Positive Deep Margin Research Articles

Cold Knife Conization Vs. Loop Electrosurgical Excision Procedure in Premalignant Cervical Lesions in a Cohort of Females in Romania

Cold knife conization and loop electrosurgical excision procedures (LEEP) are two methods of minimally invasive treatment used in Romania for high-grade cervical dysplasia. The purpose of this study is to identify correlations between the results of the Papanicolaou (PAP) smear and biopsy and to evaluate the positivity of resection margins in both types of conizations: cold knife conization versus LEEP. The 96 cases enrolled in this study were gathered from ‘Prof. Dr. Ioan Pușcaș’ City Hospital of Șimleu Silvaniei, Romania, in a time interval from 01.01.2022 to 01.01.2024. The results of our study showed that out of 20 women who underwent PAP smear for ASC-US, 4 were actually found to have high-grade squamous intraepithelial lesion (H-SIL) according to biopsy results. The estimated risk in females who underwent LEEP procedure with positive margins in the histopathological examination, in the studied population, is almost 0.5 times higher compared to those who underwent cold knife conization. Histopathological examination of cervical specimens is the gold standard method in detecting high-risk cervical lesions. Our study shows that positive deep endocervical margins are more likely to occur in loop electrosurgical excision procedures compared with cold knife conization.

Preoperative and Intraoperative Identification of Sentinel Lymph Nodes in Melanoma Surgery.

According to the American Joint Commission on Cancer (AJCC) 8th edition guidelines, SLN biopsy is recommended for primary melanomas with a Breslow thickness of at least 1 mm. Additionally, the National Comprehensive Cancer Network (NCCN) recommends that a SLN biopsy may be considered for melanoma patients with T1b lesions, which are 0.8-1 mm thick or less than 0.8 mm thick with ulceration. It can also be considered for T1a lesions that are less than 0.8 mm thick but have other adverse features, such as a high mitotic rate, lymphovascular invasion, or a positive deep margin. To reduce the false negative rate of melanoma SLN biopsy, we have introduced the intraoperative use of Sentinella, a gamma camera, to enhance the identification rate of SLNs beyond that of the traditional gamma hand-held probe. At the Center for Melanoma Research and Treatment at the California Pacific Medical Center, a multidisciplinary approach has been established to treat melanoma patients when the diagnosis of primary melanoma is made with a referral to our melanoma center. This comprehensive approach at the melanoma tumor board, including the efforts of pathologists, radiologists, dermatologists, surgical, medical and radiation oncologists, results in a consensus to deliver personalized and high-quality care for our melanoma patients. This multidisciplinary program for the management of melanoma can be duplicated for other types of cancer. This article consists of current knowledge to document the published methods of identification of sentinel lymph nodes. In addition, we have included new data as developed in our melanoma center as newly published materials in this article to demonstrate the utility of these methods in melanoma sentinel lymph node surgery. Informed consent has been waived by our IRB regarding the acquisition of clinical data as presented in this study.

Predictors of residual neoplasia after noncurative (R1) endoscopic submucosal dissection of lesions in the gastrointestinal tract.

Endoscopic submucosal dissection (ESD) is a minimally invasive resection technique that enables the en bloc resection of gastrointestinal lesions. Despite en bloc resection, pathological evaluation of lesions can reveal positive vertical or horizontal margins, which is referred to as R1 resection. Not all R1 lesions referred for surgical resection or endoscopic surveillance show evidence of residual tumor. We aimed to identify the predictors of residual neoplasia in patients with an R1 resection following ESD. All lesions resected via ESD between June 2016 and September 2021 at a tertiary referral center were retrospectively identified. Lesions with an R1 resection and adequate follow-up were eligible for inclusion. Patient, lesion, and procedural characteristics were analyzed to identify predictors of residual neoplasia. Of 614 lesions, 163 (28%) had R1 resection. Of these, 56 lesions in 51 patients had complete follow-up and were included. Thirteen patients (25.5%) underwent surgical resection and the remainder underwent endoscopic surveillance. Seven (12.5%) patients had residual disease. All patients with residual disease had esophageal carcinoma. Positive deep and lateral margins, severe submucosal fibrosis, and moderate/poorly differentiated tumors were identified as significant predictors of residual neoplasia. Most R1 lesions (87.5%) resected by ESD did not have residual disease on follow-up. Those without identified risk factors for residual disease, such as esophageal carcinoma, severe submucosal fibrosis, or both histological margin positivity, may benefit from a strategy of close endoscopic surveillance rather than referral for surgical resection.

