Residual Tumor Rate Research Articles

Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision

Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit. Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed. The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%. After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Giant craniopharyngiomas in children: short- and long-term implications.

Craniopharyngiomas (CPs) are histologically benign tumors, yet they may carry an unfavorable prognosis. "Giant" tumors are associated with worse prognosis. Our aim was to evaluate the impact of tumor's size on different short- and long-term clinical factors. Between 2002 and 2012, a total of 36 consecutive CP patients less than 18years of age and with at least 12months of post-operative follow-up (FU) underwent a total of 54 operations for excision of CPs. Gross total resection (GTR) was the goal for all the first surgical resections. Twenty-seven patients were identified as eligible for inclusion in this study. Data were retrospectively collected by reviewing pertinent clinic/office notes and inpatient records as well as pre- and post-operative imaging. Long-term neurosurgical, ophthalmological, and endocrinological outcomes were obtained from records of the most recent FU office visit. Statistical analysis was performed to compare data from patients with tumors greater than or equal to 4.5cm (nine patients) to those with smaller ones (<4.5cm; 18 patients). Mean age at the time of surgery was 5.4years (median 5years, range 1.3-15.3years) for patients in the large-tumor group (LTG) and 8.9years (median 9.6years, range 2.1-17.1years) for the small-tumor group (STG). Average duration of follow-up was 82.1 and 105.4months for LTG and STG patients, respectively. There was a noticeable difference in the rate of emergent surgeries between the two groups (33.3 vs. 5.5% in the LTG and STG, respectively; p = 0.055) as well as in recurrent surgeries (RR = 3.76; CI = 95%, 1.793-7.877) and radiotherapy (RR = 2, 95% CI 0.775-5.154). Rates of residual tumor on both initial post-operative imaging and last FU imaging were significantly increased in LTG patients (44.5 vs. 27.7% and 66.6 vs. 16.6%; respectively). Progression-free survivals (PFS) assessed at 2 and 5years were 33.3 vs. 73.3% (RR = 2.2, 95% CI = 0.171-1.202) and 33.3 vs. 53.3% (RR = 1.6, 95% CI 0.221-1.765) in favor of smaller tumors. No difference in 2-, 5-, and 10-year overall survival was found. We found no significant difference in mean BMI at last follow-up between the two groups (23.83 ± 4.86 and 27.33 ± 8.09, respectively; p = 0.27), although significantly more patients in the LTG had shorter stature (mean height SDS -1.72 ± 1.88 and -0.17 ± 1.08 in LTG and STG patients, respectively; p = 0.027). Tumor's size has significant impact on the management of CP in children. It affects both short-term factors (initial symptoms, urgency of surgical resection, extent of resection, and perioperative morbidity) as well as long-term parameters (PFS, rate of adjuvant treatments/recurrent surgeries, and metabolic/endocrinal/ophthalmological and functional outcomes). We think that a proper, world-wide accepted definition of what is "large," "giant," or even "monstrous" CP should be established. This will enable carrying multi-institutional studies on a larger group of patients, allowing further determining the importance of tumor's size in the management and outcome of craniopharyngiomas in children.

Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery?

BackgroundSoft tissue sarcomas (STS) are often diagnosed unexpectedly after surgery, and many excisions are incomplete. As histopathological assessments are challenging, patients later referred to comprehensive cancer centers (CCC) often come with an unclear status. This can make treatment planning problematic. We investigated the reliability of primary histopathological assessments, whether revisional surgery improved resection status, and the prognostic value of residual tumor at re-excision.MethodsWe analyzed the demographic and clinical characteristics of all patients referred to our CCC between 2003 and 2013. We compared patients treated exclusively at our CCC with those who had primary surgery elsewhere, and focused on resection margins, re-excision type, residual tumor, resection status after re-excision, and oncological outcome.ResultsOver half (n = 110) of all patients (n = 204) were referred from elsewhere. Seventy-one had undergone an excision without suspicion of malignancy. Resection status in referred patients was significantly inferior to the CCC group (p < 0.0001), although the latter had significantly more serious tumors and advanced disease stages (p < 0.05). The residual tumor rate was 53.13 %, with a significantly higher probability in an upper extremity (p = 0.001). Initial histopathological classification was misleading in 46.9 % of cases. Re-excision improved resection status in 69 % of cases. Residual tumor presumably leads to higher rates of local recurrence (p = 0.057) and significantly shorter times to recurrence (p < 0.05).ConclusionsRe-excision should always follow unplanned STS excisions. Resection margins and histopathological assessments from referring institutions are often unreliable and unsuitable for treatment planning. Residual tumor is a risk factor for earlier and more likely local recurrence.

