Pathological Resection Research Articles

Neoplastic Myelopathy

Neoplastic myelopathy may be due to external compression or to direct intraparenchymal involvement of the spinal cord. In this review, the authors discuss the most common cause for compressive neoplastic myelopathy, metastatic disease. They also review other compressive lesions and discuss primary intramedullary spinal tumors. In the acute setting, compressive metastatic disease should be treated with high-dose steroids when clinically necessary; surgery should be considered for selected patients, followed by radiation therapy. For most primary intramedullary spinal tumors, surgical resection remains the standard initial therapy. Patients with incomplete resection of infiltrative tumors, high-grade pathology, or recurrent tumors may benefit from radiation, but most spinal tumors are relatively insensitive to traditional chemotherapy. Neoplastic myelopathy from either compressive or intraparenchymal causes remains a diagnostic and therapeutic challenge. In complex cases, referral to a specialty center with access to neurosurgeons, neuroradiologists, neuropathologists, and neurooncologists is recommended.

Evaluation of versatility and effectiveness of pedicled buccal fat pad used in the reconstruction of intra oral defects.

The use of buccal fat pad as a grafting source in the closure of intraoral defects has gained popularity in the last quarter of this century. Because of the ease of access and rich blood supply, its use in oral defects is an attractive concept. The study comprised of 8 patients with oral submucous fibrosis, 1 patient with oroantral fistula, 1 patient with verrucous hyperplasia. The acquired oral defects following resection of pathology in the oral cavity, were reconstructed with pedicled buccal fat pad. The Post operative follow up at the intervals of 1st, 7th and 15th day, followed by 1st month, 2nd month and 3rd month was done. The procedure was successful in all the patients. Healing was satisfactory with no breakdown or liquefaction necrosis post operatively. All the patients had definitive colour change at the end of 1st post operative month owing to the epithelialisation. Residual defect was present in one patient diagnosed of verrucous hyperplasia on the 1st and the 7th post operative day which subsequently healed. In 8 patients with oral submucous fibrosis post operative mouth opening was measured in and was observed to be in the range of 12-26mm on the 1st post operative day and 34-42mm during 3rd month post operatively. The results of this study support the view that the use of buccal fat pad is a simple, convenient and reliable method for the reconstruction of small to medium sized intra oral defects.

BRAF mutation detection in indeterminate thyroid cytology specimens

BRAF mutations are highly specific for papillary thyroid carcinoma (PTC) and many cytology specimens with BRAF mutations are expected to demonstrate cytologic features typical of PTC. However, indeterminate thyroid cytology cases are inevitable and understanding the significance of the BRAF mutation within the context of the Bethesda System for Reporting Thyroid Cytopathology would be valuable. Thyroid cytology cases submitted for conventional cytomorphologic evaluation and BRAF mutational analyses were selected from the authors' cytopathology files from April 2007 to October 2011. From this group, the diagnostic usefulness of BRAF mutations in indeterminate and malignant cases was assessed and analyses of cytologic and histopathologic features associated with the mutations in this gene were performed. A total of 131 cases with a BRAF mutation were identified. Of these, 119 underwent surgical pathology resection follow-up and demonstrated PTC. Approximately 75% of the cases were cytologically diagnosed as being positive for malignancy and these cases were associated with both the classic and tall cell variants of PTC at the time of resection, a greater likelihood of extrathyroidal extension, and the V600E type of BRAF mutation. In contrast, BRAF-mutated cases with diagnoses of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) and follicular neoplasm/suspicious for follicular neoplasm were found to be more strongly associated with the follicular variant of PTC, a K601E BRAF mutation, and a lower likelihood of extrathyroidal extension. However, a subset of AUS/FLUS cases with the V600E BRAF mutation appeared to represent sampling variability of the classic or tall cell variants of PTC. Bethesda thyroid diagnoses in the setting of a BRAF mutation reflect differences in PTC subtypes, the nature of cytology specimens, and molecular characteristics.

