Tumor-positive Margins Research Articles

Clinicopathological investigation of 20 cases of primary tracheal cancer.

Primary tracheal cancer is considered to be relatively rare. Its epidemiology, therapeutic strategy and prognosis are not well understood. We retrospectively investigated the clinicopathological aspects of 20 patients with primary tracheal cancer. Patients included 11 men and nine women with a mean age of 57.3 years. There were 12 squamous cell carcinomas and eight adenoid cystic carcinomas. Four patients received only palliative therapy. Sixteen patients underwent surgical treatment such as segmental tracheal, laryngotracheal, or carinal resection. One patient with squamous cell carcinoma died of postoperative mediastinitis. Although resected specimens from five patients had tumor positive margins, only one of those patients died after local recurrence and only three patients had postoperative treatment. The 5-year survival rate for patients who underwent surgery was 72.3%. Surgical treatment is the first choice therapeutic modality for primary tracheal cancer in consideration of its prognosis. While performing the operation, safety of the anastomosis should take precedence over completeness of resection.

Management of women with ductal carcinoma in situ of the breast: a population-based study

BackgroundIncreasing incidence of ductal carcinoma in situ (DCIS) confronts patients and clinicians with optimal treatment decisions. This multidisciplinary study investigates therapeutic modalities of DCIS in daily practice and provides recommendations on how to increase quality of care. Patients and methodsAll women (n = 116) with unilateral DCIS recorded in the Geneva Cancer Registry from 1995 to 1999 were considered. Information concerned patient and tumor characteristics, treatment and outcome. Factors linked to therapy were determined using a case–control approach. Cases were women with treatment of interest and controls other women on the study. ResultsMost DCIS cases (62%) were discovered by mammography screening. Ninety (78%) women had breast-conserving surgery (BCS), 18 (16%) mastectomy and seven (6%) bilateral mastectomy. Eight (7%) patients had tumor-positive margins, 18 (16%) lymph node dissection and two (1.7%) chemotherapy. Twenty-five per cent of women with BCS had no radiotherapy, three had radiotherapy after mastectomy. Less than 50% underwent breast reconstruction after mastectomy. Method of discovery, multifocality, tumor localization, size and differentiation were linked to the use of BCS or lymph node dissection. ConclusionsBecause of important disparities in DCIS management, recommendations are made to increase quality of care, in particular to prevent axillary dissection or bilateral mastectomy and to increase the use of radiotherapy after BCS.

Non-metastatic Ewing's sarcoma of the ribs: the French Society of Pediatric Oncology Experience

From 1984 to 1997, 57 consecutive patients with non-metastatic Ewing's sarcoma of the ribs were treated according to multimodal French Society of Pediatric Oncology (SFOP) protocols EW 84, EW 88 and EW 93. The results of treatment were reviewed and analysed. Median age was 12 years. 34 patients had large tumours (greatest tumour dimension ⩾8 cm); pleural effusion was noted in 26. A tumour-positive margin after surgery was noted in 15 patients. Histological response after chemotherapy was assessed in 34 patients. 34 patients received radiation therapy. With a median follow-up of 5 years, the projected overall and relapse-free survival rates were 69 and 62%, respectively. The major site of relapse was local. None of the following was significant in predicting relapse: tumour size, gender, age at diagnosis, existence of pleural effusion, level of rib tumour, rib component, type of local control, surgical margin (positive or negative). Response to chemotherapy was the sole significant prognostic factor (P=0.004). Patients with pleural effusion had a higher percentage of relapse if they were treated without local radiation therapy. Our study confirms the prognostic significance of response to initial chemotherapy. Radiation therapy may be withheld in selected cases, but seems necessary in patients with pleural effusion.

Aggressive multimodal treatment of pleuropulmonary blastoma

Pleuropulmonary blastoma is a rare intrathoracic neoplasm almost solely confined to childhood. Survival is poor. The authors report 2 children with extensive intrathoracic disease who are long term survivors after multimodal therapy. Both children received multiagent neoadjuvant chemotherapy, followed by surgical resection to remove all gross tumor. Postoperative chemotherapy was given to both children; radiotherapy was also given in the second case because of a question of positive tumor margins. Experience supports the use of multimodal therapy, including an aggressive surgical approach in the potentially curative treatment of this tumor.

