Number Of Positive Margins Research Articles

Mastectomy or Margin Re-excision? A Nomogram for Close/Positive Margins After Lumpectomy for DCIS.

Anatomic extent of ductal carcinoma in situ (DCIS) may be uncertain in spite of clinical, pathologic, and imaging data.Consequently close/positive margins are common with lumpectomy for DCIS and often lead to a challenge in deciding whether to perform a re-excision or mastectomy. From a single health system, we identified cases of lumpectomy for DCIS with close/positive margins who underwent re-excision for the purpose of constructing a nomogram. In total, 289 patients were available for analysis. The patients were randomly divided into two sets allocating 70% to the modeling and 30% to the validation set.A multivariable logistic regression model was used to estimate the probability of overall positive margin status using multiple clinicopathologic predictors.Nomogram validation included internal tenfold cross-validation, internal bootstrap validation, and external validation for which a concordance index was calculated to assess the external validity. Significant predictors of persistent positive margins from regression modeling included necrosis at diagnosis (non-comedo or comedo); DCIS not associated with calcifications on core biopsy; high-grade DCIS; progesterone receptor positivity; and number of positive margins at initial surgery.When subjected to internal validation, the nomogram achieved an uncorrected concordance index of 0.7332, a tenfold cross-validation concordance index of 0.6795, and a bootstrap-corrected concordance index of 0.6881. External validation yielded an estimated concordance index of 0.7095. Using clinical and pathologic variables from initial diagnosis and surgery for DCIS, this nomogram predicts persistent positive margins with margin re-excision, and may be a valuable tool in surgical decision-making.

Risk factors for the presence of residual disease in women after partial mastectomy for invasive breast cancer: A single institution experience

BackgroundWe hypothesize that in addition to specimen margin widths other clinical variables may help predict the presence of residual disease in the lumpectomy bed. MethodsPatients with Stage I-III invasive breast cancer (BC) who underwent partial mastectomy (PM) and re-excision from July 2010–June 2015 were retrospectively reviewed. Bivariate analyses were conducted using two-sample t-tests for continuous variables and Fisher's Exact tests for categorical variables. A multivariate logistic regression was then performed on significant bivariate analyses variables. Resultsne-hundred and eighty-four patients were included in our analysis; 47% had residual disease on re-excision, while 53% had no residual disease. Tumor and nodal stage, operation type, type of disease present at margin, and number of positive margins were significantly associated with residual disease. On multivariate logistic regression, DCIS alone at the margin (p = 0.02), operation type (PM with cavity margins) (p = 0.003), and number of positive margins (3 or more) (p < 0.001) remained predictive of residual disease at re-excision. ConclusionBased on a more comprehensive review of the initial pathology, there are additional factors that can help predict the likelihood of finding residual disease and help guide the surgeon in the decision for re-excision.

Predictors of Residual Disease After Breast Conservation Surgery.

Breast-conserving therapy is the standard of care for early-stage breast cancer. In the era of multimodality therapy, the debate on the value of revision surgery for compromised margins continues, and high re-excision rates persist despite updated guidelines. Our study sought to identify the local re-excision rate for compromised margins after lumpectomy, and identify predictors of residual disease at re-excision. This population-based retrospective cohort study included women with breast cancer who underwent a lumpectomy between 2009 and 2012 in Manitoba, with close (≤2mm) or positive margins that led to re-excision. Patient demographics and tumor characteristics were identified through provincial cancer registries and chart reviews. For patients with invasive cancer, the six anatomical margins were reported for margin status, width, and pathology type at the margin. Of the 2494 patients identified, 556 women underwent re-excision, yielding a re-excision rate of 22.29%. Of our 311 patients with invasive cancer who underwent re-excision, 62.7% had residual disease identified on revision. On univariable analysis, the size and grade of the invasive component, nodal stage, and the number of positive margins were associated with residual disease on re-excision (p<0.05). With the exception of nodal stage, the same variables remained statistically significant on multivariable analysis. Our results suggest that even in the absence of 'no ink on tumor', the cancer size and grade in lumpectomy specimens are high-risk factors for residual disease, and this subgroup of patients may benefit from re-excision. Long-term follow-up of this cohort is required to determine their risk of recurrence after adjuvant treatment.

Do All Positive Margins in Breast Cancer Patients Undergoing a Partial Mastectomy Need to Be Resected?

