Microscopic Surgical Margins Research Articles

Surgical Resection for Pediatric Synovial Sarcoma: What Margin Is Adequate?

INTRODUCTION: Synovial sarcoma is the most common nonrhabdomyosarcoma soft tissue sarcoma in children. Guidelines concerning the size of resection margins are lacking. We sought to evaluate if negative microscopic resection margins predicted overall survival. METHODS: A retrospective chart review showed 22 patients with synovial sarcoma from September 2011 to November 2019 at Texas Children’s Hospital. Pearson’s chi-square test and multivariate regression analyses were used. RESULTS: Relapsed free survival was 59% and overall survival was 72% with a median follow-up of 3 years (with interquartile range [IQR] 1.6 to 4.9 years) from initial resection (Figure). The patients with negative margins had a median resection margin of 1.5 mm (IQR 1 to 27mm). Positive microscopic margins were noted in 71% (5/7) of the patients who died compared with 12% (2/16) of patients who survived (p = 0.01). Survival in patients with surgical margins of <5 mm was 100% (7/7) compared with the 28% (2/7) of patients with positive surgical margins (p = 0.02). Positive microscopic margin was an independent risk factor for death (odds ratio 40, 95% CI 1.98 to 807; p = 0.02) when adjusting for adjuvant chemotherapy and radiation.FigureCONCLUSION: This study revealed that a negative microscopic surgical margin in pediatric synovial sarcoma is an independent prognostic predictor of overall survival.

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.

Salvage surgery for patients with residual/persistent diseases after improper or insufficient treatment of oral squamous cell carcinoma: can we rectify these mistakes?

BackgroundPatterns of failure after treatment of oral and squamous cell carcinomas (OSCC) are diversified, with recurrences being one of the common causes. A special group of patients are sometimes encountered in the outpatient clinic for improper or insufficient initial treatment with reports of positive margins, implying residual/persistent diseases. The question of whether these patients can be surgically salvaged remain unanswered.MethodsA retrospective study was performed between January 2013 and December 2017 for patients with residual or rapid recurrent (within 3 months) OSCCs, who received salvage surgeries in our institution. The patients with residual/persistent OSCCs were those with microscopic or macroscopic positive surgical margins, while those with rapid recurrent OSCCs were those with close or negative margins, but unabated painful symptoms right after treatment. Both clinicopathological and prognostic variables were analyzed. The focus was also directed towards lessons for possible initial mistakes, resulting in these residual/persistent diseases.ResultsOf 103 patients, 68 (66%) were men, with mean age of 56.3 years. The overall survival reached 60.2%. Regarding the primary OSCC status, most of our patients (n = 75, 72.8%) were diagnosed with ycT2–3 stages. Besides, most patients were found with macroscopic residual diseases (52.4%) before our salvage surgery. The sizes of the residual/persistent OSCCs were generally under 4 cm (87.3%) with minimally residual in 21 (20.4%). Among all the variables, primary T stage (p = 0.003), and residual lesion size (p < 0.001) were significantly associated with the prognosis in multivariate analysis. Though the causes for the initial surgical failure were multifactorial, most were stemmed from poor planning and unstandardized execution.ConclusionsCases with residual/persistent OSCCs were mostly due to mistakes which could have been avoided under well-round treatment plans and careful surgical practice. Salvage surgery for cases with smaller residual/persistent OSCCs is still feasible with acceptable outcomes.

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.

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.

Surgical Resection of Hepatoblastoma: Factors Affecting Local Recurrence.

This study aimed to investigate potential factors contributing to local recurrence after surgical resection of hepatoblastoma (HB). This retrospective study involving all patients with HB who underwent nontransplant surgery at our tertiary center between July 2007 and July 2018. Data were analyzed regarding microscopic surgical resection margin, tumor multifocality and extracapsular tumor extension in correlation with local recurrence. These relations were assessed by logistic regression. The study included 133 patients with a median age of 1.3 years (range: 0.5-12.8 years). They were classified into 99 cases (74.44%) standard risk and 34 cases (25.56%) high risk. Delayed surgical resection was adopted in all patients. Follow-up to July 2019 revealed that 23 patients (23/133, 17.3%) developed local recurrence, whereas the remaining 110 were locally disease free. Microscopic positive margin (R1) was detected in 29 patients, 8 of them had local recurrence (p = 0.097). Regarding tumor multifocality, there were 12 patients who had multifocal lesions, 3 of them developed local recurrence (p = 0.459). Forty-four patients had extracapsular tumor extension in their pathological reports, 12 of them had local recurrence (p = 0.032). Extracapsular tumor extension was a significant prognostic factor of local recurrence after surgical resection of HB. R1 margin does not necessarily require a second resection, and it could achieve accepted results when combined with adjuvant platinum-based chemotherapy. However, patients who are not eligible for surgical resection must be transferred for primary transplantation to obtain favorable outcome.

