Positive Deep Margin Research Articles

Transoral laser microsurgery: feasibility of a new exoscopic HD-3D system coupled with free beam or fiber laser.

In the last decades, new technological devices and instruments have been developed to overcome the technical limits of transoral laser microsurgery. The recent introduction of 3D endoscopy seems to be a promising tool in the field of diagnostic and operative laryngology as an alternative to the traditional microlaryngoscopy. Our work aims to present a novel transoral microsurgical setting that expands the use of exoscopic systems (in this case the VITOM® 3D-HD) as an alternative to the standard operating microscope. A customized support arm and an adaptor to firmly connect the VITOM® 3D-HD camera to the laser micromanipulator were specially designed. This setup was used as an alternative to the standard operating microscope in a cohort of 17 patients affected by suspicious early to intermediate pharyngo-laryngeal neoplasms. A historical cohort of patients treated with the traditional setting and matching the same inclusion criteria was used as a reference for the duration of surgical procedures. The surgical procedures comprised 7 cordectomies, 2 endoscopic partial supraglottic laryngectomies, 4 tongue base resections, and 4 lateral oropharyngectomies or hypopharyngectomies. In 6 cases (35%), a simultaneous neck dissection was performed. The low rate of positive deep (6%) or superficial (12%) margins reinforced the safety of this platform, and the results obtained in terms of operating time were comparable to the control group (p > 0.05), which confirms the feasibility of the system. Our surgical setting setup is a convincing alternative to traditional transoral laser microsurgery for early to intermediate pharyngo-laryngeal neoplasms. The main advantages of this system are comfortable ergonomics for the first surgeon and a potential benefit in terms of teaching if applied in university hospitals, since the entire surgical team can view the same surgical 3D-HD view of the first operator. Further work is still needed to objectively compare the traditional and new technique, and to validate our preliminary clinical findings.

247 LAPAROSCOPIC INTRAGASTRIC SUBMUCOSAL DISSECTION FOR EARLY GASTRIC CANCER: A VIDEO OF THE OXFORD APPROACH

Abstract Laparoscopic intragastric submucosal dissection (LISD) is a novel approach to the resection of early gastric cancers not amenable to conventional gastroscopic approaches. The technique permits favourable access to lesions situated high on the posterior wall or lesser curvature of the stomach, enables en-block resection of large areas of tissue, and can prevent the need for formal gastrectomy. Using intraoperative video capture, we demonstrate our approach to LISD, and describe our peri-operative and long-term outcomes. Methods Six cases were identified as suitable for LISD by multidisciplinary team panel following EUS assessment and employing locally developed inclusion criteria. As demonstrated by video tutorial, a 3-port laparoscopic approach to the stomach was undertaken and gastrotomies performed to enable port insertion into the stomach. Following establishment of stable pneumogastrium, the area of interest was circumferentially marked with cautery and submucosal colloid injection performed to provide a cushion in the plane of dissection. Resection was completed using cautery hook, and intracorporeal suture closure of gastrotomies performed. Measures were taken to ensure correct orientation of resected specimens prior to fixation. Results Four male and two female patients (median age 74.5 years) sequentially underwent LISD, with complete curative excision confirmed histologically in 5 cases. In one case, a positive deep margin necessitated completion total gastrectomy, later confirmed to be T0 resection. No immediate or late complications, including haemorrhage, perforation or stenosis, occurred in these cases. Conclusion In this, the largest United Kingdom case series, LISD is shown to be a safe and effective intervention for the treatment of early gastric cancers in selected patients having undergone appropriate mapping endoscopy and deemed not to be amenable for endoscopic mucosal resection. Its application can serve as route to avoid formal gastrectomy and the associated morbidity. Video https://www.dropbox.com/s/nqlp7b9v64z56z8/Low.mp4?dl=0 This video demonstrates a novel approach to the resection of early gastric cancers not amenable to conventional gastroscopic approaches. Laparoscopic intragastric submucosal dissection (LISD) involves 3-port laparoscopy and intragastric port passage via gastrotomies. Stable pneumogastrium is performed and the field circumferentially marked by cautery. Submucosal colloid injection aids dissection. Tumour resection is completed by cautery and specimens removed via ports. Of 6 cases performed in Oxford, complete curative excision was confirmed histologically in 5, with 1 necessitating completion gastrectomy later confirmed to be T0 resection. No immediate or late complications were encountered. LISD is a safe and effective intervention which permits favourable access to lesions situated high on the posterior wall or lesser curvature of the stomach, enables en-block resection of large areas, and can prevent the need for gastrectomy.