Minimally invasive resection of thymomas with the da Vinci(R) Surgical System

The resection of thymic tumours requires completeness and may be technically challenging due to the anatomical proximity of the delicate mediastinal structures. An open approach by sternotomy is still recommended in all cases with locally extended disease. Video-assisted thoracoscopic surgery is feasible, but limited by the two-dimensional vision and the impaired mobility of the instruments. We evaluated the da Vinci® Surgical System for the resection of various mediastinal pathologies, particularly thymomas. Among 105 patients operated on by robotic assisted thoracoscopic surgery (RATS) for mediastinal tumours between 27 August 2004 and 12 July 2011, 20 patients with thymomas were studied prospectively. Of these, 10 males with a median age of 53 years, with a well-circumscribed thymic lesion on computed tomography (CT) and a diameter of <6 cm were resected by RATS alone, and selected ones (n = 3), with a diameter of >6 cm, underwent a hybrid procedure with a contralateral thoracotomy on the side of the main tumour extension. A regular follow-up with chest CT scans was performed every 6 months. Thymoma resection was complete in all patients. Partial pericardial resection was needed in five and pulmonary resection in two patients. Eighty-five percent of patients had an R0 resection. Histological classifications included thymoma WHO type A (n = 3), AB (n = 8), B1-2 (n = 5) and B3 (n = 4). All B3 thymomas received adjuvant radiotherapy. No intraoperative complications occurred. The median hospitalization time was 5 days (range 2-14 days). There were no local, but two pleural, recurrences. After a median observation time of 26 months, 19 patients (95%) are alive. Well-circumscribed thymomas can be safely and completely resected with the da Vinci® Surgical System with excellent short- and mid-term outcomes. Selected tumours with large diameters may be resectable using a hybrid procedure combining RATS with a thoracotomy.

Erlotinib as neoadjuvant treatment in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) with activating epidermal growth factor receptor (EGFR) mutation (NCT01217619, ESTERN).

e17551 Background: Patients with stage IIIA N2 NSCLC have poor outcomes with 5-year survival rate. Tyrosine kinase inhibitor monotherapy have been demonstrated a significant improvement in OR rate and PFS as first-line treatment for metastatic NSCLC patients with EGFR mutation. The objective of trial is to explore the efficacy and safety profile of erlotinib as neoadjuvant treatment in patients of stage IIIA-N2 NSCLC with EGFR mutation. The purpose of this neoadjuvant regime is to down-stage and increase complete resection rate in this patients setting. Methods: This is a single arm, one center, phase II study of erlotinib as neoadjuvant treatment in patients with Endobronchial Ultrasound (EBUS) confirmed stage IIIA-N2 NSCLC with activating EGFR mutation in exon 19 or 21. The primary endpoint is to evaluate radical resection rate. The secondary endpoint is pathological complete resection rate (pCR), objective response rate (ORR), disease free survival (DFS), overall survival (OS), quality of life (QoL) and safety profile. A total of 44 patients will be enrolled. Patients with IIIA-N2 NSCLC with pathologically confirmed ipsilateral mediastinal metastasis by EBUS. The biopsy specimen shows EGFR mutation in exon 19 or 21. All patients will be treated by erlotinib 150mg orally per day for 56 days. Patients will be assessed by Chest CT for the efficacy evaluation in day 29 and right after day 56. Patients get benefit from neoadjuvant treatment and evaluated as technically resectable will receive surgery. All the post-operative patients will receive standard adjuvant treatment. The adjuvant regime is decided by the investigator for the patients’ benefits. After adjuvant treatment patients will enter nomal follow-up including regular chest CT and ultrasound examination Results: Current enrollment: The study has enrolled 5 patients. One male patient, aged 47, with stable disease after neoadjuvant treatment, got right upper lobe resection on 17 Jan 2012. Conclusions: Erlotinib as neoadjuvant treatment in patients of stage IIIA-N2 NSCLC with activating EGFR mutation is feasible.

Phase II trial of fixed-dose rate gemcitabine, bevacizumab, and concurrent 30 gy radiotherapy as preoperative treatment for potentially resectable pancreatic adenocarcinoma.

258 Background: Effective multimodality treatment for localized pancreatic cancer is elusive. We hypothesized that preoperative fixed-dose rate (FDR) gemcitabine (GEM) combined with short-course radiotherapy (RT) and the angiogenesis inhibitor bevacizumab (BEV) would improve margin negative surgical outcomes and complete pathological response rates. Methods: Multisite phase II trial evaluating all potentially-resectable pancreatic adenocarcinoma without major arterial involvement or portal venous occlusion. Dual primary endpoints included complete pathological response and margin negative resection rates of 10% and 80%. Subjects received FDR GEM on days 1, 15, and 29 combined with BEV (10 mg/kg IV), followed on day 43 by BEV and concurrent 30 Gy RT (3 Gy/fraction) over 10 days. After restaging, subjects underwent laparoscopy and possible resection after day 85. Stopping criteria required continuous monitoring of serious wound complications. Results: 58 subjects enrolled, of which 29 (50%) had suspected venous involvement. 57 completed treatment without dose-limiting toxicity or delays in surgery. Two grade 4 (3.4%) and 17 grade 3 toxicities (28.8%) occurred. Four patients progressed before surgery. 54 subjects underwent laparoscopy; ten had unexpected carcinomatosis, and one was unresectable. 43 subjects were resected (74%; 33 pancreatico-duodenectomy, 8 distal pancreatectomy, 1 total pancreatectomy, 1 Appleby); 19 (44%) required portal vein resection. Margin negative outcome was achieved in 38 (88%, 95% CI: 75%-96%) with one complete pathological response (2.3%; 95% CI: 0.1%- 12%) and seven (6 grade 3; 1 grade 4) wound complications (13%). Median overall survival (OS) was 16.3 months (95% CI: 13.9 -22.1) and 21.3 months (95% CI: 15.0-32.9) after resection. Median progression-free survival (PFS) was 5.7 months (95% CI: 3.9-9.1) and 9.9 months (95% CI: 5.7 to 14.1) after resection, with 7 local and 21 distant recurrences. Conclusions: Combination therapy was well-tolerated and was within statistical design parameters for the primary endpoints despite a significant proportion of borderline tumors.