Implications of New Lumpectomy Margin Guidelines for Breast-Conserving Surgery: Changes in Reexcision Rates and Predicted Rates of Residual Tumor

The 2014 guidelines endorsed by Society of Surgical Oncology, the American Society of Breast Surgeons, and the American Society for Radiation Oncology advocate "no ink on tumor" as the new margin requirement for breast-conserving therapy (BCT). We used our lumpectomy margins database from 2004 to 2006 to predict the effect of these new guidelines on BCT. Patients with neoadjuvant therapy, pure ductal carcinoma-in situ, or incomplete margin data were excluded. We applied new ("no ink on tumor") and old (≥2 mm) margin guidelines and compared rates of positive margins, reexcision, and rates of residual disease found at reexcision. A total of 437 lumpectomy surgeries met the eligibility criteria. Eighty-six percent had invasive ductal carcinoma, 12% invasive lobular carcinoma, and 2% invasive ductal carcinoma and invasive lobular carcinoma. Using a ≥2 mm margin standard, 36% of lumpectomies had positive margins compared to 18% using new guidelines (p < 0.0001). Seventy-seven percent of patients with "ink on tumor" had residual disease found at reexcision. Fifty percent of subjects with margins <2 mm had residual disease (p = 0.0013) but would not have undergone reexcision under the new guidelines. With margins of ≥2 mm, residual tumor was seen in the shaved margins of 14% of lumpectomies. Residual tumor was more common in reexcisions for ductal carcinoma-in situ <2 mm from a margin than for invasive cancer (53 vs. 40%), although this was not statistically significant. Use of new lumpectomy margin guidelines would have reduced reoperation for BCT by half in our patient cohort. However, residual disease was present in many patients who would not have been reexcised with the new guidelines. Long-term follow-up of local recurrence rates is needed to determine if this increase in residual disease is clinically significant.

Diagnostic significance of intraoperative ultrasound contrast in evaluating the resection degree of brain glioma by transmission electron microscopic examination.

Background:Contrast-enhanced ultrasound is a dynamic and continuous modality providing real-time view of vascularization and flow distribution patterns of different organs and tumors. In order to evaluate the diagnostic significance of intraoperative contrast-enhanced ultrasound in assessing the resection degree of brain glioma by transmission electron microscopic (TEM) examination, it is important to have specific knowledge about contrast-enhanced ultrasound.Methods:Ultrasound contrast was applied in operations of 120 cases of brain glioma, to evaluate the degree of tumor resection. Biopsy tissues were obtained the suspicious residual tumors surrounding the tumor cavity. The sensitivity and specificity of the residual tumors were determined by the intraoperative ultrasound contrast according to TEM examination results.Results:There were 44 cases of low-grade gliomas and 76 cases of high-grade gliomas. Three hundred and sixty biopsy tissues were obtained. The sensitivity of intraoperative ultrasound contrast in diagnosing the residual tumor was 62.2%, while the specificity degree of it was 92.8%. The consistency coefficient of the ultrasound contrast diagnosis and TEM examination results was 0.584 (Kappa = 0.584), which was between 0.4 and 0.6, therefore it was of medium consistency.Conclusions:Intraoperative ultrasound contrast was of a high sensitivity and specificity in evaluating the excision degree of tumor. The consistency of the residual tumor rate detected, respectively, by ultrasound contrast and TEM examination was of medium consistency. The application of intraoperative ultrasound contrast can improve the resection rate of brain glioma.

Clinicopathologic characteristics of patients who underwent additional gastrectomy after incomplete endoscopic resection for early gastric cancer.

