Safe Surgical Margin Research Articles

Urologic Disorders in Living Renal Donors and Outcomes of Their Recipients

BackgroundThere is an expanding gap between the number of patients listed for kidney transplantation and the number of kidney transplantations performed annually. The use of sensitive imaging methods results in increased discovery of many urologic asymptomatic problems, such as urolithiases, renal cysts, and solid renal masses. This result has brought the question of whether all donors with these urologic disorders should be rejected for donation. MethodsWe retrospectively analyzed donor and recipient records of all living kidney transplantations performed from 2004 to 2014. ResultsAmong 251 living-related donor kidney transplantations, 51 donors (20.3%) had urologic disorders. Mean donor age was significantly higher in donors with urologic disorders than in the standard donor group (50 y vs 41 y). The identified disorders were 32 renal cysts, 8 urolithiases, 3 renal tumors, 6 adrenal adenomas, and 2 microscopic hematurias. After nephrectomy, the graft kidneys with cysts were inspected carefully and all of the cortical-peripheral cysts were decorticated. Renal tumors were excised in 3 renal units. Transplantations had proceeded after the confirmation of low malignancy potentials of the lesions with safe surgical margins. Two out of 8 patients had undergone stone removal with ex vivo ureteroscopy and 1 by means of pyelotomy incision because of calix neck stenosis. None of those donors and recipients developed clinically significant renal stone disease with a mean follow-up of 28 months. Neither donors nor recipients of asymptomatic microscopic hematuria patients developed any problem with a mean 28 months' follow-up period. ConclusionsAsymptomatic urologic problems are very common. The significance of these asymptomatic pathologies is unclear. Our results suggest that in a selected group, at least some of these candidates can be accepted for donation.

Surgical treatment of basal cell carcinoma: an algorithm based on the literature.

Although basal cell carcinoma can be effectively managed through surgical excision, the most suitable surgical margins have not yet been fully determined. Furthermore, micrographic surgery is not readily available in many places around the world. A review of the literature regarding the surgical treatment of basal cell carcinoma was conducted in order to develop an algorithm for the surgical treatment of basal cell carcinoma that could help the choice of surgical technique and safety margins, considering the major factors that affect cure rates. Through this review, it was found that surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas, although some good results can be achieved with smaller margins and the use of margin control surgical techniques. For treatment of high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required. Previous treatment, histological subtype, site and size of the lesion should be considered in surgical planning because these factors have been proven to affect cure rates. Thus, considering these factors, the algorithm can be a useful tool, especially for places where micrographic surgery is not widely available.

V9-02 SELECTIVE CLAMPING OF THE SEGMENTARY ARTERY IN ROBOTIC PARTIAL NEPHRECTOMY OPERATION

You have accessJournal of UrologyRobotics – Renal1 Apr 2015V9-02 SELECTIVE CLAMPING OF THE SEGMENTARY ARTERY IN ROBOTIC PARTIAL NEPHRECTOMY OPERATION Omer Aytaç, Hasan Tavukçu, Haluk Kulaksizoglu, and Fatih Atug Omer AytaçOmer Aytaç More articles by this author , Hasan TavukçuHasan Tavukçu More articles by this author , Haluk KulaksizogluHaluk Kulaksizoglu More articles by this author , and Fatih AtugFatih Atug More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2277AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A close relationship exists between the duration of partial ischemia and loss of renal function. Clamping the main artery of the kidney results in ischemia in the whole renal parachymal tissue. Selective clamping of the segmentary artery prevents global ischemia in the kidney and preserves renal functions. The aim of this video is to present a robotic partial nephrectomy operation with selective clamping of the segmentary artery. METHODS A 45 years old male patient was diagnosed with an incidental 3 cm mass located in the upper pole of the right kidney. A robotic right partial nephrectomy operation was planned. The colon was medialized after an incision on the toldt line and retroperitoneal space was entered. The hilum of the right kidney was exposed. The renal artery and vein were dissected separately. The branch of segmental artery supplying the tumour was dissected and suspended with a vessel tape. The margins of the tumour was scored with monopolar cautery and excision line was marked. Than segmental artery was clamped with a bulldog clamp. The tumour was excised by cold scissors without using cautery in order to achieve safe surgical margins. The tumour bed was sutured with 3/0 v-lock suture. Renography was performed with sliding-weck clip technique by 2/0 vicryl. The duration of ischemia was 13 min, operative time was 105 min and blood loss was 20 cc. No postoperative complications occured and the surgical drain was removed at postoperative day 1. Patient was discharged at postoperative 48th hour. RESULTS The pathologic examination was reported clear cell renal carcinoma with negative surgical margins. CONCLUSIONS The selective clamping of the segmentary artery in robotic partial nephrectomy operation is an important and feasible technic in decreasing the ischemic trauma and the associated functional deterioration of the kidney. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e775 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Omer Aytaç More articles by this author Hasan Tavukçu More articles by this author Haluk Kulaksizoglu More articles by this author Fatih Atug More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Virtual-assisted lung mapping: outcome of 100 consecutive cases in a single institute.

