Surgical Margin Status Research Articles

Surgery with curative intent is associated with prolonged survival in patients with cutaneous angiosarcoma of the scalp and face -a retrospective study of 38 untreated cases in the Japanese population

BackgroundIn patients with cutaneous angiosarcoma of the scalp and face, the validity of surgery remains controversial, because of the potentially diffuse nature of involvement and difficulty in obtaining negative margins. ObjectiveTo evaluate the survival benefit of surgery as a primary treatment. Patients and methodsFifty-one patients with primary cutaneous angiosarcoma of the scalp and face presenting with locoregional involvement were referred to National Cancer Center Hospital, Tokyo, Japan, between May 1982 and March 2013. Data of those patients in whom the diagnosis had been confirmed histologically and the primary treatments had been initiated at our center were analysed retrospectively. Only untreated cases were selected with aim to evaluate actual survival benefit of surgery as a primary treatment. ResultsOf the 51 patients, 38 were found to be eligible for inclusion in this analysis; of these 38 patients, 29 (29/38 = 76.3%) patients had tumour diameter > 5 cm, and 29 underwent surgery with curative intent (curative-intent surgery) as the initial treatment. Histologically positive margins were found in 10 patients. Multivariate analysis identified curative-intent surgery as being significantly associated with improved overall survival (OS; HR = 0.26; 95% CI, 0.10–0.63). In the Surgery group, neither negative margins nor combined-modality treatment had any significant influence on the OS. ConclusionRemoval of primary tumour with curative-intent surgery may be a valid treatment option even for patients with primary cutaneous angiosarcoma of the scalp and face larger than 5 cm in size, regardless of the histological surgical margin status.

Impact of Micro- and Macroscopically Positive Surgical Margins on Survival after Resection of Adrenocortical Carcinoma.

Adrenocortical carcinoma (ACC) is a rare, aggressive cancer; complete surgical resection offers the best chance for long-term survival. The impact of surgical margin status on survival is poorly understood. Our objective was to determine the association of margin status with survival. Patients with ACC were identified from the National Cancer Data Base, 1998-2012, and stratified based on surgical margin status (negative vs. microscopically positive [+] vs. macroscopically [+]). Univariate/multivariate regression/survival analyses were utilized to determine factors associated with margin status and overall survival (OS). A total of 1553 patients underwent surgery at 589 institutions: 86% had negative, 12% microscopically (+), and 2% macroscopically (+) margins. Those with microscopically (+) and macroscopically (+) margins more often received adjuvant chemotherapy (39.4% macroscopically (+) vs. 38.5% microscopically (+) vs. 25.2% negative margins, p<0.001). For unadjusted analysis, there was a significant difference in OS between the groups (log-rank p<0.001), with median survival times of 58months (95% confidence interval [CI] 49-66) for those with negative margins, 22months (95% CI 18-34) microscopically (+), and 14months (95% CI 6-27) macroscopically (+) margins. After adjustment, both microscopically (+) (HR 1.76, p<0.001) and macroscopically (+) (HR 2.10, p=0.0019) margin status were associated with compromised survival. Having micro- or macroscopically (+) margin status after ACC resection is associated with dose-dependent compromised survival. These results underscore the importance of achieving negative surgical margins for optimizing long-term patient outcomes.

Pelvic Exenteration With Rectal Resection for Different Types of Malignancies at Two Tertiary Referral Centers

IntroductionPelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyze results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction. MethodFrom January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analyzed retrospectively at two national tertiary referral centers. ResultsThirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. 5-Year overall survival following R0 resection was 62.6%; R1, 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence. ConclusionPelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.

AB084. Correlation between histopathology and optical coherence tomography in periocular tumors

Background: Basal cell carcinoma (BCC) accounts for 90% of the eyelid malignancies followed by sebaceous cell carcinoma (SC) and squamous cell carcinoma (SCC). Even though biopsy for histopathological (HP) evaluation remains the gold standard for confirming the diagnosis of eyelid tumors and the status of surgical margins, noninvasive techniques such as dermoscopy and optical coherence tomography (OCT) may increase diagnostic sensitivity and contribute to more accurate delineation of surgical margins. The purpose of this prospective study was to correlate the HP and OCT findings of eyelid malignancies.