The quandary of autoimmune pancreatitis and pancreatic ductal adenocarcinoma: A case report and review of IgG4 immunostaining in a cohort of patients receiving neoadjuvant chemotherapy

ABSTRACT Introduction: Autoimmune pancreatitis (AIP) is an inflammatory disease whose clinical presentation can mimic that of pancreatic ductal adenocarcinoma (PDA). AIP can appear on imaging as a bulky, sausage­like pancreatic mass with biliary and pancreatic ductal obstruction, resembling the classic “double duct sign” appearance of PDA. A definitive preoperative diagnosis of AIP can be difficult because the two diseases (AIP and PDA) are similar in clinical presentation. Recent advances in serum marker evaluation such as IgG4 serum levels and immunostaining techniques have shown some promise in the differentiation of AIP from PDA. Case Report: We report the case of a patient with a preoperative diagnosis of locally advanced PDA who was treated with neoadjuvant gemcitabine based chemotherapy followed by surgical resection, but whose post­ resection pathology was indicative of AIP and not PDA. To explore the possibility that the pre­ resection gemcitabine­based chemotherapy had generated a complete pathological response and an inflammatory reaction of IgG4­positive plasma cells, we studied the histology features and IgG4 plasma cell immunostaining characteristics of the pathology specimens of 14 patients with a diagnosis of PDAwho were treated with neoadjuvant chemotherapy and surgical resection at our institution. Conclusion: Our results indicate that none of the patients treated with neoadjuvant chemotherapy had increased IgG4­positive plasma cell immunostaining post­ operatively, further supporting the diagnosis of AIP and not PDA in our patient.

Malignant abdominal paraganglioma presenting as a giant intra-peritoneal mass

INTRODUCTIONParaganglioma is a malignant tumor that arises from the extra adrenal paraganglionic cells of the sympathetic or parasympathetic systems. Herein, we present a case of abdominal mass of unknown histology that underwent a very difficult surgical mass resection. Its final histologic diagnosis was non-functional paraganglioma that was presented as a huge intra-peritoneal mass. PRESENTATION OF CASEThe patient was a 55-year-old Iranian lady who referred to our center with a giant abdominal mass. Fine needle aspiration (FNA) biopsy showed undifferentiated carcinoma. After laparotomy for mass resection pathology evaluation revealed; malignant paraganglioma, non-metastatic type. Further post-operative patients evaluations showed that the tumor was sporadic in nature and the subsequent patient's natural history was uneventful. DISCUSSIONPathologic evaluations have key roles in the exact diagnosis of abdominal masses with unidentified sources. For the paragangliomas, all of them should be regarded malignant until proved otherwise. However, combined use of biochemical markers, immunohistochemical techniques (IHC), and genetic analysis have key roles in the diagnosis and treatment of paragangliomas. Additionally, surgical removal is the proved curative way of paraganglioma treatment. CONCLUSIONAsymptomatic intra-peritoneal paraganglioma is very rare, especially its malignant variety. This case emphasizes that full pathologic investigation would reveal the exact nature of idiopathic abdominal masses, especially in the state of absence of typical clinical and para-clinical symptoms.

