Microscopic Positive Surgical Margins Research Articles

Recurrent neck myxofibrosarcoma: a case report\xa0

BackgroundMyxofibrosarcoma (MFS) is a rare soft tissue sarcoma with a high recurrence rate and a low risk of distant metastasis. It occurs mainly in the extremities of elderly men. Head and neck MFS is extremely rare. Surgery is the cornerstone of treatment. The role of radiotherapy (RT) and chemotherapy (CHT) on MFS is still debated.Case presentationA 67-year-old Caucasian man presented to our sarcoma referral center (SRC) with a history of MFS of the neck excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis. After a multidisciplinary discussion, preoperative RT was administered with a total dose of 50 Gy followed by wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred during the 24-month postoperative follow-up.ConclusionsThe case described suggests the importance of planned combined treatments with both RT and surgery for high-grade soft tissue sarcoma. RT seems to be promising within this specific histotype. Close follow-up is advisable in all cases. Further studies are needed to confirm if the observed efficacy of combined treatments results in a prolonged time of disease-free survival and overall survival.

Microscopic positive surgical margins in thyroid carcinoma: a proposal for thyroid oncology teams.

In the case of well-differentiated thyroid cancer, the importance of microscopic margin status remains controversial. We discuss the relevance of the effect of microscopic positive surgical margins in the early stages of differentiated thyroid cancer. A comprehensive literature search and review of available evidence in English literature was undertaken. A previous meta-analysis did not find an association between microscopic positive surgical margins and local recurrence. Heterogeneity of definitions and differences between microscopic surgical margins and extrathyroid extension are discussed. Impact on clinical decision-making is explored. The finding of microscopic positive surgical margins in a patient with a thyroid tumor without intraoperative evidence of macroscopic invasion to adjacent structures, with complete resection made by the surgeon and without pathological report of extrathyroid extension, does not have a worse prognostic effect. We present a classification of surgical margins that may help thyroid oncology teams to tailor further management in patients with thyroid cancer.

Positive microscopic surgical margins: Is there an association with survival in resected small gastrointestinal stromal tumors?

BackgroundFew studies evaluate the relationships between surgical approach, histologic margin, and overall survival in gastrointestinal stromal tumor. We test the hypothesis that margin positive resection is associated with compromised overall survival. MethodsWe queried the National Cancer Data Base to identify patients undergoing resections for gastrointestinal stromal tumors ≤3 cm in size between 2010 and 2015. Multivariable logistic regression was used to identify factors associated with positive microscopic margins on final pathology. Cox proportional hazard methods were used to evaluate factors associated with overall survival. Results2064 patients met inclusion criteria; 135 (6.5%) had a microscopically positive surgical margin. On multivariable regression, minimally invasive approach was not associated with risk of a positive margin (OR 1.06 95% CI [0.71, 1.59]). On Cox analysis, positive margin status was not associated with OS (R1: 1.03, CI [0.46–2.31], reference R0). ConclusionsPositive microscopic surgical margins are not associated with compromised overall survival in patients undergoing resection of small gastrointestinal stromal tumors. Minimally invasive surgical approaches do not compromise oncologic outcomes in these cases.

Effective Radiotherapy in Tracheobronchial Adenoid Cystic Carcinoma With Positive Surgical Margin

The study aimed to evaluate the role of postoperative radiotherapy (PORT) in the treatment of trachea and main bronchus adenoid cystic carcinoma (ACC) with a positive surgical margin. Patients with pathologically confirmed trachea or main bronchus ACC operated on at Shanghai Chest Hospital were enrolled. Survival, univariate, and multivariate analyses were performed. The χ2 test was applied to analyze the failure patterns among different groups (R0/0: negative margin resection without PORT; R1/0: positive margin resection without PORT; R1/1: positive margin resection with PORT). From January 2001 to December 2014, 77 patients were deemed eligible for the study. Pairwise comparisons showed that the overall survival rate of group R1/1 was comparable to that of group R0/0 (P=.438), and significantly longer than the rate of group R1/0 (P= .032). Additionally, the local disease-free survival rate of group R1/1 was much higher than that of group R0/0 (P= .023) and R1/0 (P= .001). Cox multivariate analysis identified the radiologic feature (P= .012) and PORT (P= .006) as significantly favorable prognostic factors for locoregional disease-free survival. By contrast, for overall survival, PORT (P= .032) was the only corresponding variable identified by univariate analysis. Furthermore, PORT significantly decreased the locoregional recurrence rate (P= .002) but not distant metastases (P > .999). PORT helped patients with tracheobronchial ACC and microscopic positive surgical margins to achieve a similar outcome as patients with complete resection. R0 resection may not be necessary for tracheobronchial ACC if it is difficult to be completely resected.

