Tumour Excision Margins Research Articles

36. Does the use of hand-held dermatoscope smart phone photography help in achieving clear peripheral margins in cutaneous malignancy – A Preliminary Study

Use of Dermatoscope is well recognised for the assessment and diagnosis of cutaneous malignancies. Peripheral margins are usually identified under good lighting and use of magnification loupes before excision. Limiting extent of surgical resection on the face in key cosmetic areas without compromising tumour excision margins is sometimes a challenge. Aim for our study to identify and mark peripheral margins pre-operatively with the use of handheld dermatoscope smart phone photography.

Lentigo Maligna of the head and neck: A retrospective study assessing surgical excision margins in a South African population

BackgroundLentigo maligna (LM) is a subtype of melanoma in situ that occurs on sun-damaged skin and is associated with significant subclinical extension beyond the clinical margins of the lesion.ObjectivesThis study aimed to determine if the standard recommended tumor excision margins for LM are adequate to achieve a 97% clearance rate and if any patient or tumor characteristics warranted wider margins.MethodsThis study is a retrospective chart review of all patients who were diagnosed with LM of the head and neck and treated with staged excision.ResultsThe study included 64 patients. With a 6 mm surgical excision margin, only 60.9% of LM were completely excised. A 9 mm margin resulted in complete clearance of 71.9% of LM cases, and a 12 mm margin resulted in complete clearance in 90.6%. A surgical excision margin of 18 mm would have been required to excise 96.7% of tumors completely. Recurrent tumors (P = .01) and tumor size larger than 20 mm were associated with wider surgical excision margins (P = .154).ConclusionThis study of LM in a South African population corroborates that the standard surgical excision margins recommended by international melanoma guidelines for LM are inadequate to achieve a 97% clearance rate.

Laminin - A Prognostic Marker in Oral Squamous Cell Carcinoma

Introduction: Squamous cell carcinoma is one of the most common malignant tumours of the oral cavity and is the tenth most common cause of death worldwide. Because of the high malignant potentially these cases are detected at an advanced stage. Also the recurrence rate is high which invites challenge to the treating surgeon. Laminin, a basement membrane molecule is a reliable marker to predict dif-ferentiation and aggressiveness of the oral squamous cell carcinomas. Methods: The study was conducted in the department of pathology, S. C B Medical College, Cuttack with an aim to predict the tumour aggressiveness and thereby prognosis. A total number of 76 cases were studied using the laminin immunostaining and the results tabulated and interpreted. Results: Majority were well differentiated squamous cell carcinomas, which showed mild to moderate intra cytoplasmic staining of laminin and an intense staining at the tumour host interface, in contrast to an intense intra cytoplasmic staining in poorly differentiated squamous cell carcinoma cases. Those with lymph node metastasis and involved surgical margins also showed intense intra cytoplasmic laminin staining pointing to a higher grade tumour. Conclusion: Laminin immunostaining is definitely superior to the conventional staining procedures for the as-sessment of tumour aggressiveness and differentiation, intra-operative assessment of tumour excision margins and thus access prognosis. Recent researches highlight on Laminin antibodies, which can be used as specific chemotherapeutic agents, to check the process of tumour growth and invasion.

An experience of slow-Mohs micrographic surgery for the treatment of Dermatofibrosarcoma protuberans: A long-term cohort study.

Dermatofibrosarcoma protuberans (DFSP) is a rare dermal mesenchymal tumor known as a low-grade, slow-growing malignancy. The local invasion and high rate of recurrence following surgical treatment are the main concerns to plan the best surgical approach of treatment. In the current study, it is aimed to provide an experience of slow-Mohs surgery for the treatment of patients with DSFP. Number of 25 patients with the diagnosis of DFSP through histological and immunostaining study was included. The slow-Mohs was performed by excision of the tumor with margins accounting for 1-2cm from both the tumor margins and three-dimensional thickness. The obtained tissue margins were horizontally, and if any of the specimens was not margin-free, the procedure was repeated. The patients' opinion about the procedure was assessed using Patient-Observer Scar Assessment Scale (POSAS). Number of 25 patients were included and followed for a median of 46.9 months. The median of the area of excision was 35.56cm2 , and the median clinical excision margins were 19mm (tumor excision margins + thickness of the three-dimensional excision). The surgery was performed once for 16 (64%), and postoperative skin closure within 5-7days after the procedure was performed for 19 (76%) patients. None of the patients represented any recurrence. The patients' overall opinion and satisfaction POSAS score accounted for 2.3±1.65 and 1.6±0.59, respectively. The findings of the current study are in favor of slow-Mohs surgery for the management of DFSP, while more extensive studies are strongly recommended for generalization of this procedure.