Abnormal Uterine Bleeding and the MyoSure™ Tissue Removal System. A Retrospective Analysis of 14 Cases

Study ObjectiveTo assess the effectiveness of a new hysteroscopic tissue removal system to remove intrauterine tissue and facilitate the diagnosis of endometrial carcinoma and premalignant abnormalities.DesignRetrospective analysis of 14 consecutive cases.SettingOutpatient surgical center.PatientsFourteen patients with abnormal uterine bleeding underwent hysteroscopic resection of intrauterine pathology. Mean patient age was 49.7 years (range 33 to 79 years); 64% were pre-menopusal and 36% were post-menopausal. All of the procedures were performed under general laryngeal mask anesthesia.InterventionPathology removal using the MyoSure™ Tissue Removal System (6.25 mm diameter hysteroscope and 3.0 mm diameter morcellator) and sterile saline for uterine distension.Measurements and Main ResultsHysteroscopic findings included seven polyps, three fibroids, and one gestational implantation site. The mean pathology size was 2.7 cm (range 1.9 to 5.8 cm). Pathological analysis of resected tissue revealed simple hyperplasia in three patients, and the presence of endometrial adenocarcinoma in one patient. There were no intraoperative complications. Patients were followed to an average of 8.3 months post procedure. There were no adverse events reported. There has been no pathology reoccurrence.ConclusionThe MyoSure™ Tissue Removal System resects intra-uterine tissue including fibroids, polyps, and endometrium under direct hysteroscopic visualization. By using mechanical energy, the cautery effect on tissue is avoided, and the tissue can be assessed clearly for pathological diagnosis. Abnormal uterine bleeding, both premenopausal and postmenopausal in nature, may be associated with malignant and premalignant conditions of the uterus. This case series demonstrates that MyoSure can safely and effectively remove these lesions and adequately enable pathological review of the specimen. Study ObjectiveTo assess the effectiveness of a new hysteroscopic tissue removal system to remove intrauterine tissue and facilitate the diagnosis of endometrial carcinoma and premalignant abnormalities. To assess the effectiveness of a new hysteroscopic tissue removal system to remove intrauterine tissue and facilitate the diagnosis of endometrial carcinoma and premalignant abnormalities. DesignRetrospective analysis of 14 consecutive cases. Retrospective analysis of 14 consecutive cases. SettingOutpatient surgical center. Outpatient surgical center. PatientsFourteen patients with abnormal uterine bleeding underwent hysteroscopic resection of intrauterine pathology. Mean patient age was 49.7 years (range 33 to 79 years); 64% were pre-menopusal and 36% were post-menopausal. All of the procedures were performed under general laryngeal mask anesthesia. Fourteen patients with abnormal uterine bleeding underwent hysteroscopic resection of intrauterine pathology. Mean patient age was 49.7 years (range 33 to 79 years); 64% were pre-menopusal and 36% were post-menopausal. All of the procedures were performed under general laryngeal mask anesthesia. InterventionPathology removal using the MyoSure™ Tissue Removal System (6.25 mm diameter hysteroscope and 3.0 mm diameter morcellator) and sterile saline for uterine distension. Pathology removal using the MyoSure™ Tissue Removal System (6.25 mm diameter hysteroscope and 3.0 mm diameter morcellator) and sterile saline for uterine distension. Measurements and Main ResultsHysteroscopic findings included seven polyps, three fibroids, and one gestational implantation site. The mean pathology size was 2.7 cm (range 1.9 to 5.8 cm). Pathological analysis of resected tissue revealed simple hyperplasia in three patients, and the presence of endometrial adenocarcinoma in one patient. There were no intraoperative complications. Patients were followed to an average of 8.3 months post procedure. There were no adverse events reported. There has been no pathology reoccurrence. Hysteroscopic findings included seven polyps, three fibroids, and one gestational implantation site. The mean pathology size was 2.7 cm (range 1.9 to 5.8 cm). Pathological analysis of resected tissue revealed simple hyperplasia in three patients, and the presence of endometrial adenocarcinoma in one patient. There were no intraoperative complications. Patients were followed to an average of 8.3 months post procedure. There were no adverse events reported. There has been no pathology reoccurrence. ConclusionThe MyoSure™ Tissue Removal System resects intra-uterine tissue including fibroids, polyps, and endometrium under direct hysteroscopic visualization. By using mechanical energy, the cautery effect on tissue is avoided, and the tissue can be assessed clearly for pathological diagnosis. Abnormal uterine bleeding, both premenopausal and postmenopausal in nature, may be associated with malignant and premalignant conditions of the uterus. This case series demonstrates that MyoSure can safely and effectively remove these lesions and adequately enable pathological review of the specimen. The MyoSure™ Tissue Removal System resects intra-uterine tissue including fibroids, polyps, and endometrium under direct hysteroscopic visualization. By using mechanical energy, the cautery effect on tissue is avoided, and the tissue can be assessed clearly for pathological diagnosis. Abnormal uterine bleeding, both premenopausal and postmenopausal in nature, may be associated with malignant and premalignant conditions of the uterus. This case series demonstrates that MyoSure can safely and effectively remove these lesions and adequately enable pathological review of the specimen.