The intersection of surgery and bioengineering: innovative solutions for clinical problems in pancreatic and other cancers

Background: Surgical cancer margin status affects prognosis. Negative margins may be impossible if tumor abuts vascular structures. We created a novel device to produce lethal heating in cancers abutting major blood vessels without causing thrombosis. Methods: We modeled pancreatic adenocarcinoma (PDAC) because it may involve the superior mesenteric artery (SMA). Human PDAC received hyperthermia in an orthotopic model to determine thermal sensitivity. We built devices to produce heat to the arterial wall without occlusion. These devices were tested using the femoral artery or SMA of swine. Results: Tests with human PDAC cells established 46 °CC for 10 minutes as the temperature and time to kill PDAC cells without killing normal cells. Femoral artery studies showed 46 °C for 10 minutes on the outer wall was associated with 2 °CC lower temperature in the lumen. Treatment of the SMA caused no occlusion or bowel injury, and the vessel was patent 48 hours after treatment. Conclusion: We demonstrated a surgical device can produce temperatures sufficient to kill cancer cells involving critical arteries and not cause endothelial damage or vascular thrombosis. Additional studies will confirm there is no subacute or chronic arterial injury or issues with bowel perfusion.

1035 - Impact of surgical margin status after partial nephrectomy for renal cell carcinoma

1035 - Impact of surgical margin status after partial nephrectomy for renal cell carcinoma

Effectiveness of adjuvant radiotherapy after radical cystectomy for locally advanced bladder cancer.

484 Background: Local-regional failure (LF) for locally advanced bladder cancer (LABC) after radical cystectomy (RC) is common even with chemo and is associated with high morbidity/mortality. Adjuvant radiotherapy (adjRT) can reduce LF and may enhance overall survival (OS) but has no defined role. We hypothesized that the addition of adjRT would improve OS in LABC in a large multi-institutional cohort. Methods: We identified ≥pT3 pN0-3, M0 LABC pts in the NCDB diagnosed in 2004 – 2013 who underwent RC +/- adjRT. AdjRT cohort included pts treated to ≥40Gy to the pelvis within 1 yr of diagnosis. Propensity matching was performed to match RC pts who received adjRT vs. those who did not. OS was calculated using Kaplan-Meier. Factors significant on univariate analysis were entered into Cox proportional hazards regression model to identify predictors of OS. Results: 15,246 RC pts were identified, with 450 (3.0%) receiving adjRT. Median OS was 23.0 mo (95% CI, 22.4-23.6) for RC vs. 19.7 mo (95% CI, 17.7-21.7) for adjRT [Log-rank P = 0.002; Wilcoxon P = 0.862]. Propensity score matching on demographic, clinical, &amp; treatment variables yielded 742 pts (371 in each group). In the matched cohort, OS was 17.1 mo [95%CI, 14.5 - 19.6] for RC vs. 20.1 mo [95% CI, 17.8– 22.5] for adjRT [Log-rank P = 0.044]. On MVA in the matched cohort, factors predictive of OS were sex, pT stage, pN+ status, surgical margin status, number of nodes removed, adjRT, &amp; chemo (p &lt; 0.01 for all). On MVA of subgroups, adjRT was associated with significantly improved OS in pts with positive margins [HR 0.55 (95% CI, 0.43 – 0.71), P &lt; 0.001], pN+ disease [HR 0.62 (95% CI, 0.49 – 0.79), P &lt; 0.001], &amp; pT4 disease [HR 0.68 (95% CI, 0.55 – 0.85), P = 0.001]. In MVA of pts with urothelial carcinoma (N = 578), adjRT remained associated with improved OS in pts with positive margins [HR 0.57 (95% CI, 0.43 – 0.76), P &lt; 0.001], pN+ disease [HR 0.65 (95% CI, 0.50 – 0.86), P = 0.002], &amp; pT4 disease [HR 0.68 (95% CI, 0.54 – 0.85), P = 0.001]. Conclusions: In this observational study, adjRT was associated with improved OS in LABC. While the data should be interpreted cautiously, these results lend support to the use of adjRT in selected pts with LABC, regardless of histology. Prospective trials of adjRT are warranted.