Positive margins have been reported in 20% to 40% of patients undergoing a partial mastectomy, often resulting in re-excision. How often the re-excision yields additional cancer and whether there are predictors of residual disease remain unknown. Patients who had a positive margin (defined as tumor at ink for patients with invasive disease or within 1 mm for patients with ductal carcinoma in situ) in the SHAVE (A Randomized Controlled Trial of Routine Shave Margins Versus Standard Partial Mastectomy in Breast Cancer Patients) trial before randomization were evaluated to determine the rate of additional disease either in cavity shave margins or at re-excision. Details of the SHAVE trial can be found elsewhere. Of the 235 patients in the trial, 82 (34.9%) had a positive margin before randomization; 58 of these patients underwent either cavity shave margins excision or a re-excision of the positive margin(s). Twenty-one (36.2%) patients had residual disease. On bivariate analysis, residual disease was associated with younger patient age (median 51 vs 62 years; p= 0.007), and the presence of high-grade ductal carcinoma in situ (57.1% vs 31.3% for grade 2 and 0% for grade 1; p= 0.025). The following factors were not associated with further disease: patient race; ethnicity; BMI; volume of resection; number of positive margins; extent of ductal carcinoma in situ; and extent, grade, and histologic subtype of invasive cancer. On multivariate analysis, only patient age younger than 60 years remained a significant predictor of residual disease (odds ratio 3.920; 95% CI 1.081 to 14.220; p= 0.038). Positive margins are associated with further disease in more than one-third of patients and, aside from young age, there are no predictors of this. These findings support continued re-excision of positive margins, particularly in patients younger than 60 years of age.

Abstract S3-08: Radioactive seed localization versus wire guided localization of nonpalpable invasive and in situ breast cancer: A Danish multicenter randomized controlled trial

Abstract Background: The current standard method for locating nonpalpable breast lesions is wire guided localization (WGL) despite several methodological difficulties. Radioactive Seed Localization (RSL) has been developed to reduce these difficulties. The aim of this randomized trial was to compare the rate of positive resection margins between RSL and WGL in patients with nonpalpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS). Material and Methods: Patients with nonpalpable IBC or DCIS visible on ultrasound were randomized to either of the two localization methods. Primary outcome was margin status at the final pathological evaluation. According to Danish standard in the study period margins were defined positive if cancer cells were found &amp;lt; 2mm from the inked margin. Secondary outcomes were duration of the surgical procedure, weight of the excised specimen and patient's pain perception. χ2-test, Fisher's exact test and Wilcoxon rank-sum test, respectively, were used to test differences between groups. Level of statistical significance was set to 5%. The average activity of seeds used in the trial was 1.70 MBq (range 0.7-3.27). Results: 413 cases representing 409 patients were randomized; 207 were allocated to RSL and 206 to WGL. 23 cases, who did not meet inclusion criteria, chose to withdraw, or had a change in surgical management, were excluded. The remaining 390 were included in the analysis. Patient, surgical and pathological characteristics between the two groups were alike, except for significantly more patients with DCIS in the WGL group (5.1% vs 0.5%). Significantly more cases in the WGL group (9.7%) needed additional localization compared to the RSL group (2.1%) (p=0.0014). In all cases but one in the RSL group, the index lesion was removed. Margins were positive in 23 cases (11.8%) in the RSL group compared to 26 cases (13.3%) in the WGL group. We were not able to detect a difference in margin status between the two groups (p=0.65). For IBC only, the number of positive margins was 22 (11.3%) in the RSL group and 21 (11.4%) in the WGL group (p=0.997). There was no difference between the two groups in the amount of tissue removed whether the analysis was done on the primary excision (p=0.18) or the total weight including intraoperative re-excisions (p=0.33). There was no difference in pain perception between the two groups whether patients who received local anesthesia were kept in the analysis (p=0.28) or excluded (p=0.91). Local anesthesia was used more frequently in the RSL group. Finally, there was no difference in the duration of the surgical procedure (p=0.12), the complication rate (p=0.89) or the identification rate for SN (p=1.0). Conclusions: We were not able to detect any differences considering positive margins, patient's pain perception or duration of the surgical procedure between the two localization methods. However, RSL offers a major logistic advantage, as the seed localization can be done several days before surgery without any risk or discomfort for the patient, with a low proportion of patients needing additional localization. So the RSL procedure has now been found preferable at our institutions. Citation Format: Langhans L, Tvedskov TF, Klausen TL, Jensen M-B, Talman M-L, Vejborg I, Benian C, Roslind A, Hermansen J, Oturai PS, Bentzon N, Kroman N. Radioactive seed localization versus wire guided localization of nonpalpable invasive and in situ breast cancer: A Danish multicenter randomized controlled trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S3-08.

