Surgical Resection Margins Research Articles

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BackgroundRobotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study. MethodsFrom July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments. ResultsTwenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days. ConclusionsThe results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.

Do predetermined surgical margins compromise oncological safety in computer-assisted head and neck reconstruction?

Computer assisted head and neck reconstruction has gained popularity over the past few years. In computer assisted surgery (CAS), surgical margins are predetermined in virtual surgery and resection guides are designed to be fitted intra-operatively. However, concerns have been raised regarding the oncological safety of predetermined surgical margins. Therefore, the aim of this study was to compare surgical margins, recurrence and survival outcomes in patients underwent CAS and non-CAS in head and neck reconstruction. We retrospectively reviewed the patients underwent oral and maxillofacial malignancies surgical excision and free flap reconstruction from October 2014 to December 2019 by the same chief surgeon. Patients were divided into two groups depending on whether CAS and predetermined surgical margins were adopted. The primary outcome was surgical resection margin and the secondary outcomes included recurrence and survival. A total of 66 subjects were recruited with 37 in the CAS group and 29 in the non-CAS group. The follow-up rate was 100%. The average follow-up time was 24.5months. No significant difference in resection margin was identified between the groups (p=0.387). Tumor staging, margin status, perineural invasion, lymphovascular invasion and extranodal extension were identified as significant factors influencing survival. Both before and after adjustment for these prognostic factors identified, CAS and non-CAS group showed no significant difference in survival outcome. Predetermined surgical margins do not compromise oncological safety in terms of resection margin, disease recurrence and patient survival.

Association of Image-Guided Navigation With Complete Resection Rate in Patients With Locally Advanced Primary and Recurrent Rectal Cancer

The percentage of tumor-positive surgical resection margin rates in patients treated for locally advanced primary or recurrent rectal cancer is high. Image-guided navigation may improve complete resection rates. To ascertain whether image-guided navigation during rectal cancer resection improves complete resection rates compared with surgical procedures without navigation. This prospective single-center nonrandomized controlled trial was conducted at the Netherlands Cancer Institute-Antoni van Leeuwenhoek in Amsterdam, the Netherlands. The prospective or navigation cohort included adult patients with locally advanced primary or recurrent rectal cancer who underwent resection with image-guided navigation between February 1, 2016, and September 30, 2019, at the tertiary referral hospital. Clinical results of this cohort were compared with results of the historical cohort, which was composed of adult patients who received rectal cancer resection without image-guided navigation between January 1, 2009, and December 31, 2015. Rectal cancer resection with image-guided navigation. The primary end point was the complete resection rate, measured by the amount of tumor-negative resection margin rates. Secondary outcomes were safety and usability of the system. Safety was evaluated by the number of navigation system-associated surgical adverse events. Usability was assessed from responses to a questionnaire completed by the participating surgeons after each procedure. In total, 33 patients with locally advanced or recurrent rectal cancer were included (23 men [69.7%]; median [interquartile range] age at start of treatment, 61 [55.0-69.0] years). With image-guided navigation, a radical resection (R0) was achieved in 13 of 14 patients (92.9%; 95% CI, 66.1%-99.8%) after primary resection of locally advanced tumors and in 15 of 19 patients (78.9%; 95% CI, 54.4%-94.0%) after resection of recurrent rectal cancer. No navigation system-associated complications occurred before or during surgical procedures. In the historical cohort, 142 patients who underwent resection without image-guided navigation were included (95 men [66.9%]; median [interquartile range] age at start of treatment, 64 [55.0-70.0] years). In these patients, an R0 resection was accomplished in 85 of 101 patients (84.2%) with locally advanced rectal cancer and in 20 of 41 patients (48.8%) with recurrent rectal cancer. A significant difference was found between the navigation and historical cohorts after recurrent rectal cancer resection (21.1% vs 51.2%; P = .047). For locally advanced primary tumor resection, the difference was not significant (7.1% vs 15.8%; P = .69). Surgeons stated in completed questionnaires that the navigation system improved decisiveness and helped with tumor localization. Findings of this study suggest that image-guided navigation used during rectal cancer resection is safe and intuitive and may improve tumor-free resection margin rates in recurrent rectal cancer. Netherlands Trial Register Identifier: NTR7184.