Locally recurrent extraskeletal myxoid chondrosarcoma of the shoulder: a case of complete neoadjuvant radiotherapy response

BackgroundExtraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue tumor that typically affects the lower limbs of men between the ages of 50 and 60. EMC of the shoulder is rare with a high risk of local recurrence and distant metastasis. A planned surgical excision in sarcoma referral centers (SRCs) is mandatory to obtain the best outcome. The role of chemotherapy (CHT) and Radiotherapy (RT) on soft tissue chondrosarcoma is still controversial.Case presentationA 47-year-old man presented to our referral center with a history of EMC in the right shoulder excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis or residual disease, but during follow-up a local recurrence was detected. After a multidisciplinary discussion, preoperative radiotherapy was administered with a total dose of 50 Gy, and then the patient underwent wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred in a 24-months post-operative follow up.ConclusionsThe case here described suggests the importance of patient’s management in SRCs. A planned combined treatments with both surgery and RT seems to be the best choice to improve local control. RT seems to be promising within this specific histotype. Further studies are needed to confirm if the observed efficacy of combined treatments reflects in a consistent survival benefit for EMC patients.

Microscopic Positive Tumor Margin Increases Risk for Disease Persistence but Not Recurrence in Patients with Stage T1-T2 Differentiated Thyroid Cancer.

Introduction Differentiated thyroid cancer (DTC) has an overall excellent prognosis. Patients who develop recurrent disease have a more unfavorable disease course than those with no recurrence. Higher recurrence rates are seen with incomplete surgical resection and gross positive margins. It is unclear whether microscopic positive margin affects disease recurrence rates as much as grossly positive margin. Aim of the Study. To assess whether microscopic positive margin is an independent predictor of disease recurrence in patients with overall low-risk DTC. Patients and Methods. We conducted a retrospective single-center institutional review of 1,583 consecutive patients' charts from 1995–2013 using the Canadian Thyroid Cancer Consortium Registry. We included adult patients with nonmetastasizing T1 and T2 DTC with a minimum of three years follow-up. Univariate and multivariate analyses were used to study factors that may influence the risk of persistent/recurrent disease. Strict definitions of persistent versus recurrent disease were applied. Results 963 patients (152 men and 811 women) were included in the study with a mean age of 46 years. Microscopic positive margins were present in 12% of the specimens and were associated with an increased rate of persistent disease (8% versus 2% in the controls) but not with an increased risk of recurrent disease (1% in both groups). T2 tumors had a significantly higher incidence of positive margins than T1 tumors (48% versus 36%) and significantly higher nodal staging. Conclusions Microscopic positive margin in the histopathology report in patients with low-risk DTC was associated with a higher rate of persistent disease but did not increase the risk of disease recurrence. A close follow-up of biomarkers and occult residual cancerous lesions is needed, especially in the first year. Further studies are needed to determine whether additional therapeutic measures to prevent recurrence are indicated in T1 and T2 DTC with positive microscopic surgical margins.

Impact of margin status on survival after surgery for sinonasal squamous cell carcinoma.