Increased rate of upstaging of plantar melanomas may warrant more radical treatment: Study at a single NCI-designated Cancer Center

BackgroundAcral lentiginous melanoma holds the worst prognosis of all cutaneous melanomas. We aim to further detail the incidence of upstaging in plantar melanoma (PM) as well as identify factors associated with upstaging. MethodsA retrospective analysis of medical records was performed of patients who underwent surgical intervention for non-metastatic primary PM at a single NCI-designated Comprehensive Cancer Center (January 2011-August 2023). The primary outcome was rate of upstaging, defined as an increase in the T-stage on final surgical pathology compared to biopsy. Clinical and pathologic staging were determined by the AJCC 8th edition. Statistical analysis included Pearson’s Chi-squared test, Fisher’s exact test, Wilcoxon rank sum test, and Kruskal-Wallis rank sum test. ResultsForty-nine patients were identified, with an average age of 65 years (51 % male). Majority self-identified as Caucasian (55 %). Initial biopsy techniques were shave (49 %), punch (34 %) and excisional (17 %). Twenty-four patients (50 %) demonstrated upstaging. Seventy-seven percent (n = 10) of patients with clinical Tis were upstaged. Eight patients required reoperation due to upstaging, with 6 having melanoma in situ on biopsy. On multivariable logistic regression, patients with clinical Tis-T1 were more likely to be upstaged compared to T2-T3 (OR 8.75, p < 0.041). Type of biopsy, lesion size < 15 mm and positive deep margins on biopsy were not associated with risk of upstaging. ConclusionsOur findings suggest a high incidence of upstaging of PM with no identifiable factors associated with upstaging. Patients with clinical Tis or T1 PM should undergo resection with wider margins and be strongly considered for sentinel lymph node biopsy at time of index operation. SynopsisIn this large cohort of patients with non-metastatic primary plantar melanoma, half of the cohort was upstaged following resection. The risk was higher in patients diagnosed with Tis or T1 on biopsy compared to T2-T3. Biopsy type, lesion size < 15 mm and positive deep biopsy margins were not associated with upstaging. More radical treatment of plantar melanomas may be warranted.

Analysis of surgical margins and prognostic factors in dermatofibrosarcoma protuberans after wide local excision: Amulticenter study of 116 Japanese patients.

Cutaneous dermatofibrosarcoma protuberans (DFSP) is a fibrohistiocytic tumor characterized by a high risk of local recurrence but a low risk of metastasis. Wide local excision (WLE) has been an important treatment option, but its clinical outcomes and safety have not been thoroughly evaluated in previous reports. The aim of this study was to determine appropriate surgical margins (deep and lateral) and prognostic factors associated with recurrence-free survival (RFS) of DFSP. A database collected by two dermatology departments in Japan was retrospectively reviewed to identify 116 patients with DFSP who underwent complete resection with WLE between 1994 and 2021. Sixty-one men (53%) and 55 women (47%) were included in our cohort. The primary sites of DFSP were as follows: 11 head and neck (9%); seven face (7%); 12 upper extremities (10%); 20 lower extremities (17%); and 66 trunk (57%). There were 103 cases (89%) of primary DFSP and 13 cases (11%) of recurrent DFSP. Total 10-year RFS was 96.6%. There were significant differences in RFS by tumor size (median size: 3 cm), disease status (primary versus recurrent DFSP), and fibrosarcomatous change (positive versus negative) (all p < 0.05). Two patients (1.7%) with buccal or head lesions had positive deep margins. In all cases, the lateral margin was negative at the postoperative evaluation. Tumor size, disease status, and fibrosarcomatous change are important risk factors for recurrence. Both face and head-neck lesions were more likely to have positive deep margins than other anatomic areas in DFSP. Although this study was limited by its retrospective design, a narrow 2-cm lateral margin is especially considered for low-risk patients.