Surgical treatment of early oral carcinoma-results of a prospective controlled multicenter study.

To assess whether early stage (pT1-2,pN0-1) oral cavity carcinoma is adequately treated by radical surgical resection alone. Prospective multicenter study. Of 105 patients with cT1-2 cN0-1 oral carcinoma treated in conformity with the study design, 12 had to be excluded because of tumor-positive margins or pN stage > N1. The remaining 93 patients were monitored for at least 2 years. Seventeen patients had local or regional recurrence develop. In 12 of the 17 patients locoregional control was achieved by second treatment. Overall, the 4-year disease-specific survival probability was 94%. Patients treated initially without selective neck dissection had significantly higher recurrence rates than those with neck dissection, although the survival probability was not adversely affected. Early (pT1-2, pN0-1) squamous cell carcinoma of the oral cavity is adequately treated by surgery alone, provided the resection margins are tumor free. On the basis of the presented data, we would also advocate routine selective neck dissection.

Clinical and histologic features of 141 primary basal cell carcinomas of the periocular region and their rate of recurrence after surgical excision

The aim of this study was to assess clinical and histologic features of primary basal cell carcinomas of the periocular region and to calculate the rate of recurrence of these tumors after surgical excision without intraoperative frozen section control. All primary basal cell carcinomas of the periocular region which were treated by surgical excision at the University Eye Hospital and Clinic of Ulm between 1993 and 1998 were reviewed and special attention was paid to age and sex of the patient and localization and histology of the tumor. The recurrence rates were calculated depending on whether the margins were free or involved on histologic examination of the excised specimens. We could include 137 patients with 141 tumors into this study. In 92 patients with 95 tumors, follow-up data of at least 3 months was available with a mean follow-up period of 31.3 months. The mean age of the patients was 68.9 years, range 28.7-91.3 years. The tumor was located at the lower eyelid, medial canthus, upper eyelid and lateral canthus in 63.1%, 29.8%, 5.7% and 1.4%, respectively. The solid (53.9%) and the solid-cystic (17.7%) type were the most common encountered histology followed by the mixed type with sclerosing foci (12.1%) and the morphea or sclerosing type (10.6%). A free margin on histologic examination was achieved in only 47.6% of cases. The overall recurrence rate was 9.5% [definite recurrences: 6 cases (6.3%); questionable recurrences: 3 cases (3.2%)]. With histologically complete excision the recurrence rate was only 2.3% (1 case) and in the case of an incomplete excision definite recurrent tumors were observed in 11.8% (6 cases) and questionable recurrences in 3.9% (2 cases) of cases during the follow-up period. Surgical excision of basal cell carcinomas of the periocular region without utilizing intraoperative frozen section control or Mohs' micrographic surgery is associated with a high rate of positive tumor margin on histologic examination. However, our study showed that this is only infrequently followed by local recurrences. This result may raise the question whether simple surgical excision is still an option in the case that more cumbersome methods such as Mohs' micrographic surgery or intraoperative frozen section control are not available. However, with positive tumor margin on histologic examination of the excised tissue or with the presence of a sclerosing type regular follow-up is mandatory.

Laparoscopy in the management of gastric submucosal tumors.