Sinonasal squamous cell carcinoma (SNSCC) is the most common malignancy of the paranasal sinuses. Surgery is the mainstay of treatment, yet positive surgical margins (PSM) are common and the prognostic impact on overall survival (OS) is mixed. Given the heterogeneity of impact of PSM on OS within the literature, we hypothesized that extent of tumor extirpation (microscopic PSM vs macroscopic PSM) may play a role in OS. Patients with SNSCC were identified in the National Cancer Database (NCDB, n = 7808). Of these, 4543 patients underwent surgery, 3265 patients underwent nonsurgical therapy. Kaplan-Meier curves were used to compare OS between negative surgical margin (NSM), micro-PSM, and macro-PSM cohorts vs patients undergoing primary nonsurgical therapy in a propensity-score-matched analysis. Multivariable analysis of factors associated with macro-PSM was also performed. One thousand thirty-three (22.0%) of the surgery patients had PSM, and approximately half (n = 521, 50.6%) of these had macro-PSM. When compared with nonsurgical treatment, propensity-score-matched results demonstrated improved OS in patients with NSM and micro-PSM (p < 0.001), but macro-PSM patients did not demonstrate improvement (p = 0.20). Tumor within the paranasal sinuses and advanced nodal classification (N2/N3) (odds ratio [OR], 1.18; p = 0.02; and OR, 15.09; p = 005, respectively) was associated with increased odds of macro-PSM on multivariable analysis. We demonstrate that the degree of tumor extirpation correlates with OS. Macro-PSM did not confer a benefit to OS when compared with nonsurgical therapy, and factors including tumor location and advanced nodal status affect whether surgery will result in macro-PSM. Given these findings, informed, shared decisionmaking between patient and surgeon regarding nonsurgical alternatives should occur before electing to proceed with surgery in SNSCC.

Preoperative Intensity Modulated Radiation Therapy Compared to Three-Dimensional Conformal Radiation Therapy for High-Grade Extremity Sarcomas in Children: Analysis of the Children's Oncology Group Study ARST0332

For pediatric patients with large, high-grade, extremity nonrhabdomyosarcoma soft-tissue sarcomas, preoperative radiation therapy (RT) provides the opportunity for smaller radiation fields and tumor shrinkage resulting in less extensive surgery. The potential disadvantage is an increased risk of wound complications after surgery compared with rates after postoperative chemoradiation. We assessed the impact of preoperative RT technique on target coverage in relationship to dose to skin and adjacent joints to determine whether acute wound complications and late musculoskeletal injury might be influenced by treatment technique. Of 550 eligible patients <30years of age, 200 were enrolled in arm D of ARST0332 and received neoadjuvant ifosfamide/doxorubicin, then chemoradiotherapy (45Gy and ifosfamide) and surgery followed by postoperative RT if gross or microscopic positive surgical margins. One-hundred thirteen patients had extremity nonrhabdomyosarcoma soft-tissue sarcomas, of which 56 patients had preoperative RT plans for digital review. The doses to the target volume, skin (surface to 5mm depth), adjacent joint, and extremity diameter were analyzed with respect to RT technique. Thirty-eight patients (65%) received 3-dimensional conformal RT (3D-CRT) and 18 (32%) received intensity modulated RT (IMRT). There was no difference in clinical target volume (CTV) size between groups (P=.920); however, IMRT plans had improved CTV coverage to 100% of the prescription dose compared with 3D-CRT plans (median CTV coverage, 92.7% vs 98.6%; P=.011). In patients without target overlap with the skin, IMRT use was associated with reduced percent volume of skin receiving 45Gy or more (V45Gy) compared with 3D-CRT (median, 1.6% vs 6.3%, respectively; P=.005). IMRT was also associated with reduced V45Gy to the adjacent joint compared with 3D-CRT (median, 1.1% vs 13.2%; P=.018). Preoperative IMRT may improve CTV coverage and reduce the volume of skin and adjacent joint treated to high doses. Future studies should assess whetherthese dosimetric findings produce differences in clinical and toxicity outcomes.