SAKK 08/15-promet: Multicenter, randomized phase II trial of salvage radiotherapy +/- metformin for patients with prostate cancer after prostatectomy.

TPS157 Background: Salvage radiotherapy (SRT) is as a potentially curative treatment for prostate cancer (CaP) patients presenting biochemical relapse after radical prostatectomy (RP). Metformin is a well-known antidiabetic drug that has demonstrated anti-cancer and radio-sensitizing effects. We aim to study whether metformin combined with SRT will improve cancer control by prolonging time to progression (TTP). Methods: This is a multicenter, randomized (1:1) phase II trial of SRT (70Gy/35fr to the prostate bed) with or without metformin (850mg BID for 52 wks) (NCT02945813). Metformin 850mg q.d. is started 4 wks prior to SRT. Stratification variables include Gleason score, PSA at randomization, surgical margin status and ADT use (allowed if PSA &gt; 0.5, R0, post-RP PSA-DT &lt; 6 mos or pT3b). Major eligibility criteria include: histologically proven CaP adenocarcinoma pT2a-3b, pN0 or cN0, M0; RP &gt; 12 wks before registration; PSA progression after RP defined as 2 consecutive rises with final PSA &gt; 0.1 ng/mL or 3 consecutive rises; and PSA ≤ 2 ng/mL within 14 days prior to registration. A sample size of 170 patients (85 per arm) is planned based on the primary endpoint TTP. Using a type I error of 5% and a power of 80%, 62 events are needed to show superiority of the treatment arm under the alternative hypothesis that the hazard ratio (HR) is 0.65 (TTP at 18 mos of 80% in the control arm vs. 86.5% in the treatment arm). All efficacy endpoints will be analyzed based on the full analysis population. The treatment effect will be assessed using Cox regression with the treatment arm as independent variable and the stratification factors as strata. Correlative studies including prostate tissue, blood (metabolic parameters), saliva and feces (microbiota) will be performed. Conclusion: Centers in Switzerland, Germany and France (GETUG) will recruit patients for this study. If positive, these results could help elucidate the role of metformin in CaP and determine the design of a subsequent phase III trial. Clinical trial information: NCT02945813.

Digital versus light microscopy assessment of surgical margin status after radical prostatectomy

Positive surgical margin (PSM) extension reported as focal or non-focal/extensive is an important pathologic prognostic parameter after radical prostatectomy. Likewise, there is limited or no agreement on how to measure and what the best cut-off points to be used in practice are. We hypothesized that digital microscopy (DM) would potentially provide a more objective way to measure PSM and better define its clinical significance. To further our knowledge, we have evaluated PSM status in 107 laparoscopic radical prostatectomies using digital and conventional light microscopy (LM). DM evaluation detected three additional PSM cases, but no differences were seen (LM vs DM; p = 0.220). Mean linear measurement correlated to biochemical recurrence (BR) (LM, p = 0.002; DM, p = 0.001). ROC analysis identified a cut-off point to assess linear measurement by LM (3.5mm) or DM (3.2mm), but only digital measurement was significant for BR-free survival. Our study also evaluated a cut-off ≤ 3mm that was associated to BR using LM (p = 0.023) or DM (p = 0.001). Finally, the number of paraffin blocks bearing PSM correlated with BR (p < 0.001) status with either LM or DM. In conclusion, DM produces similar data than LM but shows more accurate measurements. Reporting of PSM with score of ≤ 3 vs. > 3mm linear extent using LM (3.2mm if digital microscopy is applied) might represent an important prognostic feature after radical prostatectomy. Alternatively, reporting the number of blocks with PSM 1 vs. 2 or more might also provide important prognostic data in practice.