Gastric tumors, including early gastric cancers, can be safely removed laparoscopically. They do not require an open laparotomy. From March 1995 to December 1998, we used laparoscopy to resect gastric submucosal lesions in 32 patients. There were 22 men and 10 women. The patients ranged in age from 23 to 67 years (median, 51.4 yr). The lesions were located in the upper third in one patient, in the middle third in 20 patients, and in the lower third in 11 patients. The tumors ranged in size from 2 to 6 cm in diameter. The operative procedures were wedge resection in 19 patients, wedge resection with gastrotomy in two patients, intragastric surgery in nine patients, intragastric surgery with gastrotomy in one patient, and proximal gastrectomy in one patient, using a four- or five-port technique. The exophytic mass was resected with an Endo-GIA, and the tumors on the mucosal surface were exposed via a gastrotomy and excised. The gastrotomy was closed with an intracorporeal suture. In all cases, the operation was finished after the confirmation of tumor-free margins on frozen-section biopsy specimens. The duration of the operation ranged from 80 to 180 mins. The final pathologic findings were leiomyoma in 24 patients, adenomyoma in three patients, hyperplastic polyp in two patients, lipoma in one patient, hamartoma in one patient, and leiomyosarcoma in one patient. One case (3.1%) was converted to a mini-laparotomy due to technical difficulty; in one other case, more margin was resected laparoscopically due to the tumor-positive margin; and in one further patient, leakage was repaired by laparoscopic suturing on the 1st postoperative day. There were no other major complications and no deaths. The hospital stay ranged from 6 to 7 days. The maximum follow-up to date in these patients, including a case of leiomyosarcoma, was 42 months. There has been no evidence of tumor recurrence. The application of laparoscopy to submucosal tumors of the stomach is technically feasible, safe, and useful. It should be considered a viable alternative to open surgery and gastroscopic management because of its low invasiveness and good postoperative results.

Patterns of local horizontal spread of melanomas: consequences for surgery and histopathologic investigation.

Understanding local spreading patterns of melanomas is a precondition for the localized surgical treatment and histopathologic investigation. We used hematoxylin and eosin-stained paraffin sections for a two-phase, cellular and microscopic study of patterns of lateral spread in superficial spreading melanomas (SSMs), nodular melanomas (NMs), lentigo maligna melanomas (LMMs), and acral lentiginous melanomas (ALMs). Complete histologic examination of vertical excisional margins was carried out with paraffin sections 5 mm beyond the clinical tumor border of 1395 SSMs, 376 NMs, 179 LMMs, 46 ALMs, and 37 acrally located SSMs or NMs. Further sections of embedded material were analyzed when tumor-positive margins were found. In case of continuous tumor spread, reoperations were continued until the tissue was free of tumor cells. In case of noncontinuity, a final excision was made to a minimum safety margin of 10 to 20 mm. Concentrically consecutive, 5-microm thick hematoxylin and eosin-stained sections were taken from the outside of a 10-mm safety margin inward to the clinical borders of 34 SSMs, five NMs, 10 LMMs, and five ALMs. Noncontinuous subclinical spread was found in all SSMs and NMs in the form of few isolated cell nests at the epidermis-dermis junction. Ninety-two percent of these were located within 6 mm of the central tumor. All LMMs and ALMs showed a clearly demonstrable, uninterrupted spread into the periphery at the epidermis-dermis junction, too, usually in groups of outgrowths. The probability of finding these outgrowths 5 mm beyond the clinical tumor border was 54% in LMM and ALM. Complete histologic examination of vertical excisional margins (micrographic surgery) is therefore the therapy of choice only for LMM and ALM and is inefficient for SSM and NM.

Prognostic value of resection-line involvement in patients undergoing curative resections for gastric cancer

Prognostic value of microscopical resection-line involvement of the proximal and distal resection lines was examined in patients undergoing potentially curative resection in a multicentre trial with strict quality control. Tumour-positive resection lines were seen in 41 of the 699 evaluable patients (5.9%). Resection-line involvement was associated with T stage (P < 0.001), N stage (P = 0.003), tumour location (P < 0.001) and tumour differentiation (P < 0.001). Presence of resection-line involvement was also associated with significantly worse survival. Together with T3 and T4 stage (relative risk (RR) 2.04), N(+) stage (RR 4.02) and tumour differentiation (RR 1.33), resection-line involvement (RR 2.28) was also an independent prognostic factor for survival. Survival in patients with resection-line involvement was comparable with patients with positive cytology. In patients undergoing potentially curative resection for gastric cancer, peri-operative frozen-section examination should be mandatory, especially in those with poorly differentiated, signet ring cell or anaplastic tumours, with tumours covering the entire stomach and T3 or T4 tumours. In case of tumour-positive margin(s) at final histology, re-laparotomy could be considered if achieving tumour-free resection lines seems realistic.