Laparoscopic nephrectomy: initial experience and 3 years follow-up with 68 cases

Introduction : Partial nephrectomy is considered the gold standard procedure in managing small renal masses less than 4cm, even less than 7 cm in the last decade. Minimal invasive surgery is a preferred option in those cases. Laparoscopic partial nephrectomy has equivalent oncological results with open partial nephrectomy, offering in the same time all the advantages of minimal invasive surgery. The purpose of our study is to present our initial experience in laparoscopic partial nephrectomy. Material and Methods : Between May 2015 and December 2017, 68 selected patients with renal masses smaller than 7cm observed by CT scan, were submitted to laparoscopic partial nephrectomy. Patient demographics, preoperative tumor characteristics and detailed operative, postoperative and pathologic data were collected. Results : Mean age of patients is 56,1 years (44-71), mean diameter of renal tumor 5, 3 cm (3,3 - 7,4 cm).36 patients had a right partial nephrectomy and 32 a left one, with no intraoperative complications. In four patients a laparoscopic radical nephrectomy was done, there are no cases of conversion to open surgery. The operation time ranged from 90 to 211 min, estimated blood loss (EBL) ranged from 30 to 300 ml and warm ischemia time (WIT) ranged from 5 to 31 min. Overall, four cases of postoperative complications CDC ≥ 3 were observed. One patient presented with a ureteric stricture and 3 with bleeding which necessitate angiographic intervention. There was one patient with a microscopic positive surgical margin and all patients are disease free during follow up (3-20 months, mean 12,2 months). Mean serum creatinine level has increased 23 mcmol/L (0-114). Conclusion : Laparoscopic partial nephrectomy is a safe and feasible approach in small renal masses, offering all the advantages of minimal invasive surgery

Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience

To evaluate oncologic outcomes and management of patients with microscopic positive surgical margin (PSM) after partial nephrectomy (PN) for renal cell carcinoma (RCC). We reviewed our database to identify patients who underwent PN between 1990 and 2015 for RCC and had PSM on final pathology. A 1:3 matching was performed to a negative surgical margin (NSM) cohort. Kaplan-Meier method and log-rank test were used to estimate survival and differences in outcomes, respectively. Cox proportional hazards models were conducted to estimate the Hazards ratio. A total of 2297 patients underwent PN at our institution, of which 1863 (81%) had RCC. Microscopic PSM was found in 34 (1.8%) RCC patients who were matched to 100 patients with NSM. Of these 34 patients, local recurrence (n=4), distant kidney recurrences (n=4), and metastases (n=5) developed during a median follow-up of 62months. Bilateral tumors/tumors in a solitary kidney (n=12/13, 92%), and multifocal tumors (n=7/13, 54%) were found in patients who developed recurrence/metastasis. PSM patients were at a higher risk of shorter overall survival (p=0.001), local recurrence-free survival (p=0.003), distant recurrence-free survival (p=0.032) and metastasis-free survival (p=0.018). There was statistically significant association between PSM and bilateral tumors, prior treated RCC at presentation and higher nephrometry score in multivariable model. There was a low rate of microscopic PSM in our large cohort of patients undergoing PN despite tumor complexity. Higher nephrometry score, bilateral tumors, and prior treated RCC independently predicted PSM which showed worse survival, recurrence and metastasis compared to patients with NSM.

Early Recurrence of Neuroendocrine Liver Metastasis After Curative Hepatectomy: Risk Factors, Prognosis, and Treatment

BackgroundEarly tumor recurrence after curative resection typically indicates a poor prognosis. The objective of the current study was to investigate the risk factors, treatment, and prognosis of early recurrence of neuroendocrine tumor (NET) liver metastasis (NELM) after hepatic resection. MethodsA total of 481 patients who underwent curative-intent resection for NELM were identified from a multi-institutional database. Data on clinicopathological characteristics, intraoperative details, and outcomes were documented. The optimal cutoff value to differentiate early and late recurrence was determined to be 3 years based on linear regression. ResultsWith a median follow-up of 60 months, 223 (46.4%) patients developed a recurrence, including 158 (70.9%) early and 65 (29.1%) late recurrences. On multivariable analysis, pancreatic NET, primary tumor lymph node metastasis, and a microscopic positive surgical margin were independent risk factors for early intrahepatic recurrence. While recurrence patterns and treatments were comparable among patients with early and late recurrences, early recurrence was associated with worse disease-specific survival than late recurrences (10-year NELM-specific survival, 44.5 vs 75.8%, p < 0.001). Among the 34 (21.5%) patients who underwent curative treatment for early recurrence, post-recurrence disease-specific survival was better than non-curatively treated patients (10-year NELM-specific survival, 54.2 vs 26.3%, p = 0.028), yet similar to patients with late recurrences treated with curative intent (10-year NELM-specific survival, 54.2 vs 37.4%, p = 0.519). ConclusionsEarly recurrence after surgery for NELM was associated with the pancreatic type, primary lymph node metastasis, and extrahepatic disease. Re-treatment with curative intent prolonged survival after recurrence, and therefore, operative intervention even for early recurrences of NELM should be considered.