Radioactive Seed Versus Wire-Guided Localization for Ductal Carcinoma in Situ of the Breast: Comparable Resection Margins

BackgroundThere are currently two widely used methods for preoperative localization of ductal carcinoma in situ (DCIS) of the breast: wire-guided localization (WGL) and radioactive seed localization (RSL). Several studies compared these localization techniques in small cohorts.ObjectiveThe aim of this study was to compare the surgical resection margin status between RSL and WGL in a large national cohort of patients with DCIS.Patients and MethodsWe included patients from the Dutch Pathology Registry who underwent breast-conserving surgery for DCIS by either RSL (n = 1851) or WGL (n = 2187) between 2009 and 2019. Several clinicopathological characteristics were compared between these two groups, including resection margin status and number of re-excisions.ResultsPatients undergoing RSL were younger (p = 0.014) and were more often diagnosed with a large DCIS (p = 0.013), high grade DCIS (p < 0.001) and comedonecrosis (p < 0.001) compared with patients undergoing WGL. There was no significant difference in resection margin status between both groups (p = 0.089) and the number of re-excisions (p = 0.429). However, in case of re-excision, patients in the RSL group were more often treated with breast-conserving surgery (p = 0.029).ConclusionIn this large national cohort study of patients with DCIS, we demonstrated that there was no difference in resection margin status between both procedures, or in the number of re-excisions, but patients in the RSL group were more often treated with breast-conserving therapy in case of a re-excision.

Prognostic factors influencing pelvic, extra-pelvic, and intraperitoneal recurrences in lymph node-negative early-stage cervical cancer patients following radical hysterectomy

ObjectiveThe aim of this study was to evaluate the clinicopathologic factors influencing pelvic, extra-pelvic, and intraperitonal recurrences and survival in patients with lymph node-negative early-stage cervical cancer treated with abdominal/laparoscopic/robotic radical hysterectomy (ARH/LRH/RRH). Study designWe retrospectively reviewed clinicopathologic data of 342 patients with FIGO stage IB-IIA cervical cancer (2018 FIGO staging) treated with RH and retroperitonal lymphadenectomy between February 2000 and November 2018. Several clinicopathologic factors such as surgical methods including LRH/RRH-vaginal colpotomy (VC) and LRH/RRH-intracorporeal colpotomy (IC), surgical resection margin, and parametrial/endomyometrial infiltration were selected. Univariate and multivariate Cox proportional hazard regression and logistic regression models were used to determine prognostic factors. ResultsThe median follow-up time was 54 months (range, 6–202 months). In multivariate analysis, positive endomyometrial infiltration (HR, 13.576; 95 % CI, 2.917−63.179; P = 0.001), positive parametrial resection margin (HR, 32.648; 95 % CI, 2.774−384.181; P = 0.006), and LRH/RRH-IC (HR, 4.752; 95 % CI, 1.154−19.578; P = 0.031) were significantly related to overall survival. Six (26.3 %) out of 21 patients with endomyometrial infiltration showed extra-pelvic recurrences associated with lung, liver, and brain. Three (50.0 %) out of 6 patients with positive parametrial margin showed both pelvic and extra-pelvic metastases, such as pelvis and supraclavicular/paratracheal lymph nodes. Five (62.5 %) out of the eight relapsed patients who received LRH/RRH-IC showed intraperitoneal recurrences including omentum, liver surface, colon serosa, and splenic hilum. ConclusionsThree risk factors including parametrial margin, endomyometrial infiltration, and laparoscopic IC appear to be involved in pelvic, extra-pelvic, and intraperitoneal recurrences in node-negative early-stage cervical cancer patients following RH. In particular, endomyometrial infiltration may be one of the strongest independent prognostic factors for extra-pelvic recurrence. Adjuvant systemic therapy may be indicated for lymph node-negative early-stage cervical cancer patients with endomyometrial infiltration.

