Positive Microscopic Margins Research Articles

WEO Newsletter.

WEO Newsletter.

Adjuvant Chemoradiotherapy Associated with Improved Overall Survival in Resected Esophageal Squamous Cell Carcinoma after Neoadjuvant Chemoradiotherapy in Intensity-Modulated Radiotherapy Era.

The prognosis of patients with resected esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy is particularly poor in those who were staged as ypT3/T4 and/or ypN+. This study investigated whether adjuvant chemoradiotherapy was associated with improved clinical outcomes in these patients. we identified patients with esophageal squamous cell carcinoma who were staged as ypT3/T4 and/or ypN+ after being treated with neoadjuvant chemoradiotherapy followed by esophagectomy between the years 2013 and 2019. Patients were divided into two groups based on whether they received adjuvant chemoradiotherapy. The Kaplan-Meier method and Cox regression modeling were performed for survival analyses and multivariable analysis, respectively. 76 eligible patients were included in the analyses. The median follow-up for the study cohort was 43.4 months. On Kaplan-Meier analyses of the overall population, adjuvant chemoradiotherapy was associated with significantly improved median overall survival (31.7 months vs. 16.3 months, p = 0.036). On Kaplan-Meier analyses of the 35 matched pairs generated by propensity score matching, adjuvant chemoradiotherapy was associated with significantly longer median overall survival (31.7 months vs. 14.3 months; p = 0.004) and median recurrence-free survival (18.9 months vs. 11.7 months; p = 0.020). In multivariable analysis, adjuvant chemoradiotherapy was independently associated with a 60% reduction in mortality (p = 0.003) and a 48% reduction in risk of recurrence (p = 0.035) after adjusting for putative confounders. In addition, microscopic positive resection margin and Mandard tumor regression grade 3-4 were independently associated with increased mortality and risk of recurrence. While a greater number of lymph nodes dissected was independently associated with significantly improved overall survival, the number of positive lymph nodes was independently associated with significantly worse overall survival and a trend (p = 0.058) towards worse recurrence-free survival. This study demonstrated that adjuvant CRT was independently associated with a significantly improved survival and lower risk of recurrence than observation in esophageal squamous cell carcinoma patients staged as ypT3 and/or ypN+ after receiving neoadjuvant chemoradiotherapy and radical surgery. The results of this study have implications for the design of future clinical trials and may improve treatment outcomes of patients in this setting who cannot afford or are without access to adjuvant nivolumab.

PSUN22 Outcomes of Adrenalectomy for Adrenocortical Carcinoma at a Single Institution

Abstract Background Adrenocortical carcinoma (ACC) is a rare malignancy with a poor overall prognosis. Complete surgical resection is the mainstay of therapy. Methods We performed a retrospective review of adult patients at a single institution undergoing index adrenalectomy for initial diagnosis of adrenocortical carcinoma from 2012 through 2021. Clinical and demographic variables were assessed. Results Fifteen patients were identified who underwent adrenalectomy for ACC during the study period with a mean age of 49.2 years (SD 17.8) with 6 (40%) male, 13 (87%) white, mean body mass index 29.5 kg/m2 (SD 7.5). On preoperative cross-sectional imaging nine (60%) were left sided tumors and the largest dimension was a mean of 11.1cm (SD 4.5), with pre-contrast density of 27.8 Hounsfield units (SD 9.6), five patients (36%) had evidence of local invasion and four patients (29%) had evidence of metastatic disease on imaging. Ten patients (67%) had biochemical evidence of hormone excess and eight had secretion of more than one cortical hormone, with overall ten (67%) glucocorticoid secretion, six (40%) androgen secretion, two (13%) mineralocorticoid secretion. Four patients (27%) had minimally invasive laparoscopic or robotic adrenalectomy. Three patients (20%) had a surgical complication including ileus, pancreatic leak and pleural effusion requiring intervention. Complications were not associated with hormone excess (p = 0.50). On final pathology, one patient (7%) was staged T0 who later presented with metastatic disease 18 months postoperatively, six (43%) were T2, 4 (29%) T3, and 3 (21%) T4. No patients had locoregional lymph node metastases. Ten patients (67%) had R0 resection with negative margins, 4 (27%) had microscopic positive margins, and 1 had grossly positive margins. Seven patients had Ki-67 assessed with a mean of 29% (SD 20.6). Ten patients (71%) received adjuvant mitotane, eight (53%) systemic chemotherapy, and 4 (27%) adjuvant radiation. Within the study period, nine patients (60%) had a recurrence and six patients died (40%) with a median survival of 24 months. Positive margin status was associated with mortality with mortality of one (10%) of patients with negative margins and 5 (100%) of those with positive margins (p = 0.002). Of the four patients who presented with initial evidence of metastatic disease on imaging, two died during the study period and the other two remain alive on therapy. Adjuvant treatment with mitotane, systemic chemotherapy, or radiation were not associated with survival. Conclusions In this cohort, complete surgical resection with negative margins was associated with improved survival compared with patients with microscopic or grossly positive margins. The overall median survival was 24 months. Differences in outcome by adjuvant therapy are limited by the sample size. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Outcomes Following Proton Radiotherapy for Pediatric Salivary Gland Tumors