Transoral Laser Microsurgery (TLM) for Glottic Cancer: Prospective Assessment of a New Pathology Workup Protocol.

Background/Purpose: The value of margin status after TLM for glottic cancer is debatable, due to difficulties in specimen orientation and margin analysis. Purpose of this study was the prospective evaluation of feasibility of a new standardized technique of oriented fixation of the TLM specimen and identification of the added value on tissue processing and margin status reporting.Methods: Patients with suspicious glottic lesions undergoing TLM were included. After resection, the specimen margins were inked in the OR using different colors. Subsequently, the specimens were fixed on a pig liver carrier and sent for further processing, accompanied with photographs of the larynx pre-TLM and of the mounted specimen. Feasibility was assessed by registration of duration of specimen preparation in the OR and the lab and by procedure-specific questionnaires. Objective evaluation included assessment of margin status and proportion of evaluable margins. Chi square tests were used to make comparisons of proportions.Results: One hundred and four consecutive patients were included between May 2016 and September 2019. TLM was performed in a primary and salvage setting in 89.4 and 10.6% of patients, respectively. Mean duration of intraoperative specimen preparation was 5.1 min (SD 2.6 min). No difficulties in orientation nor fixation during intraoperative preparation were reported in 87.5 and 88.2%, respectively. Specimen orientation was judged by the pathologist as very adequate in 89.4%, with the accompanying photographs considered helpful for orientation and processing in 84.6%. Substantial difficulties in further lab processing and pathologic examination were identified in 17.7%. Deep margin evaluability was very high (98.0%) and significantly higher than the evaluability of superficial mucosal margins. Compared to our previous series published by our group (n = 142), deep margin evaluability significantly rose from 62.7 to 98.0% (p < 0.001) and true positive rate of the deep margins increased from 0 to 44.4% (p = 0.002).Discussion/Conclusion: The new and standardized technique of oriented fixation of TLM specimens on a pig liver carrier proves feasible both in the OR and lab setting and results in high margin evaluability rates, especially for the deep margin, as well as a decreased rate of false positive deep margins when compared to a historical TLM cohort.

The usefulness of the narrow band imaging (NBI) in decision-making process regarding second look procedure (SL) in laryngeal cancer follow-up after transoral laser microsurgery

BackgroundThe prognostic value of positive surgical margins after transoral laser microsurgery (TOLM) is still under debate. In case of positive superficial margins, some experts recommend a second-look surgery (SL) and some recommend wait and watch approach with close observation. Narrow band imaging (NBI) is an advanced imaging system used to enhance visualization of mucosal vascular pattern. In laryngology, NBI is used to improve the detection of premalignant, dysplastic and malignant lesions.AimTo assess the usefulness of NBI imaging in guiding clinical decision making regarding follow-up plan and SL after TOLM.Materials and methodsA prospective cohort of 127 patients was divided into three groups based on the histology results and NBI vascular pattern of the mucosa. Group A (24/127, 18.90%) consisted of patients with suspicious vascular pattern in NBI or/and with positive deep margin. Group B (52/127, 40.94%) consisted of patients with positive or uncertain superficial margins and non-suspicious vascular pattern in NBI. Group C (51/127, 40.15%) had non-suspicious vascular NBI pattern and all negative margins.ResultsAfter the first TOLM procedure, 9/24 (37.5%) patients had positive deep margins, 1/24 (4.2%) had uncertain deep margin and 1/24 patient (4.2%) had both positive deep margin and suspicious vascular pattern in NBI. The remaining 13 cases in Group A had a suspicious NBI finding only during the first follow-up. All of the 24 patients (Group A) underwent a second look surgery. The final histology after SL showed squamous cell carcinoma in 10/24 (41.7%) patients. All 10 patients had suspicious vascular pattern in NBI and one patient had both a positive deep margins after the first TOLM and positive NBI finding. None of Group B and C subjects developed an early recurrence.ConclusionsOur study provides evidence that NBI imaging will be a useful adjunct to margin status after TOLM and will facilitate clinical decision-making regarding performing the SL in patients with positive or uncertain superficial surgical margins in the first TOLM procedure. However, additional investigation with more subjects is required at this time to further validate this technique and change the standard of care.