39 Background: Endoscopic resection (ER) is widely accepted as standard treatment for early gastric cancer (EGC) without lymph node metastasis. However, surgery is sometimes needed after endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) due to incomplete resection. We analyzed the clinicopathological characteristics of patients who underwent additional gastrectomy after incomplete EMR/ESD. Methods: From 2003 to 2013, 80 patients received additional gastrectomy after EMR/ESD due to incomplete resection. The patients were grouped according to the presence of histologic residual tumor in specimens obtained by gastrectomy as residual tumor (RT, n = 47) or non-residual tumor (NRT, n = 33). We analyzed reasons for gastrectomy, tumor characteristics of RT and NRT group, risk factors associated with residual tumor, retrospectively from medical records. Results: After the gastrectomy, the positive residual tumor rate and lymph node metastasis rate were 58.7% (47/80) and 7.5% (6/80). RT group showed significantly higher rate of lateral and vertical margin involvement compared to NRT group (59.5 vs. 15.1%).Multivariate analysis demonstrated that endoscopic piecemeal resection, H. pylori infection, depressed or mixed type, large tumor size (&gt; 2cm), histologic diagnosis (signet ring cell carcinoma or mixed carcinoma) were significantly independent predictive factors associated with positive residual tumor of patients who underwent additional gastrectomy after incomplete EMR/ESD (p &lt; 0.05). Conclusions: For complete and curative ER, endoscopists should try to determine the depth of invasion, histologic diagnosis accurately and to eradicate the H. pylori infection before ER. During ER, wide marking and En bloc resection could be considered to avoid the risk of incomplete resection.

Does the Type of Initial Biopsy Method Determine Re-Excision Rate of Cutaneous Melanoma?

Background: Various biopsy types are used to diagnose melanoma, after which wide local excision (WLE) is the gold standard for treatment. Depending on the final pathology report, further re-excision may be necessary despite an initial, presumably adequate, WLE. In this study, we analyzed the impact of initial biopsy type (shave, punch, or excision) on the management of melanoma. Methods: A retrospective chart review of 243 patients with clinically node-negative melanoma was completed. Evaluated variables included the initial biopsy type, initial and final peripheral and deep margin status, further reexcision rates, tumor site, and clinician specialty performing the biopsy. Univariate and multivariate analyses tests were performed using SPSS software. Results: 29.5% of specimens with both positive peripheral and deep margins underwent further excisions. Overall, 14.6% of cases had re-excision regardless of initial biopsy type after initial WLE. There was higher rate of re-excision with an initial excision biopsy (28.6%) than with initial punch (13.3%) or shave biopsies (11.2%) Dermatologists, Surgeons, and Primary Care Physicians performed 13%, 34%, and 32% of the excision biopsies respectively. Neither the anatomic location of the tumor nor the survival rates were significantly correlated to the biopsy type, margin status, or re-excision rates. Conclusion: Both shave and punch biopsies showed high rates of residual tumor in either peripheral or deep margins but this does not translate into a higher re-excision rate. Although the biopsy type is important, the clinical specialty performing the biopsy could be influential. Surprisingly, there was a higher positive peripheral margin than deep margin with shave biopsy.

Assessment of diagnostic gain with hexaminolevulinate (HAL) in the setting of newly diagnosed non–muscle-invasive bladder cancer with positive results on urine cytology

ObjectiveIn accordance with the European Association of Urology guidelines, a second transurethral resection of the bladder (TURB) is recommended for high-grade or T1-category tumors. This practice brings into question the benefit of photodynamic diagnosis (PDD) in reducing the residual disease after TURB in patients with positive results on urine cytology showing high-grade cancer cells. Methods and materialsA prospective, bicentric, randomized study comparing white light cystoscopy (WLC)+PDD with hexaminolevulinate arm with WLC alone (control arm) during the first TURB in patients with primary non–muscle-invasive bladder cancer and with positive results on urine cytology showing high-grade cancer cells. Patients underwent a first TURB with WLC and PDD or WLC alone, and then a second TURB with WLC and PDD, after 4 to 6 weeks. The number of tumors visualized in WLC and PDD and histology of the TURB specimen was recorded to perform a statistical analysis comparing both the 2 arms. ResultsA total of 151 patients were enrolled (hexaminolevulinate, n = 72; control, n = 79). The number of visualized tumors did not increase with PDD in the first or second TURB. During the second TURB, the residual tumor rate was not reduced in patients who had PDD during the first TURB. No significant difference was observed regarding the pattern of category and grade, the size, and the recurrence and progression risks during either the first or the second TURB. ConclusionsIn the setting of primary non–muscle-invasive bladder cancer with positive results on urine cytology, performing a second TURB allows to diagnose residual tumor in approximately half of the cases. This rate was not significantly reduced by the use of the PDD during the first TURB.