Do microscopic surgical margins matter for primary gastric gastrointestinal stromal tumor?

BackgroundAlthough tumor size and mitotic rate are established prognostic factors for worse survival in patients undergoing surgical resection for gastric gastrointestinal stromal tumors, the impact of microscopic margins, or R1 resection, is not completely established. MethodsPatients who received no neoadjuvant therapy and underwent surgical resection for stage I to III gastric gastrointestinal stromal tumors were identified from the 2010 to 2013 National Cancer Database and divided into 2 cohorts, R0 and R1 resections. Cox proportional hazards ratio and Kaplan Meier survival estimates were utilized to analyze 5-y overall survival. ResultsOf 2,084 patients, those with R1 resection (57, 2.7%) were more likely to have tumors >10 cm (28.1% vs 11.9%, odds ratio 3.51, P = .017) and stage III disease (26.3% vs 11.2%, odds ratio 2.26, P = .047). Although margin status was associated with higher risk tumors, it was not associated with receipt of adjuvant therapy. After multivariate Cox regression, R1 and R0 patients did not have a difference in 5-y overall survival (82.5% vs 88.6%, hazards ratio 1.26, P = .49). When stratified by stage of disease, there remained no difference in survival across all stages when comparing R1 and R0 patients. ConclusionPositive microscopic margins are uncommon but do not appear to impact survival outcomes in patients with resected localized gastric gastrointestinal stromal tumors.

Resection of recurrent hepatocellular carcinoma with thrombi in the inferior vena cava, right atrium, and phrenic vein: a report of three cases

BackgroundPrognosis for patients with advanced hepatocellular carcinoma with a tumor thrombus in the inferior vena cava or right atrium is extremely poor due to cancer progression, pulmonary embolism, and congestion of the circulatory system caused by right heart failure. Surgical resection of the tumor thrombi may potentially yield better results than non-surgical treatments through prevention of sudden death. However, the benefits of surgical resection in patients with hepatocellular carcinoma and a tumor thrombus extending to the inferior vena cava, right atrium, and potentially in the phrenic vein are unclear. Here, we report three such cases.Case presentationOf the total 136 patients who underwent hepatectomies for hepatocellular carcinoma in our institution, three patients with prior hepatectomies and recurrent hepatocellular carcinoma had tumor thrombi in the inferior vena cava, right atrium, and phrenic vein. Surgical resections were performed, as there was a possibility of sudden death, despite the risk of leaving residual tumor. For all patients, we performed resection of the tumor thrombi in the inferior vena cava and right atrium and combined diaphragm resection. Surgical resection was performed using the total hepatic vascular exclusion technique in all cases. Additional passive veno-venous bypass was also performed in two cases, in which complete tumor resections could not be achieved. The microscopic surgical margins of the combined resected diaphragms were positive in all cases. Progression-free survival was 20.2, 3.8, and 9.5 months for case 1, 2, and 3, respectively. The respective overall postoperative survival was 98.0, 38.9, and 30.9 months. The patients died due to liver cirrhosis, acute heart failure, and hepatocellular carcinoma, respectively. Sudden death did not occur for any of the patients.ConclusionSurgical resections may extend prognosis for patients with recurrent hepatocellular carcinoma with tumor thrombi in the inferior vena cava, right atrium, and phrenic vein, although the indications should be considered carefully.

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.