Morphological assessment of the prevalence of ductal adenocarcinoma of the pancreas

To systematize the concept of "surgical margin" with ductal carcinoma pancreas to determine the prognostic value of regional lymph node and perineural invasion in these patients. Results. Status R1 pancreatic cancer detected in 69,1% (38/55), while often affects the medial and anterior surface - 14,5% and 9% (8/38 and 5/38), respectively. By the number of positive margins: 1 surface - 27,3 % (15/38), both surfaces - 35,5% (19/38) and 3- surfaces - 7,3% (4/38). Conclusions: ductal carcinoma in the pancreas along with direct tumor spread should provide locoregional spread and mixed (a combination of direct and locoregional). Undoubtedly, reliably identify R0 resection is impossible without improvement and standardization of protocols mortem examinations.

Surgical resection margins in desmoid-type fibromatosis: a critical reassessment.

The prognostic value of surgical resection margins in predicting recurrence of desmoid-type fibromatosis remains inconclusive, and appropriate resection margins are not defined. We analyzed whether specific factors related to margin status, including the adequacy of pathologic assessment, affect the prognostic impact of surgical resection margins in a retrospective cohort study. The distance (clearance) and tissue composition of resection margins were recorded for primary desmoid resections with negative margins. The number of positive margins and the linear extent of marginal involvement were recorded for cases with positive margins. The number of tissue sections submitted for histopathologic evaluation of resection margins was also noted. Factors predictive of a positive margin and local recurrence were evaluated by logistic regression and survival analyses. The probability of documenting a positive margin increased with the number of tissue sections submitted for assessment of margin status (odds ratio 1.16; P=0.007). Recurrence-free survival at 10 years for patients with positive (N=52) or negative (N=40) resection margins was 68% and 60%, respectively. Only tumor clearance was predictive of local recurrence. A positive or close (<1 mm) resection margin was an independent prognostic factor for local recurrence in a multivariate Cox regression model accounting for patient age and anatomic site (hazard ratio 9.52; P=0.028). Surgical resection margin status, as currently evaluated and reported, fails to predict recurrence-free survival for desmoid tumors. Instead, positive or close (<1 mm) resection margins are predictive of disease recurrence. In addition, multiple targeted sections are necessary for accurate assessment of surgical resection margins of desmoid-type fibromatosis.

Utility of intraoperative frozen section examinations of surgical margins: implication of margin-exposed tumor component features on further surgical treatment.

In patients who underwent breast-conserving surgery, we attempted to identify the histological characteristics of margin-exposed tumor components on intraoperative frozen section examinations that were predictive of residual tumor components in additionally resected specimens. Of 1835 patients who underwent breast-conserving surgery, we identified 220 patients who had positive surgical margins determined by intraoperative frozen section examinations and who had undergone immediate additional resections. Two observers (M.K., H.T.) reviewed the slides of frozen sections and confirmed the presence of tumor components. In additionally resected specimens, residual tumors were detected in 115 cases (52.3%) but not in 105 cases (47.7%). The primary tumor characteristics of extensive intraductal component (+), younger age, invasive lobular carcinoma and pathological T3 classification were significantly associated with the residual tumor components. The margin-exposed tumor components of the maximum diameter, number of positive margins and histological type were correlated with the residual tumors. Multivariate analysis showed that the maximum tumor diameter was an independent risk factor for residual tumors. Diagnosis of positive margins by intraoperative frozen section examinations was useful for predicting residual tumors, and three histological properties of the margin-exposed tumor components were correlated with the status of residual tumor components. Although it was impossible to clearly identify the single main factor for predicting patients for whom additional resections were not necessary, it may be possible to consider stratification of additional surgical therapy according to the characteristics of margin-exposed tumor components on intraoperative frozen section examinations.

