Positive Margin Rate Research Articles

Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis

BackgroundTransanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored. MethodsThis was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival. ResultsOf 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001). ConclusionPositive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

Backgroundno data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP. Methodsall patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed. ResultsOf 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6). Conclusionsp-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.

Cutaneous Squamous Cell Carcinoma in Immunocompromised Patients-A Comparison between Different Immunomodulating Conditions.

Immunosuppression is strongly associated with an increased risk of developing cutaneous squamous cell carcinoma (cSCC). Studies on solid organ transplant recipients (SOTR) and chronic lymphocytic leukemia (CLL) patients have already demonstrated higher rates of aggressive cSCC tumors in these populations compared to immunocompetent controls. Studies on other immunosuppressed patient groups are scarce. This study was aimed at assessing the effects of different immunomodulating conditions on patients diagnosed with cSCC. We sought to compare the clinical features, treatments, and survival rates among the different study groups, as well as outcomes to those of immunocompetent controls with cSCC. A retrospective analysis of 465 cSCC patients, both immunosuppressed (IS) and immunocompetent controls. Etiologies for immunosuppression included SOTR, CLL, chronic kidney disease (CKD), psoriasis, rheumatoid arthritis (RA) and systemic lupus erythematous (SLE). Compared to the control group, IS patients demonstrated several significant differences. These include higher rates of positive resection margins, higher recurrence rates, and multiple SCC tumors. Patients in the IS group, who were also given immunomodulating agents, demonstrated even lower survival rates. Cox regression analysis demonstrated statistically significant decreased overall survival (OS) rates for IS patients compared to the controls (OR = 1.9, p = 0.031). SOTR patients tend to have multiple cSCC tumors (35%), with the highest number of primary tumors compared to controls (2.54 tumors per patient on average, p < 0.001), but also compared to all other IS groups. The average SCC lesion size in the SOTR group was the smallest, measuring at 13.5 mm, compared to the control group and all other IS groups. Decreased survival rates were seen on Cox regression analysis compared to controls (HR = 2.4, p = 0.001), but also to all other IS groups. CLL patients also had the highest rates of positive margins compared to controls (36% vs. 9%, p < 0.01) and to all other IS groups. They were also most likely to get adjuvant or definitive oncological treatments, either radiotherapy or chemotherapy, compared to controls (36% vs. 15%, p = 0.02) and to other IS groups. Patients in the CKD group demonstrated the highest rates for multiple cSCC (OR = 4.7, p = 0.001) and the worst rates of survival on Cox regression analysis (HR = 3.2, p = 0.001). Both rheumatoid arthritis and psoriasis patients demonstrated the shortest disease-free survival rates (2.9y ± 1.1, 2.3y ± 0.7, respectively), compared to controls (4.1y ± 2.8) and to all other IS groups. Among cSCC patients, immunosuppression due to SOTR, CLL, CKD, RA, and psoriasis is associated with worse outcomes compared to controls and other IS groups. These patients should be regarded as high-risk for developing aggressive cSCC tumors. This study is the first to assess and compare cSCC outcomes among multiple IS patient groups.

Single-center comparative study of short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers.

Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10cm) or low (< 5cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared. Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%. Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer.

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Abstract OT1-12-03: Precision breast conserving surgery with the guidance of localization combined with multidetector CT 3-dimensional image reconstruction: a single center, prospective, cohort study