Basal Cell Carcinoma Pathology Requests and Reports Are Lacking Important Information.

Introduction Basal cell carcinoma (BCC) is the most common cancer affecting humans. Luckily it has negligible risk for metastasis; however it can be locally destructive to surrounding tissue. The diagnosis of this tumor relies on clinical and dermoscopic features; however confirmation requires biopsy and histologic examination. Based on clinical and pathologic findings, BCC is classified as low or high risk subtype. The clinician requesting pathology examination for BCC should provide the pathologist with detailed information including patient details, relevant clinical and medical history, site and type of the biopsy, and whether this is a primary or recurrent lesion. The pathologist on the other hand should write an adequate report containing a minimum of core set of parameters including type of BCC, depth of invasion, presence of lymphovascular or perineural invasion, and the excision margins. ObjectivesThe objective of this study is to evaluate whether requests by clinicians and pathology reports of BCC are adequate. MethodsThis is a retrospective analysis done at the dermatology department, faculty of medicine at Jordan University of Science and Technology, Irbid, Jordan. Reports for the period from January 2003 to December 2017 were retrieved and analyzed for data completeness. ResultsMost clinical request forms of BCC provided by clinicians are inadequate and lack important relevant information especially in regard to lesion history, patient medical history, and whether BCC is a primary or a recurrent one. Pathology reports for BCC cases also have significant deficiency especially in describing the histologic subtype, depth of invasion, and presence of lymphovascular and perineural invasion. However, the tumor excision margins are adequately described in almost all reports. ConclusionsThe study shows that clinicians do not provide adequate clinical information when submitting a request for histopathologic examination of BCC. Similarly, pathologists write incomplete reports that lack important pathologic features. Having pre-set forms (electronic proforma) can help overcome missing information.

Abstract P2-12-14: Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer

Abstract Introduction: Incomplete excision rate for lobular cancer is much higher compared to other types of breast cancer, since lobular cancer is frequently occult on imaging. This, and the inability to downstage lobular cancer with neoadjuvant therapy lead to the highest mastectomy rate of all subtypes. Here, we investigated the association between histopathological characteristics and incomplete excision as well as mastectomy rates. Further, we investigated whether the application of level 2 therapeutic mammoplasty (TM) would extend the indication for conservation with lobular cancers. Methods: Data of 1389 consecutive patients underwent surgery for (non)invasive breast cancer between January 2008 and June 2012 was analysed. Pathological and preoperative radiological results were analysed in the context of final surgery and tumour excision margins. Statistical significance was calculated using Chi-square, Mann-Whitney and Z-tests with a significance<0.05. Results: Overall incomplete excision rate was 13.74% (131/953), and mastectomy rate was 35.35% (491/1389). Higher incomplete excision and mastectomy rates were strongly associated with lobular subtype (IE: 26.03% (19/73)); M: 51.22% (63/123); p<0.01 vs. other subtypes), node positivity (IE: 25% (36/144) vs. 10.43% (68/652); p=0 and M: 60.69% (193/318) vs. 25.65% (216/842); p=0) and tumour size (IE:T3 80% (4/5) vs. T2 22.51% (43/191) vs. T1 9.23% (55/596); all p<0.01; and M: T3 95.35% (41/43) vs. 59.46% (242/407) vs. 16.16% (112/693); all p=0). Incomplete excision rates were independent of hormonal and HER-2 expressions (ER+: 12.55% (89/709) vs. ER-: 16.67% (15/90); p=0.27 and HER2 neg.: 12.67% (91/718) vs. HER2 pos.: 16.67% (13/78); p=0.32) and it was just higher in grade 2 and 3 cancers (14.6% (60/411); p=0.037 and 16.22% (36/222); p=0.021 vs. G1:6.86% (7/102). However, hormonal and HER-2 expressions as well as tumour grade were in strong association with mastectomy rate (ER pos.: 33.28% (335/1007) vs. ER neg.: 48.75% (78/160); p<0.01; HER2 neg.: 33.43% (341/1020) vs. HER2 pos.: 49.65% (71/143); p<0.01; G3: 50.49% (205/406) vs. G2: 30.77%(172/559) vs. G1: 14.28% (17/119); all p=0). 135 patients underwent surgery for lobular cancer (simple wide excision: 66; TM:19; mastectomy: 50). TM was offered for significantly larger tumours than lumpectomy (28.29mm (10-62) vs. 19.96mm(5-57);p<0.01; vs. mastectomy: 37.56 mm(5-110);p=0.096). Incomplete margins were found with significantly smaller tumours when lumpectomy was applied compared to TM(25.94 mm(6-56) vs. 38.6 mm(30-45);p=0.031). Conservation was achieved with significantly bigger tumours when TM was used (25.46mm (10-62) vs. 17.66mm (5-57); p=0.032). Multifocality, however, significantly increased the chance for incomplete excision even after TM (4/7; p=0.019). Conclusion: Higher incomplete excision rate is strongly associated with lobular subtype, node positivity and tumour size, but independent of hormonal end HER-2 expression, while tumour grade is not a strong predictor. All histopathological characteristics are strong predictors of final mastectomy rate. Using TM, breast conservation can be achieved for significantly larger lobular cancers, and incomplete excision rate decreased in smaller cancers, which are routinely treated with wide excision. Citation Format: Romics L, Kabir SA, Mansell J, Mallon EA, Stallard S, Doughty JC. Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-14.