Robot‐assisted radical cystectomy (RARC) with intracorporeal neobladder – what is the effect of the learning curve on outcomes?

To evaluate the effect of the learning curve on operative, postoperative, and pathological outcomes of the first 67 totally intracorporeal robot-assisted radical cystectomies (RARCs) with neobladders performed by two lead surgeons at Karolinska University Hospital. Between December 2003 and October 2012, 67 patients (61 men and six women) underwent RARC with orthotopic urinary diversion by two main surgeons. Data were collected prospectively on patient demographics, peri- and postoperative outcomes including operation times, conversion rates, blood loss, complication rates, pathological data and length of stay (LOS) for these 67 consecutive patients. The two surgeons operated on 47 and 20 patients, respectively. The patients were divided into sequential groups of 10 in each individual surgeon's series and assessed for effect of the learning curve. Patient demographics and clinical characteristics were similar in both surgeons' groups. The overall total operation times trended down in both surgeons' series from a median time of 565 min in the first group of 10 cases, to a median of 345 min in the last group for surgeon A (P < 0.001) and 413 to 385 min for surgeon B (not statistically significant). Risk of conversion to open surgery also decreased with a 30% conversion rate in the first group to zero in latter groups (P < 0.01). Overall complications decreased as the learning curve progressed from 70% in the first group to 30% in the later groups (P < 0.05), although major complications were not statistically different when compared between the groups. Patient demographics did not change over time. The mean estimated blood loss was unchanged across groups with increasing experience. The pathological staging, mean total lymph node yield and number of positive margins were also unchanged across groups. There was a decrease in LOS from a mean of 19 days in the first group to a mean (range) of 9 (4-78) days in the later groups, although the median LOS was unchanged and therefore not statistically significant. Totally intracorporeal RARC with intracorporeal neobladder is a complex procedure, but it can be performed safely, with a structured approach, at a high-volume established robotic surgery centre without compromising perioperative and pathological outcomes during the learning curve for surgeons. An experienced robotic team and mentor can impact the learning curve of a new surgeon in the same centre resulting in decreased operation times early in their personal series, reducing conversion rates and complication rates.

Preoperative hormonal pattern in patients undergoing radical prostatectomy due to prostate cancer

ObjectiveThere is controversial evidence regarding preoperative testosterone levels related to poor prognosis factors after radical prostatectomy. The aim of this manuscript is to determine the relationship between preoperative testosterone levels and final pathologic report together to biochemical recurrence after radical prostatectomy (RP). Materials and methodsWe prospectively analyzed 143 patients submitted to RP from February 2008 to June 2010 in our center. Pre-treatment testosterone (T) and sex hormone-binding globulin (SHBG) levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) testosterone were calculated using Vermeulen's formula. Low testosterone levels were defined as 346ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumor burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4ng/dL and PSA>0.2ng/dL as cut-off values) was performed, according to preoperative levels of T. ResultsVariables Gleason score, rate and number of positive margins, tumor burden, tumor multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346ng/dL was not found to be related to PSA recurrence (PSA>0.4ng/dL log-rank, p=0.512), although a trend was observed when PSA>0.2ng/dL (log-rank, p=0.097). ConclusionPreoperative testosterone levels were not related to final pathological report or to biochemical recurrence.

Perfil hormonal preoperatorio en pacientes sometidos a prostatectomía radical por cáncer de próstata

ObjectiveThere is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP. Materials and methodsWe prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulen's formula. Low T levels were defined as 346ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4ng/dL and PSA>0.2ng/dL as cut-off values) was performed, according to preoperative levels of T. ResultsVariables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346ng/dL was not found to be related to PSA recurrence (PSA>0,4ng/dL log-rank, P=.512), although a trend was observed when PSA>0,2ng/dL (log-rank, P=.097). ConclusionPreoperative T levels were not related to final pathological report or to biochemical recurrence.

