Pathologic Margin Status Research Articles

154 POSITIVE SURGICAL MARGINS AT RADICAL PROSTATECTOMY: NATIONAL AVERAGES WITHIN PSA AND GLEASON STRATA

INTRODUCTION AND OBJECTIVES: Positive surgical margins (PSM) are an important determinant of biochemical recurrence after radical prostatectomy (RP). Unlike most factors associated with disease-specific outcomes after RP (stage, Gleason score, PSA), surgical margin status can be influenced by the urologist. The majority of reports of PSM are from small institutional series and may not reflect realistic benchmarks for PSM. Further, differences in disease pathology affect the risk of PSM, including stage, Gleason score and PSA such that strata specific rates may be important. In this study, we utilize a national population-based cancer registry to evaluate the impact of primary disease characteristics that associate with PSMs and how this may affect surgical approaches. METHODS: Men undergoing RP were identified from the SEER cancer registry for the years 2004–2007 (for which PSA data were available). Pre-operative PSA, pathologic Gleason sum, stage, and surgical margin status were recorded. Differences between those with and without PSM were compared with chi-squared tests. The proportion of cases with PSM were determined and stratified by PSA and Gleason sum for both pT2 and pT3a tumors. Differences in PSM within strata were determined with chi-squared tests. RESULTS: 28,461 RP patients were identified and a PSM was present in 5,538 (19.5%). As expected, PSM were more common in pT3 (42%) than pT2 (16%) cases. Higher PSAs ( 4.0, 4–9.9, 10) were also associated with higher proportions of PSM (12%, 20% and 28%, respectively, p 0.001). Similarly, higher Gleason scores ( 6, 3 4, 4 3, 7) were associated with PSM (12%, 22%, 27% and 33%, respectively, p 0.001). The incidence of PSMs varied widely when stratified with primary disease characteristics. For pT2 tumors, the proportion of PSM ranged from 8% (Gleason 6, PSA 4.0) to 28% (Gleason 8–10, PSA 10). For pT3 tumors, the variation was even more substantial, ranging from 28% (Gleason 6, PSA 4.0) to 63% (Gleason 8–10, PSA 10). CONCLUSIONS: In this contemporary, population-based study of PSM after RP, we find that the proportion of PSMs vary significantly within both pT2 and pT3a cases when stratified by PSA and Gleason grades. These data can be used as a national reference for urologists in order to assess their own results.

Abstract P4-10-05: Factors Associated with Ipsilateral Breast Tumor Recurrence in Breast Cancer Patients Treated with Breast Conserving Surgery and Radiotherapy after Preoperative Chemotherapy

