Pathological Resection Margin Research Articles

Salivary duct carcinoma of the parotid

Salivary duct carcinoma is one of the rarest and most aggressive forms of parotid tumor. We report two cases. Case 1: a 78-year-old man was referred for a salivary duct carcinoma of the left parotid gland. Treatment was surgical (parotidectomy with ipsilateral selective neck dissection), without capsule rupture, and with healthy margins. At seven years' follow-up, the patient was alive and disease-free. Case 2: a 41-year-old man was referred for a salivary duct carcinoma of the left parotid gland. Parotidectomy with ipsilateral selective neck dissection left healthy but insufficient margins (<1 cm), and postoperative radiation therapy (70 Gy) was undertaken. At eight years' follow-up, the patient was alive and free of recurrence. Mean patient age in the literature is 60 years, with a male-to-female ratio of 2:1. Mean five-years' recurrence-free survival was 34%. Surgery is the main form of treatment in this indication. Postoperative radiation therapy is indicated in case of extraparotid extension, pathological resection margins, cervical lymph node metastasis, lymphatic embolus and/or neurologic invasion. Chemotherapy is generally reserved for metastatic forms of the disease.

Laparoscopic approaches to resection of suspected gastric gastrointestinal stromal tumors based on tumor location

Surgical resection of gastric gastrointestinal stromal tumor (GIST) should be optimized to achieve a negative pathologic surgical margin while limiting the extent of stomach volume loss. Careful identification of exact gastric tumor location using preoperative computed tomography (CT) scans and gastroscopy should allow for selection of a specific operative approach. This retrospective case series involved 12 patients (7 men and 5 women; mean age, 60.5 years) with suspected gastric GIST undergoing tumor resection at Fletcher Allen Health Care, a university medical center, from January 2005 to August 2006. The main outcome measures were pathologic resection margins, operative time, estimated blood loss (EBL), morbidity, and duration of hospital stay. The 12 patients were separated into three groups on the basis of tumor location as follows: type 1 (fundus/greater curvature, n = 5), type 2 (prepyloric/antrum, n = 3), and type 3 (lesser curvature/perigastroesophageal junction, n = 4). Preoperative imaging (CT scan and/or endoscopy) used to identify tumor location accurately predicted the operative approach before surgery for 11 of the12 patients. The surgical approach was selected solely by tumor location as follows: type 1 (laparoscopic partial gastrectomy [LPG]), type 2 (laparoscopic distal gastrectomy [LDG]), and type 3 (laparoscopic transgastric resection [LTG]). Nine patients had a final pathologic diagnosis of GIST. The average tumor size was 4.6 cm, but this did not influence procedure selection. Histologic margins were microscopically negative in all patients. The LPG and LTG approaches had similar outcomes in terms of estimated blood loss (EBL; 80 vs 100 ml) and hospital stay (3.4 vs 3.3 days; p = 0.0198), but LTG had longer operative times (236 vs 180 min). The LDG procedure had longer operative times, greater EBL, and a longer hospital stay. The operative morbidity was 17%, and there was no operative mortality. The selection of an operative technique for resection of gastric submucosal tumors can be based on preoperative identification of tumor location, for better definition of both the extent of gastric resection and the technical complexity of the laparoscopic procedure.

Randomized Control Trial of Fluorescence-Guided Surgical Excision of Nonmelanotic Cutaneous Malignancies