Postresection CA19-9 and margin status as predictors of recurrence after adjuvant treatment for pancreatic carcinoma: Analysis of NRG oncology RTOG trial 9704

PurposeNRG Oncology RTOG 9704 was the first adjuvant trial to validate the prognostic value of postresection CA19-9 levels for survival in patients with pancreatic carcinoma. The data resulting from this study also provide information about predictors of recurrence that may be used to tailor individualized management in this disease setting. This secondary analysis assessed the prognostic value of postresection CA19-9 and surgical margin status (SMS) in predicting patterns of disease recurrence. Methods and materialsThis multicenter cooperative trial included participants who were enrolled as patients at oncology treatment sites in the United States and Canada. The study included 451 patients analyzable for SMS, of whom 385 were eligible for postresection CA19-9 analysis. Postresection CA19-9 was analyzed at cut points of 90, 180, and continuously. Patterns of disease recurrence included local/regional recurrence (LRR) and distant failure (DF). Multivariable analyses included treatment, tumor size, and nodal status. To adjust for multiple comparisons, a P value of ≤ .01 was considered statistically significant and > .01 to ≤ .05 to be a trend. ResultsFor CA19-9, 132 (34%) patients were Lewis antigen–negative (no CA19-9 expression), 200 (52%) had levels <90, and 220 (57%) had levels <180. A total of 188 patients (42%) had negative margins, 152 (34%) positive, and 111 (25%) unknown. On univariate analysis, CA19-9 cut at 90 was associated with increases in LRR (trend) and DF. Results were similar at the 180 cut point. SMS was not associated with an increase in LRR on univariate or multivariate analyses. On multivariable analysis, CA19-9 ≥ 90 was associated with increased LRR and DF. Results were similar at the 180 cut point. ConclusionsIn this prospective evaluation, postresection CA19-9 was a significant predictor of both LRR and DF, whereas SMS was not. These findings support consideration of adjuvant radiation therapy dose intensification in patients with elevated postresection CA19-9.

High expression of SLCO2B1 is associated with prostate cancer recurrence after radical prostatectomy.

Solute carrier organic anion (SLCO) gene families encode organic anion transport proteins, which are transporters that up-take a number of substrates including androgens. Among them, high expression of SLCO2B1 is known to associate with the resistance to androgen deprivation therapy in prostate cancer (PCa). We hypothesized that high expression of SLCO genes enhances PCa progression by promoting the influx of androgen. Here, we demonstrated the impact of the expression levels of SLCO2B1 on prognosis in localized PCa after radical prostatectomy (RP) utilizing 494 PCa cases in The Cancer Genome Atlas (TCGA). SLCO2B1 high expression group showed significantly worse Disease-free survival (DFS) after RP (p = 0.001). The expression level of SLCO2B1 was significantly higher in advanced characteristics including Gleason Score (GS ≤ 6 vs GS = 7; p = 0.047, GS = 7 vs GS ≥ 8; p = 0.002), pathological primary tumor (pT2 vs pT3/4; p < 0.001), and surgical margin status (positive vs negative; p = 0.013), respectively. There was a significant difference in DFS between these two groups only in GS ≥ 8 patients (p = 0.006). Multivariate analysis demonstrated that only SLCO2B1 expression level was an independent predictor for DFS after RP in GS ≥ 8. SLCO2B1 high expressed tumors in GS ≥ 8 not only enriched epithelial mesenchymal transition (EMT) related gene set, (p = 0.027), as well as Hedgehog (p < 0.001), IL-6/JAK/STAT3 (p < 0.001), and K-ras signaling gene sets (p < 0.001), which are known to promote EMT, but also showed higher expression of EMT related genes, including N-cadherin (p = 0.024), SNAIL (p = 0.001), SLUG (p = 0.001), ZEB-1 (p < 0.001) and Vimentin (p < 0.001). In conclusion, PCa with high expression of SLCO2B1 demonstrated worse DFS, which might be due to accelerated EMT.