Prognostic Value of Pathological Resection Margin Distance in Squamous Cell Cancer of the Vulva

A tumor-free resection margin of at least 8 mm is considered state of the art in vulvar cancer. This standard is based on small and heterogeneous patient cohorts, and its implementation can result in mutilation. One hundred two consecutive patients with primary squamous cell vulvar cancer were analyzed. All patients received resection of the primary tumor and the inguinofemoral lymph nodes via three separate incisions, resulting in complete tumor resection. Median follow-up was 31 months. Minimal margin distances were pathologically determined in all dimensions after fixation. Median age of the patients was 62 years; 38.2% had International Federation of Gynecology and Obstetrics (FIGO) stage I, 17.6% stage II, 24.4% stage III, and 8.8% stage IV disease. The median minimal resection margin was 5 mm (range 0.5-25 mm). Sixteen patients (15.6%) developed disease recurrence, of whom 10 (62.5%) at the vulva. Margin distance had no significant impact on disease-free survival when analyzed continuously (p = 0.388). When cases were divided into three subgroups of <3 mm (28.4%), ≥3 to <8 mm (42.2%), and ≥8 mm (29.4%) resection margin, neither univariate nor multivariate analysis revealed a difference in disease-free survival. There was no significant difference between any of the subgroups regarding tumor stages and adjuvant radiotherapy of the vulva. These results were independent of the direction of the minimal margin distance and consistent when only vulvar recurrences were analyzed. A tumor-free resection margin is essential for locoregional control in vulvar cancer. However, in this large, single-center study, we could not demonstrate any prognostic impact of pathological margin distance.

Is Ductal Carcinoma In Situ With “Possible Invasion” More Predictive of Invasive Carcinoma Than Pure Ductal Carcinoma In Situ?

ObjectivesTo compare the underestimation of ductal carcinoma in situ (DCIS) vs DCIS with “possible invasion” at breast biopsy and to determine if any factors related to clinical indication, imaging abnormality, biopsy, or DCIS-grade affected the likelihood of underestimation. MethodsOf 3836 consecutive lesions that were biopsied by using a 14-gauge needle, 117 lesions revealed DCIS. Surgical pathology results of invasive carcinoma were compared with needle biopsy results of DCIS or DCIS with possible invasion. Clinical indication, imaging abnormality, biopsy guidance modality, sample number, and histologic grade were recorded. Yates corrected χ2 and Fisher exact tests were used to determine differences between groups. ResultsA total of 101 lesions were DCIS and 16 were DCIS with possible invasion at biopsy. Thirty-six of 117 lesions (31%) revealed invasive carcinoma at resection pathology. Invasive carcinoma was present more often when DCIS with possible invasion was diagnosed compared with pure DCIS (7/16 [44%] vs 29/101 [29%], P = .36). No factor, including clinical indication, imaging abnormality, biopsy guidance method, sample number, or grade, was found to significantly affect the likelihood of underestimation for lesions diagnosed as DCIS vs DCIS with “possible invasion.” The likelihood of pure DCIS underestimation significantly increased when lesions were high grade compared with either intermediate or low grade (18/44 [41%] vs 9/44 [21%] vs 2/10 [20%], P = .03). ConclusionFor lesions biopsied by using a 14-gauge needle, there is a trend towards underestimation of the presence of invasive carcinoma when pathology reveals DCIS with possible invasion compared with pure DCIS. High-grade DCIS was significantly more likely to be underestimated.

Salivary duct carcinoma of the parotid

Salivary duct carcinoma is one of the rarest and most aggressive forms of parotid tumor. We report two cases. Case 1: a 78-year-old man was referred for a salivary duct carcinoma of the left parotid gland. Treatment was surgical (parotidectomy with ipsilateral selective neck dissection), without capsule rupture, and with healthy margins. At seven years' follow-up, the patient was alive and disease-free. Case 2: a 41-year-old man was referred for a salivary duct carcinoma of the left parotid gland. Parotidectomy with ipsilateral selective neck dissection left healthy but insufficient margins (<1 cm), and postoperative radiation therapy (70 Gy) was undertaken. At eight years' follow-up, the patient was alive and free of recurrence. Mean patient age in the literature is 60 years, with a male-to-female ratio of 2:1. Mean five-years' recurrence-free survival was 34%. Surgery is the main form of treatment in this indication. Postoperative radiation therapy is indicated in case of extraparotid extension, pathological resection margins, cervical lymph node metastasis, lymphatic embolus and/or neurologic invasion. Chemotherapy is generally reserved for metastatic forms of the disease.