Is the outcome of a salvage surgery for T4 thoracic esophageal squamous cell carcinoma really poor?

Among patients with T4 thoracic esophageal squamous cell carcinoma (TESCC), it is unclear whether the outcomes of late responders who undergo high-dose chemoradiotherapy (CRT) followed by salvage esophagectomy differs from those of early responders who undergo low-dose CRT followed by esophagectomy. A total of 153 patients with T4 TESCC were treated with CRT. The first evaluation was performed after 40 Gy of CRT for downstaging. Of these, 28 patients could be downstaged, and underwent subsequent surgery (early responders). For the remaining patients, additional CRT was administered, and patients were re-evaluated after treatment and underwent salvage surgery. In total, 40 patients (early + late responders) were analyzed. The primary tumors exhibited a grade 3 response in six (21.4 %) of the early responders and two (16.7 %) of the late responders (p = 1.000). The rate of residual tumor in the primary tumor was 80 % (32/40 patients). The proportions of resected lymph nodes and positive metastatic nodes were similar between early and late responders (p = 0.406 and p = 0.859, respectively). The 5-year overall survival rates among the early and late responders were 25.9 and 36.5 %, respectively, and the median survival times were 24.8 and 24.3 months (p = 0.925), respectively. The 5-year cause-specific survival rates in the early and late responder groups were 61.5 and 72.9 % (p = 0.425), respectively. The outcomes of both early and late responders to CRT were similar, and salvage surgery for T4 TESCC outweighs the risks in patients with T4 TESCC.

Comparison of 2D HD and 3D Endoscopy during Endonasal Endoscopic Transsphenoidal Surgery (EETS) for Treatment of Perisellar Pathologies

Objective: EETS for central skull base pathology treatment offers many advantages over microsurgical procedures. HD resolution improves the image detail accuracy but no stereoscopic vision is provided. The objective was to compare treatment results between a 2D HD and a 3D system after EETS with respect to residual tumor, periprocedural complications or new postoperative endocrinological deficit. Methods: Between December, 2008 and October, 2013; 134 patients (64 males, 47.8%) underwent EETS to treat (para)sellar pathologies (103 pituitary adenomas, 6 pituitary abscesses, 4 cysts, 3 meningiomas, 2 chordomas, and 16 other pathologies). In 65 patients the 2D HD system (Karl Storz, Germany) and in 69 the 3D system (VisionSense, New York, United States) was used. Prospective collected data were entered into a SPSS database. Results: Sex, age, pathology, and tumor volume did not statistically differ between groups. Three months MRI depicted residual tumor in 24% in the 2D and 26% in the 3D group. In 17 and 10 patient's residual tumor was difficult to differentiate in the 2D and 3D group, respectively. Overall 9 and 12 patients developed a new endocrine deficit in any of the hormone axis during the postoperative course in the 2D and 3D group. In the 2D seven (11%) and in the 3D eight (12%) patients had perioperative complications. Conclusions: In this series the rate of residual tumor, perioperative complications and new endocrine deficiency after EETS was similar using a 2D HD or a 3D system.

Faut-il proposer une seconde résection systématique pour toutes les tumeurs de vessie n’infiltrant pas le muscle vésical à risque élevé ?