Complete circumferential endoscopic submucosal dissection for early Barrett’s neoplasia

Background and aimsEndoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the western world. Contrary to Asia, the majority of esophageal cancers in North America are associated with Barrett’s esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy. Increased experience with ESD has allowed for an endoscopic alternative. We aim to present our experience with complete circumferential esophageal ESD at a North American referral center. MethodsAll patients undergoing 100% circumferential esophageal ESD between Oct 2016 and Jan 2023 at a single tertiary care center in Canada were included in the cohort. Demographic, procedural data and lesion characteristics are presented in this series. ResultsEleven patients underwent 100% circumferential esophageal ESD during this period for Barrett’s neoplasia. All patients had technically successful procedures with en bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on final pathology, of which 6 (86%) had upstaging from their initial biopsy.The median area of resected specimen was 48cm2 (IQR 26-80) and the median procedure time was 231 minutes (IQR 180-246). Procedural efficiency was 4.0 min/cm2 (IQR 2.7-5). Two patients (18%) developed refractory strictures following the procedure, which were endoscopically managed to resolution. ConclusionMultifocal dysplastic Barrett’s esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and low adverse outcomes. This should be balanced against the risk of stricture development, as the optimal post procedural prophylaxis regimen is investigated.

Synchronous Multifocal Early Gastric Cancer: How Important is A Meticulous Endoscopic Examination? A Case Report and Literature Review

Introduction: The incidence rate of synchronous early gastric cancer is reported to be 5% to 15%, and several risk factors that increase its incidence have already been identified. Synchronous lesions are reported to be neglected in 32.4% of early gastric neoplasia cases. Method: Case report of a 75-year-old woman, with mucosa atrophy, intestinal metaplasia, with early gastric adenocarcinoma in antrum, CT staging without alterations, underwent surgical treatment using endoscopic submucosal dissection (ESD). Results: The anatomopathological result demonstrated a lesion of 2 cm, a well-differentiated non-ulcerated adenocarcinoma, without lymphatic-vascular invasion, with a positive deep submucosal margin, eCURE C-2. A D1+ complementary laparoscopic partial gastrectomy was performed. The analyzes of the surgical specimens showed an ESD area of ulcer scar without tumor and another early gastric cancer (T1a) at 2.2 cm distance with normal mucosa between them. Thirty six lymph nodes were free of disease. Conclusion: In this case, the patient had 3 risk factors for synchronic injury, but it was only discovered during the salvage gastrectomy. Thorough endoscopy should be performed in all patients and even more so in patients with risk factors. Failure to recognize these lesions can result in evolution to advanced cancer

321. ESD AND ELPS A NOVEL MINIMALLY INVASIVE TREATMENT FOR MULTI-EPISODE SUPERFICIAL ESOPHAGEAL SCC AND 2ND PRIMARY HYPOPHARYNGEAL SCC:A CASE REPORT

Abstract Background Esophageal SCC is a common cancer worldwide. Major risk factors were tobacco and alcohol use. It’s also a cause of head and neck cancers, particularly hypopharyngeal SCC. ESD was established as standard procedure for curative early esophageal SCC. However, conventional ESD for hypopharyngeal lesions is technically difficult. This report describes a patient who had superficial hypopharyngeal SCC following multiple esophageal ESD sessions. This VDO presentation shows how to perform safe ELPS and achieve oncological purposes. Methods A 77-year-old Thai man. He had primary cervical esophageal SCC and 1 month after complete response from definite CCRT, he began presenting four other recurrent episodes of superficial esophageal SCC in the lower, middle, and two times of cervical regions over a 3-year period. ESD and APC were applied and showed a complete response. The last endoscopic finding also revealed of superficial hypopharyngeal SCC and ELPS was decided by the following step: curve laryngoscope placement, laryngeal packing, lesion identification and marking, submucosal injection, circumferential incision, submucosal dissection, and bleeding control. The specimen was removed transorally and sent for pathological examination. Result The operation was successful without complications. The patient was able to start a liquid diet on day 1 and a soft meal on second day post operation. He was discharged on 3rd day without any complications. The pathological report was moderated differentiate SCC with positive deep margin, so he was planned for further RT. Conclusion ELPS provided good visualization, which led to a sufficient working space for resection. The procedure was safe and feasible for superficial hypopharyngeal lesions and exhibited good oncological outcomes, preserving both swallowing and phonation functions.