<h3>Purpose/Objective(s)</h3> In contrast to adult salivary gland tumors, our institutional guidelines in children utilize lower radiation doses, smaller target margins, and proton therapy to minimize radiation to the developing skull base anatomy. Furthermore, we do not routinely recommend prophylactic nodal irradiation or elective neck dissection. Previous series of children treated with adjuvant radiation therapy report 5-year local control ∼85%. Herein we report treatment outcomes using our pediatric approach. <h3>Materials/Methods</h3> Twenty-seven consecutive pediatric patients were treated with proton therapy between 2006 and 2020 for mucoepidermoid carcinoma (n= 13), acinic cell carcinoma (n= 5), adenoid cystic carcinoma (n= 4), pleomorphic adenoma (n= 2), myoepithelial carcinoma (n= 1), adenocarcinoma (n= 1), and sialoblastoma (n= 1) at our institution. The 8 patients with radiographic lymphadenopathy (cN1) underwent neck dissection prior to presentation (7/8 selective dissections involving <4 nodal levels). The most common indications for adjuvant radiotherapy were microscopic positive or close (<1 mm) margins (n=15), perineural invasion (PNI; n=9), high-grade histology (n=6), and gross residual disease (n=4). Radiotherapy was delivered in sequential plans using 2 clinical target volumes (CTV1, CTV2). Gross tumor volume (GTV=CTV2) included the residual tumor and tumor bed. CTV1 received 50.4 Gy and was defined as GTV + 1 cm and the at-risk neck if indicated. The dose to CTV2 depended on histology, grade, and margin status. The median total dose was 64.8 Gy (range, 61.2-70.2 Gy). Only 3 patients underwent prophylactic nodal irradiation. Toxicity data was graded based on CTCAE v3 or v4 using patient-reported and physician-reported outcomes according to our prospective outcome registry. <h3>Results</h3> The median follow-up was 5.5 years. Overall survival was 100% and local control was 96% with a single local recurrence seen in a patient with gross unresectable disease. There were no nodal recurrences. In terms of acute toxicity, 3 patients experienced mucositis requiring opioid pain medication and 2 patients developed grade 3 radiation dermatitis. The most serious late toxicity involved the ear or auditory system including 4 patients requiring hearing aids, 1 with chronic otitis media, 1 with osteonecrosis of the mastoid bone, and 1 with external ear canal stenosis. Four additional patients reported variable hearing loss not requiring hearing aids. Other serious late toxicity included 1 patient with persistent trismus, 1 with growth hormone deficiency, and 1 with excessive dental caries along the ipsilateral maxilla. No secondary malignancies nor toxicities grade ≥ 4 were seen. <h3>Conclusion</h3> An approach of conservative neck management and moderate-dose proton radiotherapy delivered to small volumes resulted in excellent disease control and limited toxicity in children with common salivary gland tumors at elevated risk of local recurrence.

Surgical Resection for Pediatric Synovial Sarcoma: What Margin Is Adequate?