Su1537 Feasibility of Endoscopic Treatment for Rectal Carcinoid Tumors According to Tumor Size

Feasibility of Endoscopic Treatment for Rectal Carcinoid Tumors According to Tumor Size Soung Min Jeon, Jin Ha Lee, Sung Pil Hong, Tae Il Kim, Won Ho Kim, Jae Hee Cheon Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea Background/Aims: This study was aimed to assess whether endoscopic treatment for rectal carcinoid tumors larger than 10 mm is feasible in terms of the rates of en bloc resection, histological complete resection, complication incidence, and tumor recurrence. Methods: Endoscopic treatments including conventional endoscopic mucosal resection (EMR), endoscopic mucosal resection using a cap (EMR-C), and endoscopic submucosal dissection (ESD) were performed to 101 patients among 111 patients diagnosed to have rectal carcinoid tumors at Severance Hospital in Seoul, Korea, between January 2005 and December 2009. All patients were confirmed to have no muscular layer invasion, no metastases to the lymph nodes or distal organs, and no atypical histological features. The patients were categorized into three groups by tumor size; (A) 1 10 mm, (B) 11 15 mm, and (C) 16 20 mm. We retrospectively reviewed their endoscopic pictures/video and medical records, and analyzed differences in results of endoscopic treatment and follow-up among the 3 groups. Results: Among the 3 groups, significant differences in baseline characteristics of patients and tumors were not shown except for tumor size. Although the rates of en bloc resection and pathologic complete resection did not differ according to tumor size, complication incidence and the rates of local recurrence, metastasis, and need for additional rescue therapy were higher as tumor size was larger (complication rate; 8.1%, 21.4%, 46.2%, p 0.001/ recurrence rate; 1.4%, 7.1%, 38.5%, p 0.001/ metastasis rate; 1.4%, 7.1%, 23.1%, p 0.004/ need for rescue therapy; 5.4%, 21.4%, 61.5%, p 0.001, in A, B, and C groups, respectively). In multivariate analysis for the risk factors of additional treatment after endoscopic treatment of rectal carcinoids, method of endoscopic treatment, invasion depth, and en bloc resection were not found to be independent risk factors, but only tumor size was an independent risk factor (RR of 11 20 mm to 1 10 mm in tumor size; 13.098, p 0.008/RR of 16 20 mm to 1 15 mm in tumor size; 20.894, p 0.002). ESD was superior to EMR/EMR-C in terms of rates of endoscopically and pathologically complete resection and complication. However, the procedure time of ESD was longer than EMR/EMR-C and the rate of additional rescue therapy after ESD did not reveal statistical differences compared with EMR/EMRC in all groups. Conclusions: In rectal carcinoid tumors with size 10mm, endoscopic treatment might be most feasible and both EMR/EMR-C and ESD showed similar efficacy and safety. However, surgery is still indicated for rectal carcinoid tumors which are larger than 10 mm because of high risk of need for additional rescue therapy and metastasis.

Yield and Performance Characteristics of Endoscopic Ultrasound-Guided Fine Needle Aspiration for Diagnosing Upper GI Tract Stromal Tumors

EUS-FNA is a means of sampling suspected GI stromal tumors (GIST). However, there are limited published data on factors influencing the sampling yield, and on the performance characteristics of this technique in comparison with resection pathology. We analyzed the yield of EUS-FNA for submucosal lesions of the upper GI tract, and determined the performance characteristics of EUS-FNA for diagnosing GISTs. We retrospectively reviewed procedural and pathology data from consecutive patients undergoing EUS-FNA of submucosal lesions from two medical centers over a 4-year period. We analyzed the yield of EUS-FNA, and calculated performance characteristics of EUS-FNA for GIST based on resection pathology. A total of 65 patients underwent EUS-FNA of 66 submucosal lesions during the study period. EUS-FNA was either diagnostic (68%) or suspicious (12%) in a total of 80%. EUS-FNA yielded the following diagnoses: GIST based on cytology and immunohistochemistry (56%), suspected GIST (12%), leiomyoma (9%), other neoplasm (3%), and non-diagnostic (20%). Larger lesion size, gastric location, and presence of on-site cytopathology were associated with higher yield in univariate analysis. Larger needle size and number of FNA passes were not associated with improved yield. Based on resection pathology from 28 specimens, the EUS-FNA performance characteristics for diagnosing GISTs included a sensitivity of 82%, a specificity of 100%, and an overall accuracy of 86%. EUS-FNA provides a high yield for sampling submucosal lesions and is highly accurate for diagnosing GISTs. EUS-FNA has an important role in the evaluation of suspected GISTs.