We developed virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using three dimensional (3D) virtual imaging, for precise thoracoscopic sublobar lung resection with safe surgical margins. We herein review the results of 100 consecutive cases of VAL-MAP in our institute to identify types of tumours or resections that benefit from VAL-MAP. Markings were bronchoscopically made within 2 days preoperatively using virtual 3D images. Post-VAL-MAP computer tomography (CT) scans localizing the actual markings were reconstructed into 3D images for intraoperative navigation. All data on patients, markings and outcomes were prospectively collected, and the contribution of VAL-MAP to the operation was graded by the surgeon. Resections of 156 lung lesions in 100 consecutive patients were planned from July 2012 to March 2014. The lesion diameter was 8.3 ± 4.9 (range, 2-24) mm. The total number of actually conducted markings was 380 (3.83 ± 1.07 markings/patient). Eighty-four lesions were resected by 71 wedge resections using 158 markings (2.1 ± 0.1/resection; range, 1-3). Seventy lesions were resected by 63 segmentectomies using 224 markings (3.6 ± 0.1/resection; range, 2-6). Markings were identifiable on post-VAL-MAP CT mostly as ground-glass opacities (87.7%) and/or bronchial dilatation (56.1%). During the operation, 357 of 380 markings (93.9%) were visible on the pleural surface and significantly associated with marking visibility on CT. Multiple markings that were complementary to one another appeared to have contributed to the high rate of successful resection (99.3%) with satisfactory resection margins. The contribution of VAL-MAP to the operation as graded by surgeons demonstrated that VAL-MAP is most effective during wedge resection or complex segmentectomy for hardly palpable, small tumours, while VAL-MAP still plays an important role in simple segmentectomy or resection of palpable tumours by providing higher confidence levels to surgeons during the operation. Minor pneumothoraces were found on post-VAL-MAP CT images in 4 patients without symptoms or a need for treatment. The present study further demonstrated the efficacy and safety of VAL-MAP. VAL-MAP is likely to benefit a broader range of patients than are conventional marking techniques by assisting with both accurate tumour identification and precise determination of resection lines.

Postoperative Glottal Function and Voice‐Related QOL after Type1 and Type2 Cordectomy against Laryngeal Leukoplakia

Objectives: Recent progress in phonomicrosurgical technique and equipment enabled one to precisely differentiate the subepithelial (type1) and subligamental (type2) cordectomy concept as needed. The purpose of this study was to compare postoperative glottal function and voice-related quality of life (QOL) between these 2 surgical concepts against laryngeal leukoplakia. Methods: From January 2007 to August 2013, 42 consecutive laryngeal leukoplakia patients had excisional biopsies using type1 procedures. Of these, cancer patients (n = 10) had additional type2 laser surgeries. Furthermore, some severe dysplasia/carcinoma in situ patients (n = 11) preferred additional type2 surgery aiming at relatively safe surgical margins. Sequential pre- and postoperative measurements of Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale and evaluations of laryngeal videostroboscopic images were performed. Acoustic measurements and voice-related QOLs (VHI and V-RQOL) were examined at the patients’ last visits. All data were compared between type1 and type2 groups. Results: Vocal quality was well-preserved in type1 group after surgery. Although immediate postoperative deterioration of GRBAS score was observed in type2 group, vocal recovery was obtained in 6 months to present no significant difference compared with type1 group. Impaired glottal closure and pliability were observed in both groups after surgery. While videostroboscopic findings of type1 group recovered to normal in 3 months, impaired glottal findings remained for 1 year in half of the type2 patients. Moreover, voice-related QOLs were significantly better in type1 group. Conclusions: Our study proved that advanced phonomicrosurgical technique and equipment could offer a well-preserved vocal quality even in the type2 group. However, subjective voice-related QOLs were better in the type1 group with superior videostroboscopic findings.

