Negative Margins Research Articles

Chondroblastic Osteosarcoma of the Clavicle: A Rare Case Report

Introduction: Osteosarcoma is the most common primary malignant bone tumor, typically arising in the metaphyseal regions of long bones. Clavicular osteosarcoma is exceedingly rare, accounting for less than 1% of all osteosarcomas. Chondroblastic osteosarcoma is a histologic subtype characterized by the presence of chondroid matrix in addition to the typical osteoid component. This case report aims to present the diagnosis and management of a rare case of chondroblastic osteosarcoma of the clavicle and discuss the relevant literature on the topic. Case Presentation: A 21-year-old male presented with a growing lump on his left neck since nine months ago. The patient underwent biopsy which revealed chondroblastic type osteosarcoma in the left medial clavicle. He had received four series of neoadjuvant cisplatin and doxorubicin. Tumor resection was done with thoracic surgeon backup. Postoperative care included immobilization with collar brace and arm sling, active distal range of motion exercises, and regular wound care. Discussion: Clavicular osteosarcoma is exceedingly rare, accounting for less than 1% of all osteosarcomas. Clavicle has a unique characteristic from other long bone and flat bone which supported the fact that that clavicle had low incidence of bone tumor. Neoadjuvant chemotherapy, followed by surgical resection and postoperative adjuvant chemotherapy, has been the mainstay of treatment for osteosarcoma. primary goal of surgery is to achieve wide en bloc resection with negative margins while preserving function. Prognosis of clavicular osteosarcoma is not well-established due to the rarity of the condition. Long-term follow-up is crucial for monitoring local recurrence and detecting distant metastases. Conclusion: The diagnosis and management of clavicular osteosarcoma can be challenging due to its uncommon location and proximity to vital structures. A multidisciplinary approach is essential for optimal management and improved survival outcomes in such cases. Further studies and case reports are necessary to better understand the prognostic factors and long-term outcomes for patients with clavicular osteosarcoma. Keywords: chondroblastic osteosarcoma, clavicle, primary malignant bone tumor, tumor resection.

Initial experience with the novel modular robotic system Carina in urology: a prospective study on safety feasibility and surgical settings

Robot-assisted surgery has transformed urology, but widespread adoption remains limited by the high cost, complex setup, and rigid system design. This prospective single-center study evaluates the safety and efficacy of the novel modular Carina in 19 upper and lower urinary tract surgeries. All cases were completed robotically without conversion, with one major complication. For partial nephrectomy (PN), median operative time (OT) was 120 min with 50 mL estimated blood loss (EBL), including one off-clamp PN completed in 77 min (EBL: 50 mL). Pyeloplasty had a median OT of 105 min (EBL: 50 mL), while radical prostatectomy (RP) achieved a median OT of 150 min (EBL: 50 mL). Radical cystectomy was completed in 301 min without major complications, and an uncomplicated postoperative course. Median docking times were 5 and 8 min for upper and lower tract surgeries, with negative margins and preserved renal function in all PN, and social continence post-RP. The Carina system demonstrates procedural safety and feasibility in complex urological procedures. The modular design may enhance workflow and space utilization, suggesting the potential for promising tool and broader clinical applications. Further validation with larger sample sizes and long-term follow-up is needed.

Right robotic-assisted thoracic surgery retrograde fissureless en bloc S2/6 bisegmentectomy.

We describe a demanding procedure involving resection of a non-palpable lesion resting in the middle of the posterior aspect of the undeveloped oblique fissure, between the right S2 and S6 segments. Four ports were utilized, and the da Vinci X system was used. The resection started from the V6. Because the fissure was not complete, a tunnel was created below the B6 and towards the area between the A6 and the rest of the basal pulmonary artery. The division of the S6 segment from the lower lobe followed. After the B6 was divided, the A6 was divided separately from the A2 although they originated with a common trunk. The B2 division followed. Finally, the S2 segment was detached, completing the S2/6 bisegmentectomy. Postoperative recovery was uneventful, and the patient was discharged on post-operative day 1. The final histologic report confirmed an adenocarcinoma non-small cell lung cancer (pT1bN0M0V1PL0) with negative margins (R0). At the follow-up examination, the patient was well without cancer recurrence.