Quantify the rate of residual bladder tumor following systematic second look resection of pTa high-grade versus pT1 high-grade patients. From January 2010 to July 2013, 53 patients with a non-muscle-invasive bladder cancer with high-risk of recurrence and progression underwent a second systematic resection in accordance with the current guidelines of the French Association of Urology (AFU). Among the 53 patients with a high-risk non-muscle-invasive bladder cancer, histological examination of the initial resection identified: 17 pTa high-grade (32.1%) and 36 pT1 high-grade (67.9%). There was a significant difference between the 2 groups of patients (Ta high-grade versus T1 high-grade) concerning the rate of residual tumor on second look resection (11.8% versus 66.7%, P=0.0002). The predictive factors of residual tumor after second resection were the pT1 stage (P=0.0002), tumor multifocality (P=0.02) and presence of associated Cis (P=0.0005). The high rate of residual tumor in our series confirmed the importance of a systematic second look resection for high-risk non-muscle-invasive bladder cancers. However, for the pTa tumors without associated Cis, the interest of this second look seemed of less concern. 5.

Pediatric giant pituitary adenomas: are they different from adults? A clinical analysis of a series of 12 patients.

To evaluate clinical presentation and microsurgical outcome of giant pituitary adenomas (GPAs) in pediatric age. All patients <18 years, who were operated on at our center for GPA (tumor >40 mm in maximum diameter) were included in study. Clinical features, hormonal profile, radiology, surgical approach, results and complications were analysed. A total of 12 children with GPA were managed microsurgically. Visual deterioration (73 %) was most common presentation. Functioning adenomas were found in 83 % patients, with prolactinomas being most common. Twelve patients underwent a total of 16 microsurgical procedures, with a single surgery done in eight (75 %) patients. Out of the 12 primary surgeries, eight (67 %) were performed trans-sphenoidally. A near-total excision (>90 % tumor removal) could be achieved in six (50 %) patients. Visual improvement was observed in 44 % patients. However, there was no improvement in those where the eye was negative to perception of light prior to surgery. At the last follow-up, all the patients with functioning adenomas were in hormonal remission, and there was no residual/recurrent tumor in patients with non-functional adenomas. 25 % experienced single or multiple perioperative or postoperative complications. There was one perioperative death (8 %). GPAs are very rare in the pediatric population, with majority being functional and more aggressive in nature as compared to in adults. However, most of them can be approached trans-sphenoidally. The combination of surgery and radiotherapy, as well as medical therapy with bromocriptine, achieves good tumor control, despite a high rate of residual tumor and tumor recurrence.

Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases ,

IntroductionEndoscopic endonasal transsphenoidal surgery has gained increasing acceptance by otolaryngologists and neurosurgeons. In many centers throughout the world, this technique is now routinely used for the same indications as conventional microsurgical technique for pituitary tumors. ObjectiveTo present a surgical experience of consecutive endoscopic endonasal trans-sphenoidal resections of pituitary adenomas. MethodsIn this study, consecutive patients with pituitary adenomas submitted to endoscopic endonasal pituitary surgery were evaluated regarding the rate of residual tumor, functional remission, symptoms relief, complications, and tumor size. ResultsForty-seven consecutive patients were evaluated; 17 had functioning adenomas, seven had GH producing tumors, five had Cushing’s disease, and five had prolactinomas. Of the functioning adenomas, 12 were macroadenomas and five were microadenomas; 30 cases were non-functioning macroadenomas. Of the patients with functioning adenomas, 87% improved. 85% of the patients with visual deficits related to optic nerve compression progressed over time. Most of the patients with complaints of headaches improved (76%). Surgical complications occurred in 10% of patients, which included with two carotid lesions, two cerebrospinal fluid leaks, and one death of a patient with a previous history of complications. ConclusionEndoscopic endonasal pituitary surgery is a feasible technique, yielding good surgical and functional outcomes, and low morbidity© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Completion thyroidectomy in differentiated thyroid cancer: When to perform?