Immunohistochemical analysis of hormone receptors and proliferating cell nuclear antigen in aggressive angiomyxoma of the vulva

Aggressive angiomyxoma (AA) is a frequently misdiagnosed tumor which tends to locally recur. The purpose of our case study and review is to characterize this tumor by immunohistochemical analysis of its estrogen and progesterone status and its proliferating capacity by proliferating cell nuclear antigen (PCNA), as well as, note any recurrent sites of spread. A 43 year old woman presented with a suspected Bartholin's gland abscess. Physical examination was consistent with a mass in the left labium majus. Marsupialization of the mass failed. Resection of this tumor revealed an AA with positive tumor margins. Lost to follow up, the patient was located 6 months later. Examination revealed a palpable mass in the ischiorectal fossa. Extended-left, radical hemivulvectomy revealed recurrent tumor. Estrogen and progesterone receptor status was weakly positive. PCNA stained with the same intensity as the fibroconnective, tissue background. We report on a case of AA as well as examine the literature to review a total of 32 cases. We note that AA is often misdiagnosed and tends to recur in the ischiorectal and retroperitoneal spaces. By means of immunohistochemical analysis, we conclude: the estrogen and progesterone receptor status was weakly positive, but could not be distinguished from the background-fibroblastic tissue, PCNA correlates well in this tumor with its low mitotic index; however, further similar studies are needed to characterize this tumor. This may aid in treatment.

The status of the resection margin as a prognostic factor in the treatment of head and neck carcinoma

The value of the status of the resection margin as a prognostic factor after surgical treatment was investigated in 80 patients with squamous cell carcinoma of the oral cavity, oropharynx and laryngohypopharynx. The relation of locoregional recurrence with the presence or absence of tumour at the surgical margin was analysed together with other indications for postoperative radiotherapy. Locoregional recurrence was observed in 20% and was correlated with tumour thickness over 5 mm, spidery growth and tumour-positive margins. Tumour-positive margin as a single indication for postoperative irradiation was not related to an increased recurrence rate. When however occurring together with other indications for postoperative irradiation, the recurrence rate was higher than in the patient group with the same number of indications for postoperative radiotherapy but without tumour at the surgical margins.

Prediction of Subclinical Tumor Infiltration in Basal Cell Carcinoma

Two thousand-sixteen basal cell carcinomas (BCCs) were documented in terms of age, anatomic location, tumor diameter, initial excision depth, safety margin, histologic type, and the position of tumor outgrowths as determined by three-dimensional histologic study of the tumor margins in paraffin sections (micrographic surgery). The extent of each subsequent excision was recorded until tumor-free tissue was reached. The results showed that BCCs have a highly irregular infiltration pattern and a predilection for small, fingerlike outgrowths whose bases occupy 1-30 degrees of the tumor circumference. When superficial extension was expressed mathematically, the resulting exponential functions varied highly significantly (P = .001) according to histologic tumor type and diameter. The resulting curves permitted very precise prediction of the probability of tumor-positive margins (ie, subtotal excision), depending on the safety margin, histologic tumor type, and tumor diameter. For example, the probability of tumor-positive margins after excision of a BCC up to 10 mm in diameter is 30% with a safety margin of 2 mm, 16% with a safety margin of 3 mm, and 5% with a safety margin of 5 mm. The probability of tumor-positive margins for fibrosing primary BCCs 10-20 mm in diameter is 48, 34, and 18% with safety margins of 2, 3, and 5 mm, respectively. Recurrent tumors have a significantly higher probability of positive margins (P = .001) than primary ones. Anatomic location and tumor age affect subclinical extension only indirectly.

