True Local Recurrence Research Articles

The Controversy and Value of Mohs Micrographic Surgery for Melanoma and Melanoma in Situ on the Trunk and Extremities.

The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world. The purpose of this article is to expose the value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines. This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery. The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma. Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression.

MP58-09 TRUE LOCAL RECURRENCE FOLLOWING PARTIAL NEPHRECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP58-09 TRUE LOCAL RECURRENCE FOLLOWING PARTIAL NEPHRECTOMY Cameron J. Britton, Vidit Sharma, Christine M. Lohse, Aaron M. Potretzke, Stephen A. Boorjian, R. Houston Thompson, and Bradley C. Leibovich Cameron J. BrittonCameron J. Britton More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Christine M. LohseChristine M. Lohse More articles by this author , Aaron M. PotretzkeAaron M. Potretzke More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , and Bradley C. LeibovichBradley C. Leibovich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: True local recurrence (LR) in the partial nephrectomy (PN) bed is uncommon, with reported rates of 1-3%. To date, there is sparse literature examining oncologic outcomes in this population. Our study seeks to define oncologic outcomes and determine if there is an association of LR with distant metastasis and cancer-specific survival (CSS). METHODS: We identified 2,164 adults treated with PN for unilateral, sporadic, localized (M0) renal cell carcinoma (RCC) from 2000 to 2019. LR was defined as new enhancing tumor growth within the PN bed on MRI or CT. Survival rates were estimated using the Kaplan-Meier method. Associations with death from RCC following PN were evaluated using Cox proportional hazards regression models. The association of LR with CSS was analyzed in the subset of patients with clear cell RCC. RESULTS: A total of 106 true LR were identified. Median time to LR was 3.3 years (IQR 1.7-5.1). Management of LR included 89 surgeries, 5 systemic therapy, 4 surveillance, 8 others. Forty-five patients died at a median of 3.5 years (IQR 1.6-5.3), including 26 from RCC at a median of 1.9 years (IQR 0.8-4.0). Median duration of post-recurrence follow-up was 5.1 years (IQR 2.3-9.1). Among 83 patients who remained M0 at LR, 26 subsequently developed metastases at a median of 1.5 years (IQR 0.3-2.4). Estimated MFS and CSS following LR are summarized in Table 1. When analyzed as a time-dependent covariate, LR was associated with death from RCC following PN (HR 12.45; 95% CI 6.65-23.31; p<0.001), and after adjusting for tumor size, pT classification, and grade, LR was associated with development of metastasis (HR 6.25; 95% CI 3.5-11; p<0.001). When adjusting for metastasis, LR remained significantly associated with risk of death from RCC (HR 1.93; 95% CI 1.07-3.50; p=0.03). Multivariable associations of select features with LR in the clear cell RCC cohort are presented in Table 2. CONCLUSIONS: True LR is uncommon and is associated with adverse pathologic features including high stage and grade, histology, and margin status. Our data suggests aggressive management of LR may prevent metastasis and RCC related death. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e798 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cameron J. Britton More articles by this author Vidit Sharma More articles by this author Christine M. Lohse More articles by this author Aaron M. Potretzke More articles by this author Stephen A. Boorjian More articles by this author R. Houston Thompson More articles by this author Bradley C. Leibovich More articles by this author Expand All Advertisement PDF downloadLoading ...

Whole Breast Irradiation Versus Intraoperative Electron Radiation Therapy for Breast Conserving Therapy: A Large Mature Single Institution Matched-Pair Evaluation of True Local Relapse, Progression Free Survival, and Overall Survival