Standard Surgical Excision of Basal Cell Carcinomas in the Non-H Area of the Face: A Case Series Illustrating an Alternative to Mohs Micrographic Surgery

Introduction: Basal cell carcinoma (BCC) is the most common cutaneous malignancy among Caucasians. Most studies compare the efficacy of standard surgical excision versus Mohs micrographic surgery (MMS) for the treatment of non-melanoma skin cancers in the high-risk or H area of the face. This case series focuses on the lesser-studied non-H area and suggests the use of standard surgical excision as an alternative to MMS for these regions of the face. Methods: A total of 10 patients with BCCs of the non-H area of the face underwent standard surgical excision with repair at the James A. Lovell Federal Health Center between October 2014 to October 2018. The average age of this group was 77.3 years and all patients were males. Nine of the 10 patients had nodular type BCCs and 1 patient had micronodular type BCC with ulceration. BCCs were located on the forehead in 8 cases and the cheek in 2 cases. Diameters of the lesions ranged from 6mm-8mm. Excision margins were 3- to 5-mm. Defects were repaired using local flaps in 9 cases and linear closure in 1 case. Results: Histopathologic evaluation of the excision specimens revealed clear surgical margins in 9 out of 10 cases. There was one case in which positive deep margins were identified, although the patient had a BCC with a more aggressive histologic pattern. Of the 9 cases with clear surgical margins, none had clinical evidence of local recurrence at follow-up ranging from 2 to 38 months. Discussion: BCCs in the non-H area of the face can be successfully treated using standard surgical excision with a high cure rate and low postoperative complications. MMS should be reserved for BCCs at increased risk for recurrence on the basis of factors such as location in the H area on the face and an aggressive histologic growth pattern (e.g. micronodular, morpheaform, infiltrating, metatypical). Practice points: • Basal cell carcinomas in the non-H area of the face can be successfully treated using standard surgical excision with a high cure rate and low postoperative complications. • Mohs micrographic surgery should be reserved for BCCs at increased risk for recurrence on the basis of factors such as location in the H area on the face and an aggressive histologic growth pattern (e.g. micronodular, morpheaform, infiltrating, metatypical).

1766 Can We Avoid Esophagectomy in T1b Esophageal Adenocarcinoma?

INTRODUCTION: Current guidelines recommend esophagectomy for Esophageal Adenocarcinoma stage T1b. There are limited data regarding multimodality therapy for Esophageal Adenocarcinoma T1b using endoscopic therapy instead of a surgical option. We present a case of EAC stage T1b patient who was successfully treated by multimodality treatments. CASE DESCRIPTION/METHODS: An 84 years old female with a history of Barrett’s esophagus underwent an endoscopy and was found to have esophageal adenocarcinoma with deep submucosal invasion (T1b) with no surrounding lymphadenopathy on EUS. She was recommended to have an esophagectomy but refused and requested a less invasive approach. She was offered endoscopic mucosal resection (EMR) and cryoablative treatments. Over the course of one year, the patient underwent several sessions of endoscopic EMR followed by cryoablative therapy. The fourth EMR specimen revealed positive deep margins involving the submucosa with lymphovascular invasion (LVI). Further sessions of cryoablation and EMR were done and she was also referred to oncology for adjuvant therapy. Oncology recommended both chemotherapy (with paclitaxel and carboplatin) as well as radiotherapy. However, the patient couldn’t tolerate more than two sessions of chemotherapy so it was discontinued while radiotherapy was continued. Few months after the patient finished radiotherapy she underwent a follow-up EGD with multiple biopsies which showed no evidence of dysplasia or malignancy. DISCUSSION: Endoscopic eradication therapy is the treatment of choice for early esophageal cancer. Surgical management for T1b is recommended given higher rates of LVI. Our case represents a successful case of eradicated adenocarcinoma using a multidisciplinary approach involving gastroenterology, thoracic surgery, medical oncology, and radiation oncology. More data will be helpful in assessing the effectiveness of a multimodality approach in treating T1b esophageal adenocarcinoma with LVI without invasive surgery.