Implications of diagnosing ductal carcinoma in situ in core needle biopsies of the breast

Objective: To study the implications of Ductal Carcinoma In Situ (DCIS) diagnosis in Core Needle Biopsies (CNBs) of the breast. Method: The histology slides of 59 CNBs and BCS (Breast conserving surgery) /Mastectomy were reviewed for the presence and percentage of DCIS and 63 BCS were reviewed for positivity of the surgical margins. SPSS -13 and appropriate statistical tests were used for analysis. Results: The sensitivity of CNB to predict DCIS in the surgical specimen was 45.65%. A positive relationship was established between DCIS positivity in CNB and DCIS percentage in the subsequent surgical specimen (p=0.002). A positive correlation exists between the number of positive margins and percentage of DCIS (p Conclusion: DCIS in CNB is often associated with DCIS in BCS/mastectomy in a higher percentage of the same. A higher percentage of DCIS frequently has positive BCS margins, thus wider excisions are indicated for women with DCIS positive CNB's. Sensitivity of identifying DCIS in the CNB increases with number of CNB cores. DOI: http://dx.doi.org/10.4038/jdp.v6i1.4419 Journal of Diagnostic Pathology 2011(6); 1: 28-33

Positive margin rates following breast-conserving surgery for stage I–III breast cancer: palpable versus nonpalpable tumors

BackgroundMargin status is a significant risk factor for local recurrence. We sought to examine whether the method of tumor localization predicted the margin status and the need for re-excision for both nonpalpable and palpable breast cancer. MethodsWe identified 358 consecutive breast cancer patients who were treated with breast-conserving therapy (BCT) from 1999 to 2006. Data included patient and tumor characteristics, method of localization (needle versus palpation), and pathologic outcomes. Descriptive statistics were used for data summary and data were compared using χ2. ResultsOf 358 patients undergoing BCT, 234 (65%) underwent needle localization for a nonpalpable tumor and 124 (35%) underwent a palpation-guided procedure. Patients undergoing palpation-guided procedures were younger and had larger tumors at a more advanced pathologic stage of disease than those undergoing needle localization procedures (P < 0.05 for each). Patient race, tumor grade, presence of lymphovascular invasion, biomarker profile, and nodal status were not significantly different between the two groups (P > 0.05). Overall, 137 patients (38%) had one or more positive margins: 90 of 234 (38%) who had a needle localization procedure and 47 of 124 (38%) who had a palpation-guided procedure (P > 0.05). The number of margins affected did not differ significantly between the two groups. ConclusionAlthough patients with palpable breast cancer had larger tumors than those with nonpalpable breast cancer, the incidence and number of positive margins was similar to those who had needle localization for nonpalpable tumors. Improved methods of localization are needed to reduce the rate of positive margins and the need for re-excision.

366 IS PARTIAL SAMPLING OF A RADICAL PROSTATECTOMY SPECIMENS ASSOCIATED WITH MISSING OF POSITIVE MARGINS OR EXTRAPROSTATIC EXTENSIONS?