Mid-Infrared Imaging Is Able to Characterize and Separate Cancer Cell Lines

Malignancies are still responsible for a large share of lethalities. Macroscopical evaluation of the surgical resection margins is uncertain. Big data based imaging approaches have emerged in the recent decade (mass spectrometry, two-photon microscopy, infrared and Raman spectroscopy). Indocianine green labelled MS is the most common approach, however, label free mid-infrared imaging is more promising for future practical application. We aimed to identify and separate different transformed (A-375, HT-29) and non-transformed (CCD986SK) cell lines by a label-free infrared spectroscopy method. Our approach applied a novel set-up for label-free mid-infrared range classification method. Transflection spectroscopy was used on aluminium coated glass slides. Both whole range spectra (4000–648 cm−1) and hypersensitive fingerprint regions (1800–648 cm−1) were tested on the imaged areas of cell lines fixed in ethanol. Non-cell spectra were possible to be excluded based on mean transmission values being above 90%. Feasibility of a mean transmission based spectra filtering method with principal component analysis and linear discriminant analysis was shown to separate cell lines representing different tissue types. Fingerprint region resulted the best separation of cell lines spectra with accuracy of 99.84% at 70–75 mean transmittance range. Our approach in vitro was able to separate unique cell lines representing different tissues of origin. Proper data handling and spectra processing are key steps to achieve the adaptation of this dye-free technique for intraoperative surgery. Further studies are urgently needed to test this novel, marker-free approach.

SUN-484 Complex Thyroid Cancer with Several Recurrences and Metastases

56-year-old male with metastatic papillary thyroid cancer who underwent total thyroidectomy in 8/2014, and I-131 ablation in 9/2014, with post-operative pathology revealing multifocal, bilateral papillary thyroid cancer with extrathyroidal extension with surgical resection margins uninvolved. There were positive lymphovascular spread and multiple central compartments and bilateral neck nodes metastases with extranodal extension. Subsequent thyrogen stimulated whole-body scan in 2/2016 showed no areas of uptake.However, in 12/2016 he was found to have right supraclavicular lymph nodes positive for recurrence which was resected and given another 168 mCi I-131 and 33 treatments of XRT to R shoulder.A repeat PET in 7/2019 showed persistent hyper metabolic lesion in C7, multiple hyper metabolic nodules throughout the R lung, and a new 1.1 cm left Hilar lymph node suggesting disease progression. Biopsy of the C7 lesion confirmed dedifferentiated papillary thyroid cancer and demonstrated the presence of an NTRK mutation.This time he was given lenvatinib 24 mg daily for 4 weeks, followed by 200 mCi I-131. Post-treatment whole body scan showed good uptake in all lesions, except the C7 lesion which was treated with external radiation. DiscussionWhile cure is achieved in most cases of differentiated thyroid cancer, a minority of cases demonstrate disease progression. Loss of response to I-131, very low serum thyroglobulin levels despite known disease, and high PET avidity provide clinical evidence of dedifferentiation, confirmed with tissue sampling.If feasible targeted systemic therapy remains the best tolerated treatment option.While several studies demonstrate an increase in iodine avidity in approximately 50-60% of patients with dedifferentiated thyroid cancer that were treated with tyrosine kinase inhibitors (TKI), (cite alan Ho’s 2013 NEJM article, and the 2015 debrafenib study Rothenberg SM et al, clin cancer res 2015), selumetanib remains unavailable for clinical use and dabrafenib may only be beneficial in cases with known BRAF V600E mutations. Moreover, it is unknown whether a planned short course of TKI therapy would potentially induce resistance to future TKI therapy.Therefore, lenvatinib, which inhibits activity of at least 6[VM1] different tyrosine kinase enzymes important in thyroid cancer was chosen rather than entrectanib, which was reserved for use if the need arises. This patient demonstrated excellent response to I-131 therapy with lenvatinib pretreatment.A number of formal studies of various TKIs for thyroid cancer re-differentiation are currently underway. (cite Brown SR, Hall A, et al BMC cancer 2019; and also cite the CIII trial with cabozatanib)Conclusion This case represents the emerging paradigm for the ability of TKI therapy to redifferentiate advanced thyroid cancer and allow for re-treatment with I-131 targeted therapy.