Safety and feasibility of laparoscopic multivisceral resection for surgical T4b colon cancers: Retrospective analyses.

Laparoscopic (Lap) surgery has not been established as a standard procedure for locally advanced colon cancers. Here, we evaluated the safety and feasibility of Lap multivisceral resection (MVR) for tumors that had invaded adjacent organs (T4b). We performed retrospective analyses using a single institutional database. Eighty-four patients who underwent Lap or open MVR for surgical T4b primary colon cancers satisfied the inclusion criteria. Among the 84 patients, 48 underwent Lap MVR and 36 underwent open MVR. More patients in the open group were clinical T4b and were receiving neoadjuvant chemotherapy. Patients in the open group had worse performance status (P=0.037) and tumors of greater diameter. Lap completion was achieved in 42 cases (87.5%); the conversion rate was highest in cases involving the urinary tract (40.0%). Lap reconstruction of the bladder or ureter was extremely challenging, and therefore, adjacent organ reconstruction influenced Lap completion. Regarding perioperative outcomes, Lap was superior to open surgery in terms of intraoperative blood loss, morbidity, and postoperative hospital stay. Conversion was required in six cases; five were strategic conversions, and conversion was not associated with severe morbidity. The microscopic positive surgical margin rate was not higher in the Lap group than in the open group. Kaplan-Meier analyses of overall and disease-free survival were comparable between the groups. Cox regression analyses revealed that the operative approach did not have a significant adverse effect on long-term outcomes. The Lap approach could be considered for surgical T4b cancers, except for urinary tract invasion cases that require complicated reconstruction.

A propósito de un caso; paciente joven con tumor desmoide de mama diagnosticado tras tumorectomía

We report the case of a 16-year-old patient with no relevant gynecologic history, who was diagnosed with a phyllodes tumor in the border between the lower and upper outer quadrants of the right breast. The patient was treated with a tumorectomy/lumpectomy, and after pathological study of the specimen, was diagnosed with a desmoid breast tumor. Given the rarity of this entity, and the positive microscopic surgical margins, we consider that a literature review of desmoid breast tumor (etiology, clinical presentation and treatment) is timely.

A gene expression profile to predict recurrence of advanced tongue squamous cell carcinoma (TSCC): Discovery and external validation.

6032 Background: Extracapsular spread and positive microscopic surgical margins are known high risk factors of recurrence in head and neck cancer patients. However, molecular biological markers to predict recurrence have not been identified. Here, we aimed to identify markers of recurrence using DNA microarray profiling in patients with squamous cell carcinoma of the tongue (TSCC). Methods: We conducted exploratory Affymetrix gene expression profiling using 26 primary tumor tissue samples from patients meeting the following criteria: 1) histologically confirmed TSCC, 2) surgical resection of the primary tumor and lymph node dissection, and 3) follow-up for longer than one year after surgery. Median age and pathological stage were 60 years (37-85) and pStageIII/IV = 8%/92% (pT: 2/3/4a = 3/1/22, pN: 0/1/2a/2b/2c = 5/5/0/8/8), respectively. The relationship between gene expression pattern and relapse-free survival (RFS) was examined. Predictive candidate genes were independently validated using published sur...