You have accessJournal of UrologyProstate Cancer: Staging II1 Apr 2012366 IS PARTIAL SAMPLING OF A RADICAL PROSTATECTOMY SPECIMENS ASSOCIATED WITH MISSING OF POSITIVE MARGINS OR EXTRAPROSTATIC EXTENSIONS? Viacheslav Iremashvili, Soum Lokeshwar, Merce Jorda, Murugesan Manoharan, Saleem A. Umar, and Mark S. Soloway Viacheslav IremashviliViacheslav Iremashvili Miami, FL More articles by this author , Soum LokeshwarSoum Lokeshwar Miami, FL More articles by this author , Merce JordaMerce Jorda Miami, FL More articles by this author , Murugesan ManoharanMurugesan Manoharan Miami, FL More articles by this author , Saleem A. UmarSaleem A. Umar Miami, FL More articles by this author , and Mark S. SolowayMark S. Soloway Miami, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.428AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The pathologic stage and surgical margin status of a radical prostatectomy (RP) specimen may directly impact subsequent patient management. The aim of our study was to determine if different methods of partial sampling affect the accuracy of detection of positive margins (PMs) and/or extraprostatic extensions (EPEs). METHODS Between January 1992 and May 2011 1,975 patients underwent open RP performed by one surgeon. We identified 808 cases that had either PM or EPE or both. In all cases a 2 mm apical margin was obtained from the most distal part of the prostate. The gland was than step-sectioned at 3-4-mm intervals in transverse planes into separate blocks according to the Stanford protocol. 697 of our cases had a diagram describing the outline of cancer areas as well as location of PM and EPE in each of the blocks. Using these diagrams we analyzed the potential outcomes of four published methods of partial sampling (Table 1). The rates of PM § and EPEs that could have been identified using each of these techniques were compared to the actual rates obtained by entire sampling. Table 1. Studied methods of partial prostate sampling No. Description Publication 1 Three “representative” sections including apical, mid and basal parts of the gland Samaratunga H, et al. Mod Pathol. 2011; 24: 6-15. 2 Alternate sections Cohen MB, et al. Am J Clin Pathol. 1994; 101: 250-2. 3 Alternate sections representing the posterior aspect of the gland in addition to one of the mid-anterior Salem S, et al. J Urol. 2010; 184: 1334-40. 4 Every section representing the posterior aspect of the gland in addition to one of the mid-anterior, supplemented by additional sections based on tumor size Sehdev AES, et al. Hum Pathol. 2001; 32: 494-9. RESULTS Of 697 RP specimens, only PMwas identified in 387 (56%) cases, only EPE in 136 (20%), and both were identified in 174 (25%). All alternative sampling methods missed a significant number of PM § and/or EPEs (p<0.001 (McNemar test) for all pairs of comparison), however the numbers of missed cases varied considerably (Figure 1) among the studied techniques. The lowest rates were noted for method 4, which would have missed only 6% of PM § and 7% of EPEs. CONCLUSIONS Most methods of partial sampling miss considerable proportion of PM § and/or EPEs. The latter was particularly dependent on the sampling technique. The only method which missed less than 10% of PM §/EPEs found on entire sampling was the technique described by Sedhev et al. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e150 Peer Review Report Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Viacheslav Iremashvili Miami, FL More articles by this author Soum Lokeshwar Miami, FL More articles by this author Merce Jorda Miami, FL More articles by this author Murugesan Manoharan Miami, FL More articles by this author Saleem A. Umar Miami, FL More articles by this author Mark S. Soloway Miami, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Margin status and neoadjuvant chemoradiation in patients with borderline resectable pancreatic cancer.

304 Background: The objective of this study was to examine the effect of margin status and neoadjuvant therapy in determining outcomes for borderline resectable (BLR) pancreatic cancer and how neoadjuvant chemoradiation impacts margin of resection. Methods: A retrospective chart review was conducted to identify patients who underwent resection for BLR pancreatic cancer based on the AHPBA/SSO/SSAT consensus definition. Outcomes including overall survival (OS) and disease free survival (DFS) were determined based on margin status, location of positive margin (artery, vein, or pancreas), and receipt of neoadjuvant chemoradiation. Results: One hundred and three patients who met the definition of BLR pancreatic cancer and underwent resection between April 1993 and July 2010 were reviewed. Mean age at diagnosis was 65 with a median follow up time of 19.7 months. Neoadjuvant chemoradiation was administered in 49.5% of patients. Twenty-five percent of patients underwent portal and/or superior mesenteric vein resection, and 7% hepatic artery resection. Microscopic positive margin rate was 54%. Median OS was 17.2 months for patients with positive margins versus 24.9 months for patients with negative margins (p=0.003). Median DFS was 13.1 months for patients with positive margins versus 18.6 months for patients with negative margins (p=0.001). There was no difference in OS or DFS for patients with positive margins based on location or number of positive margins. Of the patients who received neoadjuvant chemoradiation, 61.7% had a negative margin of resection versus a 38.3% negative margin of resection rate for patients who did not receive neoadjuvant chemoradiation (p=0.02). Among patients with a positive margin, there was no difference in OS or DFS with or without neoadjuvant chemoradiation. Conclusions: A positive margin of resection, irrespective of location or number, is associated with worse outcome in patients with BLR pancreatic cancer. The use of neoadjuvant chemoradiation is associated with higher rates of margin free resection.

Does Initial Learning Curve Compromise Outcomes for Robot-Assisted Radical Cystectomy? A Critical Evaluation of the First 60 Cases While Establishing a Robotics Program