Abstract Introduction: Precision breast conserving surgery (PBCS) requires doctors to precisely remove the tumor while preserving as much normal tissue as possible. The aims of this study were to determine whether wire-guided localization (WGL) combined with multidetector CT (MDCT) guided 3D reconstruction could guide PBCS. Methods: From 2020 to 2022, 31 patients with unifocal breast cancer were enrolled for PBCS guided by WGL combined with MDCT guided 3D reconstruction. Surrounded WGL was performed under local anesthesia, followed by an immediate contrast enhanced MDCT scan. PBCS guided by MDCT guided 3D reconstruction was performed one day after the localization. Women who underwent palpation guided BCS were included as control, and logistic regression analysis was applied. Results: PBCS were performed in 31 patients. The mean tumor size in US was 19.48±5.86mm (9-32mm). Compare with control group, a smaller specimen diameter was observed in PBCS group (P=0.005), and the rate of the largest margin greater than or equal to 20mm were significantly lower (P=0.004). The operation time of PBCS was shortened (P=0.046). Moreover, PBCS does not affect the reoperation rate (P=0.514) or the rate of positive margins (P=0.660). Conclusion: For patients with unifocal breast cancer, WGL combined with MDCT guided 3D reconstruction could guide PBCS without affecting the safety. Table 1. Baseline characteristics of patients in PBCS group and control group. BMI, body mass index; US, ultrasound; HR, hormone receptor. Table 2. Surgical outcomes of patients in PBCS group and control group. Citation Format: Yiqin Xia, Da Cao, Lili Yang, Mingjie Zheng, Miaomiao Weng, Ke Shi, Ruoxi Wang, Meng Zhao, Hui Xie, Shui Wang. Precision breast conserving surgery with the guidance of localization combined with multidetector CT 3-dimensional image reconstruction: a single center, prospective, cohort study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT1-12-03.

Assessing Rates of Positive Surgical Margins After Standard Excision of Vulvar Melanomas.

Vulvar melanoma is a rare malignancy with frequent recurrence and poor prognosis. National guidelines recommend wide local excision of these tumors with allowances for narrower margins for anatomic and functional limitations, which are common on specialty sites. There is presently a lack of data of margin positivity after standard excision of vulvar melanomas. We aim to evaluate the rate of positive margins after standard excision of vulvar melanomas. Retrospective cohort study of surgically excised vulvar melanomas from the NCDB diagnosed from 2004 to 2019. We identified a total of 2,226 cases. Across surgical approaches and tumor stages, 17.2% (Standard Error [SE]: 0.8%) of cases had positive surgical margins. Among tumor stages, T4 tumors were most commonly excised with positive margins (22.9%, SE: 1.5%). On multivariable survival analysis, excision with positive margins was associated with significantly poorer survival (Hazard Ratio 1.299, p = .015). We find that positive margin rates after standard excision of vulvar malignancies are higher than for other specialty site melanomas. Our data suggest that use of surgical approaches with complete margin assessment may improve local control and functional outcomes for patients with vulvar melanoma as they have for patients with other specialty site melanomas.

Abstract P1-09-10: Factors associate with borderline or invaded margins in breast cancer surgery at the Val d’Aurelle Montpellier CRLC

Abstract Factors associate with borderline or invaded margins in breast cancer surgery at the Val d’Aurelle Montpellier CRLC Véronique Mboua Batoum*, Esther Dina Bell, Christianne Nsahlai, Junie Annick Metogo Ntsama, Esther Juliette Meka, Marian Gutowski, Simon Thezenas, William Jacot *Corresponding autor : vbatoum@gmail.com Introduction: The inadequate status of the resection margins after breast cancer surgery is an important predictor of local tumor recurrence. The objective of our study was to determine the factors associated with positive or invaded resection margins. Methodology: Our retrospective study included a cohort of 652 patients with early invasive breast cancer who underwent breast cancer conserving surgery at the Val d’Aurelle Regional Cancer Center. We defined positive margins as those with a distance of less than or equal to 2 mm from the tumour. The data were analysed using STATA® 10.0 software. Results: In our study, The median distance from the tumour to the surgical resection site was 5mm [0.0 - 35.0mm]. Resection margins were positive in 208 patients (31.9%). The rate of positive resection margins was significantly higher in non-menopausal patientss (P =0,0050), in those with tumours less than 2 cm in size (P = 0,0004), with ductal carcinoma in situ (DCIS) component and without lymph node involvement (P =0,0082). Re-excision surgery was performed in 229 patients (35.1%). Conclusion: Consideration of each of these factors associated with positive resection margins shoud help the surgeons to perform a wider excision, in other to obtain clear resection margin during the initial breast cancer surgery. Key words: breast cancer, conservative surgery, resection margins, risk factors for positive margins Citation Format: veronique M. Mboua Batoum, esther D. Dina Bell. Factors associate with borderline or invaded margins in breast cancer surgery at the Val d’Aurelle Montpellier CRLC [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-09-10.