Evaluation of shrinkage of surgical margins on tongue specimens following formalin fixation

This study aims to evaluate the alterations in distances to the surgical margins on sheep tongue specimens, through resection, formalin fixation, frozen section, and microscopic examination. Fifty fresh sheep tongues were used in the study. A metal plate was fixed on the lateral aspect of each tongue to represent tumor tissues. A total of 40 specimens with either 1 cm or 2 cm distances as surgical safety margins of the surrounding plate were prepared using either scalpel or monopolar cautery (10 specimens were prepared for each group). Additional 10 specimens with 1 cm safety margins were prepared using either scalpel or monopolar cautery (5 specimens per group) for frozen section examination. Distances to the metal plates before resection were compared with the ones which were determined after resection, frozen section examination, 24-hour formalin fixation and microscopic examination. Distances to the surgical margins were found to be decreased in all specimens after resection, 10% formalin fixation and microscopic examination. The distances to the surgical margins were observed to be reduced by 6.5-7.5% on average after resection, 10-12% on average after formalin fixation and 30% on average after microscopic examination, compared to the baseline values. The level of shrinkage was reduced by 6.3-10% following microscopic section preparation during frozen section examination. Seven to eight-millimeter distance to the surgical margin at minimum should be maintained to achieve a 5 mm in height surgical safety margin during sheep tongue resection. The distance defined by the pathologist may be multiplied with 1.42 to estimate around in-situ distance to the surgical margins. Therefore, 1.42 may be used as a corrective factor for sheep tongue tissues.

Magnetic resonance imaging-radioguided occult lesion localization (ROLL) in breast cancer using Tc-99m macro-aggregated albumin and distilled water control

BackgroundMagnetic resonance imaging (MRI) guided wire localization presents several challenges apart from the technical difficulties. An alternative to this conventional localization method using a wire is the radio-guided occult lesion localization (ROLL), more related to safe surgical margins and reductions in excision volume. The purpose of this study was to establish a safe and reliable magnetic resonance imaging-radioguided occult lesion localization (MRI-ROLL) technique and to report our initial experience with the localization of nonpalpable breast lesions only observed on MRI.MethodsSixteen women (mean age 53.2 years) with 17 occult breast lesions underwent radio-guided localization in a 1.5-T MR system using a grid-localizing system. All patients had a diagnostic MRI performed prior to the procedure. An intralesional injection of Technetium-99m macro-aggregated albumin followed by distilled water was performed. After the procedure, scintigraphy was obtained. Surgical resection was performed with the help of a gamma detector probe. The lesion histopathology and imaging concordance; the procedure’s positive predictive value (PPV), duration time, complications, and accuracy; and the rate of exactly excised lesions evaluated with MRI six months after the surgery were assessed.ResultsOne lesion in one patient had to be excluded because the radioactive substance came back after the injection, requiring a wire placement. Of the remaining cases, there were four malignant lesions, nine benign lesions, and three high-risk lesions. Surgical histopathology and imaging findings were considered concordant in all benign and high-risk cases. The PPV of MRI-ROLL was greater if the indication for the initial MR examination was active breast cancer. The median procedure duration time was 26 minutes, and all included procedures were defined as accurate. The exact and complete lesion removal was confirmed in all (100%) patients who underwent six-month postoperative MRI (50%).ConclusionsMRI-ROLL offers a precise, technically feasible, safe, and rapid means for performing preoperative MRI localizations in the breast.