Risk factors analysis and stratification for microscopically positive resection margin in gastric cancer patients

BackgroundCancer cells are often found postoperatively at surgical resection margins (RM) in patients with gastric cancer because of submucosal infiltration or hesitation to secure adequate RM. This study was designed to evaluate risk factors for microscopic positive RM and to clarify which patients should undergo intraoperative frozen section diagnosis (IFSD).MethodsPatients who underwent R0/1 gastrectomy for gastric adenocarcinoma between 2000 and 2018 in a single cancer center in Japan were studied. We divided the patients into a positive RM group and negative RM group according to the results of definitive histopathological examinations. We performed multivariate analysis to analyze risk factors for positive RM by and used the identified risk factors to risk stratify the patients.ResultsA total of 2757 patients were studied, including 49 (1.8%) in the positive RM group. The risk factors significantly associated with positive RM were remnant gastric cancer (odds ratio [OR] 4.7), esophageal invasion (OR 6.3), tumor size ≥80 mm (OR 3.9), and a histopathological diagnosis of undifferentiated type (OR 3.6), macroscopic type 4 (OR 3.7), or pT4 disease (OR 4.6). On risk stratification analysis, the incidence of positive RM was 0.1% without any risk factors, increasing to 0.4% with one risk factor, 3.1% with two risk factors, 5.3% with three risk factors, 21.3% with four risk factors, and 85.7% with five risk factors.ConclusionsThe risk of macroscopically positive RM increased in patients who have risk factors. IFSD should be performed in patients who have four or more risk factors.

Overview of Breast Conservative Treatment for Early Breast Carcinoma: Experience at Sir Ganga Ram Hospital Lahore

&lt;p&gt;&lt;strong&gt;Background and Objectives:&lt;/strong&gt; Treatment of early breast cancer involves surgery, chemotherapy and radiation therapy. Present study was designed to describe the cosmetic outcome, prognosis, recurrence rate and complications after breast conservative surgery in patients with early breast carcinoma.&lt;br /&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A descriptive study was carried out at Surgical Unit III of Fatima Jinnah Medical University (FJMU), Lahore, Pakistan. A total of 54 female patients diagnosed with early breast carcinoma were included from July 2015 to January 2019. All of these patients underwent breast conservative surgery with axillary level II dissection or sentinel lymph node biopsy. Frozen section technique was used to evaluate clear surgical margins per operatively. These patients were followed up for a period of 12 months.&lt;br /&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean age of the patients was 49.6 &amp;plusmn; 11.3 years. Stage I disease was found in n = 17 (31.5%) females while stage II in n = 37 (68.5%) patients. Most of the patients had invasive ductal carcinoma. Tumor free surgical resection margin status was 1mm-20mm and it was &amp;gt;10mm in 32 (59.3%) patients. Post-operative good cosmetic outcome regarding symmetry of the breast (90.7%), shape of the breast (85.2%), shape of nipple (88.9%) and appearance of scar (81.4%) was observed. A total of 40 (74.1%) patients were satisfied with symmetry of breast, 41 (75.9%) patients were satisfied with shape of breast and 45 (83.3%) patients were satisfied with appearance of scar after breast conservative surgery through a validated questionnaire. Complications noted after the surgery were seroma in 1 (1.8%) and wound infection in 2 (3.7%) patients. Post Radiation oedema was seen in 44 (81.5%) and ulcers were seen in 6 (11.1%) patients. Local recurrence was developed in 2 patients (3.7%). Disease free survival was observed&lt;br /&gt;in 52 patients (96.3%).&lt;br /&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;Breast conservative surgery for early breast carcinoma is cosmetically good regarding the scar&lt;br /&gt;and shape of the breast after surgery and satisfactory for the patients to accept. There were minimal&lt;br /&gt;postoperative complications and low recurrence rate therefore breast conserving surgery in early breast&lt;br /&gt;carcinoma can safely be recommended for early breast carcinoma.&lt;/p&gt;

