Presence Of Positive Resection Margins Research Articles

Preoperative MRI-based estimation of risk for positive resection margin after radical prostatectomy in patients with prostate cancer: development and validation of a simple scoring system.

To develop a simplified MRI-based model to predict the risk for positive surgical margins (PSMs) after radical prostatectomy (RP) in patients with prostate cancer (PCa). Consecutive patients who underwent RP for PCa were retrospectively identified from a tertiary referral hospital. Patients who underwent RP between January 2014 and June 2014 were assigned as derivation cohort (n = 330) and those between January 2018 and February 2018 were assigned as validation cohort (n = 100). MRI-based predictors associated with PSM were assessed: tumor size, tumor-capsule contact length, the Prostate Imaging Reporting and Data System (PI-RADS) category, tumor location (tumor contact to the apex or posterolateral side near the neurovascular bundle), apical depth, and prostate volume. A prediction model was developed by using multivariable logistic regression, and then it was transformed into a scoring system. The prediction and calibration performance of this scoring system was evaluated using the C statistics and Hosmer-Lemeshow goodness-of-fit test. A total of 121 (36.7%) and 32 (32.0%) of patients in the derivation and validation cohorts had PSMs after RP. The scoring system consisted of the following variables: tumor-capsule contact length, PI-RADS category, tumor located at the apex and/or posterolateral side. This scoring system provided good prediction performance for PSM in the derivation (C statistics, 0.80 [95% CI: 0.76, 0.85]) and validation (C statistics, 0.77 [95% CI: 0.68, 0.87]) cohorts, and also showed good calibration in both cohorts (p = 0.83 and 0.86, respectively). An MRI-based scoring system can help estimate the risk of PSM after RP. • An MRI-based scoring system served as a tool to estimate the risk of positive surgical margin (C statistics, 0.80 and 0.77 in the derivation and validation cohorts, respectively) after radical prostatectomy. • Tumor with contact to the apex or posterolateral aspect, the tumor contact length to capsule, and higher PI-RADS category were independent predictors for the presence of positive resection margins after radical prostatectomy in men with prostate cancer. • High-risk patients as determined by the scoring system demonstrated adverse post-surgical outcomes compared with low- or intermediate-risk patients, in regard to longer length (mean length, 13.0 mm versus 3.9 mm in low risk or 6.2 mm in intermediate risk; p ≤ 0.001) and higher Gleason grade at the margin (grades 4 and 5 in 69.4% and 20.4% versus 16.7% and 16.7% in low risk or 46.7% and 5.4% in intermediate risk; p < 0.001).

Assessment of tumor margins in head and neck cancer using a 3D-navigation system based on PET/CT image-fusion – A pilot study

ObjectivesDetermination of tumor margins in patients with squamous cell carcinoma of the head and neck (SCCHN) is mostly based on preoperative magnetic resonance imaging (MRI) or computed tomography scans (CT). Local recurrence of disease is often correlated with the presence of positive resection margins after surgical treatment. Positron emission tomography/computed tomography (PET/CT) imaging plays a crucial role in the assessment of patients with SCCHN. The purpose of this study was to determine whether PET/CT could predict tumor extension. MethodsIn 12 patients who underwent surgical treatment of primary SCCHN (Stage III-IV) F18-FDG PET/CT image-fusion was performed on a 3D navigation-system based workstation. Image-guided needle biopsies were obtained from four different, color-coded metabolic areas within the tumor. The histopathological findings were correlated with findings on corresponding PET/CT scans. Results81.3% of biopsies from the central area were positive. Specimens taken from the outer metabolic zone were positive in 66.7% of the patients. The highest incidence of positive biopsies was found in the zone adjacent to the outermost area. There was a statistically significant difference in positive tumor histopathology when comparing the various metabolic zones (p = 0.03). ConclusionExact determination of tumor is an important research topic, although results remain controversial. The results of this study suggest that in some cases PET scans may overestimate tumor extension.

Mammary-type Myofibroblastoma: Clinicopathologic Characterization in a Series of 143 Cases.