INTRODUCTION: Synovial sarcoma is the most common nonrhabdomyosarcoma soft tissue sarcoma in children. Guidelines concerning the size of resection margins are lacking. We sought to evaluate if negative microscopic resection margins predicted overall survival. METHODS: A retrospective chart review showed 22 patients with synovial sarcoma from September 2011 to November 2019 at Texas Children’s Hospital. Pearson’s chi-square test and multivariate regression analyses were used. RESULTS: Relapsed free survival was 59% and overall survival was 72% with a median follow-up of 3 years (with interquartile range [IQR] 1.6 to 4.9 years) from initial resection (Figure). The patients with negative margins had a median resection margin of 1.5 mm (IQR 1 to 27mm). Positive microscopic margins were noted in 71% (5/7) of the patients who died compared with 12% (2/16) of patients who survived (p = 0.01). Survival in patients with surgical margins of <5 mm was 100% (7/7) compared with the 28% (2/7) of patients with positive surgical margins (p = 0.02). Positive microscopic margin was an independent risk factor for death (odds ratio 40, 95% CI 1.98 to 807; p = 0.02) when adjusting for adjuvant chemotherapy and radiation.FigureCONCLUSION: This study revealed that a negative microscopic surgical margin in pediatric synovial sarcoma is an independent prognostic predictor of overall survival.

Diagnostic performance of tomosynthesis, digital mammography and a dedicated digital specimen radiography system versus pathological assessment of excised breast lesions.

The aim of the study was to compare the performance of full-field digital mammography (FFDM), digital breast tomosynthesis and a dedicated digital specimen radiography system (SRS) in consecutive patients, and to compare the margin status of resected lesions versus pathological assessment. Resected tissue specimens from consecutive patients who underwent intraoperative breast specimen assessment following wide local excision or oncoplastic breast conservative surgery were examined by FFDM, tomosynthesis and SRS. Two independent observers retrospectively evaluated the visibility of lesions, size, margins, spiculations, calcifications and diagnostic certainty, and chose the best performing method in a blinded manner. We evaluated 216 specimens from 204 patients. All target malignant lesions were removed with no tumouron-ink. One papilloma had positive microscopic margins and one patient underwent reoperation owing to extensive in situ components. There were no significant differences in measured lesion size among the three methods. However, tomosynthesis was the most accurate modality when compared with the final pathological report. Both observers reported that tomosynthesis had significantly better lesion visibility than SRS and FFDM, which translated into a significantly greater diagnostic certainty. Tomosynthesis was superior to the other two methods in identifying spiculations and calcifications. Both observers reported that tomosynthesis was the best performing method in 76.9% of cases. The interobserver reproducibilities of lesion visibility and diagnostic certainty were high for all three methods. Tomosynthesis was superior to SRS and FFDM for detecting and evaluating the target lesions, spiculations and calcifications, and was therefore more reliable for assessing complete excision of breast lesions.

Overall survival in patients with re-excision of positive microscopic margins of limb and trunk wall soft tissue sarcoma operated outside of a reference center: a nationwide cohort analysis

BackgroundThis French nationwide NETSARC exhaustive prospective cohort aims to explore the impact of systematic re-excision (RE) as adjuvant care on overall survival (OS), local recurrence free survival (LRFS), and local and distant control (RFS) in patients with soft tissue sarcoma (STS) with positive microscopic margins (R1) after initial resection performed outside of a reference center.MethodsEligible patients had experienced STS surgery outside a reference center from 2010 to 2017, and had R1 margins after initial surgery. Characteristics and treatment comparisons used chi-square for categorical variables and Kruskall-Wallis test for continuous data. Survival distributions were compared in patients reexcised (RE) or not (No-RE) using a log-rank test. A Cox proportional hazard model was used for subgroup analysis.ResultsA total of 1,284 patients had experienced initial STS surgery outside NETSARC with R1 margins, including 1,029 patients with second operation documented. Among the latter, 698 patients experienced re-excision, and 331 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, tumor size, tumor depth, and histotype in the population of patients re-excised (RE) or not (No-RE). The study identified RE as an independent favorable factor for OS (HR 0.36, 95%CI 0.23–0.56, p<0.0001), for LRFS (HR 0.45, 95%CI 0.36–0.56, p<0.0001), and for RFS (HR 0.35, 95%CI 0.26–0.46, p<0.0001).ConclusionThis large nationwide series shows that RE improved overall survival in patients with STS of extremities and trunk wall, with prior R1 resection performed outside of a reference center. RE as part of adjuvant care should be systematically considered.Level of evidence II

S2827 Endoscopic Full Thickness Resection of a Sigmoid Colon GIST Diagnosed by EUS FNA