Salvage surgery after energy ablation for renal masses

To evaluate the feasibility, safety, pathological, radiological and functional outcomes of salvage surgery after previous renal mass ablation therapy. After institutional review board approval, we reviewed our renal tumour database, and described the characteristics and outcomes of patients who experienced a local recurrence after energy ablation for renal masses and underwent salvage surgical therapy. A total of 14 patients fit the inclusion criteria. The median (interquartile range [IQR]) age was 65 (59-77) years, with a median (IQR) Charlson comorbidity index score of 2 (0.75-3.00). Three patients had a solitary kidney. Seven patients received their ablation therapies at an outside institution. Ten patients had undergone percutaneous radiofrequency ablation, three percutaneous cryoablation and one laparoscopic cryoablation. The median (IQR) R.E.N.A.L. nephrometry score at time of surgery was 7 (5-9), while the median (IQR) time from ablation to surgery was 26.5 (16.3-39.3) months. Of the 14 patients, 11 underwent partial nephrectomy and three underwent planned radical nephrectomy. The median (IQR) surgery time was 203 (177-265) min and the median length of stay was 5.5 days. There was one microscopic positive surgical margin. The median tumour size at final pathology was 3.1 cm. In all, 13 patients had renal cell carcinoma and one had no tumour present. Nine were pT1a, 1 pT1b, 2 pT3a, and 1 pT3b tumours. There were four Clavien grade III complications in four patients. The median preoperative estimated glomerular filtration rate (eGFR) and the eGFR at last follow-up were 66 and 66 mL/min/1.73 m(2) . There had been no deaths by the median (IQR) follow-up of 26.5 (10.5-49.5) months. Patients who have undergone previous renal ablation therapy can be salvaged with partial or radical nephrectomy with good intermediate-term outcomes. These procedures may be associated with a high rate of adverse events. Longer follow-up is necessary.

Risk factor analysis of locoregional recurrence after sublobar resection in patients with clinical stage IA non–small cell lung cancer

Although lobectomy is the standard surgical procedure for operable non-small cell lung cancer (NSCLC), sublobar resection also has been undertaken for various reasons. The aim of this study was to identify risk factors of locoregional recurrence and poor disease-specific survival in patients with clinical stage IA NSCLC undergoing sublobar resection. We retrospectively reviewed 328 patients with clinical stage IA NSCLC who underwent segmentectomy or wedge resection. Demographic, clinical, and pathologic factors were analyzed using the log-rank test as univariate analyses, and all factors were entered into a Cox proportional hazards regression model for multivariate analyses to identify independent predictors of locoregional recurrence and poor disease-specific survival. The 5- and 10-year locoregional recurrence-free probabilities were 84.8% and 83.6%, respectively, and the 5- and 10-year disease-specific survivals were 83.6% and 73.6%, respectively. Four independent predictors of locoregional recurrence were identified: wedge resection (hazard ratio [HR], 5.787), microscopic positive surgical margin (HR, 3.888), visceral pleural invasion (HR, 2.272), and lymphatic permeation (HR, 3.824). Independent predictors of poor disease-specific survival were identified as follows: smoking status (Brinkman Index; HR, 1.001), wedge resection (HR, 3.183), microscopic positive surgical margin (HR, 3.211), visceral pleural invasion (HR, 2.553), and lymphatic permeation (HR, 3.223). All 4 predictors of locoregional recurrence also were identified as independent predictors of poor disease-specific survival. Segmentectomy should be the surgical procedure of first choice in patients with clinical stage IA NSCLC who are being considered for sublobar resection. Patients having tumors presenting with no suspicious of pleural involvement would be suitable candidates for sublobar resection.

Clinical outcomes for patients with soft tissue sarcoma of the hand

In an earlier report from the current study center regarding surgical treatment for patients with soft tissue sarcoma (STS) of the hand, it was concluded that repeat resection or amputation improves outcomes. Since then, the authors have aggressively sought to achieve negative resection margins, using standard or modified amputations when needed, and performing repeat resections to negative surgical margins when they were not achieved at the time of initial surgery. The current review was conducted to determine whether this approach resulted in better outcomes. A retrospective review of 53 patients with STS of the hand who were treated between 1996 and 2005 was performed. Recurrence-free survival (RFS) and functional outcome of hand-preserving procedures were assessed according to the Musculoskeletal Tumor Society (MSTS) system. The median RFS was not reached at the time of last follow-up. Of 53 patients, 6 (11%) had positive microscopic resection margins. Three patients underwent repeat resection to negative surgical margins, whereas another 3 patients did not. All 3 patients with positive microscopic surgical margins that were not re-excised developed local disease recurrence; 2 patients also developed distant metastases. Two of the 50 patients with negative resection margins developed distant metastases. All 5 patients who developed local and/or distant disease recurrence had deep tumors. The median MSTS score was 29 (interquartile range, 27-30). Patients who underwent more extensive resections, such as double ray amputations, had lower MSTS scores. Suboptimal biopsies and positive resection margins are associated with local and distant disease recurrence in patients with STS. The results of the current study suggest that aggressive surgical treatment can result in better clinical outcomes, and underscore that care must be taken when planning biopsies of hand tumors.