Abstract P1-09-03: Impact of BRCA1/2 pathogenic variants on ipsilateral breast tumor recurrence and prognosis following breast-conserving surgery

Abstract Background The risk of ipsilateral breast tumor recurrence (IBTR) and the prognostic outcome of breast-conserving surgery (BCS) for germline BRCA1/2 pathogenic variant (BRCA1/2+) carriers remain controversial. We examined differences in IBTR and prognosis between BRCA1/2+ carriers and non-carriers following BCS for breast cancer. Methods Clinical and pathological data were collected by retrospectively reviewing charts of consecutive patients with stage 0-III breast cancer who underwent genetic testing for germline BRCA1/2 and BCS between 1996 and 2020. Patients with variants of breast cancer-associated genes other than BRCA1/2 were excluded. We compared the incidence of IBTR and prognosis, including overall survival (OS), breast cancer-specific survival (BCSS), and distant recurrence-free survival (DRFS), between BRCA1/2+ carriers and non-carriers. Results We analyzed 551 patients (587 breasts with cancer), including 30 BRCA1+ carriers (32 breasts) and 31 BRCA2+ carriers (32 breasts). The median follow-up was 5.8 years (7.2 and 5.3 years for carriers and non-carriers, respectively). The median age at breast cancer diagnosis was 43 and 46 years for carriers and non-carriers, respectively, indicating younger onset of cancer in carriers (age ≤ 40 years; 46.9% for carriers vs. 27.5% for non-carriers, p = 0.001). In carriers, breast cancer more frequently expressed estrogen receptor-negative (56.2% for BRCA1+ carriers and 15.6% for BRCA2+ carriers vs. 22.0% for non-carriers, p = 0.013), progesterone receptor-negative (62.5% for BRCA1+ carriers and 31.3% for BRCA2+ carriers vs. 29.5%, p = 0.005), nuclear grade III (45.3% for carriers vs. 29.5% for non-carriers, p = 0.010), or a higher Ki-67 index (Ki-67 index &amp;gt; 20) (89.5% vs. 61.8%, p = 0.001) than non-carriers. Moreover, carriers underwent chemotherapy more frequently than non-carriers (62.5% vs. 42.4%, p = 0.002). Cancer stage, tumor size, HER2 status, presence of lymphovascular invasion, and the rate of positive or close surgical margins did not statistically differ between the examined groups. No statistical differences were detected in the number of patients who underwent whole-breast radiotherapy following BCS: 59 breasts in carriers and 503 in non-carriers (92.2% vs. 96.4%). During follow-up, we noted that 9 breasts of BRCA1/2+ carriers (5 [15.6%] for BRCA1+ and 4 [12.5%] for BRCA2+) and 35 breasts (6.7%) of non-carriers developed IBTR (p = 0.035). In an analysis excluding patients who did not undergo radiotherapy, the rate of IBTR remained significantly higher in BRCA1/2+ carriers (p = 0.034) than that in non-carriers. The median time to IBTR was 10.2 years in carriers (10.2 years for BRCA1+ and 8.5 years for BRCA2+) and 3.5 years in non-carriers. Carriers were more likely than non-carriers to exhibit distinct subtypes of recurrent tumors in the ipsilateral breast (66.7% for carriers vs. 19.4% for non-carriers, p = 0.006), occurring in a different quadrant from the primary tumor (50.0% vs. 27.3%, p = 0.215). No significant differences in OS (p = 0.068), BCSS (p = 0.109), or DRFS (p = 0.359) were noted between carriers and non-carriers. Conclusion BRCA1/2+ carriers exhibited a higher risk of IBTR after BCS and a longer time to IBTR than non-carriers. One limitation of the present study is a longer follow-up period for carriers than for non-carriers, as carriers typically underwent long-term observation at our institution; hence, further data accumulation is warranted for validating these findings. Subtypes and quadrants of IBTR were frequently distinct in carriers, indicating the increased incidence of new primary breast cancer. Although the prognosis did not differ between carriers and non-carriers, our results suggest the necessity for long-term intensive breast surveillance of BRCA1/2+ carriers after BCS. Citation Format: Sakiko Kondo, Kumiko Kida, Misato Suzuki, Chika Fukano, Atsushi Yoshida, Naoki Hayashi, Junko Takei, Michiko Yamanaka, Hideko Yamauchi. Impact of BRCA1/2 pathogenic variants on ipsilateral breast tumor recurrence and prognosis following breast-conserving surgery [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-09-03.