Searching for novel multimodal treatments in oligometastatic pancreatic cancer

BackgroundMetastatic pancreatic cancer has a median overall survival of less than 12 months, even if treated with chemotherapy. Selected patients with oligometastatic disease could benefit from multimodal treatments connecting chemotherapy and surgical treatment or radiofrequency ablation (RFA) of metastases.Case presentationWe present a patient with oligometastatic pancreatic cancer recurrence who was successfully treated with a multimodal therapeutic approach.A 57-year-old male initially presenting with resectable pancreatic cancer underwent pancreatoduodenectomy. The histopathological diagnosis revealed ductal pancreatic adenocarcinoma with positive surgical resection margins and negative lymph nodes. He completed six cycles of adjuvant therapy with gemcitabine (1000 mg/mq 1,8,15q 28), followed by external radiotherapy (54 Gy in 25 fractions) associated with gemcitabine 50 mg/mq twice weekly. Three years later, the patient developed multiple liver metastases, and he started FOLFIRINOX (oxaliplatin 85 mg/mq, irinotecan 180 mg/mq, leucovorin 400 mg/mq and fluorouracil 400 mg/mq given as a bolus followed by 2400 mg/mq as a 46 h continuous infusion,1q 14) as a first-line treatment.The CT scan showed a partial response after 6 cycles. After multidisciplinary discussion, the patient underwent a laparotomic metastasectomy of the three hepatic lesions. After additional postsurgical chemotherapy with 4 cycles of the FOLFIRINOX schedule, the patient remained free of recurrence for 12 months. A CT scan showed a new single liver metastasis, which was treated with radiofrequency ablation (RFA). A second radiofrequency ablation was performed when the patient developed another single liver lesion 12 months after the first RFA; currently, the patient is free from recurrence with an overall survival of 6 years from the diagnosis.ConclusionsOur case has benefited from successful multimodal treatment, including surgical and local ablative techniques and systemic chemotherapy. A multimodal approach may be warranted in selected patients with oligometastatic pancreatic cancer and could improve overall survival. Further research is needed to investigate this approach.

Fluorescence Imaging System for Biological Tissues Diagnosis: Phantom and Animal Studies

Currently, optical biopsy is a promising area of diagnosing the state of tissues in real time during the surgical treatment of oncological diseases. The important part of this direction is the development of fluorescence imaging systems and ensuring the accuracy of the calibration of optical measurements. The article describes the development of fluorescence imaging system to define tumor surgical resection margins of abdominal organs. In this study, we proposed of low-cost optical tissue-mimicking phantom combining solid base and liquid part that suitable for quick calibration of fluorescence imaging systems depending on the target endogenous fluorophores. The results of two series of experimental measurements are described. The first measurements of the optical phantom with riboflavin mononucleotide (imitating flavin adenine dinucleotide) and protoporphyrin IX demonstrated the sensitivity of the developed device to proportionally changing concentrations of target fluorophores. The second part of the study included in vivo measurements of liver tumors modeled in mice. The obtained results showed the ability of the developed fluorescence imaging system to register changes in fluorescence due to carcinogenesis .

Improving oral cavity cancer diagnosis and treatment with fluorescence molecular imaging.

Early diagnosis and radical surgical excision of oral squamous cell carcinomas are essential for achieving optimal treatment outcomes. To date, diagnostic tools that rely on anatomical anomalies provide limited information and resolution in clinical practice. As a result, oral cancer is often detected in an advanced stage. Also, no reliable real‐time intraoperative tools are readily available for the evaluation of surgical resection margins. Fluorescence imaging visualises biological processes that occur in early carcinogenesis and could, therefore, enable detection of small tumours in early stages. Furthermore, due to the high sensitivity and spatial resolution, fluorescence imaging could assist in resection margin assessment during surgery. In this review, we discuss several techniques that employ fluorescence for early diagnosis and surgical guidance in oral squamous cell carcinoma and present future perspectives on the potential of fluorescence imaging in oral cancer in the near future.

Assessment of surgical tumor-free resection margins in fresh squamous-cell carcinoma resection specimens of the tongue using a clinical MRI system.