Abstract Background: Although preoperative chemotherapy (PCT) was originally used to make locally advanced breast cancers (BC) operable, it is now frequently utilized to make relatively large primary tumors small enough for breast conserving treatment (BCT). A large number of studies have been performed to identify risk factors of ipsilateral breast tumor recurrence (IBTR) after breast conserving treatment for originally small tumors. However, those studies for patients (Pts) who received BCT after PCT for relatively large tumors are limited. We have done a multicenter retrospective study to identify factors which were associated with IBTR in Pts treated with BCT after PCT. Patients and methods: From 7 Japanese hospitals, data, which regard characteristics of tumors and Pts, and treatment, of Pts who fulfilled the following criteria; 1. Female BC Pts who started PCT before January 2007 2. Her tumor was invasive, clinically solitary, and 2 cm or largerby palpation at diagnosis 3. She received 3 or more cycles of PCT 4. She received breast conserving surgery as a definitive surgery after PCT including axillary dissection or sentinel node biopsy 5. She received radiotherapy at least to the conserved breast. Pts with inflammatory BC and BC Pts who received preoperative treatment(s) other than chemotherapy were excluded. Kaplan-Meier method was used to estimate cumulative recurrence rates. Log rank test and Cox's proportional hazard model were used for statistical analyses. Receiver Operating Characteristic (ROC) Curves and C statistics were used for evaluating the prediction ability of Cox's proportional hazard model about IBTR. Results: A total of 324 Pts were registered. The median age at diagnosis of them was 48 years old. The median size of the primary tumors by palpation at diagnosis was 4 cm. For PCT anthracycline-based regimens were used for 83 Pts, taxane-based regimens were for 29, and anthracycline-taxane regimens were for 212. One hundred forty two Pts (43.8%) received postoperative chemotherapy, 180 (55.6%) had postoperative endocrine therapy, and only 7 had postoperative trastuzumab therapy. The median follow-up period was 45 months. Nineteen Pts (5.9%) developed IBTR. The cumulative 4-year IBTR rate was 5.5%. Univariate analyses revealed that estrogen receptor (ER) status both before and after PCT, pathological nodal status after PCT, and pathologically residual invasive tumor (solitary vs. multifocal, 1.7 cm or smaller vs. 1.8 cm or larger) were statistically significantly associated with IBTR (P < 0.05 for all of them). Pathological margin status did not affect IBTR rate (P=0.73). ER status prior to PCT (positive vs. negative)(Hazard Ratio [HR], 6.76; P=0.012), size of the residual invasive tumor (1.7 cm or smaller vs. 1.8 cm or larger)(HR, 4.74; P=0.020), and pathological nodal status after PCT (0-3 positive nodes vs. 4 or more)(HR, 3.03; P=0.041) were associated with IBTR on multivariate analysis. C statistic was 78.3%. Conclusion: Mastectomy may be a better choice for the Pts who have tumors with negative ER, pathologically large (1.8 cm or larger) residual invasive lesions after PCT, or 4 or more pathologically positive nodes after PCT in terms of local control. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-05.

Impact of the primary Gleason pattern on biochemical recurrence-free survival after radical prostatectomy: a single-center cohort of 1,248 patients with Gleason 7 tumors

We aimed to evaluate the impact of the primary Gleason pattern on biochemical recurrence-free survival (RFS) after radical prostatectomy (RP) in a single-center cohort of patients with Gleason 7 tumors. From 1998 to 2008, 2,239 consecutive patients underwent RP for a localized prostate cancer. A total of 1,248 patients with Gleason score (GS) 7 cancers were included. Follow-up was standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 23.4 months. Biochemical recurrence was defined by prostate-specific antigen level > 0.2 ng/ml. In all, 721 patients (57.8%) had a final GS of 3 + 4 and 527 (42.2%) of 4 + 3. Patients with GS 4 + 3 had a significantly higher risk of biochemical progression than those with GS 3 + 4 (P < 0.001). The 3- and 5-year biochemical RFS for Gleason score 3 + 4 cancers was 84.6 and 76.4%, respectively, versus 69.9 and 61.1% in Gleason score 4 + 3 cancers. Multivariate analysis showed that the primary Gleason remained statistically predictive for PSA failure (P = 0.018). When analysis was stratified by both pathologic stage and margin status, predictive value of primary Gleason was significant in pT2R0, pT3-4R0, and pT3-4R1 cancers, whereas survival curves were not statistically different in pT2R1 cancers (P = 0.672). Primary Gleason 4 pattern is an independent predictor for PSA failure. Analysis of Gleason patterns provides clinically relevant prognostic information, which may assist in the management of patients with Gleason score 7 cancers.

Multi-Institutional Analysis of Robotic Partial Nephrectomy for Hilar Versus Nonhilar Lesions in 446 Consecutive Cases

BackgroundMinimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. ObjectiveWe compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. Design, setting, and participantsWe retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. MeasurementsPatient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. Results and limitationsForty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2cm vs 2.6cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4min vs 19.6±10.0min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience. ConclusionsThe data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.