Mammary-type myofibroblastoma (MTMF) is a benign mesenchymal neoplasm initially described to occur in the breast. MTMF is typically CD34 and desmin positive and genetically has rearrangement or deletion of 13q14, resulting in loss of Rb expression by immunohistochemistry (IHC). Although the wider anatomic distribution of MTMF is increasingly recognized, no large series with clinicopathologic information has been reported to date. Archival cases were retrieved, and the diagnosis of MTMF was confirmed. Hematoxylin and eosin-stained slides and IHC slides were reviewed when available (CD34, Desmin, Rb, SMA, S100, EMA, MDM2, CDK4). The patient age, sex, tumor anatomic location and size, preceding symptoms, and margin status were recorded when possible. Clinical follow-up data were requested for tumor recurrence, metastasis, and patient status at last follow-up. A total of 143 cases of MTMF comprised this study, affecting 94 (66%) male and 49 (34%) female individuals. Mean tumor size was 6.6 cm (range, 1 to 22 cm). Anatomic locations included: inguinal/groin region (65; 45%), breast (15; 10%), chest wall/axilla (7; 5%), trunk (17; 12%), lower (18; 13%) and upper (2; 1%) extremities, or intra-abdominal/retroperitoneal (14; 10%). MTMFs were characterized by spindle cells with relatively short, stubby nuclei and a variable adipocytic component. Hyalinization and myxoid stroma were common. Less common morphologic features included nuclear atypia, epithelioid tumor cell morphology, and neurilemmoma-type nuclear palisading. CD34 and desmin were positive in 89% and 91%, respectively, and were both negative in 3%. Rb expression was lost in 92% (57/62). No cases with follow-up data available had tumor recurrence, although 1 case was reportedly a recurrence itself. In summary, MTMF appears more common at extramammary sites than in the breast and can cause diagnostic difficulty when atypia or epithelioid morphology is present or when located in an unusual anatomic location. MTMF is frequently positive for CD34 and desmin by IHC; however, rare cases are negative for both. There is no evidence of any significant recurrence risk for MTMF, even in the presence of positive resection margins. The degree of morphologic overlap between spindle cell lipoma, cellular angiofibroma, and MTMF, in combination with shared genetics and slightly overlapping anatomic distribution, raises the question of whether or not these tumors are truly distinct entities or instead represent points along a single spectrum of genetically related tumors.

Tumor Staging But Not Grading Is Associated With Adverse Clinical Outcome in Neuroendocrine Tumors of the Appendix

Appendiceal neuroendocrine neoplasms (NENs) are rare and usually incidentally discovered. Most cases are clinically indolent, although the rare aggressive ones are poorly predictable. The aim of this study was to test the applicability and prognostic significance of the new World Health Organization (WHO) classification and to test the several pathologic features and TNM staging systems (American Joint Committee on Cancer and European Neuroendocrine Tumor Society) in these tumors. A multi-institutional retrospective series of 138 appendiceal NENs was selected on the basis of the availability of both pathologic material and clinical information, including follow-up data. All cases were reviewed to record pathologic features and to apply year 2000 and 2010 WHO classifications, as well as European Neuroendocrine Tumor Society and American Joint Committee on Cancer TNM stages. Clinical and pathologic characteristics were compared with disease outcome by contingency, univariate, and multivariate survival analyses. Although up to one third of cases presented several malignancy-associated pathologic features, only 4 patients died of the disease. Adverse outcome was significantly associated with extramural extension (including mesoappendix), well-differentiated carcinoma diagnosis (2000 WHO classification), pT3-4 stage, older age, and presence of positive resection margins, but not with tumor size, mitotic or proliferative indexes, and, consequently, 2010 WHO grading. In the appendix, at variance with midgut/hindgut NENs, the 2000 WHO classification performs better than the grading-based 2010 WHO scheme and, together with tumor stage, is the most relevant parameter associated with clinical aggressiveness.

Radioguided Occult Lesion Localisation Versus Wire-Guided Lumpectomy in the Treatment of Non-Palpable Breast Lesions

The purpose of this study was to compare the two methods-guidewire localisation and the radioguided occult lesion localisation-used in the localisation and surgical removal of non-palpable breast tumours. This retrospective study enrolled patients diagnosed with nonpalpable malignant breast tumours. In this study either guidewire localisation (GWL, n = 69) or radioguided occult lesion localisation (ROLL, n = 321) was used for the detection and removal of the tumours. The two methods were compared with regards to preoperative localisation time, operating time, removed specimen volume, the pathological tumour size, the presence of positive surgical margins and postoperative complications. Furthermore, we have also investigated other factors that could have an impact on the frequency of positive resection margins. The localisation time was significantly shorter in the ROLL group, both with ultrasound guidance (5.7 ± 1.44min vs. 21.6 ± 2.37min, p = 0.05) and with radiographic guidance (21.8 ± 3.1min vs. 41.6 ± 3.75min, p = 0.021) as well. No significant difference was observed between the two methods in terms of operating time, removed specimen volume and pathological tumour size, or the presence of positive resection margins, or the occurrence of postoperative wound infections. The size of the tumour (ROLL, GWL grps), the presence of a multifocal tumour (ROLL grp), the presence of an extensive in situ breast carcinoma around the invasive cancer (ROLL, GWL grps) and the volume of the removed breast specimen (GWL grp) significantly increased the frequency of positive resection margins. We recommend the use of the ROLL method for the removal of nonpalpable breast tumours as it has a much shorter localisation time, and it is a simpler surgical technique as well.