Introduction: Subepithelial lesions of colon are often encountered during colonoscopy with lipoma being a common etiology, with other etiologies such as neuroendocrine tumors, leiomyoma, schwannoma, and GIST being rare. While a lipoma can be diagnosed by endoscopic appearance, pillow sign, and fat on biopsy; a diagnostic dilemma is presented if these findings are not present. EUS can be used for lesions that are within reach of an echoendoscope, but the sonographic appearance may still not be diagnostic without tissue sampling. This is a case of a subepithelial lesion in the sigmoid colon noted on colonoscopy that was diagnosed as a gastrointestinal stromal tumor by EUS FNA. Case Description/Methods: A 67 year old man was noted to have a one centimeter smooth round lesion in his sigmoid colon on screening colonoscopy. The endoscopic appearance was consistent with a subepithelial lesion. A pillow sign was negative, showing a firm mobile mass. He was referred for endoscopic ultrasound. A radial echoendoscope was used to localize the lesion. It was round, well demarcated, hypoechoic, and originated in the fourth layer (muscularis propria). The radial scope was exchanged for a linear echoendoscope and FNA was performed using a 20 gauge biopsy needle. Pathology showed a spindle cell lesion that was positive for CD 117 staining consistent with a gastrointestinal stromal tumor. Multidiscipline discussion with colorectal surgery was had, and the decision to proceed with endoscopic resection using an over the scope clip to perform full thickness resection. Following the resection the patient had some post-procedure pain and was hospitalized for observation, treated with antibiotics, and serial imaging. No perforation was noted. Final pathology showed a 1.7cm low grade GIST with positive microscopic margins. Multidiscipline discussion at tumor board recommends continued surveillance for the low grade GIST. (Figure) Discussion: Colonic GISTs are rare lesions with variable clinical courses. Full thickness endoscopic resection is an option using either an over the scope clip or dedicated full thickness resection device, or surgery are available options for management. Size, location, and multidiscipline discussion are needed to determine the best management strategy.Figure 1.: 4th layer hypoechoic lesion, sigmoid colon.

Proposal of novel staging system CNM (Crohn's primary site, nodes, mesentery) to predict postoperative recurrence of Crohn's disease.

After oncologic resection, histological grading and staging of the tumor give important prognostic information about the future risk of recurrence and hence influence the subsequent management plan. Several studies and their meta-analysis have shown that various histological features (e.g., microscopic positive resection margins, plexitis, granuloma, mesenteric inflammatory activity) can predict postoperative clinical/endoscopic/surgical recurrence after resection in Crohn's disease (CD). Inclusion of mesentery in surgical resection specimens has been shown to reduce surgical recurrence after ileocolonic resection in CD. However, there is no uniform histopathological staging system for risk stratification in postoperative CD to systematically predict postoperative recurrence. This is because the prediction to date is based on clinical characteristics (smoking status, disease phenotype, surgical history). Histopathological predictors are still not adopted in routine clinical practice due to the lack of a uniform staging system, heterogeneity of published studies and lack of standardized definition of histological features. In this article, we attempted to incorporate all such histological features in a single histological staging system CNM (Crohn's primary site [resection margin positivity, plexitis, granuloma, depth of infiltration], nodes [presence of granuloma], mesentery [involved or not]) in surgical resection specimen in CD. The proposed CNM classification would help to enable systematic reporting, design future clinical trials, stratify postoperative recurrence risk and choose appropriate postoperative prophylaxis.

Rhabdomyosarcoma of the gallbladder

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in the pediatric population, for 45% of soft tissue sarcomas in children. Commonly located in the head and neck, urogenital system, extremities and torso, RMS of the biliary system is rare. We present a specific case of RMS in the gallbladder of a 4-year-old girl who presented with epigastric abdominal pain and vomiting. Her work-up revealed transaminitis and tumefactive sludge in the gallbladder neck. After she had persistent symptoms and repeated work-up, the patient underwent a laparoscopic cholecystectomy and was found to have cholecystitis intraoperatively with cholelithiasis. However, pathology revealed botryoid embryonal RMS with positive microscopic margins. This case demonstrates the difficulty in diagnosing gallbladder RMS and the importance of considering malignancy in pediatric biliary disease.

Inflammatory myofibroblastic tumor: A multi-institutional study from the Pediatric Surgical Oncology Research Collaborative.

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.

Modified autotransplantation technique for surgical resection of complex pericardial synovial sarcoma.

Technical details for complex cardiac tumor resection are sparse. We describe the operative technique of modified autotransplantation for resection of a complex pericardial synovial sarcoma in a 63-year-old, Caucasian female. Surgical exposure demonstrated tumor origin at the superior cavoatrial junction and invasion of the aorta, main pulmonary artery, superior pulmonary veins, and left atrial roof. Full macroscopic surgical resection was achieved. The patient received adjuvant radiation for microscopic positive margins and remains alive and with no tumor progression at one year postoperatively. We conclude that modified autotransplantation is a challenging but effective surgical technique when performed with careful patient selection and availability of skilled, cardiothoracic surgeons at a cardiac center of excellence.