Progression and survival results after radical hepatic metastasectomy of indolent advanced neuroendocrine neoplasms (NENs) supports an aggressive surgical approach

Neuroendocrine neoplasms most commonly metastasize to the liver. Operative extirpation of neuroendocrine neoplasm hepatic metastases improves symptoms and seems to improve survival, but subsequent evidence is required. The current study evaluates the progression-free survival and overall survival of patients after resection (with or without ablation) of neuroendocrine neoplasm hepatic metastases. As a secondary endpoint, the prognostic factors associated with progression-free survival and overall survival were evaluated. Seventy-four patients with neuroendocrine neoplasm hepatic metastases underwent hepatic resection between December 1992 and December 2009. Thirty-eight patients underwent synchronous cryoablation. Patients were assessed radiologically and serologically at monthly intervals for the first 3months and then at 6-month intervals after treatment. Progression-free survival and overall survival were determined; clinicopathologic and treatment-related factors associated with progression-free survival and overall survival were evaluated through univariate and multivariate analyses. No patient was lost to follow-up. The median follow-up for the patients who were alive was 41 months (range, 1-162). The median progression-free survival and overall survival after hepatic resection were 23 and 95 months, respectively. Five- and 10-year overall survival were 63% and 40%, respectively. Two independent factors were associated with overall survival: histologic grade (P<.001) and extrahepatic disease (P = .021). The only independent predictor for progression-free survival was pathologic margin status (P = .023). In selected patients, aggressive operative extirpation of neuroendocrine neoplasm hepatic metastases is effective in achieving long-term survival. Disease progression, however, is a common occurrence; therefore, a multimodality treatment approach for progressive disease is necessary. Integrating the knowledge of identified prognostic factors can both improve patient selection and identify patients at greatest risk of treatment failure.

Patterns of recurrence in 208 patients with Merkel cell carcinoma.

8556 Background: Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous tumor that has a propensity for locoregional and distant metastasis. Despite this overall aggressive biology, little is known regarding the patterns and extent of metastasis in these patients. Methods: The records of 208 patients (pts) with MCC who were treated between 1990 and 2006 at a single institution were reviewed. Tumor characteristics, treatment, and patterns of recurrence were documented. Median follow-up and time to recurrence were calculated. Results: Primary MCC tumors were most commonly located in the head and neck region (51%) followed by the extremities (40%). Primary tumor size was < 2.0 cm (ie, AJCC T1) in 74% of pts. In pts who underwent primary surgical resection with pathologic margin status known (n=151), 84% had a margin-negative resection. The majority of patients (77%) presented without clinical regional lymphadenopathy. At a median follow-up of 20 months, 87 (42%) of the 208 pts had thus far recurred. The median time to first recurrence was 8 months. Among these pts who recurred, sites of first recurrence were locoregional (local, intransit, and/or regional nodal), distant, or both in 70.1%, 25.3%, and 4.6% of pts, respectively. Regional nodes comprised the most common first site of recurrence (n = 36, 41.4%), the majority of whom had nodal disease only at first recurrence (n = 22). Among the 25 pts (28.7%) who developed distant metastasis as a first site of recurrence, 15 had visceral metastases. Liver and bone were the most common distant sites affected. While metastases to a spectra of visceral sites were observed, lung was an uncommon site (n = 4). Pts with distant disease at first recurrence were more likely to have primary tumors > 2.0 cm and clinically-positive regional nodes. Conclusions: Merkel cell carcinoma is characterized by frequent nodal and distant recurrences in the first year after treatment, emphasizing the importance of close surveillance after initial diagnosis and treatment. In contrast to melanoma, lung metastases are relatively uncommon, while liver and bone metastases are frequently observed. A better understanding of the patterns of treatment failure may help identify those patients most likely to benefit from adjuvant therapy. No significant financial relationships to disclose.

Robotic Assisted Laparoscopic Prostatectomy Versus Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer: Comparison of Short-Term Biochemical Recurrence-Free Survival

We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution. A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence. There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not. The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed.

Tumor Volume, Tumor Percentage Involvement, or Prostate Volume: Which Is Predictive of Prostate-specific Antigen Recurrence?