Surgical Continuity of Care: A Multidisciplinary Approach to Managing the Mohs Micrographic Surgery Positive Deep Margin at the Parotid in Cutaneous Squamous Cell Carcinoma

Background: While high-risk characteristics for cutaneous squamous cell carcinoma (cSCC) and the management of metastatic cSCC have received considerable attention in the literature, standard of care management for the positive MMS margin at the parotid fascia in cSCC has yet to be clarified. The aim of this study is to better define optimal management approaches for the positive deep Mohs Micrographic Surgery (MMS) margin at the parotid fascia. Methods: Inclusion criteria for this retrospective case series were patients presenting to the Saint Louis University with biopsy proven cSCC with a positive deep MMS margin at the parotid fascia who were referred to HNS and treated with curative intent. The following data were recorded: age; gender; NCCN high-risk factors; adjuvant surgical, medical, radiation (RT), or chemoradiation (CRT) therapies; outcomes; and follow-up data. Results: Eight patients undergoing MMS had a positive deep margin at the parotid fascia. HNS performed 7 parotidectomies and 1 wide local excision (WLE), obtaining negative margins in 75.0% (6/8) of patients (5/7 parotidectomies and 1/1 WLE). Obtaining negative surgical margins (6/8 patients) resulted in a disease free survival (DFS) and overall survival (OS) of 27.8 and 43.6 months, respectively; compared to a DFS of 20.6 months and OS of 39.1 months for positive margins (2/8 patients). Conclusion: This study demonstrates that resection with negative surgical margins results in excellent long-term local and regional disease control, and overall survival for cSCC patients with positive deep MMS margin at the parotid fascia.

Early case ascertainment and prospective multidisciplinary review for management of new melanoma diagnoses within an integrated healthcare system: The Kaiser Permanente Northern California experience.

6523 Background: Appropriate surgical treatment of early-stage melanoma yields a high cure rate, but this management can be nuanced. In particular, surgical management, including sentinel lymph node biopsy (SLNB), of thin melanoma (≤1.0mm) is not well-defined. Methods: Biopsies with new melanoma diagnoses were identified electronically and manually reviewed. In a community oncology setting, we organized a review panel of physicians specialized in melanoma from dermatology, medical oncology, nuclear medicine, radiation oncology, and surgical subspecialties (oncology, plastics, head and neck). Patients were assigned to care pathways based on NCCN and ASCO guidelines, including guidance on SLNB for thin melanomas with high-risk features like lymphovascular invasion, high mitotic rate, positive deep margin, and ulceration. These recommendations were documented in the chart and communicated directly to the patient’s care team. Results: From 11/2016 through 10/2018, our multidisciplinary committee reviewed 3626 patients with new melanoma from 22 sites in our integrated, regional hospital system. Median age was 66 (range 19-99); 60% were male. cT2N0 tumors comprised 7%, cT3 3%, and cT4 2%. Thin melanomas ≤1.0mm represented 71% of cases, of which 34% were ≤0.5mm. SLNB was performed in 9.8% of thin melanomas, and 18% were positive, much higher than historical positive rates of 3-4%. Conclusions: Early case ascertainment and prospective multidisciplinary review in a community oncology setting resulted in increased identification of high-risk thin melanoma, and consequently increased identification of nodal disease through SLNB. Positive SLNB triggers important clinical decision-making regarding need for node dissection versus clinical surveillance, and need for adjuvant therapy, which have been shown to improve survival. This clinical practice structure improved risk-stratification and adherence to national guidelines. We plan to further study the impact of these improvements to melanoma care on disease-free survival and overall survival.