Is BMI associated with post-operative complication risk among patients undergoing major abdominal surgery for cancer? A systematic review.

We systematically reviewed 118 studies comparing peri-operative outcomes among obese and non-obese patients. Obesity was associated with longer operative time in 60% of available studies. Just 35.8% of studies that evaluated overall morbidity identified high morbidity in obese patients. Lymph node yield or surgical margin status, was only affected by obesity in 19.6% of studies. In this review obesity was frequently found to have no effect on peri-operative and oncologic outcomes.

Predictors of overall survival after surgery in gastric cancer patients from a Latin-American country.

Gastric cancer is one of the major causes of cancer-related deaths in several Latin-American countries, including Costa Rica. However, determinants of poor outcomes are fairly unknown for patients from this region. The aim of this study was to determine prognostic variables of overall survival (OS) in a cohort of Hispanic patients after curative-intent surgery for gastric cancer. We retrospectively evaluated the clinical records of 236 consecutive patients who underwent surgery for advanced gastric cancer at four major hospitals in Costa Rica. Univariate and multivariate Cox proportional models were used to assess the influence of age, sex, clinical stage, adjuvant therapy, type of dissection (D1 vs. D2), extent of gastrectomy (partial vs. total), margin status (R0 vs. R1/2), tumour differentiation, and tumour location on OS. After a median follow-up of 46.5 months, median OS was 47.6 months [95% confidence interval (CI): 34.7-60.4]. There was no survival benefit of adjuvant chemotherapy [hazard ratio (HR): 1.18; 95% CI: 0.70-2.00; P=0.53] or postoperative chemoradiotherapy (CRT) (HR: 1.04; 95% CI: 0.71-1.52; P=0.85) compared to surgery alone. After adjustment for potential confounders, the R0 status was associated with better OS (HR: 0.51; 95% CI: 0.28-0.92; P=0.03). Similarly, clinical stage (III vs. I) (HR: 2.26; 95% CI: 1.39-4.29; P=0.001), poor differentiated (HR: 1.72; 95% CI: 1.22-2.76; P=0.03) and undifferentiated tumours (HR: 2.37; 95% CI: 1.39-4.23; P=0.001) were associated with worse outcomes. The surgical margin status, clinical stage, and tumour differentiation were predictor variables for OS in this cohort of gastric cancer patients.

Risk factors for HPV persistence and cytology anomalies at follow-up after treatment for cervical dysplasia.

To evaluate predictor factors of persistent cytologic dysplasia and/or high-risk human papillomavirus (hrHPV) infection at 6-month follow-up and at 3-5years during routine cervical smear testing. The present retrospective study included data from women treated for cervical dysplasia by large loop excision of the transformation zone (LLETZ) at Ipswich Hospital, UK, between January 1 and December 31, 2012. Age, parity, smoking, status of resection margins, and previous LLETZ treatment were evaluated by multivariate analyses. There were 192 patients included in the study. There was no association between age (relative risk [RR] 1.0, 95% confidence interval [CI] 0.80-1.23; P>0.99), smoking (RR 1.12, 95% CI 0.79-1.59; P=0.516), or parity (RR 1.10, 95% CI 0.88-1.38; P=0.382) and abnormal cytology and/or persistent hrHPV infection at 6months. There was an association between positive margins (RR 1.64, 95% CI 1.20-2.24; P=0.003), previous LLETZ (RR 3.48, 95% CI 1.69-7.15; P<0.001), and dyskaryosis and/or hrHPV infection at 6months. Only previous LLETZ treatment remained associated with abnormal cytology and persistent hrHPV infection at 3-5years (RR 6.37, 95% CI 3.56-11.3; P<0.001). Clinical factors, including age, smoking, treatment history, and status of surgical margins, could help to determine the risk of dysplasia recurrence and facilitate patient follow-up based on risk stratification.

Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review.

Background:Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated.Objective:To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa.Methods:Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized.Results:cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions.Conclusions:Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.

PanCD44 Immunohistochemical Evaluation in Prostatectomies from Patients with Adenocarcinoma.

Introduction CD44 has been proposed as a prognostic marker and a stem cell marker but studies in patients with prostate cancer have yielded inconsistent results. Patients and Methods Patients submitted to radical prostatectomy between 2008 and 2013 at a university hospital were followed with biannual serum PSA tests to determine the biochemical recurrence (BR). Archived paraffin blocks with neoplastic and nonneoplastic tissue were evaluated immunohistochemically for a panCD44 and MYC. Results Sixty-nine patients completed follow-up and were included. CD44 positivity was observed in inflammatory cells (42%), nonneoplastic epithelium (39.7%), and neoplastic tissue (12.3%). In nonneoplastic tissues staining was observed in basal and luminal cells with the morphology of terminally differentiated cells. In neoplastic tissues, CD44 negativity was correlated with higher Gleason scores (Rho = −0.204; p = 0.042) and higher preoperative serum PSA levels when evaluated continuously (p = 0.029). CD44 expression was not associated with tumor stage (p = 0.668), surgical margin status (p = 0.471), or BR (p = 0.346), nor was there any association between CD44 and MYC expression in neoplastic tissue (p = 1.0). Conclusion In the bulk of cells, the minority of cancer stem cells would not be detected by immunohistochemistry using panCD44. As a prognostic marker, its expression was weakly correlated with Gleason score and preoperative PSA level, but not with surgical margin status, tumor stage, or BR.

Surgical Margin Status of Patients with Pancreatic Ductal Adenocarcinoma Undergoing Surgery with Radical Intent: Risk Factors for the Survival Impact of Positive Margins.

For pancreatic ductal adenocarcinoma (PDAC), surgical margin status is an important pathological factor for evaluating surgical adequacy. In this study, we attempted to investigate predictive factors for the survival impact of positive surgical margins. From February 2004 to December 2013, 204 patients were diagnosed with PDAC and underwent surgery with radical intent; 189 patients fulfilled our selection criteria and were enrolled for analysis. For the 189 enrolled patients with PDAC, we found male predominance (112/189, 59%) and a median age of 64 years; most patients were diagnosed with stage IIB disease (n=115, 61%). The positive surgical margin rate was 21% (n=40). Carbohydrate antigen 19-9 (CA19-9) level higher than 246 U/ml (odds ratio (OR)=2.318; 95% confidence interval (CI)=1.037-5.181 p=0.040) and lesion location in the uncinate process (OR=2.996; 95% CI=1.232-7.284 p=0.015) were the only two independent risk factors for positive surgical margins. Positive retroperitoneal soft-tissue margins were the most frequently observed (24/40, 60%). Overall, positive surgical margins had no survival impact in the 189 patients with PDAC who underwent surgery; however, positive surgical margins had an unfavorable survival impact on patients with stage IIA PDAC who underwent surgery. Retroperitoneal soft-tissue was the most common site for positive surgical margins. Additionally, surgical margin positivity was more likely for tumors located in the uncinate process than for other tumors. Positive surgical margins had an unfavorable survival impact on patients with stage IIA PDAC who underwent surgery.