To compare the effects of tumor volume (TV), tumor percentage involvement (TPI), and prostate volume (PV) on prostate-specific antigen (PSA) recurrence (PSAR) after radical prostatectomy (RP). A cohort of 3528 patients receiving RP between 1988 and 2008 was retrieved from the Duke Prostate Center. Patients were stratified by TV (< 3, 3-6, > 6 cm(3)), TPI (< 10%, 10%-20%, > 20%), and PV (< 35, 35-45, > 45 cm(3)) and their effects on PSAR evaluated using Kaplan-Meier analysis. Clinicopathologic variables included in univariate analysis were age at surgery, race, year of surgery, PSA, pathologic Gleason score, pathologic tumor stage, margin status, extracapsular extension, and seminal vesicle invasion. The effects of TV, TPI, and PV (as continuous and categorical variables) on PSAR were compared using Cox analysis. TPI, TV, and PV were predictive of PSAR (P <.05) in Kaplan-Meier analysis. In multivariate analysis as continuous variables, TPI and PV were predictive of PSAR (hazard ratio [HR] = 1.16 and HR = 0.65, P <.05). As categorical variables, TPI > 20% and PV 10-35 cm(3) were predictive of PSAR (HR = 1.45 and OR = 1.25, P <.05). TV was not predictive of PSAR in either analysis. Pathologic Gleason score > or = 7, PSA, positive margins, seminal vesicle invasion, and tumor stage T3/T4 were found to be predictors of PSAR (P <.05). TV, TPI, and PV were predictive of PSAR in univariate analysis, but in multivariate analysis, only TPI and PV were predictive of PSAR. TPI and PV should be considered when evaluating, assessing, and counseling patients regarding PSAR risk.

Parapharyngeal space pleomorphic adenoma: A 30‐year review

To evaluate the treatment results of pleomorphic adenoma (PA) of the parapharyngeal space at a single institution during a 30-year period. A retrospective review. This study was performed by examining the records and reviewing the pathology of 44 patients with PA of the parapharyngeal space treated at a single medical center from January 1975 to November 2005. Of the 44 patients with PA, 35 patients underwent 38 excisions. Eleven men and 27 women were treated surgically. Follow-up varied from 24 months to 180 months. There were three recurrences in two patients. Recurrence rates at 5 and 10 years were equal at 7.9%. Gender, age, tumor volume, surgical approach, pathologic surgical margin status, and prior resections were evaluated for significant prognostic factors. Advanced age proved a poor prognostic indicator (P < .05). History of prior resection (P < .01) was significant for recurrence. Positive surgical margins (P = .69) proved a negative association. We report low recurrence rates in this patient population with two important prognostic indicators. History of prior resection is significant to predict recurrence. Interestingly, positive surgical margins are actually shown not to effect risk of recurrence. Local recurrence of the tumor is associated with further recurrence and less favorable prognosis.

A multi-institutional comparison of radical retropubic prostatectomy, radical perineal prostatectomy, and robot-assisted laparoscopic prostatectomy for treatment of localized prostate cancer.

To evaluate the pathological stage and margin status of patients undergoing radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP) and robot-assisted laparoscopic prostatectomy (RALP). We performed a retrospective analysis of 196 patients who underwent RRP, RPP, and RALP as part of our multi-institution program. Fifty-seven patients underwent RRP, 41 RPP, and 98 RALP. Patient age, preoperative prostate specific antigen (PSA), preoperative Gleason score, preoperative clinical stage, pathological stage, postoperative Gleason score, and margin status were reviewed. The three groups had similar preoperative characteristics, except for PSA (8.4, 6.5, and 6.2ng/ml) for the retropubic, robotic, and perineal approaches. Margins were positive in 12, 24, and 36% of the specimens from RALP, RRP, and RPP, respectively (P=0.004). The positive margin rates in patients with pT2 tumors were 4, 14, and 19% in the RALP, RRP, and the RPP groups, respectively (P=0.03). Controlling for age and pre-operative PSA and Gleason score, the rate of positive margins was statistically lower in the RALP versus both the RRP (P=0.046) and the RPP groups (P=0.02). In the patients with pT3 tumors, positive margins were observed in 36% of patients undergoing the RALP and 53 and 90% of those patients undergoing the RRP and RPP, respectively (P=0.015). Controlling for the same factors, the rate of positive margins was statistically lower in the RALP versus the RPP (P=0.01) but not compared with the RRP patients (P=0.32). The percentage of positive margins was lower in RALP than in RPP for both pT2 and pT3 tumors. RRP had a higher percentage of positive margins than RALP in the pT2 tumors but not in the pT3 tumors.