P094. Clinical feasibility of Cerenkov Luminescence Imaging (CLI) for intraoperative assessment of tumour excision margins and sentinel lymph node metastases in breast-conserving surgery

P094. Clinical feasibility of Cerenkov Luminescence Imaging (CLI) for intraoperative assessment of tumour excision margins and sentinel lymph node metastases in breast-conserving surgery

The Importance of Adequate Primary Tumor Excision Margins and Sentinel Node Biopsy in Achieving Optimal Locoregional Control for Patients With Thick Primary Melanomas

This study sought to investigate the impact of histopathologically measured excision margins and SNB on local and locoregional disease control in patients with primary cutaneous melanomas more than 4 mm thick. Most current guidelines recommend at least a 2-cm surgical margin (which corresponds to a 16-mm histopathologic margin). These guidelines are based on limited evidence, mostly obtained in patients who did not have an SNB. Histopathologic tumor excision margins for clinically lymph node-negative patients with melanomas more than 4 mm thick, treated at Melanoma Institute Australia (1992-2009), were determined. Clinicopathologic predictors of local and locoregional disease-free survival were investigated. There were 632 patients eligible for the study; of these, 397 (62.8%) had an SNB. The median histopathologic excision margin was 15 mm (interquartile range, 11.0-19.5 mm). After a median follow-up of 37 months, local and locoregional recurrences were observed in 48 (7.6%) and 159 (25.2%) patients, respectively. Excision margin as a continuous variable was a significant predictor of local [hazard ratio (HR), 0.91; P < 0.001) and locoregional (HR, 0.97; P = 0.042) tumor control on multivariate analyses. Patients with histopathologic margins 16 mm or less had worse local disease-free survival (HR, 2.41; P = 0.01). Patients who did not have an SNB were at higher risk of locoregional recurrence (HR, 1.67; P = 0.003). Histopathologically determined primary tumor excision margins more than 16 mm, corresponding to 2-cm surgical margins, were associated with better local control in patients with melanomas more than 4 mm thick. Patients achieved the best local and locoregional control when SNB was coupled with a more than 16-mm histologic excision margin.

534 Incomplete Tumour Excision Margins During Therapeutic Mammaplasty – Assessment of Predictive Factors

534 Incomplete Tumour Excision Margins During Therapeutic Mammaplasty – Assessment of Predictive Factors

Factors influencing loco-regional relapse in older breast cancer patients treated with tumour resection and tamoxifen

BackgroundIn breast cancer patients (≥70 years), tumour resection plus tamoxifen (T + T) has a higher loco-regional relapse (LR) rate than mastectomy. This study examines factors influencing local recurrence in these cases. MethodsClinical records of 71 patients aged ≥70 years, randomised to the T + T arm of 2 randomised trials were reviewed. Cox Proportional Hazards model was used to determine the most significant variables. ResultsAfter 15-years follow-up, LR relapse occurred in 29/71, of whom 5 had synchronous metastatic disease. Most tumours recurred in the index quadrant. Subsequently 21/24 patients with loco-regional recurrence only had salvage mastectomy. Three variables significantly predicted LR: lympho-vascular invasion (LVI) (HR [95% CI]: 11.18 [4.47, 27.95], p < 0.01), ER negative status (HR [95% CI]: 0.27 [0.10, 0.72] p = 0.01), and tumour necrosis (HR [95% CI]: 2.65 [1.10, 6.37], p = 0.03). Final margin status was not associated with LR. ConclusionsTumour resection + Tamoxifen in older patients results in long-term local control in the majority with most loco-regional failures being salvageable. Risk factors for LR are lympho-vascular invasion, ER status and tumour necrosis. Negative tumour excision margins did not significantly change local outcome in the absence of radiotherapy. In these older patients LVI significantly reduced survival time.