En Bloc Versus Conventional Resection of Primary Bladder Tumor (eBLOC): A Prospective, Multicenter, Open-label, Phase 3 Randomized Controlled Trial

BackgroundEn bloc transurethral resection of the bladder (eTURB) might improve the surgical management of non–muscle-invasive bladder cancer (NMIBC) in comparison to conventional TURB (cTURB). ObjectiveTo evaluate whether eTURB is superior to cTURB in resection of NMIBC and specimen retrieval. Design, setting, and participantsThis was a randomized, multicenter trial in patients with up to three cTa–T1 NMIBC tumors of 1–3 cm in size, who were enrolled from January 2019 to January 2022. InterventionParticipants were randomized 1:1 to undergo eTURB (n = 192) or cTURB (n = 192). Outcome measurements and statistical analysisThe primary outcome was the prevalence of detrusor muscle (DM) in the specimen retrieved. Secondary endpoints included bladder perforation, persistent disease at second-look TURB, positive lateral resection margin, positive deep resection margin, operation time, perforation rate, obturator reflex, conversion from eTURB to cTURB, recurrence-free survival, and disease recurrence at 3 mo. Results and limitationsA total of 384 patients were randomized to undergo eTURB or cTURB. A total of 452 tumors were resected and analyzed for the primary outcome. eTURB was superior to cTURB in retrieval of DM (80.7% vs 71.1%; mixed-model p = 0.01). Bladder perforation (5.6% vs 12%; difference −6.4%; 95% confidence interval [CI] −12.2% to −0.6%) and obturator reflex (8.4% vs 16%; difference −7.6%; 95% CI −14.3% to −0.9%) were less frequent in the eTURB arm than in the cTURB arm. Operation time did not differ between the two techniques (26 min, interquartile range [IQR] 20–38 for eTURB vs 25 min, IQR 17–35 for cTURB; difference 1 min, 95% CI –25.9 to 4.99). Second-look TURB was performed in 24 patients in the eTURB arm and 34 in the cTURB arm, with no difference in the rate of residual papillary disease (pTa/pT1: 56% vs 55.9%; difference 0.1%, 95% CI −25.5% to 25.7%). At median follow-up of 13 mo (IQR 7–20), 18.4% of the patients in the eTURB arm and 16.7% in the cTURB arm had experienced bladder cancer recurrence (Cox hazard ratio 0.87, 95% CI 0.49–1.52; p = 0.6). ConclusionsIn patients with clinical NMIBC with up to three tumors of 1–3 cm in size, tumor removal via eTURB resulted in a higher rate of DM in the pathologic specimen in comparison to cTURB. Moreover, eTURB was associated with lower frequency of obturator reflex and bladder perforation than cTURB was. While improving on the quality indicators for NMIBC, the long-term differential oncologic benefits of eTURB remain uncertain. Patient summaryWe compared two techniques for removal of bladder tumors and found that tumor removal in a single piece, called en bloc resection, provides a better-quality specimen for pathology analysis and fewer complications in comparison to the conventional method.This trial is registered at ClinicalTrials.gov as NCT03718754.

En bloc resection by polypectomy with over-the-scope clip for a neuroendocrine tumor located in a duodenal bulb pocket.

Neuroendocrine tumors (NETs) are located primarily in the submucosal layer and require careful resection. Conventional endoscopic mucosal resection (EMR) has a risk of positive deep resection margins. En bloc resection is more feasible in endoscopic submucosal dissection (ESD); however, in the duodenum, there is a heightened risk of intraoperative or delayed perforation owing to the thin duodenal wall and effects of inflowing bile and pancreatic juices [1]. The use of an over-the-scope (OTS) clip during polypectomy can greatly reduce the perforation risk [2] and is reportedly safe for duodenal NETs [3]. However, its use during polypectomy to resect NETs located in the pocket of a duodenal ulcer scar has not been reported. We report the use of this method for the safe, rapid, en bloc resection of such tumors located in the anterior wall of the duodenal bulb ([Fig. 1], [Fig. 2], [Video 1]).