Penoscrotal Extramammary Paget's Disease with Multiple Lymph Node Metastasis

Penoscrotal Extramammary Paget's Disease with Multiple Lymph Node Metastasis

English

INTRODUCTION: Giant cell tumor (GCT) is a benign, locally aggressive bone tumor with predilection to occur the knee joint 11 . The World Health Organisation has classified GCT as aggressive, potentially malignant lesion, which means that its evolution based on its histological features is unpredictable. Statistically, 80% of GCTs have a benign course, with a local rate of recurrence of 20% to 50%. About 10% undergo malignant transformation at recurrence and 1% to 4% gives pulmonary metastases even in cases of benign histology. Proximal femur is a relatively rare site for the occurrence of primary GCT accounting for only 1- 10% 6, 7 . GCT in this location poses a unique challenge in management owing to difficulties in preoperative diagnosis, obtaining a safe surgical margin and reconstruction of the surgical defect, considering the complex biomechanics of the hip joint8, 12, 15. CASE REPORT: We report a case proximal femur giant cell tumour in an active young female who presented with pathological fracture. The tumour was excised with wide margin and the defect was reconstructed successfully with a custom made endoprosthesis. KEY MESSAGE: Endoprosthetic replacement for Campanacci stage-III GCT of the proximal femur achieves good to excellent functional and oncological outcomes.

Planning of segmentectomy using three-dimensional computed tomography angiography with a virtual safety margin: Technique and initial experience

ObjectivesIn preoperative segmentectomy simulation for primary lung cancer, it is important to identify the intersegmental pulmonary veins and the relationship between them and the surgical safety margin. We have adopted a method that incorporates a virtual safety margin into three-dimensional computed tomography angiography images in order to plan adequate segmentectomy for lung cancer patients. In this study, we describe the new preoperative planning technique and review cases in which we performed segmentectomy based on its results. MethodsWe reviewed clinical, radiological, and pathological records and selected patients who underwent segmentectomy for a primary lung cancer lesion with a diameter of 2cm or less. These segmentectomies were planned using preoperative three-dimensional computed tomography angiography with a virtual safety margin. ResultsA total of 17 primary lung cancers in 16 patients (11 male and 5 female, aged 52–82 years) were removed by segmentectomy, planned using the new technique. In 6 of 17 tumors (35%) were non-solid type adenocarcinomas, 3 tumors (18%) were partly solid type adenocarcinomas, 6 tumors (35%) were solid type adenocarcinomas and 2 tumors (12%) were squamous cell carcinomas. Pathological examination revealed no positive surgical margins and no lymph node metastases in any patients. ConclusionsThree-dimensional computed tomography angiography with a virtual safety margin was able to non-invasively visualize the three-dimensional distances and the relationships between the primary tumor and intersegmental pulmonary veins. It was able to aid in the preoperative planning of a suitable segmentectomy procedure for patients with a primary lung cancer lesion of 2cm or less in diameter.

The preliminary study of the use of MRI navigation in identifying the safe surgical margin of the maxillofacial malignancy

To evaluate the feasibility of MRI navigation in identifing the safe surgical margin of the maxillofacial malignancy. The pathology results of the surgical margin identified by the technique of MRI navigation form 20 patients with maxillofacial malignancy were compared with those of 45 patients with maxillofacial malignancy who underwent the routine operation without MRI navigation. There was no difference between the two groups of patients in age, sex, size of tumor, tumor stages, pathologic diagnosis (P > 0.05). The negative rate of the surgical margin of the lesions treated by surgery with the technique of MRI navigation was significantly lower than that of the lesions treated without MRI navigation (P = 0.007) and highly correspondent with the pathology results. MRI navigation was helpful in identifying the safe surgical margin of the maxillofacial malignancy.

The role of molecular margins as prognostic factors in laryngeal carcinoma in Chinese patients

Conclusion: Molecular margins were a more important prognostic factor in laryngeal carcinoma in Chinese patients than histopathological margins. eIF4E was the most sensitive molecular index of those that we tested for in these patients. Objectives: Safe surgical margins are closely related to prognosis. The aim of the present study was to investigate the role of molecular margins, not traditional histopathological margins, as prognostic factors in laryngeal carcinoma in Chinese patients. An additional aim of the study was to investigate the prognostic significance of tumor markers in the primary site of laryngeal carcinoma. Methods: From January 1992 to January 2000, the data for 321 Chinese patients with laryngeal carcinoma who were divided into a recurrent laryngeal carcinoma group and a non-recurrent group were analyzed. Tumor markers in surgical margins and primary site, such as cyclin D1, p53, and eIF4E, were detected in the two groups with immunohistochemical staining. Results: There was a significant difference in the expression of cyclin D1, p53, and eIF4E in surgical margins between the recurrent laryngeal carcinoma group and the non-recurrent group. The eIF4E-positive rate in surgical margins was higher than that for the other two factors. There was a significant difference in cyclin D1 and p53 in the primary site of laryngeal carcinoma and no significant difference in eIF4E in the two groups.