Retzius-sparing robotic prostatectomy is associated with higher positive surgical margin rate in anterior tumors, but not in posterior tumors, compared to conventional anterior robotic prostatectomy.

The analysis of the oncological outcomes and postoperative continence recovery between conventional robotic-assisted radical prostatectomy (cRARP) and Retzius-sparing RARP (rsRARP), and the effect of the tumor location on them. A total of 317 patients who underwent cRARP (n=228) or rsRARP (n=89) from August 2017 to July 2020 were assessed. Patients were categorized into groups based on the tumor location by pathology. Positive surgical margin (PSM) rates and biochemical recurrence (BCR)-free survivals and continence recovery were compared between the two procedures. Patient age, prostate-specific antigen (PSA) levels, clinical stages, and Gleason score were not significantly different between the two groups. There was no significant difference in PSM rates (25.8% vs. 33.7%, p=0.13) or BCR-free survivals (p=0.28) between cRARP and rsRARP in patients. When tumor was located in the anterior lesion in the prostatectomy pathology, rsRARP was associated with significantly higher PSM rates than cRARP (53.3% in rsRARP vs. 27.0% in cRARP, p=0.0086), while BCR-free survival did not vary significantly (hazard ratio: 2.15, p=0.11). When tumors were identified in the posterior in prostatectomy pathology, PSM rates (28.8% in rsRARP vs. 24.7% in cRARP, p=0.59) or BCR-free survivals (hazard ratio: 0.78, p=0.51) did not differ significantly between the two groups. rsRARP yielded superior continence recovery in all time points compared to cRARP, which was not affected by the pathological tumor location. In posterior tumors, rsRARP results in similar oncological outcomes as cRARP with superior continence recovery, while in anterior tumors, rsRARP may associate with higher PSM rate, combined with improved continence recovery.

Abstract P2-14-01: MOLECULAR FLUORESCENCE-GUIDED SURGERY USING BEVA800 FOR THE ASSESSMENT OF TUMOR MARGINS DURING BREAST CONSERVING SURGERY OF PATIENTS WITH PRIMARY BREAST CANCER (MARGIN-II)