Clinical Impact and Accuracy of Shave Biopsy for Initial Diagnosis of Cutaneous Melanoma

IntroductionEffective treatment of malignant melanomas is dependent upon accurate histopathological staging of preoperative biopsy specimens. While narrow excision is the gold standard for melanoma diagnosis, superficial shave biopsies have become the preferred method by dermatologists but may transect the lesion and result in inaccurate Breslow thickness assessment. This is a retrospective cohort study evaluating an initial method of biopsy for diagnosis of cutaneous melanoma and indication for reoperation based on inaccurate initial T-staging. MethodsWe retrospectively analyzed consecutive patients referred to the Medical College of Wisconsin, a tertiary cancer center, with a diagnosis of primary cutaneous melanoma. Adult patients seen between 2015 and 2018 were included. Fisher's exact test was used to assess the association between method of initial biopsy and need for unplanned reoperation. ResultsThree hundred twenty three patients with cutaneous melanoma from the head and neck (H&N, n = 101, 31%), trunk (n = 90, 15%), upper extremity (n = 84, 26%), and lower extremity (n = 48, 28%) were analyzed. Median Breslow thickness was 0.54 mm (interquartile range = 0.65). Shave biopsy was the method of initial biopsy in 244 (76%), excision in 23 (7%), and punch biopsy in 56 (17%). Thirty nine (33%) shave biopsies had a positive deep margin, as did seven (23%) punch biopsies and 0 excisional biopsies. Residual melanoma at definitive excision was found in 131 (42.5%) of all surgical specimens: 95 (40.6%) shave biopsy patients, 32 (60.4%) punch biopsy patients, and four (19.0%) excision biopsy patients. Recommendations for excision margin or sentinel lymph node biopsy changed in 15 (6%) shave biopsy patients and five (9%) punch biopsy patients. ConclusionsShave biopsy is the most frequent method of diagnosis of cutaneous melanoma in the modern era. While shave and punch biopsies may underestimate true T-stage, there was no difference in need for reoperation due to T-upstaging based on initial biopsy type, supporting current diagnostic practices. Partial biopsies can thus be used to guide appropriate treatment and definitive wide local excision when adjusting for understaging.

Prevention of recurrence in malignant proliferating trichilemmal tumor of scalp in young female using adjuvant radiation therapy after surgery

Background: Proliferating trichilemmal tumors (PTTs) are rare benign neoplasms that arise from the outer sheath of a hair follicle. Group III PTTs are high-grade malignant tumors reported to exhibit a high recurrence rate, lymph nodes, and a tendency to develop distant metastasis. Case Presentation: A 25 years old female patient was presented to us with a history of recurring soft tissue scalp lesions. The lesion recurred three times within 1 year. There was no history of trauma. Every time the lesion was excised but no histopathology of the specimen was done. Upon the third recurrence, it came out to be a malignant proliferating trichilemmal tumor (MPTT). Considering the young age of the patient and keeping in view the history of multiple recurrences with positive deep margin even after the third surgery, the patient was planned external beam radiotherapy (RT) 50 Gy/25 fx to scalp with 9 Mev electron using 0.5 cm bolus. The post-RT follow-up currently of 2 years is uneventful. Conclusion: The mainstay of treatment is surgery with wide surgical margins as local recurrence is most common in MPTT. Adjuvant RT was used in this case to prevent recurrence.