BackgroundCurrent intraoperative methods of visual inspection and tissue palpation by the surgeon, and frozen section analysis cannot reliably prevent inadequate surgical margins in patients treated for oral squamous‐cell carcinoma (OSCC). This study assessed feasibility of MRI for the assessment of surgical resection margins in fresh OSCC specimens.MethodsTen consecutive tongue specimens containing OSCC were scanned using 3 T clinical whole‐body MRI. Two radiologists independently annotated OSCC location and minimal tumor‐free margins. Whole‐mount histology was the reference standard.ResultsThe positive predictive values (PPV) and negative predictive values (NPV) for OSCC localization were 96% and 75%, and 87% and 79% for reader 1 and 2, respectively. The PPV and NPV for identification of margins <5 mm were 38% and 91%, and 5% and 87% for reader 1 and 2, respectively.Conclusions mri accurately localized OSCC with high inter‐reader agreement in fresh OSCC specimens, but it seemed not yet feasible to accurately assess the surgical margin status.

Validation of the use of a fluorescent PARP1 inhibitor for the detection of oral, oropharyngeal and oesophageal epithelial cancers.

For oral, oropharyngeal and oesophageal cancer, the early detection of tumours and of residual tumour after surgery are prognostic factors of recurrence rates and patient survival. Here, we report the validation, in animal models and a human, of the use of a previously described fluorescently labelled small-molecule inhibitor of the DNA-repair enzyme poly(ADP-ribose) polymerase 1 (PARP1) for the detection of cancers of the oral cavity, pharynx and oesophagus. We show that the fluorescent contrast agent can be used to quantify the expression levels of PARP1, and to detect oral, oropharyngeal and oesophageal tumours in mice, pigs and fresh human biospecimens when delivered topically or intravenously. The fluorescent PARP1 inhibitor can also detect oral carcinoma in a patient when applied as a mouthwash, and discriminate, between fresh biopsied samples of the oral tumour and the surgical resection margin with larger than 95% sensitivity and specificity. The PARP1 inhibitor could serve as the basis of a fast and sensitive assay for the early detection, and for the surgical-margin assessment, of epithelial cancers of the upper intestinal tract.

TREATMENT OPTIONS OF BREAST CANCER PATIENTS AFTER BREAST-CONSERVING SURGERY WITH POSITIVE MARGINS R1

Introduction: in organ-preserving operations for breast cancer, the risk of recurrence is associated with many factors, including positive resection margins. The article presents data from the literature, which considers the risk of relapse depending on the positive, close and negative edges of resection. The purpose of this study was to increase the effectiveness of treatment of breast cancer patients after organ-preserving operations with positive resection edges. Materials and methods: the study included 1219 patients with breast cancer who underwent organ-preserving and on-coplastic resections of the breast. Urgent cytological and histological intraoperative examination of the resection edges is analyzed in detail, and the marking of the resection edges is presented. The clinical and morphological characteristics of patients with breast cancer at R0 and R1 are presented. Results: positive edge of R1 resection was diagnosed in 53 cases, which was 4,3±2,8%, in oncoplastic resections in 4,1±1,1%, in classical breast resections in 4,6±0,7% (p&gt;0,05). In the group of patients with R1, multicentricity of the tumor was diagnosed in 11,1±5,3%, and monocentric tumor was detected in 4,1±0,5%. Further tactics in the case of R1 detection were as follows: in 21 cases, radiation therapy was performed on the breast, in 32 cases, re - operation: resection of the edges - in 14 patients, radical mastectomy - in 9 patients, subcutaneous mastectomy with simultaneous reconstruction with autologous flaps or endoprostheses - in 9 patients. In the group of patients with re-operation, 43,7% of the planned study showed no signs of malignancy, 56,3% showed a residual tumor, while 31.3% were diagnosed with cancer in situ. So in the case of resection of the edges in 5 cases, a residual tumor was diagnosed in the resected edges, which was 35,7%, and in the case of mastectomy, a residual tumor was detected in 68,4%. Re-operation in R1 after oncoplastic resections was performed in 71,4%, and in classical resections in 56,4%, which correlates with the literature data. Conclusion: in two groups of patients after organ-preserving operations with positive resection margins, no local recurrence was detected during the follow-up period from 1 to 60 months, and distant metastases, namely, lesions of the bones of the skeleton, were diagnosed in 2 patients. Thus, with a positive edge of resection after organ-preserving surgery, both surgical treatment and radiation therapy can be performed. Although the presence of a tumor in the colored edges of resection is clearly associated with a high frequency of local relapses, but the relapse is also influenced by the biological characteristics of the tumor and the body. Individual characteristics are the basis of tumor biology, and the extent of their influence on long-term results is not reduced due to the wide surgical margins of resection.