Phyllodes Tumors of the Breast.

Objective:To study all patients with phyllodes tumors of the breast which were diagnosed at King Hussien Medical Center and Prince Rashid Military Hospital between the 1st of may 2002 till January 2009.Methods:A total of 26 patients diagnosed to have phylloedes tumors were retrieved from the hospital records. All cases were analyzed and assessed in two main categories: demographical characteristics and histopathological parameters. The demographical characteristics included: sex and age of the patients, and tumor size while the histopathological aspects were divided into three subgroups: Benign, Borderline and Malignant tumors with its stromal components characteristics. All the histopathological reports for specimens sent by surgeons were reviewed by 2 senior pathologists. Statistical analysis was done by using Chi square and P-Value.Results:All our patients were females; their age range between 17-67 years, the mean patient age at presentation was 39 years. Out of the 26 patients diagnosed to have phyllodes tumor, 6 had breast-conserving therapy and 20 women had mastectomy. The types of Phyllodes tumors include: A-Benign phyllodes tumors (15 cases), B-Borderline phyllodes (7cases) and C-malignant phyllodes (4 cases). With significant values of benign tumors occurrence (p<0.01)), while borderline and malignant ones were not significant (NS) in comparison to the benign type. There were two cases below the age of 20 and one above the age of 65, with right breast involvement in eleven out of twenty six cases (42%), fifteen out of twenty six cases have involvement of the left breast (58%) and no cases found of bilateral phyllodes tumors of the breast. The greatest dimension of the tumors ranged from 1 to 15 cm, with a mean of 5 cm. Approximately 73.1% of tumors were less or equal to 5 cm in the greatest dimension and 26.9% >5 cm. The duration of symptoms varied from one month to ten year.s Six patients had painful swellings, whereas in twenty patients the pain was absent. Four patients had recurrent tumors; the distinctive features of those with recurrent tumors were the histological findings of stromal over growth and the presence of positive resection margin. In our series, we found that three patients of those with recurrence discovered to have stromal over growth. While one only had a previous positive resection margin without stromal overgrowth.Conclusion:Rapid growth of phyllodes tumor does not necessarily imply malignancy. In our series, clinical tumor’s size was not the significant factor for recurrence. Local recurrence occur in patients who were treated with breast-conserving surgery, and it is highly significant when there is stromal over growth (P value <0.01 and Chi square of 8.21) in comparison with the resection margin without stromal overgrowth (P value <0.1 and Chi square of 3.23) which gives a clue for further studies about the stromal factor role in recurrence of the tumor.

Obtaining Adequate Surgical Margins in Breast-Conserving Therapy for Patients with Early-Stage Breast Cancer: Current Modalities and Future Directions

Inadequate surgical margins represent a high risk for adverse clinical outcome in breast-conserving therapy (BCT) for early-stage breast cancer. The majority of studies report positive resection margins in 20% to 40% of the patients who underwent BCT. This may result in an increased local recurrence (LR) rate or additional surgery and, consequently, adverse affects on cosmesis, psychological distress, and health costs. In the literature, various risk factors are reported to be associated with positive margin status after lumpectomy, which may allow the surgeon to distinguish those patients with a higher a priori risk for re-excision. However, most risk factors are related to tumor biology and patient characteristics, which cannot be modified as such. Therefore, efforts to reduce the number of positive margins should focus on optimizing the surgical procedure itself, because the surgeon lacks real-time intraoperative information on the presence of positive resection margins during breast-conserving surgery. This review presents the status of pre- and intraoperative modalities currently used in BCT. Furthermore, innovative intraoperative approaches, such as positron emission tomography, radioguided occult lesion localization, and near-infrared fluorescence optical imaging, are addressed, which have to prove their potential value in improving surgical outcome and reducing the need for re-excision in BCT.

Maxillary Sinus Cancer Review in 23 Patients Treated With Postoperative Radiotherapy

ObjectiveTo describe the survival and outcome of maxillary sinus cancer in patients managed with surgery and postoperative radiotherapy during the last 10 years in our hospital. Patients and methodDescriptive, retrospective, nonrandomized study of 23 patients with cancer of the maxillary sinus managed at the Vigo University Hospital Complex, Spain, with radical surgery and post-operative radiotherapy, between 1995 and 2004. ResultsThe 3-year actuarial survival was 47.8% and the adjusted actuarial survival was 60.8%. Permanent local tumour control was achieved in 60.8% of cases (14/23). Local tumour recurrence was the main cause of treatment failure (33.3%; 4/12). The most significant prognostic factors affecting local tumour control and survival were: clinical stage (P<.031), suprastructural location of the tumour (P<.001), and presence of positive resection margins (P<.001). ConclusionsLocal recurrence was found to be very high and generally the main cause of death. New treatment protocols should be assessed.