Parotid salivary duct carcinoma: a single institution\u2019s 20-year experience

PurposeThe aim of the study was to assess the treatment results of the parotid gland salivary duct carcinoma (SDC).Material and methodsA retrospective clinicopathological analysis of 40 patients treated for parotid SDC in 1996–2015 was performed. The impact of following factors on 5-year disease-free survival (DFS) and overall survival (OS) was studied: age, sex, preoperative 7th nerve palsy, skin infiltration, pT, pN, surgical margin, type of parotidectomy and neck dissection, histology (SDC de novo vs. SDC ex pleomorphic adenoma, SDCexPA), intra/periparotid lymph nodes metastases, perineural invasion (PNI), extraparenchymal extension (EPE), and overexpression HER2.ResultsThe average age of the patients was 62 years (ranged from 39 to 81). Males predominated (57.5%). Patients with the clinical stage IV predominated (82.5%). In 1/3 of patients preoperative, 7th nerve palsy occurred. All patients were treated surgically, and all but one had supplementary radiotherapy. In 28 patients (70%), total radical parotidectomy was performed. A neck dissection was performed in all patients. In 19 cases (47.5%), SDCexPA was diagnosed. Negative microscopic surgical margin was obtained in 60% of patients. The follow-up for the whole analyzed group ranged from 2 to 22 years, average was 11.6 years. In 23 patients (57.5%), the disease recurred. Local recurrence was observed in 10 (25%) and distant metastases in 15 (37.5%) cases. 20 patients (50%) died of cancer. 5-year DSF and OS were 42.5% and 41%, respectively. Univariate analysis proved that the significant influence on the survival had 7th nerve palsy (p = 0.024 and p = 0.017, respectively), higher pT-stage (p < 0.001), radical parotidectomy (p = 0.024 and p = 0.022), radical treatment of the neck (p = 0.001 and p = 0.002), EPE (p = 0.040 and p = 0.028), and histology SDCexPA and PNI (p = 0.036 and 0.048). Multivariate analysis showed that independent prognostic factors were the 7th nerve palsy and the histology SDCexPA, which worsened 5-year DFS, respectively, 3.61 and 3.94 times (p = 0.033 and p = 0.026). On the other hand, on 5-year OS, only 7th nerve palsy had an influence (3.86 times worse prognosis, p = 0.033).ConclusionsSDC is a clinically aggressive cancer with high risk of local recurrence and distant metastases, however, with a chance of curing of around 40%. In the majority of patients, a radical surgical treatment is necessary due to the high clinical stage of disease. Worse prognosis have patients with preoperative 7th nerve palsy and in whom SDC develops in pleomorphic adenoma.

Body weight loss after surgery affects the continuity of adjuvant chemotherapy for pancreatic cancer

BackgroundPostoperative chemotherapy is beneficial for many pancreatic cancer patients. However, some patients require dose reduction or the discontinuation of adjuvant chemotherapy because of adverse treatment-related effects. In this study, we aimed to evaluate two main outcomes. First, we evaluated the clinicopathological factors affecting patient disease-free survival (DFS) and overall survival (OS) following upfront surgery. Second, we evaluated the factors that influence the continuity of adjuvant chemotherapy.MethodsFifty-four patients with resected pancreatic cancer were enrolled. First, we evaluated the clinicopathological factors affecting postoperative survival using the Kaplan-Meier method and Cox regression method. Next, factors affecting the continuity of adjuvant chemotherapy were analyzed using multiple logistic regression analysis.ResultsUnivariate and multivariate analyses revealed that positive LN metastasis (HR (95% CI) 6.329 (2.381–16.95); p < 0.001) and relative dose intensity (RDI) < 80% for adjuvant chemotherapy (HR (95% CI) 5.154 (1.761–15.15); p = 0.003) were independent predictive factors for DFS. Regarding OS, extended dissection of the nerve plexus around the superior mesenteric artery (SMA) (HR (95% CI) 4.504 (1.721–11.76); p = 0.002), positive microscopic surgical margin (HR (95% CI) 5.565 (1.724–17.96); p = 0.004), and adjuvant chemotherapy of RDI < 80% (HR (95% CI) 3.534 (1.135–2.667); p = 0.029) were also independent predictive factors. Moreover, the level of RDI significantly correlated with DFS and OS. Multiple logistic regression analysis revealed that low RDI was significantly associated with postoperative body weight loss (BWL) ≥ 10%.ConclusionsThe following factors were significantly associated with poor survival: extended dissection of the nerve plexus around the SMA, lymph node metastasis, residual tumor, and RDI of the adjuvant chemotherapy. Patient’s prognosis with adjuvant chemotherapy of RDI < 80% was worse. BWL ≥10% was the most important factor affecting the continuity of adjuvant chemotherapy. Perioperative nutritional intervention is necessary for patients who receive adjuvant chemotherapy for advanced pancreatic cancer.