Comparative outcome data after intraoperative radiation therapy and whole breast irradiation (WBI) for breast cancer at >10 years median follow-up are rare. We present a mature, single-institution, matched-pair comparison reporting survival and relapse rates in patients treated with either modality. Complete data sets for 258 intraoperative electron radiation therapy (IOERT) patients treated between 2000 and 2010 were matched with 258 patients postoperatively treated with WBI by age/histology/tumor size, grading/lymph-node-status/hormone receptors/type of adjuvant therapy/surgical margins, and treatment date. Relapse at surgical intervention site was classified as true local recurrence (LR). All recurrences in the treated breast (any quadrant) were classified as ipsilateral recurrence (IR). Median follow-up was 157 months (12-251) for the IOERT group and 154 months (31-246) for the WBI group. Cumulative incidence of IR at 5, 10, and 15 years was 2.4%, 7.9%, and 12.7% for IOERT and 1.2%, 4.1%, and 5.0% for WBI (P=.02). Cumulative incidence of LR at 5, 10, and 15 years was 1.6%, 5.1%, and 8.3% for IOERT and 0.4%, 2.1%, and 2.5% for WBI (P=.02). No differences in overall survival, disease-free survival, second cancer incidence, or cardiac events were recorded in either treatment group. Outcome was better in the accelerated partial breast irradiation (APBI)-suitable group than in the APBI-unsuitable group (2009 criteria) (cumulative incidence of IR at 5, 10, and 15 years was 0% vs 7.3%, 6.1% vs 13.3%, and 7.3% vs 19.9% for IOERT and 0% vs 1.8%, 2.0% vs 3.9%, and 3.1% vs 3.9% for WBI) and in the revised APBI-suitable group than in the APBI-cautionary group (2017 criteria) (cumulative incidence of IR at 5, 10, and 15 years was 1.1% vs 6.4%, 6.2% vs 13.3%, and 7.8% vs 27.5% for IOERT and 1.7% vs 0%, 4.1% vs 4.4%, and 5.4% vs 4.4% for WBI). The IR and LR rate were higher after IOERT than after WBI for the American Society for Radiation Oncology suitable patient group, although without reaching statistical significance. Thus, IOERT could be an alternative to WBI upon stringent patient selection, but patients should be counseled carefully about the potential for increased IR rate with IOERT. Second cancer incidence and cardiac events did not differ between IOERT and WBI.

The clinical relevance of various methods of classifying ipsilateral breast tumour recurrence as either true local recurrence or new primary.

Describes the relevance of -various classification methods for ipsilateral breast tumour recurrence (IBTR) as either true recurrence (TR) or new primary (NP) on both disease-specific survival (DSS) and distant metastasis-free survival (DMFS). Two hundred and thirty-four of 4359 women undergoing breast-conserving therapy experienced IBTR. We compared the impact of four known classification methods and two newly created classification methods. For three of the methods, a better DSS was observed for NP compared to TR with the hazard ratio (HR) ranging from 0.5 to 0.6. The new Twente method classification, comprising all classification criteria of three known methods, and the new Morphology method, using only morphological criteria, had the best HR and confidence interval with a HR 0.5 (95% CI 0.2-1.0) and a HR 0.5 (95% CI 0.3-1.1), respectively. For DMFS, the HR for NP compared to TR ranged from 0.6 to 0.9 for all six methods. The new Morphology method and the Twente method noted the best HR and confidence intervals with a HR 0.6 (95% CI 0.3-1.1) and a HR 0.6 (95% CI 0.4-1.2), respectively. IBTR classified as TR or NP has a prognostic value for both DSS and DMFS, but depends on the classification method used. Developing and validating a generally accepted form of classification are imperative for using TR and NP in clinical practice.

Targeted Intraoperative Radiotherapy (TARGIT-IORT) for Early-Stage Invasive Breast Cancer: A Single Institution Experience.

Purpose/ObjectiveWe present our single-institution experience in the management of invasive breast cancer with targeted intraoperative radiotherapy (TARGIT-IORT), focusing on patient suitability for IORT determined by the American Society for Radiation Oncology (ASTRO) Accelerated Partial Breast Irradiation (APBI) consensus guidelines.Materials/MethodsWe identified 237 patients treated for biopsy-proven early-stage invasive breast cancer using low energy x-ray TARGIT-IORT at the time of lumpectomy between September 2013 and April 2020 who were prospectively enrolled in an institutional review board (IRB) approved database. We retrospectively reviewed preoperative and postoperative clinicopathologic factors to determine each patient’s ASTRO APBI suitability (suitable, cautionary or unsuitable) according to the 2017 consensus guidelines (CG). Change in suitability group was determined based on final pathology. Kaplan-Meier methods were used to estimate the survival probability and recurrence probability across time.Results237 patients were included in this analysis, based on preoperative clinicopathologic characteristics, 191 (80.6%) patients were suitable, 46 (19.4%) were cautionary and none were deemed unsuitable. Suitability classification changed in 95 (40%) patients based on final pathology from lumpectomy. Increasing preoperative lesion size or a body mass index (BMI) ≥ 30 kg/m2 were significant predictors for suitability group change. Forty-one (17.3%) patients received additional adjuvant whole breast radiotherapy after TARGIT-IORT. At a median follow up of 38.2 months (range 0.4 – 74.5), five (2.1%) patients had ipsilateral breast tumor recurrences (IBTR), including two (0.8%) true local recurrences defined as a recurrence in the same quadrant as the initial lumpectomy bed with the same histology as the initial tumor. IBTR occurred in 1/103 (0.09%) patient in the post-op suitable group, 4/98 (4.08%) patients in the post-op cautionary group, and no patients in the post-op unsuitable group. At 3-years, the overall survival rate was 98.4% and the local recurrence free survival rate was 97.1%.ConclusionThere is a low rate of IBTR after TARGIT-IORT when used in appropriately selected patients. Change in suitability classification pre to postoperatively is common, highlighting a need for further investigation to optimize preoperative patient risk stratification in this setting. Patients who become cautionary or unsuitable based on final pathology should be considered for additional adjuvant therapy.