Perfil epidemiológico e fatores prognósticos no tratamento cirúrgico do adenocarcinoma de próstata clinicamente localizado

Radical prostatectomy remains the standard treatment for early prostate cancer. This study was conducted to evaluate the outcome and prognostic factors of radical prostatectomy. A total of 500 patients with prostate cancer underwent radical prostatectomy at Santa Rita hospital- Maringa-PR, between 2000 and 2006. Clinical staging, preoperative prostate-specific antigen (PSA) and Gleason score were evaluated with pathological stage and margin status. Follow-up PSA monitoring and survival were analyzed. Of 500 patients with clinical localized disease with a median follow up of 36,7 + or - 18,8 months. The average operative duration was 190 + or - 45 minutes and the average intra-operative bleeding was 630 ml. The patients' preoperative serum PSA was 7,8 + or - 4,5 ng/dl , with a higher proportion of Gleason Score < 6(72%) and The TNM stage pT2c (65%). For late postoperative complications: incontinence in 2% and 46 % with erectile dysfunction. Radical prostatectomy in men shows excellent results. The chance of recurrence was directly associated with PSA = 10 ng/ml, high Gleason score and inversely proportional to age.

Robot-Assisted Surgery for Upper Aerodigestive Tract Neoplasms

To assess the feasibility and safety of performing robot-assisted resections of head and neck tumors, and to predict which variables lead to successful robot-assisted resection and better functional outcome. Prospective nonrandomized clinical trial. Academic tertiary referral center. Thirty-six patients with oral cavity, oropharyngeal, hypopharyngeal, or laryngeal tumors. Robot-assisted resection of indicated tumors. Ability to perform robot-assisted resection, final pathologic margin status, ability to extubate postoperatively, need for tracheotomy tube, and need for gastrostomy tube. Any clinically significant complications were recorded. Thirty-six patients participated in the study. Eight patients had previously been treated for head and neck cancer. Twenty-nine patients (81%) underwent successful robotic resection. Negative margins were obtained in all 29 patients. Twenty-one of 29 patients were safely extubated prior to leaving the operating room. One patient required short-term tracheotomy tube placement. A total of 9 patients were gastrostomy tube dependent (2 preoperatively, 7 postoperatively). Factors associated with successful robotic resection were lower T classification (P = .01) and edentulism (P = .07). Factors associated with gastrostomy tube dependence were advanced age (P = .02), tumor location in the larynx (P < .001), higher T classification (P = .02), and lower preoperative M. D. Anderson Dysphagia Inventory score (P = .04). Robot-assisted surgery is feasible and safe for the resection of select head and neck tumors. This clinical series demonstrates that robotic surgery can be utilized successfully in patients with T1 to T4 lesions located in the oral cavity, oropharynx, hypopharynx, and larynx with good preservation of swallow function.

Comparison of iridium implant boost versus electron boost as a component of breast conservation treatment for early-stage breast carcinoma.