Prognosis of incompletely resected small rectal neuroendocrine tumor using endoscope without additional treatment

BackgroundIn recent years, the incidence of rectal neuroendocrine tumors (NET)s has markedly increased due to the widespread use of screening colonoscopy. However, many patients are referred from local clinics after undergoing conventional endoscopic mucosal resection (EMR) for polyps without perceived NET, with a pathological report of incomplete resection. We evaluated the prognosis of incompletely resected small rectal NET without additional endoscopic resection for small rectal NET less than 10 mm in diameter present within the submucosal layer showing good prognosis, due to its rare metastatic potential.MethodsWe retrospectively reviewed patients from 2008 to 2018 at a single center who had had small rectal NET (located in the rectum from the anal verge to 20 cm in proximity) and had undergone ‘incomplete resection’ using endoscopy with a positive deep margin or with a very small safe deep margin (< 100 um). A small rectal NET was defined as a tumor ≤ 10 mm in diameter, without lymph node nor distant metastasis, and with low grade (G1) according to the WHO grading system.ResultsOf 267 patients who were diagnosed with small rectal NET, 77 were diagnosed with incomplete resection or possible remnant NET. Of those, 55 patients (55/77, 71.4%) were referred from local clinics post EMR diagnosed as polyps. The rate of histologically incomplete resection was highest in endoscopic submucosal dissection (11/21, 52.4%) and lowest in surgical resection (0/9, 0%), while endoscopic submucosal resection with band ligation showed an incomplete resection rate of 4.4% (5/113). After exclusion of 36 patients, namely 21 patients had undergone additional surgical (n = 6) or endoscopic (n = 15) resection and 25 patients who were lost during the follow-up period of 2 years, 31 patients had undergone surveillance with endoscopic evaluation or either a biopsy or radiological evaluation for distant metastasis during a median follow-up duration of 2 years. None of the incompletely resected small rectal NET patients showed local or distant metastasis.ConclusionIncomplete resection of small rectal NET with G1 grade has a good prognosis without additional treatment.

Clinicopathologic correlations of superficial esophageal adenocarcinoma in endoscopic submucosal dissection specimens

BackgroundEndoscopic submucosal dissection (ESD) is a novel endoscopic treatment for early esophageal adenocarcinoma (EAC). The western pathologists’ experience with ESD specimens remains limited. This study aimed to correlate histopathologic features of Barrett’s esophagus (BE)-associated adenocarcinoma in ESD resections with clinical outcomes to determine whether they aid future management decisions.MethodsWe retrospectively evaluated 49 consecutive ESD resection specimens from 42 patients with BE-associated adenocarcinoma (24 intramucosal and 18 submucosal EAC) at a single tertiary referral center. Pathologic evaluation included presence of dysplasia, invasive adenocarcinoma, peritumoral inflammation, desmoplasia, lymphovascular and perineural invasion; tumor differentiation, depth of invasion, morphology, and budding; and margin status for dysplasia or carcinoma. Follow up data included endoscopic biopsies in 35 patients and pathology reports of esophagectomies in 11 patients. Poor outcomes were defined as recurrence or residual invasive adenocarcinoma at esophagectomy, metastasis on imaging, or R1 resection in patients undergoing ESD for tumor debulking.ResultsTwo patients (8%) with intramucosal adenocarcinoma and 9 patients (50%) with submucosal adenocarcinoma had poor outcomes. Histopathologic features associated with poor outcomes included poor differentiation, lymphovascular invasion, submucosal invasion > 500 μm, tumor budding, and tubuloinfiltrative histologic pattern. Four patients had positive deep margin away from the deepest tumor invasion and did not show residual tumor on follow up.ConclusionsOur results validated European Society of Gastroenterology (ESGE) guidelines of high-risk pathologic features for additional therapy in esophageal adenocarcinoma and identified tumor budding frequently in association with other high-risk features. Positive deep margin distant from deepest tumor invasion could be procedural and warrants endoscopic correlation for management.

The utility of intra-oral ultrasound in improving deep margin clearance of oral tongue cancer resections