507 The Acute Development of Donor Site Squamous Cell Carcinoma: A Case Report and Review of the Literature

The mainstay of burn reconstruction remains autografting. Donor site management centers on pain control, infection prevention, and scarring mitigation. Here we report a rare case of rapidly developing squamous cell carcinoma (SCC) at a split-thickness skin graft donor site. A 49-year-old man with no significant medical history sustained a 5% total body surface area (TBSA) full-thickness burn to the right upper arm, axilla, and trunk when his shirt sleeve caught fire at work. He underwent tangential excision and split-thickness skin grafting with VAC placement on post-burn day two. His right thigh donor site was dressed with an iodine-impregnated adhesive dressing. Graft loss necessitated return to the operating room on post-operative day 17 for re-excision and split-thickness skin grafting, again harvested from the right thigh. The donor site was dressed with a collagen-bound silicone dressing. On post-operative day 58/41 a lesion was noted on his right thigh donor site, presumed to be a cyst. On post-operative day 86/69, the lesion had grown to 7 millimeters. Excisional biopsy on post-operative day 129/112 revealed the lesion to be a well-differentiated squamous cell carcinoma with positive deep and peripheral margins. The patient returned for excision to negative margins 24 days later. Since 1948, seventeen prior cases of split-thickness skin graft donor site lesions have been reported in the literature. Fourteen of these (82%) were squamous cell carcinomas, with the remainder diagnosed as keratoacanthomas (KA) - a spontaneously regressing form of SCC, which rarely becomes invasive. Of the fourteen cases of SCC, thirteen (93%) were diagnosed within one year of graft harvest, and eleven (79%) were diagnosed within 6 months. Including our case, five of the cases involved burn patients. The acute development of SCC at skin graft donor sites is a rare but serious phenomenon. Marjolin’s ulcers - the development of malignancies, commonly SCC, within chronic wounds - typically develop decades after injury. Trauma, including skin graft harvest, has been associated with the development of KAs, but, is not a typical risk factor for SCC. Given the diversity of autograft indications in reviewed literature, it seems unlikely that the burn itself contributed to the development of SCC. Rather, suspected contributing factors include an increased population of dividing cells provided by re-epithelialization in combination with decreased immune surveillance provided by the lack of lymphatic regeneration. The rapid development of squamous cell carcinoma at a skin graft donor site represents a rare but serious possibility. Donor site diligence must be maintained post-operatively.

Prognostic Significance of Positive Deep Margins on Endoscopic Resection Specimens of Esophageal Adenocarcinoma: A Cohort Study: Presidential Poster Award

Prognostic Significance of Positive Deep Margins on Endoscopic Resection Specimens of Esophageal Adenocarcinoma: A Cohort Study: Presidential Poster Award

Measuring Depth of Invasion in Early Squamous Cell Carcinoma of the Oral Tongue: Positive Deep Margin, Extratumoral Perineural Invasion, and Other Challenges.

The 8th edition of American Joint Committee on Cancer (AJCC 8th) staging manual incorporated depth of invasion (DOI) into pT stage of oral cavity cancer. The aim of this study was to characterize several histological findings that may complicate measurement of DOI in early conventional squamous cell carcinomas (SCC) of the oral tongue: (1) lack of or minimal residual carcinoma following biopsy; (2) positive deep margin; (3) extratumoral perineural invasion (PNI); and (4) lymphatic or vascular invasion. Conventional SCC of the oral tongue (n = 407) with the largest dimension of ≤ 4cm and with a negative elective cervical lymph node dissection (pN0) were reviewed. A clear plastic ruler was used to measure DOI by dropping a "plumb line" to the deepest point of the invasive tumor from the level of the basement membrane of the normal mucosa closest to the invasive tumor. Examples of identifying reference point on the mucosal surface of oral tongue from which to measure the DOIare illustrated. In the experience of one contributing institution, the residual carcinoma was absent in 14.2% of glossectomies (34/239), while in 4.8% of cases (10/205) there was only minimal residual carcinoma. In 11.5% (21/183) of pT2 cases the deep margin was positive and thus DOI and pT may be underestimated. Of all cases with PNI, extratumoral PNI was identified in 23.1% (31/134) of cases, but represented the deepest point of invasion in only two cases. In one case, lymphatic invasion represented the deepest point of invasion and could have led to upstaging from pT1 to pT2. In conclusion, DOI measurement for SCC of the oral tongue may require re-examination of the diagnostic biopsy in up to 20% of cases due to the absence or only minimal residual carcinoma in glossectomy specimens. In 11.5% of apparently pT2 cases, DOI may be underestimated due to the positive deep margin. Rarely, extratumoral PNI or lymphatic invasion may be the deepest point of invasion. Overall, two issues (absent or minimal residual disease and positive deep margin) may confound DOI measurement in early SCCs of oral tongue.

