IDH-wild-type GBM. The findings not only show that recurrence patterns differ according to EOR but also provide clinical evidence supporting the hypothesized mechanism by which distant recurrence occurs.