Long-Term Outcome of Isolated Limb Perfusion in Advanced Soft Tissue Sarcoma of the Extremity

Isolated limb perfusion with tumor necrosis factor alpha and melphalan (TM-ILP) has proven to be a successful option in treating advanced soft tissue sarcomas (STS), where amputation otherwise is needed to achieve safe surgical margins. From 2000 to 2009, 54 patients with locally advanced STS, who all were candidates for amputation, were treated with totally 57 TM-ILP procedures and then followed prospectively. The median follow-up time was 30 months. Median tumor size was 10 cm, and 94% of the patients had high-grade tumors. The clinical overall response after TM-ILP was 71% (including 21% CR), and 60% of the patients underwent resection of the tumor remnant after a median of 2 months. The histopathologic response rate in the resected specimens was 76%. Local recurrence/progress occurred in 37% of the patients after a median of 7 months. Thirteen patients finally underwent amputation after a median of 11 months, giving a long-term limb salvage of 76%. TM-ILP of advanced soft tissue sarcoma of the extremities makes limb-sparing surgery possible in a high proportion of patients.

Do different breast cancers require different free surgical margin width

The appropriate width of the free surgical margin in breast conservative treatment of cancer is a subject of interest due to the tendency of less radical surgery, while maintaining oncological safety. Several studies suggest that an adequate excision with free margins of tumor is required to obtain an optimal local control. However the definition of proper free a surgical margin is controversial and it is highly questionable whether the increased width of free surgical margins results in decreasing local recurrence rate (LR). Currently, it is considered appropriate surgical treatment to obtain a negative surgical margin, or inked free margin regardless of their width. Several pathological factors and different clinical treatments are dependently associated with LR, including tumor size, lymph node involvement, the presence of extensive intraductal component, vascular invasion, and the influence of systemic treatment and radiotherapy. The identification of LR among patients with negative margins is very important and a challenge for the clinical outcome of breast cancer. Many guidelines for safe surgical margin for invasive carcinoma and intraductal carcinoma are different; moreover the presence of intraductal component may affect the LR. Recently the molecular genetic subtype of breast cancer is also known as an important prognostic factor. It expands the concept of tumor heterogeneity of breast cancer, bringing the concept of individualization of treatment, both systemic and locoregional treatment. We reviewed the evidence of literature based on the adequate surgical margin and the influence of different tumor type and biology including molecular subtypes in identifying the risk of locoregional recurrence, bringing to discuss the possible need for different widths of free surgical margins. Keyword: molecular subtype; breast cancer; surgical margin; breast conservative surgery; mastectomy; oncoplasty

Penile Cancer Incidentally Detected During Circumcision:A Case Report

This report presented the case of an 83-year-old male with penile cancer detected accidently during circumcision for the purpose of facilitating the insertion of resecting scope for bladder carcinoma. This penile cancer was too close to collum glandis to be removed with a sufficient surgical safety margin. After due consideration, we performed the circumcision only 2 mm away from the tumor. The pathological examination of the bladder tumor revealed urothelial carcinoma, G2, pTa, and that of the penile tumor revealed SCC, pTaN0M0. We performed a punch out biopsy at six points around the surgical margin at one week postoperatively. However, we did not detect any malignant tissue in the biopsy specimen. This patient did not want additional postoperative treatment, and was followed-up this patient without treatment. This patient is still alive with no recurrence of any tumor at 1 year after the operation.