Hospital Volume as a Determinant of Outcomes After Partial Nephrectomy: A Systematic Review by the European Association of Urology Renal Cell Carcinoma Guidelines Panel.

Hospital Volume as a Determinant of Outcomes After Partial Nephrectomy: A Systematic Review by the European Association of Urology Renal Cell Carcinoma Guidelines Panel.

Clinical Trial Protocol for ACCURATE: A CCafU-UroCCR Randomized Trial: Three-dimensional Image-guided Robot-assisted Partial Nephrectomy for Renal Complex Tumor (UroCCR 99).

Clinical Trial Protocol for ACCURATE: A CCafU-UroCCR Randomized Trial: Three-dimensional Image-guided Robot-assisted Partial Nephrectomy for Renal Complex Tumor (UroCCR 99).

Hard Palate Graft Combined with Fricke Flap: Satisfactory Option for Reconstruction of Extensive Lower Eyelid Defects-A Case Series.

Background: The reconstruction of extensive full-thickness lower eyelid defects constitutes a challenge for plastic surgeons. Various techniques have been described to cater to patients' specific defect needs, with the aim of achieving the best results. Materials and Methods: We performed a retrospective observational study assessing our experience with a combination of a single-stage procedure consisting of a hard palate graft and a Fricke flap for patients with complex lower lid resections undergoing immediate total reconstruction at our institution. Clinical data, histological type and results, size of tumor, recurrences, and post-operative complications were collected to evaluate outcomes. A Visual Analogue 10-point scale was administered to all patients to assess esthetic and functional outcomes. Results: Seven lower lid reconstructions were performed, with all patients receiving immediate reconstruction. The age of the patients ranged from 55 to 82. Five skin cancers were located on the right side and three on the left side. In all cases, histological diagnosis was non-melanoma skin cancers. The mean size of the tumor was 1.7 × 1.7. In all patients, negative surgical margins were obtained. All patients underwent 24-month follow up. No immediate complication from surgery was recorded within the first 30 days. During follow-up, lower lid ectropion was observed in one patient due to the development of a retracting scar. No local cancer recurrence or nodal metastasis were detected until 2 years follow-up. In only one case, adjuvant therapy was required. The aesthetic results were deemed satisfactory by all patients. Conclusions: According to our experience, the combination of a Fricke flap and hard palate graft is an excellent option for total lower eyelid reconstruction, with low morbidity and favorable outcomes, even in elderly and frail patients where satisfactory results were achieved in a single-stage procedure and short operative times.

Frozen section pathology in IPMN: A systematic review

AbstractIntraductal papillary mucinous neoplasms (IPMNs) resection margins are assessed intraoperatively using frozen section (IFS) pathology. We conducted a systematic review to evaluate the concordance of IFS with permanent histopathology and the association between IFS margin status and recurrence. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. We queried PubMed, Embase, Scopus, and Google Scholar for studies reporting IFS in patients undergoing resection for IPMN. Data, including IFS margin status, recurrence rates, and final pathology, were extracted. Positive margins were defined as high‐grade dysplasia or invasive cancer. Seven studies, with a total of 706 patients, met the inclusion criteria. Positive IFS margins were reported in 9.4% of cases, with a high correlation (98%) between IFS and final pathology. Recurrence occurred in 15.4% of patients. Fifty‐nine of 85 (69.4%) patients with recurrence of IPMN or intraductal papillary mucinous carcinoma (IPMC) had negative IFS margins. IFS accurately predicts final pathology and is a valuable tool for guiding intraoperative decision‐making. A sizeable number of patients experienced recurrence despite negative margins, highlighting the need for adjunct diagnostic modalities and continued surveillance following resection, regardless of margin status.

Endoscopic intermuscular dissection for management of 10- to 20-mm rectal neuroendocrine tumors: Pilot study (with video).