18P Comparative genomic profiling of primary and locally recurrent luminal breast cancers (BC)

The late occurrence of isolated local recurrence (LR) of luminal BC calls into question whether these are true LR or new primaries. We evaluated the concordance of the mutation profiles between matched primary tumors (PT) and LR.

Long-term results of hypofractionation with concomitant boost in patients with early breast cancer: A prospective study

To report the long-term local control and survival of patients with early breast cancer who had hypofractionated whole breast irradiation with concomitant boost (Hypo-CB). Between October 2009 and June 2010, 73 patients with early breast cancer (T1-3N0-1M0) who underwent breast conserving surgery were enrolled into the study. Thirty-six of these participants received 50 Gy of conventional irradiation in 25 fractions over 5 weeks to the whole breast with a sequential boost to the tumor bed with 10-16 Gy in 5-8 fractions (Conv-SEQ). The other 37 participants received a hypofractionated dose of 43.2 Gy in 16 fractions with an additional daily concomitant boost (CB) of 0.6 Gy over 3 weeks (Hypo-CB). At a median follow-up time of 123 months, ipsilateral local recurrence (ILR) was found in 3 participants, 1 of whom was in the hypofractionated group. All 3 ILR were true local recurrence (TR). There were no significant differences in the 10-year disease free survival (DFS) and 10-year overall survival rates (OS) between the conventional and hypofractionated groups (93.9% vs. 94.4%, p = 0.96 and 91.9% vs. 91.6%, p = 0.792, respectively). This study showed that the effectiveness, DFS and OS were comparable between hypofractionated whole breast irradiation with a CB and the conventional irradiation with a sequential boost.

Long-Term Outcomes Using Electron IOERT APBI for Early Stage Breast Cancer: The Verona University Hospital Experience

From July 2006 to December 2015, 295 patients suitable for breast-conserving therapy entered a single-arm phase II study and were treated with IOERT as radical treatment. Inclusion criteria were age >50, postmenopausal status, cT1N0M0 stage, grade G1-G2, positive estrogen receptor status; unicentric and unifocal disease, histologically proven invasive ductal carcinoma no previous breast irradiation, good performance status. With a median follow-up of 7.1 years (95% CI, 6.5;7.4) 6 women (2.0%) experienced a true local recurrence (reappearance of the tumour in the same quadrant). Five-year overall survival and local recurrence-free survival were 96% (95% CI, 92.9;97.8) and 94.9% (95% CI, 91.6;97.0) respectively. Our trial suggests that, in highly selected early stage breast cancers, a single-dose IOERT can be safely delivered with excellent results and very low long-term recurrence rates.

Natural course of fat necrosis after breast reconstruction: a 10-year follow-up study

BackgroundAlthough fat necrosis is a minor postoperative complication after breast reconstruction, occasionally it mimics to tumor recurrence in patients with breast cancer. Therefore, the surgeon should distinguish between benign fat necrosis and true local recurrence. The authors evaluated the clinical characteristics of fat necrosis after breast reconstruction and investigated the natural course of fat necrosis.MethodsBetween 2007 and 2013, a total of 362 patients underwent breast reconstruction after partial or total mastectomy for breast cancer in Kyungpook National University Hospital. Clinicopathologic characteristics and the occurrence of fat necrosis were assessed during surveillance for 10 years of mean follow-up period.ResultsThere were 42 cases (11.6%) of fat necrosis after breast reconstruction with partial or total mastectomy which were confirmed by needle or excision biopsy. The fat necrosis was resolved after a mean period of 45.9 months (SD, ± 42.1) and 26 cases (61.9%) of fat necrosis were almost completely resolved (less than 5 mm) during 10-year follow-up period.ConclusionBased on the natural course of fat necrosis, the fat necrosis after breast reconstruction can be only monitored, if pathologic confirmation was done. More than half of the cases will be resolved within 2–3 years.