Clinical implications of determination of safe surgical margins by using a combination of CT and 18FDG-positron emission tomography in soft tissue sarcoma

BackgroundTo determine safe surgical margins for soft tissue sarcoma, it is essential to perform a general evaluation of the extent of tumor, responses to auxiliary therapy, and other factors preoperatively using multiple types of diagnostic imaging. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is a tool for diagnostic imaging that has recently spread rapidly in clinical use. At present, the roles played by FDG-PET/CT in determination of margins for surgical resection of sarcoma are unclear. The present study was undertaken to explore the roles of FDG-PET/CT in determination of surgical margins for soft tissue sarcoma and to examine whether PET can serve as a standard means for setting the margins of surgical resection during reduced surgery.MethodsThe study involved 7 patients with sarcoma who underwent surgery in our department and in whom evaluation with FDG-PET/CT was possible. Sarcoma was histologically rated as MFH in 6 cases and leiomyosarcoma in 1 case. In all cases, sarcoma was superficial (T1a or T2a). The tumor border was defined by contrast-enhanced MRI, and SUVs were measured at intervals of 1 cm over a 5-cm long area from the tumor border. Mapping of viable tumor cells was carried out on whole-mount sections of resected tissue, and SUVs were compared with histopathological findings.ResultsPreoperative maximum SUVs (SUV-max) of the tumor averaged 11.7 (range: 3.8-22.1). Mean SUV-max was 2.2 (range: 0.3-3.8) at 1 cm from the tumor border, 1.1 (0.85-1.47) at 2 cm, 0.83 (0.65-1.15) at 3 cm, 0.7 (0.42-0.95) at 4 cm, and 0.64 (0.45-0.82) at 5 cm. When resected tissue was mapped, tumor cells were absent in the areas where SUV-max was below 1.0.ConclusionsOur findings suggest that a safe surgical margin free of viable tumor cells can be ensured if the SUV cut-off level is set at 1.0. FDG-PET/CT is promising as a diagnostic imaging technique for setting of safe minimal margins for surgical resection of soft tissue sarcoma.

Management of Phyllodes Breast Tumors

Phyllodes tumors are a rare distinctive fibroepithelial tumors of the breast and their management continues to be questioned. The aim of our study was to examine the treatment and outcome of 165 patients with phyllodes tumors and to review the options for surgical management. This is a retrospective study of 165 patients who presented to the Institut Curie between January 1994 and November 2008 for benign, borderline or malignant phyllodes tumors. The median follow-up was 12.65 months [range 0-149.8]. The median age at diagnosis was 44 years [range 17-79]. One hundred and sixty patients (97%) had breast-conserving treatment, of whom 3 patients (1.8%) had oncoplastic breast surgery. Younger women had a significantly higher chance of having a benign phyllodes tumor (p = 0.0001) or a tumor of small size (p < 0.0001). Histologic examination showed 114 benign (69%), 37 borderline (22%) and 14 malignant tumors (9%). The median tumor size was 30 mm [range 5-150]. The tumor margins were considered incomplete (< 10 mm) in 46 out of 165 cases (28%) with 52% revision surgery. Only the tumor grade was a significant risk factor for incomplete tumor margins (p = 0.005). Fifteen patients developed local recurrence (10%) and two, metastases. In univariate analysis, the histologic grade (p = 0.008), and tumor size (p = 0.02) were significative risk factors for local recurrence with an accentuated risk for "borderline" tumors and tumors of large size.).Similar results were obtained using multivariate analysis (p = 0.07). The mainstay of treatment for phyllodes tumors remains excision with a safe surgical margin, taking advantage breast conserving surgery where amenable. For borderline or malignant phyllodes tumors or in cases of local tumor recurrence, mastectomy, and immediate breast reconstruction may become the preferred option. Genetic analysis will potentially supplement classical histologic examination in order to improve our management of these tumors. The role of adjuvant treatments is unproven and must be considered on a case-by-case basis.