Completion thyroidectomy is recommended in patients who have been diagnosed with differentiated thyroid cancer on histopathological evaluation, if their first operation was a conservative approach. The critical issue is when to do the second operation. The medical records of 66 patients who underwent completion thyroidectomy for the treatment of differentiated thyroid cancer in our clinic between 2006-2013 were retrospectively analyzed. All data were compared after patients were divided into two groups according to the interval between the first surgery and completion thyroidectomy. Fifty-two patients (78.8%) were women and 14 patients (21.2%) were male. Completion thyroidectomy was performed 10-90 days after the initial surgery (group 1) in 26 patients, whereas it was performed later than 90 days in 40 patients (group 2). Temporary hypoparathyroidism occurred in two patients (7.7%) in group 1, and in 3 patients (7.5%) in group 2. Transient recurrent laryngeal nerve palsy was observed in 1 patient (3.9%) in group 1, and in 1 patient (2.5%) in group 2. There were no permanent morbidities in both groups. Residual tumor rate after completion thyroidectomy was 45.5%. There was no statistically significant difference between the two groups in terms of complications after completion thyroidectomy. Although in some studies it is recommended that completion thyroidectomy should be performed either before scar tissue development or after clinical remission of scar tissue, edema and inflammation, we believe that timing of surgery has no effect on morbidity.

Preoperative motor mapping by navigated transcranial magnetic brain stimulation improves outcome for motor eloquent lesions

Navigated transcranial magnetic stimulation (nTMS) has been proven to influence surgical indication and planning. Yet there is still no clear evidence how these additional preoperative functional data influence the clinical course and outcome. Thus, this study aimed to compare patients with motor eloquently located supratentorial lesions investigated with or without preoperative nTMS in terms of clinical outcome parameters. A prospectively enrolled cohort of 100 patients with supratentorial lesions located in motor eloquent areas was investigated by preoperative nTMS (2010-2013) and matched with a control of 100 patients who were operated on without nTMS data (2006-2010) by a matched pair analysis. Patients in the nTMS group showed a significantly lower rate of residual tumor on postoperative MRI (OR 0.3828; 95% CI 0.2062-0.7107). Twelve percent of patients in the nTMS and 1% of patients in the non-nTMS group improved while 75% and 81% of the nTMS and non-nTMS groups, respectively, remained unchanged and 13% and 18% of patients in the nTMS and non-nTMS groups, respectively, deteriorated in postoperative motor function on long-term follow-up (P = .0057). Moreover, the nTMS group showed smaller craniotomies (nTMS 22.4 ± 8.3 cm(2); non-nTMS 26.7 ± 11.3 cm(2); P = .0023). This work increases the level of evidence for preoperative motor mapping by nTMS for rolandic lesions in a group comparison study. We therefore strongly advocate nTMS to become increasingly used for these lesions. However, a randomized trial on the comparison with the gold standard of intraoperative mapping seems mandatory.