Impact of Close and Positive Margins in Transoral Laser Microsurgery for Tis-T2 Glottic Cancer.

Transoral laser microsurgery (TLM) represents one of the most effective treatment strategies for Tis-T2 glottic squamous cell carcinomas (SCC). The prognostic influence of close/positive margins is still debated, and the role of narrow band imaging (NBI) in their intraoperative definition is still to be validated on large cohort of patients. This study analyzed the influence of margin status on recurrence-free survival (RFS) and disease-specific survival (DSS). We retrospectively studied 507 cases of pTis-T1b (Group A) and 127 cases of pT2 (Group B) glottic SCC. We identified the following margin status: negative (n = 232), close superficial (n = 79), close deep (CD) (n = 35), positive single superficial (n = 146), positive multiple superficial (n = 94), and positive deep (n = 48) and analyzed their impact on RFS and DSS. Close margins were defined by tumor-margin distance <1 mm. Pre-TLM margins were defined by white light in 323 patients, whereas NBI was employed in 311 patients. In Group A, DSS and RFS were reduced in positive multiple superficial and positive deep margins (DSS = 96.1 and 97%, both p < 0.05; RFS = 72%, p < 0.001 and 75.8%, p < 0.01). In Group B, DSS was reduced in positive multiple superficial margins (82.4%, p < 0.05). RFS was reduced in positive single superficial, positive multiple superficial, and positive deep margins (62.5, 41.2, and 53.3%, p < 0.01). In the entire population, RFS was reduced in CD margins (77.1%, p < 0.05). Use of NBI led to improvement in RFS and DSS. The study indicates that close and positive single superficial margins do not affect DSS. By contrast, all types of margin positivity predict the occurrence of relapses, albeit with different likelihood, depending on stage/margin type. CD margins should be considered as a single risk factor. Use of NBI granted better intraoperative margins definition.

An Interesting Case of Melena: Gastric Neuroendocrine Tumor

We present an atypical cause of melena secondary to a gastric neuroendocrine tumor successfully managed by endoscopic submucosal dissection (ESD). A 66-year-old male with a history of hypertension, gastritis and peptic ulcer disease presented with three days of melena. EGD showed an ulcerated, protruding mass at the lesser curvature of the stomach. EUS confirmed a hypoechoic, homogeneous mass measuring 16 mm originating from the muscularis mucosa with an intact muscularis propria. ESD was performed with successful en bloc resection of the gastric mass. Pathology revealed a well-differentiated neuroendocrine tumor (NET) without associated atrophic gastritis. The tumor was classified as intermediate grade 2 with a Ki-67 index of 3-4%. Of note, there was involvement of the deep margin in the resected specimen. CT of chest, abdomen, and pelvis showed no evidence of other masses or metastases. Given the positive deep margin, a subsequent EGD with full-thickness resection of the ESD site was performed with the help of an over-the-scope clip. Pathology showed gastric mucosa with chronic focal inflammation, negative for tumor, with no evidence of NET. A post-resection octreotide scan showed no areas of pathologic uptake of radio-labeled octreotide. No complications were encountered during resection and the patient has had no recurrence on follow up surveillance endoscopy. Gastrointestinal NETs are relatively rare tumors, with carcinoid tumors being the most common type. Gastric involvement is rare, representing 7% of all carcinoid tumors within the GI tract. Gastric carcinoids can be divided into 3 types, differing in behavior and prognosis. Type I (>80%) are associated with chronic atrophic gastritis and pernicious anemia. Type II (< 5%) carcinoids are associated with hypergastrinemia due to gastrinomas. Both type I and type II gastric carcinoids are generally indolent with little malignant potential. Type III (20%) carcinoids are sporadic tumors in the absence of any gastric pathology. Type III tumors have a high rate of metastasis and carry a worse prognosis. Due to their aggressive nature, type III tumors are usually treated with partial or total gastrectomy. We report a case of a type III carcinoid tumor that presented with melena due to mucosal ulceration. Our case highlights the successful management of a type III carcinoid tumor with ESD with no signs of recurrence on follow up.Figure: EGD showing an ulcerated, protruding mass with stigmata of recent bleeding at the lesser curvature of the stomach.Figure: EUS showing a hypoechoic, homogeneous mass measuring 16 mm originating from the muscularis mucosa with an intact muscularis propria.Figure: Site of endoscopic submucosal dissection (ESD) with successful en bloc resection of the gastric mass.