Abstract Introduction: The goal of breast conserving surgery (BCS) for early breast cancer (EBC) is to remove the tumor in toto and preserving as much of the normal breast tissue as possible. In 20-50% of cases a re-excision is necessary because of involved margins. Repeat surgeries are not only a burden to patients physically but also psychologically and can delay recommended adjuvant therapies. Accurate determination of tumor margins during surgery is therefore a critical need. Breast cancer tissue produces significantly higher amounts of VEGF-A than healthy tissue. VEGF-A stimulates tumor angiogenesis and is therefore a target for molecular imaging techniques. The fluorescence imaging agent bevacizumab-IRDye800CW (Beva800) is a conjugate of bevacizumab and IRDye800CW and binds specifically to VEGF-A. Beva800 provides a potentially efficacious approach to imaging specimen and cavity margins during BCS. We are presenting a phase II study that combined Beva800 with the SurgVision Explorer Air camera for intraoperative margin assessment during BCS for EBC. Methods: MARGIN II is a multicenter open-label single arm prospective clinical trial aimed at evaluating Beva800 for assessment of tumor margins in women with EBC scheduled for BCS. The study was a within-patient comparison of positive tumor margin rates using BCS standard of care margin assessment compared to intraoperative assessment with 4.5 mg Beva800 and fluorescence imaging with the SurgVision Explorer Air camera. All patients received an i.-v. bolus injection of 4.5 mg of Beva800 three days before surgery. The fluorescent signal was visualized during surgery using NIR fluorescence imaging (700–1000 nm). Standard of care margin assessment was defined as visual inspection, palpation and, in cases of pre-operative wire marking, specimen sonography or mammography. Beva800 efficacy was determined as the number of patients in which a pathology-confirmed positive margin was identified by fluorescence-guided surgery using Beva800 but not by standard of care BCS. Results: 49 patients were included in 5 centers. 4 training cases were only included in the safety analysis, 45 patients were evaluable for the efficacy analysis. 8 patients (17.8%) had involved margins after standard of care BCS, 4 of which were detected by molecular fluorescence intraoperatively resulting in the reduction of patients with positive margins by 50% (95% CI: 15.7%, 84.3%). 4 patients (8.9%; 95% CI: 2.5%, 21.1%) needed a re-excision because of involved margins. In 27 patients (60.0%) the additional molecular fluorescence guided cavity shaving did not change the resection status from positive to negative (false positive). Adverse events were reported by 16 of 49 patients (32.7%), but only 3 (6.1%) were related to Beva800 (syncope, hot flush, hypertensive crisis). One patient experienced a treatment related SAE (hypertensive crisis). No anti-Beva800 antibodies were detected. Conclusion: In our analysis the rate of necessary second operations was reduced by 50% using Beva800 and the SurgVision Explorer Air camera. The safety analysis confirmed the positive safety profile of Beva800 found in previous studies. Molecular fluorescence-guided surgery may have the potential to change the practice of breast conserving surgery by reducing unnecessary re-excisions. Future studies will have to address the high false positive rates. Citation Format: Hans-Christian Kolberg, Carmen Röhm, Angrit Stachs, Florian Schütz, Jens-Uwe Blohmer, Sarah Wetzig, Steffi Hartmann, Jörg Heil, Markus Hahn. MOLECULAR FLUORESCENCE-GUIDED SURGERY USING BEVA800 FOR THE ASSESSMENT OF TUMOR MARGINS DURING BREAST CONSERVING SURGERY OF PATIENTS WITH PRIMARY BREAST CANCER (MARGIN-II) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-01.

Real-time administration of indocyanine green in combination with computer vision and artificial intelligence for the identification and delineation of colorectal liver metastases

IntroductionFluorescence guided surgery for the identification of colorectal liver metastases (CRLM) can be better with low specificity and antecedent dosing impracticalities limiting indocyanine green (ICG) usefulness currently. We investigated the application of artificial intelligence methods (AIM) to demonstrate and characterise CLRMs based on dynamic signalling immediately following intraoperative ICG administration. MethodsTwenty-five patients with liver surface lesions (24 CRLM and 1 benign cyst) undergoing open/laparoscopic/robotic procedures were studied. ICG (0.05 mg/kg) was administered with near-infrared recording of fluorescence perfusion. User-selected region-of-interest (ROI) perfusion profiles were generated, milestones relating to ICG inflow/outflow extracted and used to train a machine learning (ML) classifier. 2D heatmaps were constructed in a subset using AIM to depict whole screen imaging based on dynamic tissue-ICG interaction. Fluorescence appearances were also assessed microscopically (using H&E and fresh-frozen preparations) to provide tissue-level explainability of such methods. ResultsThe ML algorithm correctly classified 97.2 % of CRLM ROIs (n = 132) and all benign lesion ROIs (n = 6) within 90-s of ICG administration following initial mathematical curve analysis identifying ICG inflow/outflow differentials between healthy liver and CRLMs. Time-fluorescence plots extracted for each pixel in 10 lesions enabled creation of 2D characterising heatmaps using flow parameters and through unsupervised ML. Microscopy confirmed statistically less CLRM fluorescence vs adjacent liver (mean ± std deviation signal/area 2.46 ± 9.56 vs 507.43 ± 160.82 respectively p < 0.001) with H&E diminishing ICG signal (n = 4). ConclusionML accurately identifies CRLMs from surrounding liver tissue enabling representative 2D mapping of such lesions from their fluorescence perfusion patterns using AIM. This may assist in reducing positive margin rates at metastatectomy and in identifying unexpected/occult malignancies.