Single-institution experience of preoperative chemoradiotherapy for locally advanced gastric cancer.

99 Background: To examine acute toxicity and outcomes for patients treated with preoperative chemoradiotherapy (CRT) for gastric cancer. Methods: Patients with gastroesophageal (GE) junction (Siewert type II and III) or stomach adenocarcinoma who underwent curative intent CRT followed by planned surgical resection at Duke University between 1987 and 2009 were reviewed. Tumors were staged according to AJCC 6th edition. Local recurrence was defined as radiographic or biopsy- proven disease within the radiation treatment field. Overall survival (OS), local control (LC) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. Toxicity was graded according to CTCAE v4.0. Results: Forty-eight patients (60% stage III, 8% stage IV) were included. Most (73%) had proximal (GE junction, cardia and fundus) tumors. Thirty-five percent had signet ring histology, 52% had poorly differentiated tumors and 10% had linitis plastica. Median age was 60 years and median RT dose was 45 Gy. All patients received concurrent chemotherapy (CT) with 40 (83%) receiving 5-FU-based CT. Rates of acute &gt; grade 2 hematologic and non-hematologic toxicity were 38% and 10%, respectively. Six patients (13%) required treatment break and two (4%) were unable to complete the prescribed treatment course. Thirty-six patients (75%) underwent surgery. Patients did not undergo surgery due to distant metastases at laparotomy or restaging (n=9), patient refusal (n=2) or poor performance status (n=1). Pathologic complete response and R0 resection rates were 19% and 86%, respectively. Thirty-day surgical mortality was 6%. At 42 months median follow-up, 3-year actuarial OS for all patients was 40%. For those undergoing surgery, 3-year OS, LC and DFS were 50%, 73% and 41%, respectively. Conclusions: Preoperative CRT for gastric cancer is reasonably well tolerated with acceptable rates of perioperative morbidity and mortality. In this patient cohort with advanced disease, LC, DFS and OS rates in resected patients are comparable to similarly staged, adjuvantly treated historic controls. Further study comparing neoadjuvant CRT to standard treatment approaches for gastric cancer is indicated. No significant financial relationships to disclose.

Multifokales Siegelringzell-Adenokarzinom des Magens mit inzidentellem gastrointestinalem Stromatumor in einer Typ-B-Gastritis

A 79-year-old man was admitted because of anemia during marcumar therapy with suspected bleeding in the gastrointestinal tract. Endoscopy revealed a large mutifocal poorly differentiated gastric signet ring cell adenocarcinoma. After staging by the usual oesophagogastroduodenoscopic method, a total D 2 gastrectomy was performed. In the pathological resection specimen of the stomach, a multifocal poorly differentiated signet ring cell adenocarcinoma, infiltrating the submucosa (so called early cancer of sm-type) and an incidental gastroinstinal stromal tumour, 0.8 cm in diameter, was diagnosed. This is the first case report of the synchronous occurrence of a multifocal poorly differentiated gastric adenocarcinoma with signet-ring cell morphology (diffuse type according to the Lauren classification) and a GIST incidentally within a stomach with Hp-associated gastritis.

Window resection of the trachea and secondary reconstruction for invasion by differentiated thyroid carcinoma

Objective In cases of differentiated thyroid carcinoma, the presence or absence of invasion into the circumferential organs is an important prognostic factor. Surgical procedures include circular resection of the trachea with end-to-end anastomosis and window resection with secondary closure. We have used window resection with secondary closure since 1993, and herein retrospectively analyze the treatment outcomes for this surgical procedure in order to determine the indications for procedure selection. Methods Subjects comprised 41 cases of invasion by differentiated thyroid carcinoma into the trachea, for which surgery was performed at the Department of Head and Neck Surgery of the National Cancer Center Hospital East from 1993 to 2007. The mean age was 65.7 ± 7.9 years, and the median length of the observation period was 43 months. There were 17 cases (41.4%) cases of secondary relapse. Results The 5-year and 10-year overall survival rates for this surgical procedure were 78.9% and 74.5%, respectively, while the 5-year and 10-year local control rates were 92.4% and 73.4%, respectively. The pathological resection stump was positive in 27 cases (65.8%), but no significant differences in treatment outcome were observed between the stump-positive group and the stump-negative group. There were 26 cases in which closure of the tracheal fistula was performed by the time of observation. When the tracheal defect had a diameter equivalent to 7 rings of the trachea or less and a circumference half that of the tracheal cartilage or smaller, including partial cricoid cartilage, it was possible to perform closure with only a local flap. For larger defects, reconstruction was performed using hard tissues or materials, such as hydroxyapatite, titanium mesh, and costal cartilage. There were 2 cases that required re-window because of dyspnea after closure. Conclusion The treatment outcomes for this surgical procedure for invasive cases of differentiated thyroid carcinoma into the trachea resulted in a low rate of local recurrence and similar survival rates as described in other reports. Even for cases of resection exceeding half the circumference of the trachea, closure of the tracheal fistula can be performed using hard tissues or materials; however, in such cases, we believe that closure should be attempted progressively in a two-stage reconstruction.