ObjectivesTo investigate the potential utility of intra-oral ultrasound (IOUS) in guiding deep margin clearance and measuring depth of invasion (DOI) of oral tongue carcinomas (OTC). Materials and MethodsRetrospective chart review of consecutive patients with T1-T3 OTC who underwent intraoperative ultrasound-guided resection and a comparator group that had undergone resection without the use of IOUS both by a single surgeon. Data was extracted from operative, pathology and radiology reports. Deep margins and DOI were reviewed by a dedicated head and neck pathologist. Correlation between histologic and ultrasound DOI was assessed using Pearson correlation. ResultsA total of 23 patients were included in the study cohort with a comparator group of 21 patients in the control group. None of the patients in the study cohort had a positive (cut-through) deep margin and the mean deep margin clearance was 8.5 ± 4.9 and 6.7 ± 3.8 for the IOUS and non-IOUS groups respectively (p-value 0.18) showing a non-significant improvement in the IOUS group. As a secondary outcome, there was a strong correlation between histologic and ultrasound DOI (0.9449). ConclusionUltrasound appears to be a potentially effective tool in guiding OTC resections. In this small series, IOUS facilitated deep margin clearance and resulted in a non-statistically significant increase in deep margin clearance. Intraoral ultrasound can accurately measure lesional DOI.

Shave biopsy of pediatric melanocytic tumors compromises staging and therapy planning.

e21576 Background: Melanoma is the dominant skin cancer of pediatric patients, and accounts for 1-3% of pediatric malignancies. The prognosis for both adults and children with melanoma correlates with stage at diagnosis, and initial Breslow depth is a critical determinant. Kaplan-Meier melanoma-specific survival curves show survival rates ranging from 98% (T1a) to 75% (T4b) at 10 years for adult patients with stage I and II disease at diagnosis. Pediatric patients are known to present with thicker primary melanomas as compared to their adult counterparts. The preferred biopsy method of the American Academy is Dermatology for melanoma is excisional, however partial shave biopsy is most frequently performed in children, given its simplicity, efficiency, and often low clinical suspicion for cutaneous malignancy. Despite the ease of this biopsy technique, shave biopsy has a high rate of base transection, reducing accuracy of microstaging, which is crucial for therapy planning. Methods: Retrospective chart review evaluation of the potential effects of biopsy method on staging, surgical recommendations, and treatment approach for pediatric patients with melanocytic tumors. Results: Data was available for 91 pediatric patients with a spectrum of melanocytic tumors ranging from atypical with unknown malignant potential, to melanoma. Patient characteristics including gender, age at biopsy, biopsy method, status of biopsy margins, recommendations for re-excision, sentinel lymph node biopsy, and treatment plan were collected and analyzed. There were 48 females and 43 males with age range 1—22 years (mean 10 years). Sixty-eight of 91 (75%) tumors had a positive margin (deep, peripheral, or both) on diagnostic biopsy, 52/68 (76.5%) were obtained using shave method. Evaluating the deep margin specifically, 50/91 (55%) tumors had a positive deep margin, 46/50 (92%) of which were obtained using shave method. No tumor evaluated by punch had a positive deep margin (0/18). Of all shave biopsies, 77% had positive deep margin as opposed to only 13% using alternative biopsy methods. In 10/91 (11%) patients, surgical recommendations were changed based on inaccurate microstaging and positive deep biopsy margins, 9/10 (90%) of these patients had undergone shave biopsy. Most (8/10) patients had melanoma, the remaining 2/10 had highly atypical spitzoid tumors in which melanoma could not be ruled out. Conclusions: Pediatric patients with melanocytic tumors most commonly underwent shave biopsy as the initial diagnostic biopsy method. This method of biopsy was associated with higher incidence of positive margins at diagnosis and more aggressive definitive surgical management. These findings suggest that more routine use of excisional biopsy in pediatric patients with lesions being evaluated for malignancy could decrease the incidence of inaccurate microstaging and reduce the need for more aggressive definitive surgical management.

Introduction of a New Pathology Workup Protocol for Glottic Cancer Treated With Transoral Laser Microsurgery (TLM): Prospective Analysis of Oncological Outcomes and Matched Case-Control Study.