Novel Optical Technology in Bladder Cancer Diagnosis and Treatment

Bladder cancer is diagnosed and followed-up with cystoscopy as the “gold standard”. For many decades white light cystoscopy (WLC) has been used. However, several forms of bladder cancer such as the high-risk carcinoma in situ (CIS) may be misdiagnosed with WLC. As WLC still remains the cornerstone for the diagnosis of bladder cancer progress in endoscopic technology is warranted to improve the diagnostic accuracy of both rigid and flexible cystoscopy. Recently, photodynamic diagnosis (PDD) has been introduced for the diagnosis and transurethral resection of bladder cancer (TURBT), especially in cases of CIS (1). Photo-sensitizing drugs are intravesically administrated and are selectively accumulated in cancer cells, leading to the enhancement of contrast between benign and malignant bladder tissues. Prospective randomized studies have demonstrated that PDD improved bladder cancer detection, reduced residual tumor rates after TURBT, and prolonged the recurrence-free survival (1, 2). These studies have demonstrated the superiority of PDD-guided cystoscopy over WLC in tumor detection, as the sensitivity for PDD was 76-97% compared to 46–80% for WLC (1, 2). Narrow band imaging (NBI) is a novel technique used in endoscopy to enhance tissue contrast between cancerous and normal bladder urothelium, while it does not require the administration of contrast agents (1). This technique is based on the phenomenon that the depth of light penetration into the urothelium increases when the wavelength is increased. In particular, NBI uses a light source that filters white light into two wavelengths (415 and 540 nm) which are strongly absorbed by hemoglobin, enhancing the contrast between subepithelial capillaries and mucosa (3). Prospective studies and meta-analyses have demonstrated that 10-25% cases of bladder cancer missed by WLC were detected by NBI (1, 4). Furthermore, NBI resulted in lower rates of residual bladder tumor during repeat TURBT and in reduced recurrence rates (4, 5). Optical coherence tomography (OCT) measures the backscattering of near-infrared light by tissue, and it yields in 2D and 3D images at micrometer-scale resolution, thus providing optical biopsies, approaching the resolution of histopathological imaging (6). It produces high-resolution, cross-sectional images of the bladder tissue enabling real-time bladder cancer staging (6). The principle of OCT is analogous to the B-mode ultrasound except that light is being used instead of sound. Studies have demonstrated that OCT results in high sensitivity and specificity rates for bladder cancer diagnosis (6, 7). The usage of relevant algorithms (i.e. Lingley-Papadopoulos) contributes to the differentiation of benign and malignant bladder tissue with a sensitivity rate of 92 % and a specificity rate of 62 % (7). Raman spectroscopy (RS) is a novel spectroscopic optical technique based on the phenomenon of proton emission after light and tissue molecules interaction. Studies have demonstrated that it successfully diagnosed bladder cancer with sensitivity and specificity rates of 85% and 79%, respectively (8). Similarly, confocal laser endomicroscopy (CLE) is an emerging technology based on the established principles of confocal microscopy, which enables in vivo real-time imaging of the tissue micro-architecture and cellular morphology with promising results. In vivo probe-based CLE of the bladder demonstrated distinct differences between normal mucosa and neoplastic tissues and by using mosaicing, a post hoc image-processing algorithm, individual image frames were juxtaposed to form wide-angle views to better evaluating tissue microarchitecture (9). Lastly, wireless capsule endoscopy (WCE) has been successfully used in Gastroenterology since the 1990s. Recently, it was successfully evaluated in a pig model where the ability to deploy and manipulate the capsule within the bladder was examined as well as the feasibility of capturing and retrieving images in real time (10). In conclusion, novel optical imaging technologies have emerged showing promising results for the diagnosis, management and follow up of patients with bladder cancer. The results of adequately powered comparative studies are warranted to determine the efficacy of these novel techniques in comparison to the standard WLC.

Outcome of chemoradiotherapy followed by surgery for locally advanced T4 thoracic esophageal squamous cell carcinoma.

170 Background: Chemoradiotherapy (CRT) is a standard modality for locally advanced esophageal squamous cell carcinoma (ESCC). The outcome of CRT with/without following surgery for locally advanced ESCC was demonstrated. Methods: 1,235 new ESCC patients from 2001 to 2012 were obtained. From these, locally advanced thoracic ESCC was selected. If the patients showed resectability with down-staging after CRT, a subsequent surgery was performed. For the remaining cases, an additional CRT was prescribed, following by a re-evaluation for surgery. If down-staging and resectability were achieved, the patients underwent surgery. In the surgery group, pathologic effectiveness in the primary tumor and lymph nodes was observed and survivals both in surgery and non-surgery group were calculated. Results: From 1,235 new ESCC patients, 153 patients (12.4%) were of locally advanced thoracic ESCC. Among these, 28 patients (18.3%) showed finally down-staging of the primary tumor and could undergo following surgery. 12 patients (7.8%) could obtain down-staging and underwent surgery (surgery H group). In total, 40 patients (26.1%) could undergo surgery (surgery group). The rate of residual tumor in the primary tumor was detected in 32 cases (80%). The 5-year overall survival was 33.0% in the surgery group and 10.0% in the non-surgery group (P=0.002). The 5-year cause-specific survival was 65.0% in the surgery group and 18.1% in the non-surgery group (P=0.002). Conclusions: CRT for locally advanced thoracic ESCC is the standard modality and following surgery have benefits. However, the outcome is not satisfactory and further improvements of treatments for such cases are requested.