Abstract Abstract #5144 Background: Breast conservation treatment includes lumpectomy followed by definitive radiation therapy, with radiation delivered to the whole breast followed by tumor bed boost. Currently, the boost is typically delivered by electron beams, but was previously delivered by iridium-192 implants. With re-emergence of implant radiotherapy techniques in current practice, long-term outcomes of both boost techniques are important.&amp;#x2028; Methods: From 1977 to 1983, 141 patients with early-stage breast cancer were treated with iridium-192 boost after whole breast radiation. These patients were matched 1:1 to 141 patients who received electron boost from 1980 to 1990. Most implant patients were treated before widespread electron availability. Matching criteria included age at diagnosis, final pathologic margin status, pathologic tumor stage, and pathologic nodal stage. All patients had AJCC Stage I or II invasive breast carcinoma, had surgical excision of the primary tumor, and underwent definitive radiation to at least 60 grays. Chemotherapy was administered to 30 implant patients and 41 electron patients (p=0.014), and hormonal treatment to 3 implant patients and 12 electron patients (p=0.032). These systemic treatment variations were expected due to treatment era differences. Median follow-up was 16.7 years for implant patients (range 0.7-28.5) and 12.6 years for electron patients (range 1.4-25.4) (p&amp;lt;0.001).&amp;#x2028; Results: Electron boost patients were more likely to have excellent/good cosmesis versus fair/poor cosmesis than implant boost patients. At 1-year follow-up, this was significant (p=0.014). This trend continued, with odds ratio of having excellent/good cosmesis versus fair/poor cosmesis in implant patients compared to electron patients being 0.29 after 5 years (95% CI 0.027-1.38, p=0.114) and 0.24 after 10 years (95% CI 0.005-1.93, p=0.266).&amp;#x2028; Incidence of all complications evaluated did not differ between the two groups (all p≥0.07). Incidence of breast fibrosis was 3% per year in implant patients and 4% per year in electron patients (p=0.17). In total, breast fibrosis developed in 41% of implant patients and 16% of electron patients. Incidence of infection was 14% per year in the implant group and 6% per year in the electron group (p=0.09). In total, infection developed in 7% of implant patients and 9% of electron patients. Incidence of rib fracture was 2% per year in both groups (p=0.8). Incidence of cardiopulmonary complications was 4% per year in implant patients and 3% per year in electron patients (p=0.7). Incidence of non-cardiac vascular complications was 4% per year in both groups (p=0.1). Incidence of neuropathy was 4% per year in implant patients and 1% per year in electron patients (p=0.07).&amp;#x2028; Conclusions: Patients treated with electron boost were more likely than those treated with implant boost to have excellent/good cosmesis, though this observation did not reach statistical significance at 5- and 10-year follow-up. Complication rates did not differ significantly between the groups with long-term follow-up. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5144.

Pre-operative CA 19-9 > 90 is Associated with Worse Overall Survival and Marginal Resection Status in Resectable, Invasive Pancreatic Carcinoma

Pre-operative CA 19-9 > 90 is Associated with Worse Overall Survival and Marginal Resection Status in Resectable, Invasive Pancreatic Carcinoma

Clinical Significance of Intraoperative Bile Duct Margin Assessment for Hilar Cholangiocarcinoma

Frozen section analysis of bile duct margins is often used to guide the extent of surgical resection for hilar cholangiocarcinoma (HCCA), but the usefulness of this practice is unknown. The association between disease-specific survival (DSS) and pathologic margin status determined during and after surgical resection for HCCA was assessed retrospectively for 101 patients between 1992 and 2005. Final histopathology identified three subgroups on the basis of resection margin status: wide margin (bile duct and specimen margins negative for adenocarcinoma), narrow margin (bile duct margin negative but specimen margins positive), and positive margin (bile duct and specimen margins positive). On the basis of frozen section analysis alone, 90 patients were thought to have a disease-negative bile duct margin intraoperatively. Final histopathology showed that eight patients (9%) had invasive adenocarcinoma in the cuff of bile duct submitted for frozen section analysis. Of the 82 patients with negative final bile duct margins, 54 patients were categorized as having wide margins, and 28 patients had narrow margins. The median DSS for patients with wide margins was 56 months compared with 38 months for patients with narrow margins and 32 months for margin-positive patients (P = .01). Frozen section analysis of the proximal bile duct margin is misleading in 9% of patients. Among patients with HCCA who are determined to have negative duct margins intraoperatively, only 60% will have margins adequately wide enough to be associated with an improvement in DSS.