Protoporphyrin IX (PpIX) is an endogenous photosensitizer commonly used in photodynamic therapy. This study sought to assess if PpIX fluorescence can be applied clinically to improve the delineation and excision of nonmelanotic cutaneous malignancies. Prospective, randomized control trial. A tertiary care skin cancer clinic. Fifty-one individuals with 65 cutaneous nonmelanotic cervicofacial malignancies were randomized into two groups. The control group was offered surgical excision with surgeon-delineated excision margins. The study group had their excision margins delineated while under fluorescence. The delineated lesion borders, proposed excision margins, and projected lesion-free areas were compared among the two groups. Pathologic resection margins and completeness of excision were also assessed. Excisions performed using fluorescence delineation were 20% narrower (p < .01) and 17% shorter (p < .04), with 35% less lesion-free skin excised (p < .005). All lesions excised using photodelineation had clear pathologic resection margins. A significant number of lesions excised via the traditional approach required reexcision owing to pathologically positive peripheral margins (p < .001). Follow-up at 2 years revealed no lesion recurrence among the study group and one recurrence within the control group. The results demonstrate a reliable and novel application for photodynamic photodelination and support its application in the excision of nonmelanotic cutaneous malignancies.

Total glans resurfacing for premalignant lesions of the penis: initial outcome data

To report our initial experience of total glans resurfacing (TGR), as premalignant lesions of the glans penis have conventionally been treated by local excision, topical chemotherapy, laser or cryotherapy, but these techniques are frequently associated with high local failure rates and unsightly scarring that can make monitoring by gross inspection difficult. TGR involves removing the glans and subcoronal epithelial and subepithelial tissues down to the corpus spongiosum of the glans and Buck's fascia at the coronal sulcus. The denuded glans penis is then covered with an extra-genital skin graft. Ten patients underwent TGR: six had recurrent erythroplasia of Queyrat after 5% 5-fluorouracil (5-FU) therapy; one had no clinical response to 5-FU or imiquimod; one had a severe allergic reaction and therefore could not tolerate 5-FU; and two had extensive glans hyperkeratosis and severe dysplasia. There were no postoperative complications. All skin grafts took successfully, and the cosmetic results were excellent. In all cases, pathological resection margins were clear. To date, there has been no evidence of disease recurrence on follow-up (median 30 months, range 7-45). TGR is a successful surgical alternative for managing intractable premalignant penile lesions. It has the potential to restore normal anatomy and minimize the risk of local recurrence by replacing diseased epithelium and subepithelial tissues with healthy extra-genital skin.

Association between surgical margins and long-term outcome in advanced hepatoblastoma

Background Many patients with hepatoblastoma present with unresectable disease. Neoadjuvant therapy has improved resectability rates to as high as 70% to 90%. Despite this improvement, many patients will be left with tumors that are of borderline resectability. The authors hypothesize that favorable outcomes may be achieved even with resection margins less than 1 cm thus sparing the need for liver transplantation. Methods Between January 1981 and March 2003, 23 patients age less than 16 years with a diagnosis of hepatoblastoma undergoing surgical resection were identified. The clinical characteristics, pathologic resection margins, and survival status were reviewed. Results Eighteen (78%) of the patients were alive with no evidence of recurrence at last follow-up. Thirteen (56.5%) had ≥1 cm resection margins, whereas 10 (43.5%) had resection margins less than 1 cm. Eleven (47.8%) presented with PRETEXT III tumors. There was no significant difference in survival rate between resection margins less than 1 cm and ≥1 cm ( P = .13; 95% CI 0.91 to 2.61). Thirteen patients (56.5%) presented with synchronous pulmonary metastatic disease, where survival was significantly worse ( P = .04; 95% CI 1.10 to 2.50). Subgroup analysis confirmed that margins less than 1 cm did not significantly affect survival after controlling for pulmonary metastatic disease ( P = .56; 95% CI 0.71 to 3.61). Conclusions Surgical resection with margins less than 1 cm are associated with survival that is equivalent to resection with margins ≥1 cm. Our findings suggest it is preferable to preserve key structures with a small resection margin and therefore spare the need for liver transplantation in patients with advanced hepatoblastoma.

Multimodality treatment in the control of deep musculoaponeurotic fibromatosis.