Extent of EEG Epileptiform Pattern Distribution in “Focal” Cortical Dysplasia

To assess the pathophysiological complexity of cortical dysplasia-related intractable focal epilepsy among surgical candidates, using our data-based EEG classification system, we reviewed preresection scalp awake and sleep EEGs (median, 8) in 46 consecutive patients whose resected pathology disclosed cortical dysplasia. Epileptiform phenomena occurred on at least one EEG in 42 (91%) patients. Twenty-three (50%) of the 46 patients displayed at least one type of independently occurring abnormality (spikes, excess delta, or theta) in each hemisphere. Nineteen of these 23 (83%), thus 41% of all 46 patients, showed independently occurring epileptiform abnormalities (spikes) in each hemisphere, i.e., the multiple independent spike foci phenomenon. In an additional 13 of the 46 (28%) patients, spike foci involving more than one lobe appeared within a single hemisphere. Thus, spike foci involving more than one lobe appeared in 32 of the 46 (70%) patients. Generalized bilaterally synchronous epileptiform features (spike waves, slow spike waves, or fast rhythmic waves) appeared in 10 (22%) of the 46 patients. Two findings suggest more widespread dysfunction among extratemporal patients than temporal patients: (1) a significantly higher number of lobes containing focal interictal epileptiform activity in extra temporal patients (mean = 3.14) than among temporal patients (mean = 2.14) (P = 0.02), (2) a higher percentage of bisynchronous epileptiform abnormalities: 8 of 23 (35%) versus 2 of 23 (9%). Among 34 patients with a Principal Spike Lobe (more active spiking over more EEGs), those of 32 (94%) arose from the ultimately resected lobe. Of the 30 patients with scalp-recorded seizures, relationship between seizure origin and ultimately resected lobe were same lobe (16 patients), same and adjacent lobes (12), adjacent lobe only (1), and distant lobe (1). Thus, despite the multifocality of several EEG features, Principal Spike Lobe and scalp-recorded seizure origin correlate well with epileptogenesis.

Agreement between Endoscopic Ultrasound and Endoscopic Mucosal Resection Pathology in Staging Mucosal Esophageal Cancers

Agreement between Endoscopic Ultrasound and Endoscopic Mucosal Resection Pathology in Staging Mucosal Esophageal Cancers

The Use of Sentinel Lymph Node Biopsy in Ductal Carcinoma in Situ

Although ductal carcinoma in situ (DCIS) does not require axillary evaluation, controversy exists regarding the use of sentinel lymph node biopsy (SLNB) in patients with DCIS diagnosed by core needle biopsy (CNB). Advocates of concomitant SLNB and lumpectomy cite the low morbidity of SLNB, the high rate of invasive ductal carcinoma in resected specimens, and the positive nodes found in 1 to 2 per cent of patients with resected DCIS despite finding no invasive component. Opponents of this practice cite the complication risk and the improbability of clinically significant axillary recurrence. We therefore proposed to determine our rate of invasive cancer in DCIS diagnosed by CNB and to determine whether SLNB at first operation would decrease return to the operating room. We retrospectively reviewed patients diagnosed with DCIS by CNB from 2003 to 2008. Standard clinicopathological data were collected and analyzed. In 110 patients, the prevalence of invasive cancer on final resection pathology was 13.6 per cent (15 of 110). Of those patients with invasive cancer, 93 per cent (14 of 15) had high-grade DCIS (P = 0.077) by CNB. Seventeen per cent (14 of 82) of patients with high-grade DCIS had invasive cancer. Of 34 patients with SLNB, three (9%) had positive nodes. Fifteen patients required re-excision to obtain negative margins, including 13 patients with invasive cancer. Five patients (4.5%) were spared additional operative intervention by initially performing SLNB. We suggest using concomitant SLNB when a high clinical suspicion of invasive cancer exists, in the presence of a palpable mass, or when mastectomy precludes future SLNB. Intraoperative margin assessment is needed to avoid return to the operating room.