Robot-assisted laparoscopic radical cystectomy (RARC) with pelvic lymph node dissection (PLND) has gained popularity as a minimally invasive alternative to open radical cystectomy (ORC) for the treatment of patients with bladder cancer. The learning curve (LC) for laparoscopic and robotic surgery can be steep. We aim to evaluate the effect of the initial LC on operative, postoperative, and pathologic outcomes of the first 60 RARC performed at our newly established robotics program. After obtaining Institutional Review Board approval, we reviewed the clinical and pathologic data from 60 consecutive patients with clinically localized bladder cancer who underwent RARC with PLND from January 2008 to March 2010. The patients were grouped into tertiles and assessed for effect of LC using analysis of variance. Patient demographics and clinical characteristics were similar across tertiles. The mean total operative time trended down from the 1st to 3rd tertile from 525 minutes to 449 minutes, respectively (P=0.059). Mean estimated blood loss was unchanged across tertiles. Complications decreased as the LC progressed from 14 (70%) in the 1st tertile to 6 (30%) in each of the 2nd and 3rd tertiles (P<0.013). The mean total lymph node yield and number of positive margins were unchanged across tertiles. RARC with PLND can be performed safely at a high-volume newly established robotic surgery program with an experienced team without compromising operative, postoperative, and short-term pathologic outcomes during the LC for surgeons who are experienced in ORC.

Full Functional-Length Urethral Sphincter Preservation During Radical Prostatectomy

BackgroundA key prerequisite for urinary continence after radical prostatectomy (RP) is the functional length of the urethral sphincter and the stabilisation of its anatomic position within the pelvic floor. ObjectiveWe describe our modified surgical technique for full functional-length urethra (FFLU) preservation during RP. Design, setting, and participantsWe analysed 691 consecutive patients who underwent RP over a 12-mo period (285 without and 406 with the FFLU technique). Surgical procedureThe full functional urethra length was preserved by performing an individualised apical preparation strictly along anatomic landmarks, respecting the individual length of the intraprostatically located proportion of the urethral sphincter. Anatomic fixation of the sphincter was reached by a thorough preservation of the pelvic floor and anatomic restoration of the Mueller's ligaments. MeasurementsContinence rates were assessed at 7 d and 12 mo after removal of the catheter. Continence was defined as the use of no pads and no urinary leakage. Results and limitationsThe continence rates were 50.1% and 30.9% 1 wk after catheter removal (p<0.0001) and 96.9% and 94.7% (p=0.59) at 12 mo after surgery in patients operated on with the FFLU technique versus the non-FFLU technique. In multivariate regression analysis, only the surgical technique correlated significantly with the continence status 1 wk after catheter removal. Neither the overall positive surgical margin rates nor the number of positive margins at the urethral resection border differed significantly between the FFLU and non-FFLU groups (13.6% and 0.5% vs 14.9% and 1.3%, respectively). Although the patients’ baseline characteristics were similar in the two surgical groups, the patients were not preoperatively randomised, and the number of patients in the groups was asymmetric. ConclusionsThe combination of an FFLU preparation and improved preservation of the anatomic fixation of the urethral sphincter complex resulted in significantly increased early urinary continence results.

Utility of Intraoperative Frozen-Section Examinations of Surgical Margins: With Special Reference to the Implication of Features of Margin-Exposed Tumor Components on Further Surgical Treatment.

Abstract Purpose: The assessment of surgical margins is important in breast conserving surgery (BCS). In BCS, we usually resect additional specimens after the diagnosis of positive margin by intraoperative frozen-section examinations (IFE). However, we often experience the patients who received additional resections after positive results by IFE but no tumors were detected in the permanent sections. If we can predict the absence of residual tumor components from IFE, it may be possible to avoid additional mastectomy. In the present study, we tried to identify histological characteristics of margin-exposed tumor components on IFE as predictive factors for the residual tumor components in the additionally resected specimens. Methods: 1,835 cases underwent BCS between October 1999 and July 2008 at the National Cancer Center Hospital, Tokyo, Japan. By the review of the pathological database, we chose patients who had positive surgical margins determined by IFE and had undergone immediate additional resection. Two observers (MK, HT) reviewed the slides of frozen sections and confirmed the presence of tumor components. Results: 220 cases (12%) were eligible for this study. Within the specimens of additional resection, residual tumors existed in 114 cases (51.8%) and no tumors existed in 106 cases (48.2%). As characteristics of the primary tumors, invasive lobular carcinoma, pT3, EIC(+) and lymphatic invasion were significantly associated with the residual tumor components. As characteristics of margin-exposed tumor components on IFE, the number of positive margins, their maximum diameter and histological type were correlated with the residual tumors. The rate of detection of the residual tumors was significantly higher in the group with multiple positive margins (50/72, 69%) than in the group with a single positive margin (64/148, 43%) (p=0.0003). The residual tumors were detected in 36.5% (38/104), 60.8% (62/102), and 100% (14/14) of the groups with &amp;lt;6 mm, ≥6 to &amp;lt;20 mm, and ≥20 mm of the maximum diameter of the exposed tumor components, respectively (p=0.0005). Although there was no significant relationship in the rate between the group with exposed noninvasive components and that with exposed invasive components, the residual tumor components were detected more frequently in the group with exposed lobular carcinoma components (20/29, 69%) than in the group with exposed ductal carcinoma components (94/191, 49%) (p=0.047). By a multivariate analysis, the number of positive margins and the maximum diameter were independent risk factors of the residual tumors. Conclusion: The diagnosis of positive margins by IFE was useful for the prediction of residual tumors, and three histological properties of margin-exposed tumor components were correlated with the absence of residual tumor components. It may be possible to consider stratification of additional surgical therapy according to the characteristics of margin-exposed tumor components on IFE. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4118.