Abstract PS15-19: Preoperative selection of patients with early-stage invasive breast cancer for intraoperative radiation therapy (IORT): A single-institution experience

Abstract Purpose/Objective: Intraoperative radiation therapy (IORT) is a form of accelerated partial breast irradiation (APBI) delivered at the time of lumpectomy for early-stage breast cancer. Upfront selection of patients based on favorable preoperative characteristics is important to achieve good outcomes. Here we present our single-institution experience in the management of invasive breast cancer with IORT. We focused on the classification of patient suitability for IORT by the American Society for Therapeutic Radiation Oncology (ASTRO) APBI consensus guidelines using preoperative and postoperative clinicopathologic factors, as well as treatment outcomes and recurrences. Materials/Methods: We reviewed our institutional prospective registry database (AAAJ8512) to identify patients with biopsy-proven invasive breast cancer treated with breast IORT between 9/2013 and 4/2020 using the Zeiss Intrabeam™. Patients received a single dose of 20Gy delivered to the lumpectomy cavity surface at the time of planned surgery. We excluded patients from analysis with prior radiation to the breast, or triple negative disease at initial diagnosis. We reviewed preoperative and postoperative clinicopathologic factors to determine each patient’s ASTRO APBI suitability (suitable, cautionary or unsuitable) based on the 2017 consensus guidelines. Results: 237 patients were treated with IORT for early stage breast cancer. Median age was 67 years (range 44-94 years). Median extent of disease by conventional imaging was 1.0 cm (range 0 - 3.0cm). 51/103 (49.5%) patients with heterogeneously or extremely dense breasts underwent a MRI preoperatively. Based on preoperative clinicopathologic characteristics, 191 (80.6%) patients were suitable according ASTRO APBI guidelines, 46 (19.4%) cautionary and no patients were unsuitable. APBI group suitability changed in 95 (40.1%) patients based on final pathology from the time of lumpectomy, summarized in Table 1. 17 (7.2%) patients underwent re-excision for close or positive margins. 39 (16.5%) patients received additional adjuvant whole breast radiotherapy including 10/18 (56%) of unsuitable patients. Of 212 (89.5%) patients who initiated hormone therapy (HT), 191 (80.6%) were compliant at last follow up. Median follow-up for all patients was 38.2 months (0.4 - 74.5). Five (2.1%) patients experienced ipsilateral breast tumor recurrence, 1 (0.4%) patient experienced new contralateral breast cancer, and 2 (1.6%) patients experienced distant recurrence with the median time to event of 27.8 months (range 6.3-50.4). Of the 5 patients with ipsilateral breast tumor recurrence, 2 (0.8%) were true local recurrences &amp;lt;2cm from the initial lumpectomy bed with the same histology as initial tumor, both cases were cautionary risk and one declined HT, 3 (1.3%) were new breast primaries occurring &amp;gt;2cm from lumpectomy bed with a different histology. Conclusion: Breast IORT is an attractive cost-effective option for women with early stage breast cancer, and our 3-year true local recurrence rate is 0.8%. Optimal patient selection is key based on preoperative characteristics. Patients who become unsuitable or cautionary for APBI based on final pathology should be considered for additional adjuvant therapy. Table 1ReasonASTRO APBI Pre-Op Suitability#SizeER (-)AgeT2ILCSuitable191Cautionary46114101122Unsuitable0ASTRO APBI Post-Op Suitability Change#SizeClose MarginsPositive MarginsLVIMultifocalILCEICSuitable to Cautionary7792023211124Suitable to Unsuitable12111Cautionary to Unsuitable624Abbreviations: ER = Estrogen Receptor; ILC = Invasive Lobular Carcinoma; LVI = Lymphovascular Invasion; EIC = Extensive Intraductal Component Citation Format: Andrea M Brown, Christine Chin, Eileen Connolly, Roshni Rao, Bret Taback, Lisa Wiechmann. Preoperative selection of patients with early-stage invasive breast cancer for intraoperative radiation therapy (IORT): A single-institution experience [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS15-19.

Recurrence at surgical margin following hepatectomy for colorectal liver metastases is not associated with R1 resection and does not impact survival