Extracapsular extension of transitional zone prostate cancer miss-detected by multiparametric magnetic resonance imaging.

To demonstrate the importance of extracapsular extension (ECE) of transitional zone (TZ) prostate cancer (PCa), examine the causes of its missed detection by Mp-MRI, and develop a new predictive model by integrating multi-level clinical variables. This retrospective study included 304 patients who underwent laparoscopic radical prostatectomy after 12 + X needle transperineal transrectal ultrasound (TRUS)-MRI-guided targeted prostate biopsy from 2018 to 2021 in our center was performed. In this study, the incidence rates of ECE were similar in patients with MRI lesions in the peripheral zone (PZ) and TZ (P = 0.66). However, the missed detection rate was higher in patients with TZ lesions than in those with PZ lesions (P < 0.05). These missed detections result in a higher positive surgical margin rate (P < 0.05). In patients with TZ lesions, detected MP-MRI ECE may have grey areas: the longest diameters of the MRI lesions were 16.5-23.5mm; MRI lesion volumes were 0.63-2.51ml; MRI lesion volume ratios were 2.75-8.86%; PSA were 13.85-23.05ng/ml. LASSO regression was used to construct a clinical prediction model for predicting the risk of ECE in TZ lesions from the perspective of MRI and clinical features, including four variables: the longest diameter of MRI lesions, TZ pseudocapsule invasion, ISUP grading of biopsy pathology, and number of positive biopsy needles. Patients with MRI lesions in the TZ have the same incidence of ECE as those with lesions in the PZ, but a higher missed detection rate.

Role of transoral robotic surgery in surgical treatment of early-stage supraglottic larynx carcinoma.

There are several options for primary surgical treatment of early-stage supraglottic squamous cell carcinoma (SCC), including transoral robotic surgery (TORS). The purpose of this study was to compare outcomes of TORS to open partial laryngectomy and transoral laser microsurgery (TLM). Patients with clinical classification T1-2 supraglottic SCC diagnosed 2010-2019, treated with TORS, open partial laryngectomy, or TLM in the National Cancer Database were selected. One thousand six hundred three patients were included: 17% TORS, 26.5% TLM, 56.5% open. TORS patients had the lowest rates of adjuvant treatment (28.4% vs. TLM: 45.0%, open: 38.5%, p < 0.001), and lower positive margin rates than TLM (16.9% vs. 30.5%, p < 0.001). Thirty-day and ninety-day post-operative mortality did not differ between the approaches. Five-year survival was higher following TORS compared to open surgery (77.8% vs. 66.1%, p=0.01); this difference persisted following matched-pair analysis. TORS may be a safe and effective surgical approach for early-stage supraglottic SCC in appropriate patients.

Outcomes of robotic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy in women with breast cancer: a systematic review and meta-analysis.

The promising results of the robotic approach for multiple cancer operations has led to interest in the potential of robotic nipple-sparing mastectomy (R-NSM); however, further studies are required to compare the benefits and complications of this approach with those of conventional open nipple-sparing mastectomy (C-NSM). We performed a meta-analysis to compare surgical complications of R-NSM versus C-NSM. We performed a review of literature through June 2022 in PubMed, Scopus, and EMBASE. We included randomized controlled trials (RCTs), cohorts, case-control studies, and case series with > 50 patients comparing the two techniques. Separate meta-analyses were conducted according to study design. From 80 publications, we identified six studies. The sample size ranged from 63 to 311 mastectomies from 63 to 275 patients. The tumor size and disease stage were similar between groups. The positive margin rate was 0-4.6% in the R-NSM arm and 0-2.9% in the C-NSM arm. Four studies reported early recurrence data, which were similar between groups (R-NSM: 0%, C-NSM: 0-8%). The R-NSM group had a lower rate of overall complications compared to the C-NSM group in cohorts/RCTs (RR = 0.68, 95%CI 0.49-0.96). In case-control studies, rate of necrosis was lower with R-NSM. Operative time was significantly longer in the R-NSM group in cohort/RCTs. In early experience with R-NSM, R-NSM had a lower overall complication rate compared to C-NSM in cohorts/RCTs. While these data are promising, our results show variability and heterogeneity limiting definitive conclusions. Additional trials are needed to guide the role of R-NSM and its oncologic outcomes.