Deep musculoaponeurotic fibromatoses are rare soft tissue neoplasms with a propensity for local recurrence. A retrospective analysis was carried out of the factors contributing to local disease control in 75 patients treated between 1963 and 1993. Multivariate analysis identified the type of surgical excision (P < 0.001) and involvement of pathological resection margins (P < 0.02) as significant factors contributing to local recurrence. After a median follow up of 47 months (range 24 months to 29 years) 31 (49 per cent) of the 63 patients who had an 'adequate' surgical resection developed local recurrence. The median time before development of local recurrence was 83.4 (range 8-129) months in patients with clear pathological resection margins. This was significantly shortened to 13.1 (range 2-35) months in those with positive margins (P < 0.001). Adequate surgical extirpation is the most important determinant in local disease control. Treatment of local recurrence ranged from observation during periods of disease stabilization to multimodality treatment for aggressive disease.

971 Poster Efficacy of post-operative adjuvant radiotherapy (RT) for pathological T3 (pT3) and/or positive resection margin (RM) prostate adenocarcinoma with undetectable post-operative PSA following radical prostatectomy (RP)

971 Poster Efficacy of post-operative adjuvant radiotherapy (RT) for pathological T3 (pT3) and/or positive resection margin (RM) prostate adenocarcinoma with undetectable post-operative PSA following radical prostatectomy (RP)

Prediction of Residual Neoplasia Based on Pathologic Severity and Resection Margin Status of Conization Specimens

Prediction of Residual Neoplasia Based on Pathologic Severity and Resection Margin Status of Conization Specimens

Risk factors of tracheostomal recurrence after laryngectomy for laryngeal carcinoma

Tracheostomal recurrence after total laryngectomy for laryngeal carcinoma has a poor prognosis. The independent risk factors of tracheostomal recurrence are, however, not well documented. This is a multivariate analysis of the risk factors of tracheostomal recurrence after total laryngectomy for 322 laryngeal squamous cell carcinomas. The factors included in the analysis were sex, age, tumor stage, sites of tumor involvement, preoperative airway obstruction, preoperative tracheostomy, extent of surgical resection, radiotherapy, and pathological resection margin. Seventeen (5%) patients developed tracheostomal recurrence. Univariate analysis showed that preoperative airway obstruction, subglottic involvement, and postcricoid extension were significant factors associated with tracheostomal recurrence. Multivariate analysis using logistic regression method showed that both subglottic and postcricoid involvement were independent predisposing factors for tracheostomal recurrence. The tracheostomal recurrence rates were 2% in patients without the risk factor and 10% in patients with the presence of one or both risk factors. Subglottic and postcricoid involvement were independent risk factors for tracheostomal recurrence.

Intraoperative electron beam radiation therapy for recurrent locally advanced rectal or rectosigmoid carcinoma

A multimodality approach of moderate-dose to high-dose preoperative radiation therapy, surgical resection, and intraoperative electron beam radiation therapy (IORT) has been used for patients with locally recurrent rectal or rectosigmoid carcinoma. The 5-year actuarial local control and disease-free survival for 30 patients undergoing this treatment program were 26% and 19%, respectively. The most important factor predicting a favorable outcome was complete resection with negative pathologic resection margins. The determinant local control and disease-free survival for 13 patients undergoing complete resection were 62% and 54%, respectively, whereas for 17 patients undergoing partial resection these figures were 18% and 6%, respectively. There did not appear to be a difference in local control or survival based on the original surgical resection (abdominoperineal resection versus low anterior resection). However, the likelihood of obtaining a complete resection after preoperative radiation therapy was higher in patients who had previously undergone a low anterior resection than patients undergoing prior abdominoperineal resection. For the 30 patients undergoing external beam irradiation, resection, and IORT, the most significant toxicities were soft tissue or sacral injury and pelvic neuropathy. Efforts to further improve local control are directed toward the concurrent use of chemotherapy (5-fluorouracil with and without leucovorin) as radiation dose modifiers during external beam irradiation and the use of additional postoperative radiation therapy.