Efficacy of loop electrosurgical excision procedure with cold coagulation for treating cervical intraepithelial neoplasia: A two center cohort study.

ObjectiveTo evaluate the efficacy of loop electrosurgical excision procedure (LEEP) combined with cold coagulation for treating cervical intraepithelial neoplasia (CIN).MethodsWe reviewed clinic-pathologic data of 498 patients treated with LEEP alone (n=354), and LEEP combined with cold coagulation (n=144) between January 2000 and December 2011. After LEEP, we followed up all patients by using Papanicolaou smear and human papillomavirus (HPV) test, and evaluated abnormal cervical cytology-free interval and high-risk HPV infection-free interval. Moreover, we investigated independent factors affecting abnormal cervical cytology or high-risk HPV infection after LEEP.ResultsAbnormal cervical cytology-free interval was longer in patients treated with LEEP combined with cold coagulation than in those treated with LEEP alone (mean, 92.4 vs. 84.4 months; P=0.01), and patients treated with LEEP combined with cold coagulation also showed longer high-risk HPV infection-free interval than those treated with LEEP alone (mean, 87.6 vs. 59.1 months; P=0.01). Moreover, CIN 3 and cold coagulation were factors affecting abnormal cervical cytology after LEEP (adjusted hazard ratios, 1.90 and 0.61; 95% confidence intervals, 1.27 to 2.84 and 0.39 to 0.96), and CIN 3, positive deep cervical margin and cold coagulation were also factors affecting high-risk HPV infection after LEEP (adjusted hazard ratios, 2.07, 4.11, and 0.64; 95% confidence intervals, 1.38 to 3.08, 1.63 to 10.39, and 0.43 to 0.96). When we performed subgroup analyses for patients with CIN 2 or CIN 3, the result were similar.ConclusionLEEP combined with cold coagulation may be more effective for treating CIN than LEEP alone. Moreover, cold coagulation may decrease the risk of potential of recurrence after LEEP.

Resection of a gastric fibroid inflammatory polyp by means of endoscopic submucosal dissection: how deep is deep enough?

Infl ammatory fi broid polyps (FIP) are rare mesenchymal tumors associated with mutations of the platelet-derived growth factor-α. Th ey derive from the submucosal layer and are mainly composed of loose connective tissue, vessels and an eosinophilic infl ammatory component. Th ey are found throughout the gastrointestinal tract, but most commonly in the gastric antrum and ileum. Macroscopically, they present as large polypoid lesions of 3-20 cm in size that maybe pedunculated and ulcerated. Case series and case reports have demonstrated the effi cacy of standard endoscopic techniques with snares and most recently with endoscopic submucosal dissection (ESD) in 5 cases [1,2]. We would like to share our experience in an asymptomatic 60-year-old woman who underwent ESD resection of a 4x3 cm pedunculated FIP located at the gastric antrum (Fig. 1, 2). Th e procedure was uneventful and macroscopically the lesion seemed to be completely resected. Surprisingly, the histology report showed positive deep margins. Due to the benign course of these lesions no additional surgery has been suggested and at one year of follow up there are no signs of endoscopic or histologic recurrence. Th is case illustrates that FIP may expand deep into the submucosal layer beyond the reach of invasive techniques such as ESD. Although the risk of recurrence is minimum, positive deep margins should prompt endoscopists for postoperative follow up since there is at least one report of tumor recurrence aft er endoscopic resection that was detected at 1 year of follow up [3].