Outcomes of partial nephrectomy for non-metastatic cT2 renal tumors: Results from a Canadian multi-institutional collaborative.

690 Background: The role of partial nephrectomy (PN) is not well defined for cT2 renal cell carcinoma (RCC) as compared to radical nephrectomy (RN). The aim of this study was to examine oncological outcomes of PN as compared to RN for non-metastatic cT2 RCC. Methods: The Canadian Kidney Cancer information system was used to define patients who underwent surgery for non-metastatic cT2 RCC from January 2011 to October 2022. Patients with clear-cell, papillary, and chromophobe RCC were included. Other histology, multiple tumours, and hereditary RCC syndrome patients were excluded. Each PN patient was individually matched to RN up to 1:4 depending on availability of patients based on tumor size (+/- 1cm), histology, grade (clear cell and papillary), and necrosis (clear cell). Matched patients were analyzed as clusters. Results: A total of 1523 patients were identified, and 50 PN patients met study criteria who were then matched to 185 RN patients. Both groups had similar age, gender, smoking status, BMI, Charlson comorbidity index score, symptoms at presentation, baseline eGFR, hemoglobin and pathological characteristics. PN patients had smaller tumors (7.6 cm [IQR 2] vs 8.4 [IQR 2.4], p=0.05), had higher likelihood of undergoing open surgery (72.9% vs 31.8%, p&lt;0.0001) and less likely received adrenalectomy (2% vs 24.3%, p=0.0004). Positive surgical margin rates were similar in both groups (8.2% in PN vs 3.4% in RN, p=0.2). Median follow up was not significantly different in either group (3.6 yrs [IQR 4.7] in PN vs 3.3 [4.7] yrs in RN, p=0.9). During the follow up period, PN patients had higher risk of local recurrence (HR 3.0, 95%CI 1.08-8.37), lower risk of distant metastasis (HR 0.36, 95%CI 0.15-0.88), better cancer specific survival (HR 0.56, 95%CI 0.18-1.78) and overall survival (HR 0.36, 95%CI 0.11-1.19) and as compared to RN. At 6 months and beyond after surgery, PN patients had less decline in eGFR than RN patients (-16.6 [SD 21.1] vs -24.4[SD 16.2], p=0.0002). Complications rates between PN and RN were (18% vs 9%, p=0.057). Conclusions: In this multi-institutional Canadian cohort of patients with non-metastatic cT2 RCC undergoing surgery, PN compared to RN was associated with slightly higher risk of peri-operative complications, better preservation of renal function, and higher risk of local recurrence. The lower risk of distant metastasis and death was likely from residual confounding unaccounted for in the individual patient match. [Table: see text]

Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort.

While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort. We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival. Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1). In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

Improved early and late continence following robot-assisted radical prostatectomy with concurrent bladder neck fascial sling (RoboSling).