BackgroundResection margin status has traditionally been associated with tumor recurrence and oncological outcome following liver resection for colorectal liver metastases. Previous studies, however, did not address the impact of resection margin on the site of tumor recurrence and did not differentiate between true local recurrence at the resection margin and recurrence elsewhere in the liver. This study aimed to determine whether positive resection margins determine local recurrence and whether recurrence at the surgical margin influences long-term survival. MethodsClinicopathological data and oncological outcomes of patients who underwent curative resection for colorectal liver metastases between 2012 and 2017 at 2 major hepatobiliary centers (Bern, Switzerland, and Berlin, Germany) were assessed. Cross-sectional imaging following hepatectomy was reviewed by radiologists in both centers to distinguish between recurrence at the resection margin, defined as hepatic local recurrence, and intrahepatic recurrence elsewhere. The association between surgical margin status and location of tumor recurrence was evaluated, and the impact on overall survival was determined. ResultsDuring the study period, 345 consecutive patients underwent hepatectomy for colorectal liver metastases. Histologic surgical margins were positive for tumor cells (R1) in 63 patients (18%). After a median follow-up time of 34 months, tumor recurrence was identified in 154 patients (45%). Hepatic local recurrence was not detected more frequently after R1 than after R0 resection (P = .555). Hepatic local recurrence was not associated with worse overall survival (P = .436), while R1 status significantly impaired overall survival (P = .025). Additionally, overall survival was equivalent between patients with hepatic local recurrence and patients with any intrahepatic and/or extrahepatic recurrence. In patients with intrahepatic recurrence only, oncological outcomes improved if local hepatic therapy was possible (resection or ablation) in comparison to patients treated only with chemotherapy or best supportive care (3-year overall survival: 85% vs 39%; P < .0001). ConclusionThe incidence of hepatic local recurrence after hepatectomy for colorectal liver metastases is independent of R1 resection margin status. Additionally, hepatic local recurrence at the resection margin is not associated with worse overall survival compared with any other intra- or extrahepatic recurrence. Therefore, R1 status at hepatectomy seems to be a surrogate factor for advanced disease without influencing location of recurrence and thereby oncological outcome. This finding may support decision-making when extending the indication for surgery in borderline resectable colorectal liver metastases.

Clinical Evaluation of (4S)-4-(3-[18F]Fluoropropyl)-L-glutamate (18F-FSPG) for PET/CT Imaging in Patients with Newly Diagnosed and Recurrent Prostate Cancer

(4S)-4-(3-[18F]Fluoropropyl)-L-glutamic acid (18F-FSPG) is a radiopharmaceutical for PET imaging of system xC - activity, which can be upregulated in prostate cancer. We present data on the first evaluation of patients with newly diagnosed or recurrent prostate cancer with this radiopharmaceutical. Ten patients with primary and 10 patients with recurrent prostate cancer were enrolled in this prospective multicenter study. After injection of 300 MBq of 18F-FSPG, three whole-body PET/CT scans were obtained. Visual analysis was compared with step-section histopathology when available as well as other imaging studies and clinical outcomes. Metabolic parameters were measured semiquantitatively. Expression levels of xCT and CD44 were evaluated by IHC for patients with available tissue samples. 18F-FSPG PET showed high tumor-to-background ratios with a relatively high tumor detection rate on a per-patient (89%) and per-lobe (87%) basis. The sensitivity was slightly higher with imaging at 105 minutes in comparison with 60 minutes. The maximum standardized uptake values (SUVmax) for cancer was significantly higher than both normal (P < 0.005) and benign pathology (P = 0.011), while there was no significant difference between normal and benign pathology (P = 0.120). In the setting of recurrence, agreement with standard imaging was demonstrated in 7 of 9 patients (78%) and 13 of 18 lesions (72%), and revealed true local recurrence in a discordant case. 18F-FSPG accumulation showed moderate correlation with CD44 expression. 18F-FSPG is a promising tumor imaging agent for PET that seems to have favorable biodistribution and high cancer detection rate in patients with prostate cancer. Further studies are warranted to determine the diagnostic value for both initial staging and recurrence, and how it compares with other investigational radiotracers and conventional imaging modalities.

Long-term outcomes of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities

Microscopicevaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximalportion of the extremities. To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival. Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes. True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75months and were not associated with tumor depth. Therate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values. We used a nonrandomized, single institution, retrospective design. Mohsmicrographic surgery of primary cutaneous invasive melanoma on the trunk andproximal portion of the extremities resulted in local control of 99.86% of tumors and an overalldisease-specific death rate superior to that of wide local excision.

A Prospective Study of Magnetic Resonance Imaging Assessment of Post-radiation Changes Following Stereotactic Body Radiation Therapy for Non-small Cell Lung Cancer