Endoscopic intermuscular dissection (EID) is associated with higher rates of negative margins in treating rectal neuroendocrine tumors (R-NETs), as reported in case studies. However, evidence regarding the safety and effectiveness of EID remains insufficient. This study aimed to evaluate clinical safety and effectiveness of EID in treating 10- to 20-mm R-NETs. Retrospective clinical data from patients with 10- to 20-mm R-NETs who had undergone EID from 2019 to 2024 were collected from a tertiary hospital. The primary outcome was the histological complete resection rate and secondary outcomes included en bloc resection rate and technical success rate. Twelve patients who had undergone EID were included, with one patient excluded for pathology indicative of a leiomyoma. Among the 11 patients (mean age, 42.45 years; 72.73% males), median diameter was 11.55 mm (interquartile range 10-13 mm). All patients underwent en bloc resection and postoperative pathology confirmed negative horizontal and vertical margins, achieving a histological complete resection rate of 100%. Mean procedure time was 58.55 minutes (standard deviation [SD] 13.66 minutes) and mean postoperative hospital stay was 5.7 days (SD 1.00). One patient developed fever and another experienced abdominal pain, both of which resolved within 24 hours. There were no cases of bleeding or perforation intraoperatively or postoperatively. During a mean follow-up of 31.73 months, there were no residual tumors, local recurrences, or metastases. EID is a promising treatment for 10- to 20-mm R-NETs, with high initial cure rates, and a new option for endoscopic resection. More studies of the procedure are needed.

From benign neurofibromas to malignant peripheral nerve sheath tumors (MPNST): a gaming among multiple factors.

Almost all patients of Neurofibromatosis Type I (NF1) develop benign peripheral nerve tumors called neurofibromas, which are derived from neural crest Schwann cell lineage progenitors with biallelic NF1 gene mutations. More than 90% of NF1 patients develop dermal neurofibromas (DN), and 25-50% develop plexiform neurofibromas (PN). In 8-13% of individuals with NF1, PN can transform into malignant peripheral nerve sheath tumors (MPNSTs), a type of nerve soft tissue sarcoma that is the main cause of mortality of NF1 patients. In addition to arising from benign neurofibromas (50%), MPNSTs can also occur spontaneously (~40%) or following radiation therapy (~10%). Treatment for MPNST is limited to complete resection with negative margins. Still, the high recurrence of MPNST is a major concern. However, full resection of the pre-malignant lesions can largely reduce the recurrence and mortality of patients. So, early diagnosis and distinguishing malignancy from benign and premalignant lesions are particularly important. During the progression from benign neurofibromas to malignancy, a variety of changes including tumor morphology, genetic mutations, expression of multiple signaling pathways-related proteins and genome instability gradually occur. In this review, we detail these changes with the goals of identifying the histological and/or molecular signs of malignancy initiation, and an optimal therapeutic intervention window, to inhibit tumor progression and reduce the rate of mortality.

Exact full-RSB SAT/UNSAT transition in infinitely wide two-layer neural networks

We analyze the problem of storing random pattern-label associations using two classes of continuous non-convex weights models, namely the perceptron with negative margin and an infinite-width two-layer neural network with non-overlapping receptive fields and generic activation function. Using a full-RSB Ansatz we compute the exact value of the SAT/UNSAT transition. Furthermore, in the case of the negative perceptron we show that the overlap distribution of typical states displays an overlap gap (a disconnected support) in certain regions of the phase diagram defined by the value of the margin and the density of patterns to be stored. This implies that some recent theorems that ensure convergence of Approximate Message Passing (AMP) based algorithms to capacity are not applicable. Finally, we show that Gradient Descent is not able to reach the maximal capacity, irrespectively of the presence of an overlap gap for typical states. This finding, similarly to what occurs in binary weight models, suggests that gradient-based algorithms are biased towards highly atypical states, whose inaccessibility determines the algorithmic threshold.

Do unplanned resections in soft tissue sarcomas of the extremities have an adverse impact on the prognosis? Experience of a Latin-American sarcoma reference center.