Positive margins after nephron‐sparing surgery for renal cell carcinoma: long‐term follow‐up of patients on active surveillance

To analyse our long-term oncological outcomes with active surveillance in patients with positive surgical margins (PSMs) after nephron-sparing surgery (NSS) for renal cell carcinoma (RCC), as this situation is a difficult therapeutic dilemma. We performed open NSS for renal masses with frozen-section analysis of any suspicious zone of the surgical bed, followed by extensive argon-beam coagulation. In patients where the final histopathological examination of the renal mass revealed PSMs, follow-up consisted of computed tomography (CT) every 6 months in the first 2 years and then annually up to 5 years, and thereafter we alternated ultrasonography with CT. From 1995 to 2003 we had 11 cases of microscopic definitive PSMs after NSS for RCC. Two patients required nephrectomy (one for postoperative bleeding and another as an elective procedure), so nine were followed. These patients were either operated under elective (seven) or imperative (two) conditions. The histological subtype was clear cell carcinoma in three, papillary in two, chromophobe in two and hybrid oncocytic RCC in two, with a Furhman grade of 2 in six and 3 in three. The mean size was 31.4 mm, and the stage was pT1a in six, pT1b in one and pT3a in two. After a median follow-up of 80.5 months, there was no local recurrence or distant progression. In our experience, microscopic PSMs in NSS specimens can be managed conservatively with active surveillance, achieving excellent results and avoiding extensive reoperation without compromising long-term oncological outcomes.

Adjuvant Chemoradiation for Gastric Cancer: Experience in the Chinese Population

Aims The role of adjuvant chemoradiation for gastric cancer after curative R0 gastrectomy was first established by the US Intergroup 0116 study. Although confirmatory studies are in progress, few data are available regarding its application to the Chinese population. We describe our radiotherapy technique and report the treatment results in Hong Kong. Materials and methods This was a single centre retrospective study on 63 Chinese patients who underwent adjuvant chemoradiation for gastric adenocarcinoma between June 2000 and December 2004. The treatment protocol was based on that of the Intergroup study. Computed tomography planned anteroposterior opposing field arrangement and treatment under breath hold at deep inspiration position were adopted. Results In total, 63 patients, mean age 50 years, with gastric cancer stage IB to limited metastatic IV disease were analysed. The median follow-up time was 27.2 months. The relapse-free survival and overall survival at 3 years were 50 and 54%, respectively. The recurrence pattern was dominated by distant failure and only one patient developed isolated locoregional recurrence. Of the 10 patients who had positive microscopic surgical margins after surgery, seven had recurred and died. On multivariate analysis, margin status was the only significant prognosticator for survival. Thirty per cent of patients experienced grade 3 or above acute toxicity (24% haematological, 14% gastrointestinal) and one patient died of neutropenic sepsis. There was one case of grade 3 late toxicity. Conclusions The outcome after adjuvant chemoradiation for gastric cancer seemed to be favourable, with manageable toxicities, in the Chinese population. Locoregional failure was uncommon. Patients with microscopic surgical margin involvement had a very high failure rate despite adjuvant chemoradiation.

RETRACTED: Continence after radical prostatectomy with bladder neck preservation

Bladder neck preservation during radical prostatectomy has been advocated for improving urinary continence. We evaluate bladder neck preservation looking at continence rates, surgical cancer control and bladder neck contracture. A total of 40 patients underwent retropubic radical prostatectomy for clinically localized carcinoma of the prostate. The prostatic urethra was dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. Continence was noted immediately in 26 patients, within 2 weeks in 9 and within 6 weeks in 3. Only 2 patients required pads 3 months postoperatively. Microscopic positive surgical margins were noted in 2 of 40 patients. In 1 patient the urethral margins were not involved with carcinoma. In the other patient the urethra was not the sole positive margin and microscopic positive margins were noted elsewhere. Early results of cancer control were good. Early follow-up of this technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.