The Superiority of Endoscopic Submucosal Dissection to Endoscopic Mucosal Resection for Achieving Negative Margins in Adenocarcinomas of the Gastroesophageal Junction: A Histopathological Evaluation

Background: Due to the significant morbidity associated with esophagectomy, advanced endoscopic therapies have been developed for diagnosis and resection of gastroesophageal junctional (GEJ) adenocarcinomas. Aim: To compare two commonly employed techniques, namely endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for efficacy in removing GEJ adenocarcinomas. Methods: A retrospective review of all adenocarcinomas at the GEJ removed via EMR or ESD over a ten-year period with coexisting BE (2004-2014) was performed. Thirty-one cases met the study inclusion criteria. All cases were re-reviewed by a gastrointestinal pathologist, and a chi-square analysis of all variables including tumor stage, degree of differentiation, depth of invasion, presence of lymphovascular invasion, and margin status was performed to evaluate for statistically significant differences between EMR and ESD. Results: ESDs were significantly more likely than EMRs to yield negative margins (64.3% vs. 35.7%; pvalue= 0.026). ESDs also produced fewer positive deep margins than EMRs; however, when the deep margin was analyzed independently, this number did not quite reach statistical significance (30.8% vs. 69.2%; p-value=0.057) Conclusion: This study demonstrates that ESD is superior to EMR for achieving negative margins in endoscopically resected adenocarcinomas at the GEJ. ESD also allows for better margin assessment histologically by the pathologist. Further, we believe that as the number of ESDs performed increases, we will also see that ESD will be more likely to provide both deep and lateral margin negativity.

P138. Do patients diagnosed with phyllodes breast tumours need long term follow up?

P138. Do patients diagnosed with phyllodes breast tumours need long term follow up?

Small Duodenal Carcinoids

We sought to compare the efficacy and safety of endoscopic ultrasound-guided endoscopic resection (ER) and endoscopic band ligation (EBL) for autoamputation of small duodenal carcinoids. The ideal management of small duodenal carcinoid tumors remains unclear. A retrospective review of duodenal carcinoids over a 10-year period (2002 to 2012) was performed at our tertiary-care teaching hospital. All patients with duodenal carcinoids ≤10 mm in size treated with either ER or EBL were included. The main outcome measurements were the efficacy and safety of endotherapy. A total of 37 patients with 39 subcentimeter duodenal carcinoids were identified. In the EBL group, the mean (SD) tumor size was 6.7±2.1 mm compared with 6.7±1.7 mm in the ER group (P=0.943). The mean Ki-67 index was ≤2% in specimens available for histologic analysis in both groups (16/23 EBL and 15/16 ER). The positive deep margin rate in the ER group was 68.8%. Residual carcinoid tumor cells were detected on follow-up biopsies in 1 patient after EBL, and 2 patients after ER. All underwent subsequent successful endotherapy. No adverse events occurred in the EBL group compared with an 18.8% adverse event rate in the ER group (P=0.066). Endoscopic ultrasound-guided EBL is a safe, effective method for removal of small superficial duodenal carcinoids and seems to be a lower risk alternative to conventional ER with cautery.

Hybrid push-pull endoscopic and laparoscopic full thickness resection for the minimally invasive management of gastrointestinal stromal tumors: a pilot clinical study.

Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors. Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management. Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens. Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.

Does the Type of Initial Biopsy Method Determine Re-Excision Rate of Cutaneous Melanoma?

Background: Various biopsy types are used to diagnose melanoma, after which wide local excision (WLE) is the gold standard for treatment. Depending on the final pathology report, further re-excision may be necessary despite an initial, presumably adequate, WLE. In this study, we analyzed the impact of initial biopsy type (shave, punch, or excision) on the management of melanoma. Methods: A retrospective chart review of 243 patients with clinically node-negative melanoma was completed. Evaluated variables included the initial biopsy type, initial and final peripheral and deep margin status, further reexcision rates, tumor site, and clinician specialty performing the biopsy. Univariate and multivariate analyses tests were performed using SPSS software. Results: 29.5% of specimens with both positive peripheral and deep margins underwent further excisions. Overall, 14.6% of cases had re-excision regardless of initial biopsy type after initial WLE. There was higher rate of re-excision with an initial excision biopsy (28.6%) than with initial punch (13.3%) or shave biopsies (11.2%) Dermatologists, Surgeons, and Primary Care Physicians performed 13%, 34%, and 32% of the excision biopsies respectively. Neither the anatomic location of the tumor nor the survival rates were significantly correlated to the biopsy type, margin status, or re-excision rates. Conclusion: Both shave and punch biopsies showed high rates of residual tumor in either peripheral or deep margins but this does not translate into a higher re-excision rate. Although the biopsy type is important, the clinical specialty performing the biopsy could be influential. Surprisingly, there was a higher positive peripheral margin than deep margin with shave biopsy.