The Correlation of Surgical Margins and Outcome Of Soft Tissue Sarcomas of The Extremities and Trunk in Hospital Sultan Ismail, Johor Bahru

Introduction: Patients with soft tissue sarcoma are treated following the standardized guidelines, however it is not guaranteed patient will remain free from local recurrence (LR) and metastasis. This study was conducted to determine the association between microscopic marginal status with local recurrence, metastasis and the survival of the patient. Materials and Methods: This retrospective study was conducted from January 2015 to December 2017 in Hospital Sultan Ismail, Johor Bahru. All patients underwent complete standadized resection of the tumour and had been follow up for 5 years. An operating and follow-up records of 70 cases who fulfill the inclusion and exclusion criteria were collected and analysed using Pearson chi square test and Kaplan-Meier curves. Results: Of the 70 patients, 52 were males and 18 were females. The age of the patients were between 16 and 73 years with the means age of 48.8 years old. Sixty eight patients underwent limb salvage surgery and 2 had amputation. 42 of them had positive post-operative microscopic surgical margin (PMSM) while 28 were negative. Local recurrence was noted in 28 and metastasis in 30 patients. Patient who had PMSM has higher risk to get local recurrence and metastasis compared to patient with negative margin (p-value &lt;0.001). The overall median survival was 23 months. Overall survival rates for 3 years was 80% and for 5 years was 65%. Conclusion: In our study, patient with positive post-operative microscopic surgical margin had higher possibility to develop local recurrence, metastases and decrease overall survival rate.

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS).

Reference centers (RCs) are a key point for improving the survival of patients with soft-tissue sarcomas (STS). The aim of this study was to evaluate selected items in the management of patients with STS, comparing results between RC and local hospitals (LHs). Diagnostic and therapeutic data from patients diagnosed between January 2004 and December 2011 were collected. Correlation with outcome was performed. A total of 622 sarcomas were analyzed, with a median follow-up of 40 months. Imaging of primary tumor preoperatively (yes vs. no) correlated with a higher probability of free surgical margins (77.4% versus 53.7%; p = .006). The provenance of the biopsy (RC vs. LH) significantly affected relapse-free survival (RFS; 3-year RFS 66% vs. 46%, respectively; p = .019). Likewise, 3-year RFS was significantly worse in cases with infiltrated (55.6%) or unknown (43.4%) microscopic surgical margins compared with free margins (63.6%; p < .001). Patients managed by RCs had a better 3-year overall survival compared with those managed by LHs (82% vs. 70.4%, respectively; p = .003). Perioperative chemotherapy in high-risk STS, more frequently administered in RCs than in LHs, resulted in significantly better 3-year RFS (66% vs. 44%; p = .011). In addition, patients with stage IV disease treated in RCs survived significantly longer compared with those in LHs (30.4 months vs. 18.5 months; p = .036). Our series indicate that selected quality-of-care items were accomplished better by RCs over LHs, all with significant prognostic value in patients with STS. Early referral to an RC should be mandatory if the aim is to improve the survival of patients with STS. This prospective study in patients diagnosed with soft-tissue sarcoma shows the prognostic impact of reference centers in the management of these patients. The magnitude of this impact encompasses all steps of the process, from the initial management (performing diagnostic biopsy) to the advanced disease setting. This is the first prospective evidence showing improvement in outcomes of patients with metastatic disease when they are managed in centers with expertise. This study provides extra data supporting referral of patients with sarcoma to reference centers.

Lymph Node Ratio as a Predictor of Distant Metastases in Major Salivary Gland Carcinomas