Risks of postoperative paresis in motor eloquently and non-eloquently located brain metastases

BackgroundWhen treating cerebral metastases all involved multidisciplinary oncological specialists have to cooperate closely to provide the best care for these patients. For the resection of brain metastasis several studies reported a considerable risk of new postoperative paresis. Pre- and perioperative chemotherapy (Ctx) or radiotherapy (Rtx) alter vasculature and adjacent fiber tracts on the one hand, and many patients already present with paresis prior to surgery on the other hand. As such factors were repeatedly considered risk factors for perioperative complications, we designed this study to also identify risk factors for brain metastases resection.MethodsBetween 2006 and 2011, we resected 206 brain metastases consecutively, 56 in eloquent motor areas and 150 in non-eloquent ones. We evaluated the influences of preoperative paresis, previous Rtx or Ctx as well as recursive partitioning analysis (RPA) class on postoperative outcome.ResultsIn general, 8.7% of all patients postoperatively developed a new permanent paresis. In contrast to preoperative Ctx, previous Rtx as a single or combined treatment strategy was a significant risk factor for postoperative motor weakness. This risk was even increased in perirolandic and rolandic lesions. Our data show significantly increased risk of new deficits for patients assigned to RPA class 3. Even in non-eloquently located brain metastases the risk of new postoperative paresis has not to be underestimated. Despite the microsurgical approach, our cohort shows a high rate of unexpected residual tumors in postoperative MRI, which supports recent data on brain metastases’ infiltrative nature but might also be the result of our strict study protocol.ConclusionsSurgical resection is a safe treatment of brain metastases. However, preoperative Rtx and RPA score 3 have to be taken into account when surgical resection is considered.

Complementação por coagulação com plasma de argônio após a ressecção endoscópica completa pela técnica de fatiamento para grandes adenomas colorretais

To evaluate the efficacy of complement by argon plasma coagulation to reduce the rate of residual or recurrent tumor after complete endoscopic piecemeal resection of large sessile colorectal adenomas. patients with large sessile colorectal adenomas (e" 20 mm), without morphological signs of deep infiltration, submitted to complete endoscopic piecemeal resection studied with chromoendoscopy and magnification of images. Patients were randomized into two groups: group 1 - no additional procedure, and group 2 - complementation by argon plasma coagulation. follow-up colonoscopy was performed at three, six and 12 months postoperatively. We evaluated the rate of local recurrence or residual malignancy. The study included 21 patients, eleven in group 1 and ten in group 2. There were two local recurrences or residual tumors in each group, detected at three months follow-up. Complementation by argon plasma coagulation after apparent complete endoscopic piecemeal resection of large sessile colorectal adenomas does not seem to reduce the occurrence of residual adenomatous lesions or local recurrence.

The use of MR imaging to detect residual versus recurrent nasopharyngeal carcinoma following treatment with radiation therapy

ObjectiveResidual tumor and fibrosis are commonly observed with magnetic resonance (MR) imaging following radiotherapy for nasopharyngeal carcinoma (NPC). Therefore, MR images of NPC following treatment with radiotherapy were retrospectively analyzed to evaluate whether post-radiation changes associated with residual tumors, recurrent tumors, and fibrosis could be distinguished 1 month and 3–6 months after treatment. MethodsMR images were analyzed for 108 patients who completed radiotherapy for NPC and underwent 5-years of follow-up. The presence and incidence of residual tumor versus fibrosis was evaluated and compared with 5-year tumor recurrence rates. ResultsResidual tumors were detected in 54/108 (50.0%) patients 1 month after radiotherapy, and in 18/108 (16.7%) patients 3–6 months after radiotherapy. Fibrosis was only detected in 59/108 (54.6%) patients 3–6 months after radiotherapy. After 5 years, tumor recurrence occurred in 13/108 (12%) patients, with the average interval between tumor recurrence and the completion of radiotherapy being 29.15 months. In addition, the 1-, 2-, 3-, 4-, and 5-year relapse rates were 1.9%, 5.6%, 9.3%, 11.1%, and 12.0%, respectively. Based on the images analyzed, significant differences in tumor recurrence and residual tumor rate (P=0.038), and between tumor recurrence and fibrosis (P=0.021), were observed 1 month and 3–6 months after radiotherapy, respectively. ConclusionsIn this cohort, tumor recurrence was detected 2–3 year after irradiation and a strong correlation between 5-year recurrence rate and detection of residual tumor or fibrosis by MRI up to six months after radiotherapy was observed.