Increased osteopontin expression in endometrial carcinoma is associated with better survival outcome

Osteopontin (OPN) is a key extracellular matrix protein that is involved in cancer progression. The aim of the current study is to investigate the relation of OPN immunostaining in endometrial carcinoma with clinicopathological parameters. Archival 71 endometrial carcinomas and 30 non-neoplastic endometrial tissues were obtained from the Department of Pathology at King Abdulaziz University Jeddah, Saudi Arabia. Tissue microarrays were constructed. Tissue sections were stained using anti-human OPN monoclonal antibody. Immunostaining results were recorded and analysed. In non-neoplastic endometrial tissues, high (increased) OPN immunostaining was observed in 100%. In endometrial carcinoma, high (increased) OPN immunostaining was seen in 64.8% of cases. High (increased) OPN immunostaining was more frequent in non-neoplastic tissues than in endometrial carcinoma (p < 0.001). OPN immunostaining showed no association with histological type, FIGO tumour grade, tumour size, myometrial invasion, lymphovascular invasion, surgical resection margin or lymph node metastasis. On the other hand, high (increased) OPN immunostaining was associated with better overall survival [Log Rank (Mantel-Cox) = 4.385, p = 0.003]. In endometrial carcinoma, immunohistochemical staining of OPN could be a helpful tool in the prediction survival pattern. OPN immunostaining showed no association with most clinicopathological features. Further investigations both clinical and molecular are needed to explore the downstream of OPN in endometrial carcinoma.

Referral patterns and outcomes of a highly specialised pelvic exenteration multidisciplinary team meeting: A retrospective cohort study

IntroductionThe purpose of this study was to review recommendations made from a specialist pelvic exenteration (PE) multidisciplinary team (MDT) and to provide insights as to the impact of the MDT on patient selection and clinical decision making. Materials & methodsA retrospective review was conducted at Royal Prince Alfred Hospital's PE MDT between June 2014 and December 2015. Data was collected from the recorded minutes of MDT meetings. Referral information and clinical data was extracted from individual patient files. Additional data including operative dates and surgical resection margins were collected from electronic medical records. ResultsOf the 183 patients considered for PE during the MDT meeting, 104 (57%) were recommended for surgery. Factors that influenced the recommendation in favour of surgery were referral by a surgeon (P = 0.004), referral from a rural location (P = 0.05) and having locally advanced primary cancer (P < 0.001). Patients who were seen by the unit's surgeon prior to the MDT did not impact on the MDT recommendation nor the decision for or against surgery (P = 0.771). The most common reason for recommendation against PE was unresectable distant metastatic disease (43%). ConclusionsThe PE MDT meeting is a critical step in the patient care pathway and facilitates critical decision making. Anatomically-based contraindications to surgery (i.e. involvement of adjacent organs, bone and neurovascular structures) do not appear to influence MDT decision making regarding resectability.

TRF2 Overexpression at the Surgical Resection Margin: A Potential Predictive Biomarker in Oral Squamous Cell Carcinoma for Recurrence.