Do unplanned resections in soft tissue sarcomas of the extremities have an adverse impact on the prognosis? Experience of a Latin-American sarcoma reference center.

Prognostic significance of the retroperitoneal surgical resection margin on computed tomography colonography in retroperitonealized colon cancer.

Prognostic significance of the retroperitoneal surgical resection margin on computed tomography colonography in retroperitonealized colon cancer.

Evaluation of the efficacy and safety of neoadjuvant immunotherapy in locally advanced esophageal squamous cell carcinoma.

While neoadjuvant therapy combined with surgery remains standard for locally advanced esophageal squamous cell carcinoma (ESCC), survival outcomes remain suboptimal. Refining multimodal neoadjuvant regimens (including chemoradiotherapy, chemotherapy, and emerging immunotherapy) is critical to improving prognosis. This study sought to evaluate the efficacy and safety of neoadjuvant immuno-chemotherapy in the treatment of locally advanced ESCC, and to examine the correlation between tumor regression grade (TRG) and imaging evaluation. In total, 106 patients diagnosed with ESCC-only received a 21-day cycle of intravenous camrelizumab plus nab-paclitaxel and carboplatin. The efficacy was evaluated after two cycles, and the patients subsequently underwent tumor resection. All patients completed the full treatment regime and underwent surgery. Patients' treatment response after neoadjuvant therapy, R0 resection rate, TRG, and pathologic complete response (pCR) rate were measured. The adverse events (AEs) were also documented. The R0 resection (resection with microscopically negative margins) was 97.2% (103/106). The pCR (ypT0N0) rate was 39.6% (42/106), and 50% (53/106) of the patients had a complete response (CR) of the primary tumor but had residual disease in the lymph nodes (ypT0N+). The major pathologic response (MPR) rate was 49% (52/106). Preoperative imaging evaluation of the patients showed that 33% (35/106) had a CR, 34% (36/106) had a partial response (PR), 21.7% (23/106) had stable disease (SD), and 11.3% (12/106) had progressive disease (PD). Based on the postoperative TRG classification, 47.1% (50/106) of the patients had grade 0, 11.3% (12/106) had grade 1, 18% (19/106) had grade 2, and 23.6% (25/106) had grade 3. This study showed that camrelizumab-based neoadjuvant immuno-chemotherapy was effective in the treatment of locally advanced resectable ESCC. The treatment increased the likelihood of achieving a curative surgical outcome, and the side effects were generally manageable. The treatment warrants further investigation. Moreover, the TRG was found to be significantly associated with imaging assessment; these two approaches can be combined and employed to predict the efficacy of neoadjuvant immuno-chemotherapy.

Optimizing the Follow-Up Interval After Successful Cold Knife Conization of CIN3: A 10-Year Retrospective Cohort Study.

This study was conducted to identify the risk of residual or recurrent high-grade squamous intraepithelial lesions or worse (HSIL+) in patients with successful conization and to develop a customized management strategy. This retrospective study included 939 patients who underwent cold knife conization (CKC) for cervical intraepithelial neoplasia 3 at a hospital in China between January 1, 2013 and December 31, 2020. Demographic characteristics and test results were obtained before and 6, 12, and 24 months after CKC and annually thereafter. Human papillomavirus (HPV) persistence was defined as HPV positive at both 6 and 12 months after CKC, and the primary endpoint was residual or recurrent HSIL+ after CKC. The mean follow-up period was 68.8 months. In total, 61 (6.5%) patients had HPV persistence, and 19 (2.0%) had residual or recurrent HSIL+. The risk of residual or recurrent HSIL+ was increased in patients with HPV infection at 6 months (hazard ratio [HR], 84.6; 95% confidence interval [CI], 11.2-641) and 12 months (HR, 214; 95% CI, 28.1-1625) after CKC, and HPV persistence after CKC (HR, 244; 95% CI, 32.2-1854). Comparing two different colposcopic referral criteria for HPV persistence and HPV positive 6 months post-CKC, substantially fewer colposcopies were performed per case of residual or recurrent HSIL+ detected in patients with HPV persistence after CKC (3.39 vs. 8.28). The risk of residual or recurrent HSIL+ was higher in patients with HPV persistence after CKC. In patients with negative margins, extending the follow-up interval to 12 months may reduce the number of HPV tests and colposcopy referral rates while maintaining HSIL+ detection.