Endoscopic submucosal dissection for proximal duodenal subepithelial lesions: a retrospective cohort study.

Endoscopic submucosal dissection (ESD) has been used to remove subepithelial lesions (SELs) in recent years; however, duodenal ESD is associated with high rates of immediate or delayed bleeding and perforation. Whether ESD can be recommended for the treatment of duodenal SELs remains controversial. Therefore, we evaluated the efficacy and safety of ESD for duodenal SELs. We conducted a retrospective cohort study in 62 patients (62 lesions) who underwent ESD for duodenal SELs between January 2012 and December 2020. The therapeutic outcomes from ESD for duodenal SELs and procedure-related complications were analyzed. En bloc resection and complete resection rates associated with duodenal ESD were 90.3% and 100%, respectively; four patients had a positive microscopic margin on pathologic examination. The median procedure time was 45min (range 20-106min). During the procedure, two patients received emergency surgery for uncontrolled bleeding and perforation, respectively. After the procedure, delayed bleeding occurred in three patients (4.8%), which was successfully managed by clipping, and delayed perforation occurred in two patients (3.2%) and needed emergency surgery. Risk factors related to complications were analyzed. Lesion size was found to be significantly associated with the complications (P = 0.028). No recurrences were detected, and no distant metastasis was observed in any patient during a median follow-up period of 45.5months (range, 6-103months). Duodenal ESD is relatively safe and feasible for duodenal SELs, especially for lesions no more than 2cm in size.

Treatment strategies and outcomes of primary Myxofibrosarcomas in a large patients cohort

Backgroundthis study analysed primary myxofibrosarcoma (MFS) to investigate patient outcomes focusing on histopathologic margins and perioperative treatments. Patients and methodsdata from consecutive patients affected by primary and localized MFS of the extremities or trunk wall who underwent surgery (2002–2017) were analysed. Local recurrence (LR), amputation rate, incidence of distant metastasis (DM), and overall survival (OS) were studied. ResultsOf 293 included patients, 52 (17%) patients received perioperative treatments and 54 (18%) had positive microscopic histopathologic margins (R1). Median follow-up was 80 months (IQR, 49–109). 5-yr CCI of LR was 0.12 (SE: 0.02). Status of histopathologic margins (P < 0.001), tumour malignancy grade (P = 0.018) and size (P = 0023) were independent prognostic factor for LR. Nine amputations (amputation rate: 3%) were performed (N = 1 for primary tumour; N = 8 for LR). Larger tumour size (P = 0.015) and higher grade (P = 0.025) were independent prognostic factor for DM. 5-year OS was 0.84 (95%CI 0.79–0.88). Patient age (P = 0.008), tumour size (P = 0.013) and malignancy grade (P = 0.018) were independently associated to OS. In the subgroup of patients who had a re-excision for a primary MFS (N = 116, 40%), the presence of residual disease was not associated with LR, DM, or OS. Conclusionin this study 5-year LR, DM and OS were 12%, 17%, and 84%, respectively. One in six patients had a positive surgical margin, which was a prognostic factor for LR, while DM and OS were predicted by tumour grade and size. Findings from this large patient cohort may set benchmarks for investigating new treatment options for MFS.

Optimal surgical treatment for paratesticular leiomyosarcoma: retrospective analysis of 217 reported cases