AimsFollow-up computed tomography scans after lung stereotactic body radiation therapy (SBRT) are difficult to interpret due to the presence of benign fibrosis, which can make the detection of local recurrence difficult. The objective of this study was to determine the feasibility of a novel thoracic magnetic resonance imaging (MRI) protocol incorporating diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging for the assessment of the treated lung parenchyma after SBRT. Materials and methodsOn a prospective trial, post-treatment MR images were acquired in 30 patients treated with SBRT (divided into three different cohorts according to the likelihood of local recurrence as per an expert panel). These images were assessed by an expert thoracic radiologist blind to clinical data, who indicated local recurrence in a dichotomous manner. Local recurrence was confirmed by biopsy or subsequent growth on follow-up computed tomography scans. ResultsThirty patients underwent MRI as part of this study; 27/30 patients were analysable for local recurrence. MRI was conducted at a median of 27.3 months (range 6.5–71 months) from SBRT. No side-effects resulted from either MRI or contrast administration. At a median follow-up time of 45 months after treatment, three local recurrence episodes have occurred. MRI assessment diagnosed seven patients as having a local recurrence, which was later confirmed in three and did not miss any of the true local recurrences. When comparing apparent diffusion coefficient (ADC) values according to local recurrence, the mean ADC value for the local recurrence-free group was 1770 × 10−3 mm/s2 (range 1038–3105 × 10−3 mm/s2) versus 981 × 10−3 mm/s2 (range 926.6–1065 × 10−3 mm/s2) for the local recurrence group (P = 0.0014). ConclusionsA novel 3.0 T MRI protocol incorporating DWI and DCE was feasible and confirmed the suspicion of local recurrence in patients with highly suspicious computed tomography scans. This imaging tool could potentially aid in selecting patients for salvage treatment after local SBRT failure. Future work should be pursued to validate these findings.

Low Rate of Cancer Events After Partial Nephrectomy for Renal Cell Carcinoma: Clinicopathologic Analysis of 1994 Cases with Emphasis on Definition of "Recurrence".

Systematic pathology reviews in patients who experienced a clinical "recurrence" after partial nephrectomy for renal cell carcinoma (RCC) are anecdotal; therefore, definitions of "recurrence" varies considerably. We aimed to better define local recurrence by re-evaluation of surgical specimens of patients who experienced "recurrences" after partial nephrectomy at our institution. Retrospective analysis of our institutional partial nephrectomy data set was performed. Patients who were clinically diagnosed with a local recurrence during the oncological follow-up after primary intervention for RCC were considered (January 2007 to December 2017, institutional review board number 5065, 15-1593). Re-evaluation of specimens coming from either primary treatment or management of the diagnosed recurrent disease was performed by 2 dedicated urologic pathologists. According to the findings of the pathology review, patients were assigned to 3 groups of disease event: (1) local recurrence of RCC; (2) new occurrence of RCC; and (3) micrometastatic RCC. Patient demographic characteristics, tumor pathological characteristics, oncological outcomes, disease treatment, and follow-up were reported for each patient. Cancer-specific survival was compared using the Kaplan-Meier method. Of 1994 cases recorded in the institutional database, data on 30 patients who were clinically diagnosed with a local recurrence were extracted. After pathology review, 9 patients were found who truly developed a local recurrence (group 1). Positive surgical margin status was poorly related to the likelihood of a true local recurrence as defined herein. Twelve patients were assessed with a new occurrence of RCC (group 2). Nine were diagnosed with micrometastatic RCC (group 3). With comparable follow-up lengths among the groups (39 [interquartile range (IQR), 32-45] versus 51.5 [IQR, 35-90.5] versus 42 [IQR, 13-65], group 1 versus 2 versus 3, respectively; P= .4), patients classified in group 1 and 3 had comparable cancer-specific survival (P= .5). Conversely, patients in group 2 were less likely to die of disease compared with group 1 and 3 patients (P= .02). Careful pathologic classification of RCC disease events after partial nephrectomy has important prognostic implications and allows more precise study of the clinical significance of margin status.

Risk of ipsilateral breast tumor recurrence in primary invasive breast cancer following breast-conserving surgery with BRCA1 and BRCA2 mutation in China.

BRCA1/2 germline mutations are associated with a high risk of breast cancer, which may preclude mutation carriers from breast-conserving surgery (BCS). This study retrospectively examined whether mutation status influenced the rate of ipsilateral breast tumor recurrence (IBTR) after BCS in Chinese women. Patients who underwent BCS were enrolled in carriers group and non-carriers group according to their BRCA1/2 mutation status in the study. The correlations were analyzed between IBTR incidence and BRCA1/2 mutation. The IBTR cases were further separated into new primary tumor (NP) and true local recurrences (TR). The risk factors of NP were studied in multivariate analysis. 1947 consecutive Chinese women with primary invasive breast cancer were selected. 103 patients were identified as BRCA1/2 mutation carriers and 1844 were non-carriers. BRCA1/2 mutation carriers were younger (P < 0.001) with more often negative HER-2 expression (P = 0.01) and tumor size over 2cm (P = 0.04) than non-carriers. The median follow-up for all patients was 80 months. The rate of IBTR was 3.9% in mutated carriers and 2.0% in non-carriers, respectively (P = 0.16). In IBTR cases, NP incidence was 3.9% in carrier group and 0.6% in non-carrier group, respectively (P < 0.01). After adjustment of all clinical-pathological factors, BRCA1/2 mutation was the only statistical risk factor of NP incidence (HR = 6.29, P = 0.002), while positive lymph node was nearly statistically significant (HR = 2.70, P = 0.06). BCS may be a rational option for Chinese BRCA1/2 mutation carriers. High NP incidence in mutation carriers should be paid close attention in the future.