Background/PurposeThe value of margin status after TLM for glottic cancer is debatable, due to difficulties in specimen orientation and margin analysis. To reduce these difficulties, we recently introduced a standardized protocol of oriented fixation of TLM specimens. This proved feasible and resulted in high margin evaluability rates and a decreased rate of false positive deep margins, when compared to a historical TLM cohort. For the patients whose specimens were processed according to this protocol, we prospectively analyzed oncological outcomes, identified prognostic factors and assessed the influence of the protocol introduction on outcomes compared with a historical TLM cohort.MethodsNinety-six patients with glottic malignancies treated with TLM were included. Resection specimens were processed according to the new protocol. Descriptive statistics and survival analyses were used to determine oncological outcomes. To assess the effect of the protocol introduction on outcomes, a matched-case-control analysis was performed, using a historical TLM-cohort as controls. The Cox proportional hazards model was used to analyze prognostic effects of patient and treatment characteristics, including the pathology protocol introduction, on overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and local recurrence-free survival (LRFS).ResultsTwo-year outcomes were favorable: 88.5% OS, 97.0% DSS, and 87.6% LRFS. At multivariable analysis, the presence of multiple positive superficial margins was a negative prognosticator for OS (HR 4.102) and increasing cT classification proved a negative prognosticator for DFS (HR 2.828) and LRFS (HR 2.676). Matched case-control analysis did not reveal a significant difference in oncological outcomes between cohorts. Deep margin status had a strong differential effect for DFS (p-value for interaction = 0.0205) and for LRFS (p-value for interaction = 0.0176) between cohorts, indicating a prognostic effect of deep margin status on both outcomes in the current cohort, but not in the historical cohort.Discussion/ConclusionThe introduction of a new standardized technique of oriented fixation of TLM specimens did not affect oncological outcomes when compared to a historical TLM cohort, but assigned a significant prognostic effect to deep margin status for DFS and LRFS, facilitating the decision making process with regards to planning of second-look procedures, administration of adjuvant radiotherapy or determination of follow-up intensity.

Impact of Shave Biopsy on Diagnosis and Management of Cutaneous Melanoma: A Systematic Review and Meta-Analysis.

BackgroundMelanoma is the most lethal skin cancer. Excision biopsy is generally recommended for clinically suspicious pigmented lesions; however, a proportion of cutaneous melanomas are diagnosed by shave biopsy. A systematic review was undertaken to investigate the impact of shave biopsy on tumor staging, treatment recommendations, and prognosis.MethodologyThe MEDLINE, Embase, and Cochrane Library databases were searched for relevant articles. Data on deep margin status on shave biopsy, tumor upstaging, and additional treatments on wide local excision (WLE), disease recurrence, and survival effect were analyzed across studies.ResultsFourteen articles from 2010 to 2020 were included. In total, 3713 patients had melanoma diagnosed on shave biopsy. Meta-analysis revealed a positive deep margin in 42.9% of shave biopsies. Following WLE, change in tumor stage was reported in 7.7% of patients. Additional treatment was recommended for 2.3% of patients in the form of either further WLE and/or sentinel lymph node biopsy. There was high heterogeneity across studies in all outcomes. Four studies reported survival, while no studies found any significant difference in disease-free or overall survival between shave biopsy and other biopsy modalities.ConclusionsJust over 40% of melanomas diagnosed on shave biopsy report a positive deep margin; however, this translated into a change in tumor stage or treatment recommendations in relatively few patients (7.7% and 2.3%, respectively), with no impact on local recurrence or survival among the studies analyzed.

Laryngeal adenoid cystic carcinoma: Radical or conservative surgery?

PurposeThe present paper describes our experience in surgical treatment of laryngeal ACC, and discuss the effectiveness of conservative surgery. MethodsWe retrospectively reviewed the clinical charts of 17 patients with laryngeal ACC treated surgically at the Otolaryngology Unit of Vittorio Veneto Hospital (Italy) from November 1989 to April 2020. ResultsFourteen patients underwent partial laryngectomy, and three had a total laryngectomy. Five patients (29%) experienced a laryngeal ACC relapse after a disease-free survival of 66.6 ± 50.1 months. The distant metastasis rate was 17%. At latest follow-up, two patients had died of distant metastatic disease after 156 and 243 months. ConclusionsRadical surgery for laryngeal ACC does not warrant free margins and even cases with positive deep margins rarely experience any relapsing disease. We recommend that surgical treatment for laryngeal ACC be as conservative as possible.

Current indications for adjuvant treatment following transoral laser microsurgery of early and intermediate laryngeal cancer.

This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer. A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT). The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.