BackgroundParatesticular leiomyosarcoma (LMS) is a rare tumor. Conventionally, tumor resection by high inguinal orchiectomy is performed as the preferred treatment approach for paratesticular sarcoma. On the other hand, testis-sparing surgery has recently attracted attention as a less-invasive treatment option for paratesticular sarcoma. However, the prognostic predictors and optimal treatment strategy for paratesticular LMS remain unclear because of its rarity. In this study, we systematically reviewed previously reported cases of paratesticular LMS to evaluate the prognostic factors and establish the optimal treatment strategy.MethodsA systematic search of Medline, Web of Science, Embase, and Google was performed to find articles describing localized paratesticular LMS published between 1971 and 2020 in English. The final cohort included 217 patients in 167 articles. The starting point of this study was the time of definitive surgical treatment, and the end point was the time of local recurrence (LR), distant metastasis (DM), and disease-specific mortality.ResultsPatients with cutaneous LMS had a slightly better LR-free survival, DM-free survival, and disease-specific survival than those with subcutaneous LMS (p = 0.745, p = 0.033, and p = 0.126, respectively). Patients with higher grade tumors had a significantly higher risk of DM and disease-specific mortality (Grade 3 vs Grade 1 p < 0.001, and Grade 3 vs Grade 1 p < 0.001, respectively). In addition, those with a microscopic positive margin had a significantly higher risk of LR and DM than those with a negative margin (p < 0.001, and p = 0.018, respectively). Patients who underwent simple tumorectomy had a slightly higher risk of LR than those who underwent high inguinal orchiectomy (p = 0.067). Subgroup analysis of cutaneous LMS demonstrated that the difference in LR between simple tumorectomy and high inguinal orchiectomy was limited (p = 0.212). On the other hand, subgroup analysis of subcutaneous LMS revealed a significant difference in LR (p = 0.039).ConclusionsOur study demonstrated that subcutaneous LMS and high-grade tumors are prognostic factors for paratesticular LMS. For subcutaneous LMS, tumorectomy with high inguinal orchiectomy should be the optimal treatment strategy to achieve a negative surgical margin.

Retroperitoneal Liposarcoma: An Unusual Presentation of a Rare Cancer.

Retroperitoneal liposarcomas (RLPS) are rare tumors that have variable clinical behavior and complex treatment strategies based on presentation, histopathology, and genomics. Early identification is critical, and complete surgical resection remains the primary treatment, although chemotherapy and radiation are used on individual bases. Presenting symptoms are often nonspecific; therefore, a high degree of suspicion is essential for early diagnosis. In this report, the management of a 37-year-old otherwise healthy male with a large RLPS causing right groin/testicular pain is presented. After three evaluations in the emergency department, the patient was diagnosed and received two cycles of doxorubicin/ifosfamide/mesna (AIM) neoadjuvant chemotherapy. His physical exam on presentation for second opinion demonstrated a large palpable abdominal mass and fullness around the right spermatic cord. There was no appreciable change in tumor size or distant metastases on repeat scanning. Given some obstructive symptoms, a multidisciplinary team advised neoadjuvant radiation followed by radical resection of RLPS. Final pathology demonstrated a 31-cm grade II well-differentiated (WD) liposarcoma with low-grade dedifferentiation. Scattered foci of microscopic positive WD margins were noted, and the remainder of margins were negative. Genomic evaluation showed amplification of CDK4, MDM2, and FRS2. A concise literature review of common presentations, histopathology, genomics, and treatment information is discussed herein. Thorough physical exams, attention to subtle findings, appropriate medical imaging studies, and a high index of suspicion when evaluating vague symptomatology can lead to earlier diagnosis and treatment of RLPS, and ultimately better patient outcomes.

Resection Status Does Not Impact Recurrence in Well-Differentiated Liposarcoma of the Extremity.

Well-differentiated liposarcoma (WDLPS) is a low-grade soft tissue sarcoma with a propensity for local recurrence. The necessity of obtaining microscopically free surgical margins (R0) to minimize local recurrence is not clear. This study evaluates recurrence-free survival (RFS) of extremity WDLPS in relation to resection margin status. A retrospective review of adult patients with primary extremity WDLPS at seven US institutions from 2000 to 2016 was performed. Patients with recurrent tumors or incomplete resection (R2) were excluded. Clinicopathologic factors were analyzed to assess impact on local RFS. 97 patients with primary extremity WDLPS were identified. The majority of patients had deep, lower extremity tumors. Mean tumor size was 18.2±8.9cm. Patients were treated with either radical (76.3%) or excisional (23.7%) resections; 64% had R0 and 36% had microscopically positive (R1) resection margins. Ten patients received radiation therapy with no difference in receipt of radiation between R0 vs R1 groups. Thirteen patients (13%) developed a local recurrence with no difference in RFS between R0 vs R1 resection. Five-year RFS was 59.5% for R0 vs 85.2% for R1. Only one patient died of disease after developing dedifferentiation and distant metastasis despite originally having an R0 resection. In this large multi-institutional study of surgical resection of extremity WDLPS, microscopically positive margins were not associated with an increased risk of recurrence. Positive microscopic margin resection for extremity WDLPS may yield similar rates of local control while avoiding a radical approach to obtain microscopically negative margins.