To investigate the prognostic value of lymph node ratio (LNR, number of positive lymph nodes[LN]/total number of excised LN) on distant metastases (DM) and overall survival (OS) in patients (pts) with major salivary gland carcinoma (SGC). An REB-approved retrospective review was conducted for SGC patients treated at our institution with curative surgery and neck dissection (>=6 dissected LN)+/−adjuvant treatment in 2000-2015. Patients, treatment and outcomes data were collected from our institutional maintained databases. Staging was reviewed according to the AJCC-UICC 8th edition. High risk pathology was defined with histologic grade and WHO histologic criteria, and included: adenoid cystic carcinoma (ACC), salivary duct carcinoma, SCC, G2/3 adenocarcinoma, G2/3 mucoepidermoid carcinoma (MEC), G2/3 carcinoma ex-pleomorphic adenoma, carcinosarcoma, undifferentiated (small-, large-cell or lymphoepithelial) carcinoma and G3 of other histologic subtypes. Distant control (DC) and OS were analyzed with competing risk and Kaplan-Meier methods respectively. LNR (continuous variable) was subjected to multivariable analysis (MVA) for DM and OS (adjusted for age, gender, primary SGC subsite, pathologic stage, high-risk pathology, lymphovascuar invasion [LVI], perineural invasion [PNI], extranodal extension [ENE] and surgical margin status). The optimal cutpoint of LNR that maximized the difference in outcomes was determined using maximally selected rank statistics. Subgroup analysis was performed for patients with pN+. A total of 204 pts were identified: median age: 56 yr (16-91); median follow-up: 5.2 yr (0.4- 17.6); parotid gland primary tumor location: 168 (82%); high risk pathology: 151 (74%); pT3-4: 132 (65%), pN+: 99 (44%); LVI: 49 (26%); positive microscopic surgical margin: 103 (52%); ENE: 37 (19%). PORT was used in 195 pts (96%); and adjuvant concurrent chemotherapy in 11 (5%). Of 2,725 LNs evaluated, 328 (12%) were pN+. The median number of dissected LN was 23 (6–101). For pN+ pts, the median number of involved LN was 3 (1-65) and median LNR was 14% (1%–100%). High-risk pathology and LVI were associated with high LNR (p<0.001 for both). On MVA LNR was independently correlated with DM (HR:1.18, 95%CI: 1.07-1.30, p<0.001) and OS (HR:1.16; 95%CI: 1.06-1.28, p=0.002) and so did LVI+ (DM: HR:2.54, 95%CI: 1.38-4.70, p=0.003) and OS (HR:2.50; 95%CI: 1.33-4.70, p=0.004), positive margins (DM: HR:2.47, 95%CI: 1.31-4.65, p=0.005) and OS (HR:2.59; 95%CI: 1.35-4.95, p=0.004),. The optimal cut-off point for LNR was 8%; 5-yr DC: 42% vs 88%, p<0.001; 5-yr OS: 44% vs 89%, p<0.001 for LNR ≥8% vs <8%. In a subgroup analysis of patients with pN+, LNR remained predictive for DM (HR:1.24, 95%CI: 1.14-1.35, p<0.001) and OS (HR 1.27, 95%CI: 1.16-1.38, p<0.001). High LNR is associated with a higher risk of DM and lower OS. LNR should be evaluated in future prospective studies for intensified therapy or surveillance schedule in patients with SGC.

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

Adjuvant radiotherapy in management of trichilemmal carcinoma of left nasal alae with positive surgical margins: A case report

Background: Trichilemmal carcinoma (TLC) is a rare adnexal malignant tumor developing from the outer root sheath of hair follicles with no distinct clinical features which might clinically be misdiagnosed as actinic keratosis, nodular melanoma, basal or squamous cell carcinoma. Albeit no consensus exists on standard treatment of TLC, tumor excision with adequate clear margins is the current widely accepted treatment consideration with no previous literature on use of radiotherapy (RT) in definitive or postoperative settings. Case presentation: A 60-year-old woman who was repeatedly treated with cryotherapy located on her left nasal alae for an initial diagnosis of actinic keratosis and diagnosed as TLC at last surgery was referred for RT of microscopic surgical margins. The patient was treated with 6 MeV electron beam RT prescribed to surgical bed plus 1-cm margins at all directions, namely the planning target volume. The total and per fraction doses were 60 and 2 Gy, respectively, which is commonly practiced for any skin tumor with positive margins. The treatment was well tolerated with no acute or chronic complications. The patient was alive with no local, regional, or distant recurrences at the 49 months of her follow-up. Conclusions: Although the follow-up period is relatively short and further evidence is needed to confirm the exact role of RT in adjuvant treatment of TLC, the outcomes of present rare case of a nasal TLC suggests that adjuvant RT in patients with positive surgical margins may provide satisfactory local tumor control.

Diagnosis and management of spermatic cord tumors.

Spermatic cord tumors (SCT) are very rare. The present review discusses the most recent literature regarding clinical presentation, pathological characteristics, diagnosis, and management of SCT. Although the majority of SCT are benign, when malignant almost all SCT are sarcomas. Liposarcomas are the most common; whereas rhabdomyosarcomas recorded the highest tendency of develop distant metastases. The clinical presentation is usually a unilateral solid slow-growing mass at the level of the inguinal canal and of the scrotum. Surgical excision represents the most common used treatment, and considering the risk in developing local recurrence, radical inguinal orchiectomy and resection of the tumor with negative microscopic surgical margins is mandatory. Adjuvant therapies such as radiotherapy and chemotherapy have been suggested in selected patients, but clear data to demonstrate any improvement in survival are not available. SCT are rare tumors with high risk of misdiagnosis or mistreatment. The majority are benign, but when malignant almost all are sarcomas. A surgical excision is the treatment of choice; however, no clear data exists documenting the efficacy of a multimodal treatment in reducing high local recurrence rates after surgery.

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...