Race and prostate weight as independent predictors for biochemical recurrence after radical prostatectomy

We hypothesized that factors beyond pathological stage, grade, PSA and margin status would be important predictors of biochemical recurrence (BCR) after radical prostatectomy (RP). A cohort of 3194 patients who underwent RP between 1988 and 2007 and who had neither neoadjuvant therapy nor postoperative adjuvant hormonal therapy was retrieved from the Duke Prostate Center database. Age, prostate-specific antigen (PSA), pathological Gleason score (pG), lymph node status, seminal vesicle invasion (SVI), extracapsular extension (ECE), positive surgical margin (PSM) status, year of surgery, race, adjuvant radiation therapy (XRT), percent tumor involvement in the RP specimen and prostate weight were evaluated as possible predictors of BCR in multivariate Cox regression analysis. BCR was defined as a PSA of 0.2 ng ml(-1) or higher at least 30 days after surgery. A nomogram was developed from the Cox model. Predictive accuracy was obtained by calculating bias-corrected Harrell's c and by bootstrap calibration. In multivariate analysis, PSA (hazard ratio 1.39 (95% confidence interval 1.29-1.51)), ECE (1.22 (1.04-1.44)), pG score (1.38 (1.14-1.68), 2.23 (1.76-2.84), 2.69 (2.12-3.40) for pG 3+4, 4+3, >7, respectively), SVI (1.72 (1.40-2.12)), PSM (2.05 (1.73-2.42)), year of surgery (0.65 (0.54-0.77)), African-American race (1.37 (1.13-1.66)), adjuvant XRT (0.19 (0.11-0.34)) and prostate weight (0.83 (0.76-0.92)) were identified as independent predictors of BCR (P< or =0.018 for all factors). Predictive accuracy of the nomogram was 0.75. Race and prostate weight were independent predictors for BCR after RP. By incorporating these variables, we developed a nomogram, which provides a highly accurate means for estimating risk of BCR after RP.

Positive surgical margins at radical prostatectomy: importance of intra-operative bladder neck frozen sections

To determine if intraoperative frozen sections of the bladder neck during radical prostatectomy (RP) could decrease the incidence of final positive surgical margins at the bladder neck. This prospective cohort study included 51 consecutive men who underwent anatomic RP at University of Florida & Shands Jacksonville. All patients had intraoperative frozen section of bladder neck sent for analysis. Preoperative, operative, and postoperative data were collected and analyzed. Outcome measures were intraoperative bladder neck margin status, final pathologic bladder neck margin status, and postoperative urinary complications. Median follow-up for the 51 patients was 22 months. The final positive surgical margin rate was 20% (10 patients). An additional three patients had positive surgical margins at the bladder neck intraoperatively. These patients then had a wider resection of the affected bladder neck until the frozen sections were negative for cancer or prostatic tissue. Final pathologic evaluation of bladder neck margin was negative for tumor or persistent prostatic tissue in all 51 men. With intra-operative frozen sections, we were able to obtain a negligible positive bladder neck margin rate. Surgeons who are still on the learning curve for RP should consider intra-operative frozen section of the bladder neck.

Transoral Robotic Surgery

To describe and show the feasibility of a new surgical technique for transoral robotic surgery (TORS) radical tonsillectomy. A prospective, phase 1 clinical trial. Academic, tertiary referral center. A total of 27 participants were prospectively selected using a volunteer sample. All eligible patients agreed to participate in the study. Patients underwent TORS radical tonsillectomy for previously untreated invasive squamous cell carcinoma of the tonsillar region without free-flap reconstruction, staged neck dissection, and adjuvant therapy. Outcome measures included final pathologic margin status, need for short- and long-term tracheotomy tube placement, and need for gastrostomy tube feedings among patients with a minimum 6-month follow-up. The incidence of significant postoperative complications was recorded. No mortality occurred. Final margins found to be negative for cancer were achieved in 25 of 27 patients (93%). Surgical complications included 1 case each of postoperative mucosal bleeding, delirium tremens, unplanned tracheotomy for temporary exacerbation of sleep apnea, and hypernasality and 2 cases of moderate trismus. Twenty-six of 27 patients (96%) were swallowing without the use of a gastrostomy. Radical tonsillectomy using TORS is a new technique that offers excellent access for resection of carcinomas of the tonsil with acceptable acute morbidity. Future reports will focus on long-term oncologic and functional outcomes.