Recurrent neck myxofibrosarcoma: a case report\xa0

BackgroundMyxofibrosarcoma (MFS) is a rare soft tissue sarcoma with a high recurrence rate and a low risk of distant metastasis. It occurs mainly in the extremities of elderly men. Head and neck MFS is extremely rare. Surgery is the cornerstone of treatment. The role of radiotherapy (RT) and chemotherapy (CHT) on MFS is still debated.Case presentationA 67-year-old Caucasian man presented to our sarcoma referral center (SRC) with a history of MFS of the neck excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis. After a multidisciplinary discussion, preoperative RT was administered with a total dose of 50 Gy followed by wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred during the 24-month postoperative follow-up.ConclusionsThe case described suggests the importance of planned combined treatments with both RT and surgery for high-grade soft tissue sarcoma. RT seems to be promising within this specific histotype. Close follow-up is advisable in all cases. Further studies are needed to confirm if the observed efficacy of combined treatments results in a prolonged time of disease-free survival and overall survival.

Prognostic impact of a microscopic positive margin in patients undergoing gastrectomy for gastric cancer: a propensity score‑matched analysis of a multi‑institutional dataset.

We analyzed the effect of a microscopic positive margin on survival outcomes after gastrectomy for gastric cancer METHODS: We analyzed a multi-institutional dataset to study patients who underwent gastrectomy with curative intent between 2010 and 2014. We used propensity score matching to strictly balance the patients' oncological features, backgrounds, and postoperative treatment to compare the survival outcomes of those with microscopic positive margins and those with negative margins. Among 3029 patients, 32 (1.1%) had positive margins. After matching, we enrolled 128 patients in this retrospective analysis: 32 with a positive margin and 96 with a negative margin. The recurrence-free survival of the positive-margin group was significantly shorter than that of the negative-margin group (hazard ratio [HR], 1.62, 95% confidence interval, 1.00-2.63, p = 0.0485). Consistent results were observed for patients with pStages I-III disease (HR, 1.65, p = 0.0835), whereas the survival curves overlapped in those with pStage IV disease (HR, 1.29, p = 0.5934). The prevalence of overall recurrence in the positive-margin group was higher than that in the negative-margin group (75% vs 58%, p = 0.0917). This trend was consistent with locoregional recurrence (9% vs 3%) and distant recurrence (69% vs 55%). The survival of patients after curative gastrectomy for gastric cancer was worse in those with microscopic positive margins than in those with negative margins.

Salvage surgery for patients with residual/persistent diseases after improper or insufficient treatment of oral squamous cell carcinoma: can we rectify these mistakes?

BackgroundPatterns of failure after treatment of oral and squamous cell carcinomas (OSCC) are diversified, with recurrences being one of the common causes. A special group of patients are sometimes encountered in the outpatient clinic for improper or insufficient initial treatment with reports of positive margins, implying residual/persistent diseases. The question of whether these patients can be surgically salvaged remain unanswered.MethodsA retrospective study was performed between January 2013 and December 2017 for patients with residual or rapid recurrent (within 3 months) OSCCs, who received salvage surgeries in our institution. The patients with residual/persistent OSCCs were those with microscopic or macroscopic positive surgical margins, while those with rapid recurrent OSCCs were those with close or negative margins, but unabated painful symptoms right after treatment. Both clinicopathological and prognostic variables were analyzed. The focus was also directed towards lessons for possible initial mistakes, resulting in these residual/persistent diseases.ResultsOf 103 patients, 68 (66%) were men, with mean age of 56.3 years. The overall survival reached 60.2%. Regarding the primary OSCC status, most of our patients (n = 75, 72.8%) were diagnosed with ycT2–3 stages. Besides, most patients were found with macroscopic residual diseases (52.4%) before our salvage surgery. The sizes of the residual/persistent OSCCs were generally under 4 cm (87.3%) with minimally residual in 21 (20.4%). Among all the variables, primary T stage (p = 0.003), and residual lesion size (p < 0.001) were significantly associated with the prognosis in multivariate analysis. Though the causes for the initial surgical failure were multifactorial, most were stemmed from poor planning and unstandardized execution.ConclusionsCases with residual/persistent OSCCs were mostly due to mistakes which could have been avoided under well-round treatment plans and careful surgical practice. Salvage surgery for cases with smaller residual/persistent OSCCs is still feasible with acceptable outcomes.