Clinical characteristics and prognosis of patients with ipsilateral breast tumor recurrence after breast conservation therapy

Objective: To analyze the clinical features and prognosis of the ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery. Methods: From 1999 to 2013, 63 women with IBTR after breast conserving surgery were retrospectively reviewed. All patients had adequate information on tumor location both at first presentation and at recurrence, with or without regional recurrence or distant metastasis. The histologic changes between true local recurrence and elsewhere recurrence groups were compared. The local recurrence, the overall survival after IBTR (IBTR-OS), the disease-free survival after IBTR (IBTR-DFS) were also compared. Results: All patients had undergone lumpectomy, including 38 cases with additional axillary lymph node dissection and 13 cases with sentinel lymph node biopsy. There were 11.3% (7/63) cases received neoadjuvant systemic therapy, 68.3% (43/63) had adjuvant radiotherapy, 60.3% (38/63) underwent adjuvant chemotherapy and 47.6% (30/63) received hormonal therapy. Forty-five cases (71.4%) had recurrence in the same quadrant, and 18 cases (28.6%) had elsewhere recurrence. Compared with histology at presentation, 10.3% of the patients (6/58) had different ones at recurrence and 28.9% of patients (13/45) had different molecular subtypes. The conversion rate of estrogen receptor status (33.3% vs 9.5%, P=0.012) and progesterone receptor status (56.3% vs 19.0%, P=0.005) in patients with elsewhere recurrence was significantly higher than that in patients with same quadrant recurrence. Fifty-nine cases had undergone surgery after IBTR, with 48 cases of secondary breast-conserving surgery and 11 cases of salvage mastectomy. The median time to IBTR of same quadrant recurrence and elsewhere recurrence groups were 26 months and 62 months (P=0.012), respectively. There were 84.4% and 44.4% cases who had local recurrence within 5 years after breast conserving surgery, respectively. Of all cases, the overall 5-year IBTR-OS and 5-year IBTR-DFS rates were 79.4% and 60.4%, respectively. There were no significant differences in 5-year IBTR-OS (77.4% vs. 83.6%, P=0.303) or 5-year IBTR-DFS (60.0% vs. 62.8%, P=0.780) between same quadrant recurrence and elsewhere recurrence groups. Univariate analysis showed that pN0-1 (P<0.001), luminal subtype (P=0.026), adjuvant endocrine therapy (P=0.007) at first presentation, recurrent tumor < 3 cm (P=0.036) and having surgery after IBTR(P=0.002) were favorable factors of IBTR-OS. pN0-1 (P<0.001) at first presentation, recurrent tumor stage Ⅰ-Ⅱ (P<0.001) and having surgery after IBTR(P=0.001) were favorable factors of IBTR-DFS. There was no significant difference between second breast-conserving surgery and salvage mastectomy in IBTR-OS and IBTR-DFS (P>0.05). Conclusions: The IBTR after breast conserving surgery mainly occurred at the original quadrant. Second breast-conserving surgery did not affect patient's prognosis. There were significant differences in biological features between the same quadrant recurrence and elsewhere recurrence, requiring different therapeutic strategies in the future.

A study into the association between local recurrence rates and surgical resection margins in organ-sparing surgery for penile squamous cell cancer.