Association of energy source with outcomes in en bloc TURB: secondary analysis of a randomized trial

PurposeTo comprehensively evaluate the efficacy of different energy sources used for en-bloc transurethral resection of bladder tumors (ERBT) on perioperative outcomes.MethodsThis sub-analysis derived from a prospective randomized study that enrolled patients undergoing ERBT vs conventional transurethral resection of the bladder (cTURB) from January 2019 to January 2022 (NCT03718754). Endpoints were pathological specimen quality and perioperative outcomes after either monopolar (m-ERBT) or bipolar (b-ERBT) or laser (l-ERBT) ERBT.Results237 bladder tumors resected in 188 patients included in the analyses: 29 (12.2%) m-ERBT, 136 (57.4%) b-ERBT and 72 (30.4%) l-ERBT. Detrusor muscle (DM) was detected in 191 (80.6%) specimens. Per-tumor analysis revealed comparable rate of DM in the specimens obtained via different energy modalities (p = 0.7). Operative time was longer in the l-ERBT cohort compared to m-ERBT and b-ERBT (p = 0.02) and no obturator nerve reflex (ONR) onset was reported. On logistic regression analysis, b-ERBT was associated with negative lateral resection margins (OR 2.81; 95% CI 1.02–7.70; p = 0.04). There was no significant association of the resection technique with perforation and conversion rates (all p > 0.05). Within a median follow up of 22mo (IQR 11–29), a total of 35 (18.6%) patients had a local recurrence. On Cox regression analysis, patients resected with b-ERBT were less likely to have a recurrence (HR 0.34; 95% CI 0.15–0.78; p = 0.01); When adjusting for established confounders, this association was confirmed (HR 0.24; 95% CI 0.10–0.60; p = 0.002).ConclusionsDifferent energy sources might achieve comparable perioperative outcomes. Further perspectives involve the assessment of long-term differential oncological outcomes associated with various energy modalities.

Transurethral resection and oral mucosal grafting for urethral-involved extramammary Paget disease: A function-preserving approach.

Extramammary Paget disease with urethral involvement presents considerable challenges, primarily because of the difficulty in achieving clear surgical margins while preserving urinary function. This report describes four women with urethral extramammary Paget disease who were treated using transurethral resection followed by oral mucosal grafting for urethral reconstruction. The primary objective was complete excision of the diseased area while minimizing postoperative complications, with a particular focus on preservation of urinary function. Transurethral resection enabled precise resection of the urethral mucosa without compromise of the urethral sphincter. Pathological analysis confirmed negative margins in three of the four patients; one patient had preoperative evidence of tumor cell invasion at the internal urethral orifice. Urinary function was preserved in all patients, and postoperative complications such as urethral stricture were successfully managed using dilation. No recurrences were observed during follow-up. This approach, which combines transurethral resection and oral mucosal grafting, offers a minimally invasive and function-preserving surgical option for urethral-involved extramammary Paget disease, demonstrating favorable oncological and functional outcomes.

Stage II-III colorectal cancer in geriatric patients: Clinicopathological features and chemotherapy utilization