Oral squamous cell carcinoma (OSCC) is one of the most prevalent cancers in India with high incidence rate in eastern region due to habits of tobacco, pan and gutkha chewing habits. In majority of OSCC, the cases were presented to clinicians at later stages of the disease which leads to increased mortality. In addition presence of minimal residual disease also significantly contributed towards disease progression. Therefore, identification of potential biomarker for prognostic stratification of patients with high risk of disease recurrence and appropriate management is utmost necessary. In this study, 80 OSCC patients were included and their tumour specimen along with cut margin (CM) was collected after surgical excision. Immunohistochemistry (IHC) was performed to check expression of TRF2 in tumour and CM of OSCC patients. Statistical analysis was carried out using SPSS based on clinical and pathological records. It was observed that 27 OSCC patients developed recurrence during the period of the study (2012-2016). It was observed that, in 34 cases (42.25%) TRF2 expression was positive in tumour, while in 46 cases (57.75%), it was negative, while it was just reverse at CM, respectively. The odds of recurrence among patients having high levels of TRF2 in CM were 2.6 times higher than the odds of recurrence among patients having lower levels of TRF2 in CM. In conclusion, this study showed that TRF2 at surgical cut margin has a prognostic significance and can be used as a molecular marker for predicting survival in OSCC patients.

A 4-gene signature from histologically normal surgical margins predicts local recurrence in patients with oral carcinoma: clinical validation

Prognostic biomarkers for recurrence of Oral Squamous Cell Carcinoma (OSCC) are urgently needed. We aimed to independently validate a 4-gene expression signature (MMP1, COL4A1, P4HA2, THBS2) predictive of OSCC recurrence risk. Gene expression was measured using Nanostring nCounter® in 245 histologically normal surgical resection margins from 62 patients. Association between risk scores for individual patients and recurrence was assessed by Kaplan-Meier analysis. Signature performance was quantified by concordance index (CI), hazard ratio (HR) and the area under receiver operating characteristics (AUC). Risk scores for recurrence were significantly higher than recurrence-free patients (p = 9.58e-7, Welch’s t-test). A solid performance of the 4-gene signature was determined: CI = 0.64, HR = 3.38 (p = 1.4E-4; log-rank test), AUC = 0.71. We showed that three margins per patient are sufficient to preserve predictive performance (CI = 0.65; HR = 2.92; p = 2.94e-3; AUC = 0.71). Association between the predicted risk scores and recurrence was assessed and showed HR = 2.44 (p = 9.6E-3; log-rank test, N = 62). Signature performance analysis was repeated using an optimized threshold (70th percentile of risks), resulting in HR = 3.38 (p = 1.4E-4; log-rank test, N = 62). The 4-gene signature was validated as predictive of recurrence risk in an independent cohort of patients with resected OSCC and histologically negative margins, and is potentially applicable for clinical decision making on adjuvant treatment and disease monitoring.

Microscopic Positive Tumor Margin Increases Risk for Disease Persistence but Not Recurrence in Patients with Stage T1-T2 Differentiated Thyroid Cancer.

Introduction Differentiated thyroid cancer (DTC) has an overall excellent prognosis. Patients who develop recurrent disease have a more unfavorable disease course than those with no recurrence. Higher recurrence rates are seen with incomplete surgical resection and gross positive margins. It is unclear whether microscopic positive margin affects disease recurrence rates as much as grossly positive margin. Aim of the Study. To assess whether microscopic positive margin is an independent predictor of disease recurrence in patients with overall low-risk DTC. Patients and Methods. We conducted a retrospective single-center institutional review of 1,583 consecutive patients' charts from 1995–2013 using the Canadian Thyroid Cancer Consortium Registry. We included adult patients with nonmetastasizing T1 and T2 DTC with a minimum of three years follow-up. Univariate and multivariate analyses were used to study factors that may influence the risk of persistent/recurrent disease. Strict definitions of persistent versus recurrent disease were applied. Results 963 patients (152 men and 811 women) were included in the study with a mean age of 46 years. Microscopic positive margins were present in 12% of the specimens and were associated with an increased rate of persistent disease (8% versus 2% in the controls) but not with an increased risk of recurrent disease (1% in both groups). T2 tumors had a significantly higher incidence of positive margins than T1 tumors (48% versus 36%) and significantly higher nodal staging. Conclusions Microscopic positive margin in the histopathology report in patients with low-risk DTC was associated with a higher rate of persistent disease but did not increase the risk of disease recurrence. A close follow-up of biomarkers and occult residual cancerous lesions is needed, especially in the first year. Further studies are needed to determine whether additional therapeutic measures to prevent recurrence are indicated in T1 and T2 DTC with positive microscopic surgical margins.