High‐grade prostatic intraepithelial neoplasia is an independent predictor of outcome after radical prostatectomy

To examine the relationship between the presence of high-grade prostatic intraepithelial neoplasia (HGPIN) in retropubic radical prostatectomy (RP) specimens and cancer-specific outcomes, including pathological variables and biochemical disease-free survival (bDFS), as HGPIN shares many histopathological characteristics with prostate carcinoma and has been considered a precursor lesion to prostate cancer. The Columbia University Urologic Oncology Database was reviewed; 3460 patients were identified who underwent RP between 1988-2006, and 2133 with or without HGPIN and >12 months of follow-up were included in the analysis. Analysis of variance methods were used to evaluate the relationship between HGPIN and pathological stage, Gleason sum, perineural invasion, multifocality, extraprostatic extension, margin and nodal status. Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard model fitted for preoperative prostate-specific antigen (PSA) level, Gleason sum and pathological stage were used to assess differences in bDFS. In all, 1885 (88.4%) patients had HGPIN in the RRP specimen and 248 (11.6%) had no HGPIN. There was no significant difference in the distribution of PSA level (P = 0.27), pathological stage (P = 0.18) or Gleason sum (P = 0.84) between patients with and with no HGPIN. The HGPIN-positive group had higher rates of perineural invasion (69.9 vs 57.5%; P = 0.003) and multifocality (63.0 vs 38.4%; P < 0.001). Patients with no HGPIN had a better bDFS, at 87.3% vs 81.0% at a median follow-up of 50 months, and 73.6% vs 67.0% at 9 years (P = 0.045). The risk of biochemical failure was 1.9 times greater in the HGPIN-positive group than the negative group (P = 0.006) when controlling for PSA level, pathological stage and Gleason sum. In addition to traditional pathological prognostic variables, the absence of HGPIN in RRP specimens, although found in a minority of patients, denotes a significantly lower rate of tumour multifocality, perineural invasion and ultimately biochemical recurrence.

Additional variables other than AJCC staging show clinical utility for predicting survival in colon cancer

14584 Background: The most important predictor of colon cancer patient outcome is disease stage at the time of surgery. However, staging does not accurately predict survival for all patients undergoing a resection with curative intent. The aim of this study was to analyze clinical and pathological characteristics of patients undergoing curative colon cancer, in order to identify characteristics, in addition to stage, predictive of disease outcome. Methods: Between 1997 and 2005 data for 114 patients undergoing curative resection for colon cancer at a tertiary care institution were collected. Clinical and pathological characteristics evaluated were: age, gender, tumor location, tumor size, scheduled vs emergent surgery, pathologic margin status, TNM stage, pathologic grade, number of positive lymph nodes, total number of lymph nodes resected, vascular and lymphatic invasion. Characteristics found to be significant in a Kaplan-Meier univariate survival analysis were included in a multivariate stepwise logistic regression analysis. Patient outcomes studied were overall survival, cancer specific survival, and disease free survival. Results: From the 114 patients examined in this cohort the mean age was 67 years, the male to female ratio was 0.8:1, and the mean follow up time was 2.61 years. Overall survival, cancer specific survival, and disease free survival were calculated to be 83.3%, 91.2% and 84.2%, respectively. Statistically significant variables by univariate analysis were: AJCC stage, number of positive lymph nodes, pathologic N stage, lymphatic and vascular invasion by the primary tumor. Further multivariate analysis revealed that lymphatic invasion was the only significant independent influence for predicting disease recurrence. Conclusions: Clinicopathologic characteristics, in addition to AJCC disease stage, may be of clinical utility in predicting outcome for patients who have undergone curative resection for colon cancer. Further evaluation of these clinicopathologic characteristics should be carried out in a larger colon cancer patient cohort. No significant financial relationships to disclose.