Abstract P5-14-12: Management of Phyllodes Breast Tumours: A Review of 165 Cases

Abstract Aim:The aim of our study was to examine the treatment and outcome of 165 patients with phyllodes tumours and to review the options for surgical management. Patients and Methods: This is a retrospective study of 165 patients who presented to the Institut Curie between January 1994 and November 2008 for benign, borderline or malignant phyllodes tumours. Results: The median follow-up was 12.65 months [range 0 to 149.8]. The median age at diagnosis was 44 years [range 17 to 79]. One hundred and sixty patients (97%) had breast conserving treatment, of whom 3 patients (1. 8%) had oncoplastic breast surgery. Younger women had a significantly higher chance of having a benign phyllodes tumor (p = 0.0001) or a tumour of small size (&amp;lt; 0.0001). Histological examination showed 114 benign (69%), 37 borderline (22%) and 14 malignant tumours (9%). The median tumour size was 30 mm [range 5 to 150]. The tumour margins were considered incomplete (&amp;lt; 10 mm) in 46 out of 165 cases (28%) with 52% revision surgery. Only the tumour grade was a significant risk factor for incomplete tumour margins (p = 0.005). Fifteen patients developed local recurrence (10%) and two, metastases. In univariate analysis, the histological grade (p = 0.008) and tumour size (p=0.02) were significative risk factors for local recurrence with an accentuated risk for borderline tumours and tumours of large size. Similar results were obtained using multivariate analysis (p=0.07) Conclusion: The mainstay of treatment for phyllodes tumours remains excision with a safe surgical margin, taking advantage breast conserving surgery where amenable. For borderline or malignant phyllodes tumours or in cases of local tumour recurrence, mastectomy and immediate breast reconstruction may become the preferred option.Genetic analysis will potentially supplement classical histological examination in order to improve our management of these tumours. The role of adjuvant treatments is unproven and must be considered on a case-by-case basis. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-12.

Is Minimally Invasive Gastrectomy Feasible for the Treatment of Multiple Early Gastric Cancer?

Purpose: As preoperative diagnostic tools have advanced, the rate of multiple early gastric cancer diagnoses have increased. The author investigated the clinicopathological features of multiple early gastric cancers to elucidate the clinical feasibility of minimally invasive gastrectomy such as laparoscopy or robot assisted gastrectomy for their surgical treatment. Methods: One thousand one hundred and eighty-five open gastrectomies and 607 laparoscopies or robot-assisted gastrectomies for gastric cancers from January 2003 through August 2009 were retrospectively reviewed. Among them, 844 were diagnosed as early gastric cancers, of which 47 cases had multiple early gastric cancers. Twenty-seven cases underwent open gastrectomy and 20 cases underwent laparoscopy or robot assisted gastrectomy. The author analyzed clinicopathological features in these multiple early gastric cancers. Results: The incidences of multiple early gastric cancers among the early gastric cancers were 5.6%. There were no statistical differences in the clinicopathological parameters except the type of gastrectomy and anastomosis. The distances of both proximal and distal margin show no statistical difference in both groups. The hospital stay was shorter in laparoscopy or robot assisted gastrectomy group (P=0.022). The postoperative complications developed 7 cases in open group and 1 case in laparoscopy or robot assisted gastrectomy group (P=0.046). During the mean follow-up period of and months, no recurrence was found in both groups. Conclusion: Laparoscopy or robot assisted gastrectomy are as acceptable as open methods to obtain a safe surgical margin, and to perform the desirable type of gastrectomy and radical lymph node dissection.

A retrospective study comparing the accuracy of prehistology diagnosis and surgical excision of malignant melanomas by general practitioners and hospital specialists

A retrospective study was carried out to compare the overall standard of surgical excision of malignant melanomas (MMs) between general practitioners (GPs) and hospital specialists before and after the introduction of the UK melanoma guidelines between 1989 and 2006. In total, 213 melanoma excision reports were examined and surgical excision margins recorded. The results showed a significant difference in the rate of adequate surgical excision margins (at all levels of Breslow thickness) between GPs and hospital specialists, with hospital specialists excising melanomas with safe surgical excision margins at a significantly higher rate compared with GPs. Since the introduction of the guidelines in 2002, GPs showed a significant improvement in the completeness of melanoma excision but remained poor at prehistology diagnosis and in particular at taking adequate excision margins. Implementation of the guidelines has not produced significant improvements in adequacy of excision margins in both primary and secondary care. The results show that hospital specialists maintained a high standard of prehistological diagnosis and completeness of excision throughout the time of the study, performing at a significantly higher standard compared with GPs. Our conclusions concur with the UK melanoma guidelines and the National Institute for Health and Clinical Excellence guidelines, which suggest that lesions suspicious for melanoma should be urgently referred to a dermatologist or plastic surgeon for surgical excision and should not be surgically excised in primary care, particularly if lesions have a Breslow thickness > 2 mm. We suggest that the new guidelines need to be more aggressively implemented in primary care and guidance introduced to improve the accuracy of diagnosis, with better training provided for GPs.