Expression of Laminin in Oral Squamous Cell Carcinomas

Background and objectives:Laminin is a significant basement membrane (BM) glycoprotein, the expression of which reflects BM integrity more precisely than do other ECM proteins. The present study aimed to evaluate laminin expression in oral squamous cell carcinomas OSCC and to determine any associations with clinico-pathological parameters (surgical margin status, lymph node involvement, survival and recurrence).Methods:Laminin expression was evaluated in 31 cases of biopsy-proven OSCC by immunohistochemical staining and its association with prognosticators and the Brynes grading system was determined by appropriate statistical analysis.Results:We observed a significant increase in linear staining pattern (p<0.001) at the tumour-host interface in well-differentiated OSCC cases, in contrast to poorly differentiated lesions which exhibited intense cytoplasmic expression within tumour cells. Higher cytoplasmic laminin expression was seen in 33.3% of cases with involved surgical margins and 69.2% of cases with lymph node metastasis (along with weak/absent staining of laminin around the tumour-host interface – Basement membrane around tumour islands). Similarly, in 60% of the cases who died and in 81.8% of cases with tumour recurrence, moderately intense cytoplasmic laminin expression was seen within tumour cells. On comparing variables of the Brynes grading system, significant cytoplasmic expression of laminin was linked with mild inflammation (p<0.0016) and increased mitotic activity (p<0.008).Conclusion:Based on these observations, immunohistochemical expression of laminin might be useful to evaluate histological differentiation and aggressiveness of OSCCs.

In Brief

We assessed the relationship of surgical margins across different surgical approaches to partial nephrectomy in patients with clinical T1a renal cell carcinoma in a population based cohort.We used NCDB (National Cancer Database) to identify all patients who underwent partial nephrectomy for clinical T1a renal cell carcinoma (tumor size less than 4 cm) from 2010 to 2011. The primary outcome was surgical margin status in patients treated with partial nephrectomy by the open, laparoscopic or robotic approach. Multivariable logistic regression analysis was done to identify patient, hospital and surgical factors associated with positive surgical margins.Partial nephrectomy was done in 11,587 patients, including open, laparoscopic and robotic nephrectomy in 5,094 (44%), 1,681 (14%) and 4,812 (42%), respectively. Mean ± SD age was 56 ± 12 years. Overall 806 patients (7%) had positive surgical margins. The positive surgical margin prevalence was 4.9%, 8.1% and 8.7% for the open, laparoscopic and robotic approaches, respectively (p <0.001). Laparoscopic and robotic partial nephrectomy had a higher adjusted OR for positive surgical margins (OR 1.81 and 1.79, respectively, each p <0.001) than open nephrectomy. When stratified by hospital type, differences in positive surgical margin rates remained, such that patients treated at academic medical centers who underwent laparoscopic and robotic partial nephrectomy had a higher adjusted OR (1.38, p = 0.074 and 1.73, p <0.001, respectively) than patients treated with open partial nephrectomy.Laparoscopic and robotic partial nephrectomy is associated with higher positive surgical margin rates compared to open partial nephrectomy for clinical T1a renal cell carcinoma. The effect of margin status on long-term oncologic outcomes in this context remains to be determined.

Robot-assisted Retroperitoneoscopic Partial Nephrectomy

Objective: To compare the results from 3-arm and 4-arm robot assisted retroperitoneoscopic partial nephrectomy (RARPN) in our initial case series in terms of oncologic and functional outcomes. Patients and Methods: 35 RARPN performed for malignant small renal masses in our hospital were categorized by the method used, 3-arm or 4-arm. Patient demographics (age, body mass index, tumor size, R.E.N.A.L. nephrometry score, tumor location), perioperative outcomes (operative time, warm ischemic time, estimated blood loss, length of stay, surgical margin status, complications, pathology) and functional outcomes (pre and post operative renal function change) were compared. Results: Initial 14 cases were performed in 3-arm method while latter 21 cases performed in 4-arm method. The tumor size was larger in the 4-arm group (3.5 cm vs 2.3 cm, P = 0.0261) but the warm ischemic time was significant shorter in 4-arm group (17 mins vs 23 mins, P = 0.0093). There were no other significant differences in remaining patient demographics, perioperative outcomes and functional outcomes. Conclusion: 4-arm RARPN is a safe, feasible technique in treating malignant small renal masses even the tumor is located at anterior portion as it provides good traction and exposure on surgical field, thus reducing the warm ischemic time.