Aim: This study aims to assess the clinicopathological characteristics, treatment patterns, and survival outcomes of geriatric patients with stage II-III colorectal cancer. Material and Methods: This retrospective study included 99 geriatric patients (aged ≥65 years) diagnosed with stage II-III colorectal cancer at a single center from 2020 to 2024. Clinical and pathological characteristics, treatment approaches, and survival outcomes were assessed. Results: The median age at diagnosis was 73 years, and 63.6% of patients were male. Adjuvant chemotherapy was administered to 86.9% of patients, with a significantly higher rate in stage III cases compared to stage II (91.3% vs. 58.5%, p < 0.001). Capecitabine-based therapy was the most frequently used chemotherapy regimen. Surgical resection achieved negative margins in 97.9% of cases, with right hemicolectomy being the most frequently performed procedure (54.5%). The median recurrence-free survival (RFS) was 20 months, and recurrence or metastasis occurred in 20.2% of patients, with the liver being the most frequent metastatic site. Treatment-related toxicity was observed in 53.5% of patients, leading to chemotherapy discontinuation in six cases. Conclusion: Adjuvant chemotherapy was more frequently administered in stage III patients, in line with current treatment guidelines. Differences in chemotherapy regimens between stage II and III patients underscore the importance of personalized treatment strategies in the geriatric population. Further research is required to optimize treatment decisions and improve clinical outcomes in this vulnerable group. Keywords: colon cancer, colorectal cancer, geriatrics, adjuvant chemotherapy

Paratesticular Sarcoma: Analysis of Oncological Outcomes and Prognostic Factors.

Paratesticular Sarcoma: Analysis of Oncological Outcomes and Prognostic Factors.

HIDDEN WITHIN THE JAW: AN UNUSUAL FINDING OF OSTEOSARCOMA FOLLOWING MANDIBULAR TRAUMA

This case report focuses on the aggressive nature of osteosarcoma in head and neck region which poses a diagnostic challenge and effort of maxillofacial surgeons to provide better prognosis by identifying in early stages. Background:A 24-year-old male patient presented with post traumatic swelling in left mandible with aggressive growth in just few weeks. He was initially reluctant to undergo the procedure as he overlooked the severity of the tumour. Diagnosis:Patient was diagnosed with parosteal juxtacortical osteosarcoma of the left mandible on clinicoradiohistopathological diagnosis and had no distant metastasis. Treatment:Multi-modality treatment implemented with hemi-mandibulectomy tumour free margins followed by radiochemotherapy. Outcome:There was no evidence of local recurrence and distant metastasis after one year of follow up period. Conclusion:Osteosarcomas of head and neck region are less than 2-10% of all cases. Emphasis on early diagnosis, negative surgical margins and inclusion of radio and chemotherapy provides disease free survival.

Modified Standard Total en bloc Spondylectomy for Solitary Thoracic or Lumbar Spinal Metastasis: A 1-Stage Posterior Approach Under Direct Visualization.

Solitary spinal metastasis (SM) is one of the indications for total en bloc spondylectomy (TES). Conventional TES carries the risk of damage to the great vessels anterior to the vertebral column, mainly because of a lack of visualization of the anterior structures. In this study, we devised a modified standard TES technique to achieve direct visualization in a 1-stage posterior approach. Included in this study were patients ≥18 years old with solitary thoracic or lumbar SM who underwent the modified standard TES at our institution between January 2017 and October 2022. Patient data were retrospectively sourced from medical records, and patients had a minimum of 3 months of postoperative follow-up. This study involved 71 East Asian patients (median age, 57 years; 34 males), comprising 38 patients with thoracic SM and 33 with lumbar SM. Lung cancer was the most common tumor histology. Fourteen patients (19.7%) experienced intraoperative complications; pleural rupture was the predominant complication, and there were no cases of injury to the spinal cord or great vessels. The median operative time was 305 minutes (range, 203 to 660 minutes). The median intraoperative blood loss was 1,000 mL (range, 400 to 4,000 mL). The median perioperative blood transfusion was 4 units (range, 0 to 12 units), and the median hospitalization duration was 17 days (range, 14 to 29 days). Additionally, 27 patients (38.0%) had acute (perioperative) complications. Seven patients were lost to follow-up. Significant clinical improvement was achieved 3 months postoperatively. Postoperative early and late complications were observed in 5 patients. Of the 64 patients with completed follow-up, 47 (73.4%) had negative surgical margins, and none received postoperative radiation therapy. Revision surgery for local tumor recurrence was performed in 4.7% of patients. The median follow-up was 31.5 months (range, 3 to 81 months). Our modified standard TES was demonstrated to be a safe and effective surgical technique for solitary thoracolumbar SM. Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.