Study of Frozen Section Biopsy as Intraoperative Procedure for Oral Squamous Cell Carcinoma in BSMMU

Background: Frozen section biopsy technique often helps a rapid diagnosis of a mass during surgery which in turn may helps a surgeon to know the status of the margins of his resection before closing. Objective: The study was done to achieve tumour free surgical margin after resection of oral squamous cell carcinoma (OSCC). The study also examined to determine positive margins and its relation to tumour size, grade and stage of oral squamous cell carcinoma. Method: This cross sectional study was done in 29 patients of oral sqamous cell carcinoma. Result: One hundred eleven margins of frozen section (FS) biopsy were taken from 29 patients (mean 3.8) for comparing with the permanent sections of the same tissue sample. Among them, one false positive and three false negative were found and an accuracy rate was 96.4%. Out of one hundred eleven margins, 32 (28.8%) were positive and 79 (71.2%) were negative. In case of T3 and T4 tumour, the number of the positive margins was greater (respectively 27.8% and 50%). In stage III and stage IV cases, the number of positive margins was greater (29.1 and 30% respectively). Regarding histopathology grading, grade III was the highest (33.3%). Conclusion: The intra-operative frozen section biopsy plays an important role to achieve tumour free surgical margin in the resection of oral squamous cell carcinoma. In this study, it was also observed that the number of positive margins increased in relation to increased tumour size and tumour stage (cTNM). Key Words: Oral squamous cell carcinoma; Frozen section biopsy; Radiotherapy; Chemotherapy. DOI: 10.3329/bsmmuj.v2i1.3704 BSMMU J 2009; 2(1): 8-13

Interpretability of Excisional Biopsies of the Cervix: Cone Biopsy and Loop Excision

The loop electrosurgical excision procedure (LEEP) is more commonly used than cold knife conization (CKC) for diagnosis and treatment of cervical intraepithelial neoplasia (CIN). Several randomized trials have reported that LEEP is an easy-to-use, low-cost-effective technique that is more rapid and has favorable postoperative morbidity. However, earlier studies have demonstrated that margins with LEEP are often more frequently involved and more difficult to interpret than for CKC, and that positive margins are a strong predictor for residual disease. This retrospective study compared the results of CKC and LEEP to determine if these excision procedures had a deleterious effect on pathologic interpretation of CIN and treatment recommendations. Between 2003 and 2007, a review was conducted of the charts and perioperative records of patients who underwent a CKC and a LEEP. The patients selected had received either CKC or LEEP for primary treatment for CIN, suspected invasion, discordant cytology, or glandular abnormalities. Of the 157 eligible women available for analysis, 61 had CKC and 96 had LEEP. Interpretable surgical margins were found more frequently in CKC specimens compared to LEEP (95% vs. 85%), although the difference was not statistically significant (P = 0.1). Significant differences were observed between CKC and LEEP for number of specimens collected (1.1 vs. 1.9, respectively) (P = 0.000) and involvement of surgical margins (16% vs. 38%) (P = 0.005). These differences were maintained after logistic regression analysis to correct for predictor variables. These data show that LEEP is associated with an increased number of specimens that limit interpretability and an increase in the number of positive margins. The investigators conclude from these findings that CKC may be a better choice than LEEP in cases where margin status and interpretability of the surgical specimen are critical to a clinical treatment decision.