Histologic pattern analysis of basal cell carcinoma: Study of a series of 1039 consecutive neoplasms

This study attempts to define histologic patterns in 1039 consecutive cases of basal cell carcinoma and to correlate these patterns with adequacy of margins of surgical excision. Five major histologic patterns were identified: nodular, 218 cases (21%); superficial, 181 cases (17%); micronodular, 151 cases (15%); infiltrative, 77 cases (7%); and morpheic, 11 cases (1%). A mixed pattern (two or more major histologic patterns) was present in 401 cases (38.5%). Our study indicates that nodular and superficial basal cell carcinomas can be completely removed by simple surgical excision in a high percentage of cases (93.6% and 96.4%, respectively) whereas the micronodular, infiltrative, and morpheic basal cell carcinomas have a higher incidence of positive tumor margins (18.6%, 26.5%, and 33.3%, respectively) after excision. Mixed patterns that consisted of combinations of the nodular, micronodular, or infiltrative types exhibited a behavior similar to the pattern that resulted in a greater chance of incomplete surgical removal.

Tumor margin assessment as a guide to optimal conservation surgery and irradiation in early stage breast carcinoma

Between 1982 and 1985, 108 women with AJC Stage I and II invasive mammary carcinoma were treated to 115 breasts with conservative surgery and irradiation. The irradiation dose was adjusted to the histopathological normal tissue margin around the carcinoma in the tumor excision specimens. Margins were arbitrarily determined negative, close, and positive with normal tissue margins in the inked tumor excision specimens of 5 mm, 2–5 mm, and 2 mm, respectively. Negative, close, and positive tumor margin patients were treated to radiation doses of 60, 65, and 70 Gy, respectively. The boost in excess of 50 Gy was directed to the tumor bearing quadrant of the breast using interstitial Ir-192 implants for doses ≥ 70 Gy. The draining lymphatics were irradiated to 50 Gy except in patients with tumor in the lateral half of the breast and no axillary lymph node metastases. Histopathological evaluation of re-excision specimens revealed the difficulty of obtaining negative margins for tumors 2 em. By our criteria, 54% of the patients had a positive resection margin. None of the patients experienced a local recurrence at 60 months median follow-up. Three patients failed regionally, two in un-irradiated lymph node areas, one in the skin of the contralateral breast; five patients failed systemically. Overall and disease-free survival for Stages T1/N0, T1/N1, T2/N0 was 100 and 95%, respectively, and for T2/N1, 90 and 80%, respectively. The cosmesis was excellent in 66% of the patients with minimal treatment related complications. Carefully planned standardized irradiation with assessment of resection margins yields both excellent local control rates and cosmetic results.

MOHS SURGERY REPORT: False‐Negative Tumor‐Free Margins Following Mohs Surgery

The inability to identify a neoplasm upon examination of an initial Mohs histologic section is not uncommon. Although often the neoplasm has been enclosed within the layer or extirpated by a prior biopsy, there are instances when the negative marginal reading is incorrect. This report describes circumstances when the initial Mohs layer failed to show positive tumor margins in the face of residual in situ neoplasm.

Surgical treatment of low grade soft tissue sarcomas

Nineteen patients who have undergone surgical resection of low grade soft tissue sarcomas were retrospectively reviewed. Four patients received additional radiation therapy, and 15 did not. Of the 15 patients treated by surgery alone, 4 had positive margins in the original specimen; all 4 had local recurrence within a mean of 42 months. Eleven patients had negative margins. Ten have had no recurrence in a mean of 40 months. One patient had local recurrence at 36 months. Two of the four patients with positive margins were reoperated on and in achieving negative margins have remained disease-free a mean of 84 months. Three patients receiving additional postoperative radiation therapy had positive margins, and all had recurrence in a mean of 36 months. One patient with negative margins who also received radiation therapy is disease-free at 144 months. It appears that tumor-positive margins are associated with a high likelihood of local recurrence, whereas negative margins appear associated with a long disease-free interval and possible cure. Radiation therapy to positive margins did not prevent local recurrence.