Facteurs pronostiques après résection pour cholangiocarcinome hilaire

Aims To evaluate short and long-term results in 23 patients resected for hilar cholangiocarcinoma. Methods Between January 2001 and December 2003, 23 patients with hilar cholangiocarcinoma were resected and considered for retrospective analysis. Univariate and multivariate analysis were performed on several clinicopathological variables in order to evaluate the short-term results. Median follow-up was 11 months (interquartile range 2–20 months). Results A major liver resection was performed in 19 out of 23 patients (82%): a right hepatectomy extended to segment 4 in 5 patients and a left hepatectomy in 14 patients. Resection of the caudate lobe was performed in 7 patients (30%). No hospital mortality occurred. Overall morbidity rate was 43%. The 1-year survival rate was 63.2% with a median survival of 19 months. Tumor recurrence appeared in 12 patients (52%). Low preoperative albumin level ( P = 0.006), presence of positive resection margin ( P = 0.03) and T-stage ( P = 0.02) were found to be related to a worse median survival. On multivariate analysis, only the preoperative albumin level and the presence of positive margin were confirmed as independent prognostic factors. Conclusion Aggressive surgical approach remains the only potentially curative therapy for the hilar cholangiocarcinoma. Low preoperative albumin level, presence of positive resection margin and T-stage resulted as factors influencing the prognosis after resection.

Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes.

Rectal cancer outcome depends on stage, technical aspects of surgical excision, and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific survival and recurrence. We reviewed all 495 rectal cancer patients registered in British Columbia in 1996. There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers, P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened survival, P = 0.0007, and overall recurrence, P =0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19. Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome.

Implications of tumour in resection margins following surgical treatment of squamous cell carcinoma of the head and neck.

Presence of tumour at the resection margin following primary surgical treatment for squamous cell carcinoma of the head and neck is thought to adversely affect prognosis. To confirm this we performed a review of 478 patients treated by primary surgery for squamous cell carcinoma of the head and neck and sub-divided them into those exhibiting positive margins and those with negative margins following resection. Uni-variate and multi-variate statistical methods were used to analyse survival figures and a variety of parameters associated with the presence of positive resection margins. We found 5-year survival was decreased if resection margins were found to be positive (P < 0.025). The presence of positive resection margins was also significantly associated with time to tumour recurrence (P < 0.001) and survival with nodal recurrence (P < 0.001). Other factors which were significantly associated with survival using Cox's multi-variate analysis were site of tumour (P < 0.005), nodal extracapsular rupture (P < 0.05), histology (P < 0.05) and pathological T-stage (P < 0.05). Uni-variate analysis revealed no significant associations between the presence of positive margins and the patient's age, sex, tumour site, degree of tumour differentiation, and nodal status, though using multiple logistic regression, the general condition of the patient (P < 0.01) and the tumour site P < 0.05) were significantly related. The results support the concept that every effort should be made to obtain negative resection margins when undertaking primary ablative surgery for squamous cell carcinoma of the head and neck.

Adjuvant brachytherapy for treatment of chest wall sarcomas

Thirty patients treated with surgical resection and brachytherapy for chest wall sarcoma at Memorial Sloan-Kettering Cancer Center from 1980 through 1987 were reviewed. Patients selected to receive adjuvant irradiation were those for whom there was doubt as to the completeness of surgical resection. Overall 5-year survival and locoregional control after brachytherapy were 65% and 54%, respectively. Locoregional control was similar for tumors treated at initial diagnosis (12 patients), at the time of recurrence (13 patients), or for tumors that were metastatic to the chest wall (five patients). Six patients with tumors larger than 10 cm in maximum dimension had a locoregional recurrence rate of 69% versus a recurrence rate of 39% for 18 patients with smaller tumors (p = 0.27). Fifty-four percent of high-grade tumors recurred locoregionally versus 28% of low-grade tumors (p = 0.37). Bone invasion or the presence of positive resection margins was not clearly associated with a higher locoregional failure rate. Only one patient (1/28; 7%) was known to have had recurrence within the irradiated area. Eight patients (8/28; 37%) had recurrence adjacent to the implanted area, and the precise failure site could not be determined for the remaining two patients. Because of the relatively high risk of regional versus in-field recurrence, patients with chest wall sarcoma who receive adjuvant treatment should be treated primarily with external-beam irradiation to allow more generous coverage of the tumor bed. Brachytherapy could be used as a tumor bed "boost" treatment. In patients undergoing resection of recurrent tumor in a previously irradiated site, adjuvant brachytherapy, without external-beam irradiation, should be considered to reduce the risk of extensive soft tissue necrosis.