To describe a novel RoboSling technique performed at the time of robot-assisted radical prostatectomy (RARP) and its utility for enhancing urinary function recovery postoperatively. The surgical technique involves harvesting a vascularised, fascial flap from the peritoneum on the posterior aspect of the bladder. Following completion of prostatectomy, the autologous flap is tunnelled underneath the bladder and incorporated into the rectourethralis and vertical longitudinal detrusor fibres at the posterior bladder neck with a modified Rocco suture. After urethra-vesical anastomosis is completed, the corners of the flap are hitched up to Cooper's ligament bilaterally with V-Loc sutures, tensioned and secured creating a bladder neck sling. A prospective, longitudinal cohort study was performed of 193 consecutive patients undergoing RARP between December 2016 and September 2019. The first 163 patients underwent standard RARP, and the last 30 patients had the RoboSling technique performed concurrently. Continence outcomes were the primary outcomes assessed using pad number and Expanded Prostate Cancer Composite (EPIC)-urinary domain questionnaire. Operative time (OT), estimated blood loss (EBL), complications and oncological outcomes were secondary outcomes. The two groups were comparable for demographics and clinicopathological variables. At 3 months, zero pad usage (p= 0.005) and continence rates, defined as EPIC score ≥ 85 (p= 0.007), were both higher in the RoboSling group. EBL, complication rate and positive surgical margin rate did not differ between the two groups. Superior zero pad usage was observed at 1 year in the RoboSling group (p= 0.029). The RoboSling technique added on average 16 min to OT. The RoboSling procedure at the time of RARP was associated with earlier return to continence without negatively impacting other postoperative outcomes. This improvement in continence outcomes was maintained long term.

Long-term outcomes of upfront robotic rectal cancer surgery: a single-center, retrospective cohort study in Japan.

The purpose of this study was to evaluate the long-term outcomes of robotic rectal cancer surgery and to examine the risk factors for recurrence. In a high-volume center in Japan, we retrospectively enrolled patients with pStage I-III rectal cancer within 15cm of the anal verge who underwent robotic surgery from 2011 to 2017. Almost all patients underwent upfront surgery, and lateral lymph-node dissection (LLND) was performed for patients with locally advanced lower rectal cancer. We evaluated the 5-year overall survival (OS), relapse-free survival (RFS), and cumulative local recurrence (LR) rates and examined the risk factors for the RFS. We evaluated 488 patients who underwent robotic rectal cancer surgery, including 5.1% who underwent preoperative chemoradiotherapy to obtain clear resection margins and 33.6% who underwent LLND. There were 203, 87, and 198 patients with pStage I, II, and III, respectively, and the positive resection margin rate was 1.0%. The 5-year OS, RFS, and LR rates were 95.5%, 81.7%, and 2.2%, respectively. The independent risk factors for the RFS were the presence of venous invasion, extramural tumor deposits without lymph-node structure, and pT ≥ 3. This study demonstrated the favorable long-term outcomes of robotic rectal cancer surgery.

Impact of 3Dprinted models on quantitative surgical outcomes for patients undergoing robotic-assisted radical prostatectomy: a cohort study.

Three-dimensional (3D) printed anatomic models can facilitate presurgical planning by providing surgeons with detailed knowledge of the exact location of pertinent anatomical structures. Although 3D printed anatomic models have been shown to be useful for pre-operative planning, few studies have demonstrated how these models can influence quantitative surgical metrics. To prospectively assess whether patient-specific 3D printedprostate cancer models can improve quantitative surgical metrics in patients undergoing robotic-assisted radical prostatectomy (RARP). Patients with MRI-visible prostate cancer (PI-RADS V2 ≥ 3) scheduled to undergo RARP were prospectively enrolled in our IRB approved study (n = 82). Quantitative surgical metrics included the rate of positive surgical margins (PSMs), operative times, and blood loss. A qualitative Likert scale survey to assess understanding of anatomy and confidence regarding surgical approach was also implemented. The rate of PSMs was lower for the 3D printedmodel group (8.11%) compared to that with imaging only (28.6%), p = 0.128. The 3D printed model group had a 9-min reduction in operating time (213 ± 42min vs. 222 ± 47min) and a 5mL reduction in average blood loss (227 ± 148mL vs. 232 ± 114mL). Surgeon anatomical understanding and confidence improved after reviewing the 3D printed models (3.60 ± 0.74 to 4.20 ± 0.56, p = 0.62 and 3.86 ± 0.53 to 4.20 ± 0.56, p = 0.22). 3D printedprostate cancer models can positively impact quantitativepatient outcomes such as PSMs, operative times, and blood loss in patients undergoing RARP.