To evaluate the significance of close surgical margins in organ-sparing surgery (OSS) in the treatment of penile squamous cell carcinoma (pSCC) and clinicopathological factors that may influence local recurrence. At our tertiary referral centre, between March 2001 and September 2012, 332 patients treated with OSS for pSCC had clear surgical margins. As the focus was the impact of close clear margins on local recurrence, patients with positive margins were excluded for the purpose of this study. Our overall positive margin rate for OSS in penile cancer is 7.6% (42 patients). Analysis was carried out on an on-going prospective database, including prospective accurate pathological recording of surgical margins. Patients underwent OSS after multidisciplinary team (MDT) discussion. Local recurrence was the primary outcome measured and Fisher's exact test and time-to-recurrence curves were used in the analysis. All local recurrences were scrutinised by the MDT and were categorised into: true recurrences or metachronous new occurrences (i.e. tumours arising from a background of penile intraepithelial neoplasia and forming on an epithelial surface not related to the site of initial resection). A multivariate analysis was also conducted to elucidate other factors influencing local recurrence. In all, 64% of the patients had a <5 mm clear deep surgical margin, with 16% clear by <1 mm. Overall, 4% of patients had a true local recurrence, with a median time to recurrence of 6 months. In all, 53% were due to embolic spread, with residual occult local disease accounting for 47%. There was a statistically significant relationship between cavernosal involvement (P = 0.014) and lymphovascular invasion (LVI; P = 0.001) and local recurrence. Although multivariate analysis revealed that the extent of clear margin was not a predictor of disease (P = 0.405), we found an increased risk of local recurrence in the clear margin cohort of <1 mm compared to those of >1 mm (P < 0.001). Those patients considered to have metachronous tumours were scrutinised by our MDT, and eight patients (2.4%) were found to have new occurrences. Our overall proportion of patients therefore needing further treatment for either new occurrences or recurrent disease after OSS stands at 6.4%. Overall the presence of local recurrent disease in OSS in our experience is low (4%). We report an embolic mechanism of local recurrence, strongly suggested by the presence of cavernosal involvement and LVI. We conclude that a deep clear margin of >1 mm has a very low risk of local recurrence in penile OSS.

Midterm Safety and Efficacy of Irreversible Electroporation of Malignant Liver Tumors Located Close to Major Portal or Hepatic Veins.

Purpose To investigate the efficacy and safety of irreversible electroporation (IRE) in the treatment of hepatic tumors not suitable for thermal ablation (radiofrequency ablation [RFA] or microwave ablation). Materials and Methods This was an institutional review board-approved prospective study in 29 patients (15 men, 14 women; mean age, 63 years ± 12 [standard deviation]) with 43 primary (n = 8) or secondary (n = 35) malignant liver tumors who underwent computed tomography (CT)-guided IRE. All target tumors were located immediately adjacent to major hepatic veins, portal veins, or both; thus, they were not considered suitable for RFA or microwave ablation. Patients underwent postinterventional CT and magnetic resonance (MR) imaging. Systematic follow-up MR imaging was performed for 24 months on average to assess complete ablation, intrahepatic tumor recurrence, and complications. The 95% confidence intervals (CIs) were determined for the rate of bile duct strictures, incomplete ablation, and tumor recurrence. Results Complete ablation was achieved in 40 (93%; 95% CI: 85, 100) of 43 target tumors, with a safety margin of 5-10 mm, and was confirmed at immediate postinterventional CT and MR imaging. In 13 (33%; 95% CI: 18, 47) of 40 completely ablated tumors, intrahepatic tumor recurrence was observed at 2-18 months. However, only two (15%; 95% CI: 0, 35) of these 13 tumors were observed within the ablation zone. In the remaining 11 (85%; 95% CI: 65, 100), tumor growth was observed alongside the needle tract. None of the two true local recurrences occurred at the site of the vessel. All adjacent vessels remained perfused at follow-up. Five (24%; 95% CI: 5, 39) of 21 patients with target tumors adjacent to portal veins developed mild to moderate cholestasis 2-6 weeks after IRE. Conclusion IRE is useful to avoid incomplete ablation secondary to heat-sink effects and damage to major blood vessels; however, needle tract seeding is observed in 26% of treated tumors, and IRE induces sufficient local heating to bile ducts in 24% of ablations. © RSNA, 2017.

The Ferguson Operating Anoscope for Resection of T1 Rectal Cancer

The Ferguson Operating Anoscope (FOA) is a surgical instrument, which can facilitate transanal excision of appropriate rectal tumors within 15 cm of the anal verge. Previous work showed low recurrence (4.3%) for favorable T1 tumors (no lymphovascular invasion, well/moderate differentiation, negative margins). This follow-up study evaluates outcomes in rectal cancer excised with FOA at a tertiary care center. T1 rectal cancer patients were identified in a prospectively maintained database. Tumor pathology and patient characteristics were reviewed. Primary outcomes include tumor recurrence and patient and disease-free survival. Secondary outcomes are quality of excision (intact specimen). Twenty-eight patients had pathologic stage T1 rectal cancer (average 8 ± 2.6 cm from the anal verge). Final path demonstrated 14 per cent to be well differentiated, 82 per cent moderately differentiated, and 93 per cent without angiolymphatic invasion. All specimens removed were intact. One patient had a true local recurrence and underwent a salvage operation 24 months after her index operation. Patient survival was 96.4 per cent (n = one death from primary lung cancer) at median follow-up 64 ± 35 months. With appropriate tumor selection and quality of initial resection, FOA has demonstrated utility in achieving optimal oncologic resection of T1 rectal tumors.