Single-incision laparoscopically assisted colectomy using standard laparoscopic instrumentation

A prospective case series of transumbilical single-incision laparoscopic colectomies using conventional laparoscopic trocars and instruments is described. Seven selected patients with colonic neoplasm underwent transumbilical SIL colectomy between November 2008 and March 2009. Three trocars via a single small umbilical incision were used. The bowel was mobilized and the vessels ligated intracorporeally with an extracorporeal anastomosis. This series of seven patients (6 men and 1 woman) had no conversion to standard multiport laparoscopy or open surgery. Six of the patients had pathology in the right colon, and one had a carcinoma at the splenic flexure. The patients had an average age of 71 years (range, 63-83 years) and an average body mass index (BMI) of 24.3 kg/m(2) (range, 21-28 kg/m(2)). The average operating time was 89 min (range, 75-115 min). No significant blood loss or complications occurred. The average length of hospital stay was 5.4 days (range, 4-11 days). The average incision length was 3.1 cm (range, 2.5-4.5 cm). Histopathology showed adequate tumor excision margins and an average lymph node yield of 15 nodes (range, 7-26 nodes). Single-incision laparoscopic surgery for colectomy is feasible. It can be performed without specialized instrumentation and at no extra cost. Further evaluation is required.

Factors Determining Outcome for Breast-Conserving Irradiation with Margin-Directed Dose Escalation to the Tumor Bed

Purpose: A prospectively applied treatment policy for breast-conserving therapy used margin assessment as the exclusive guide to the intensity of therapy directed at the tumor-bearing quadrant. Methods and Materials: From 1982–1994, there were 509 treated Stage I and II breast carcinomas with a median follow-up of 72 months. For operational purposes, tumor excision margins were prospectively defined as: > 5 mm, 2.1–5 mm, > 0 ≤ 2 mm, and positive. If a margin was assessed as ≤2 mm or indeterminate, and it was deemed cosmetically feasible, a reexcision of the tumor bed would be performed. All patients received whole breast irradiation to 50–50.4 Gy. The following scheme for tumor bed boost irradiation as a function of final margin status (FMS) was observed: (a) Minimal risk = no tumor found on reexcision, no boost performed; (b) low risk = FMS > 5 mm, boost of 10 Gy; intermediate risk = FMS 2.1–5 mm, boost to 14 Gy; high risk = FMS ≤ 2 mm or positive, boost to 20 Gy. Cases were analyzed for local failure (LF) with respect to histology (invasive ductal (IDC), IDC with associated DCIS (IDC/DCIS), invasive lobular (ILC)), age, tumor size, total excision volume, reexcision, total dose, tamoxifen therapy, and chemotherapy. Results: There were 19 breast recurrences for a Kaplan–Meier local failure rate for all cases at 5 and 10 years of 2.7% and 7.1%, respectively. Local failure in the first 4 years of follow-up was rare, with a mean annual incidence rate of 0.25% that rose to a mean of 1.1% in subsequent years. Univariate results of Cox proportional hazards regression survival models found positive FMS ( p = 0.02), IDC/DCIS ( p = 0.04) and age (0.0006) as significantly associated with local failure. In a multivariable model of FMS and IDC/DCIS, FMS retained significance ( p = 0.01) but IDC/DCIS was borderline ( p = 0.06). When FMS and age were included in a multivariable model, there was a significant interaction ( p = 0.01) between the two variables. There was a significant increase in the relative risk of LF for age ≤ 45 years (range 11.1–17.4), irrespective of FMS category. Although excellent overall control rates were achieved for patients > 45 years, for younger patients LF rates appeared to remain proportional to the relative closeness of the FMS, despite rigorous dose escalation. Conclusions: Graded tumor-bed dose escalation in response to FMS results in an exceptionally low risk of “early” local recurrence within the first 5 years of follow-up. However, this strategy is unable to completely overcome the longer term adverse influence of young age and positive FMS.

Wire-directed localization biopsy of the breast: an audit of results and analysis of factors influencing therapeutic value in the treatment of breast cancer

Fine-wire localization biopsy is an accurate technique for diagnosis of mammographically-detected breast abnormalities, and may also be therapeutic in the management of impalpable malignant lesions. A number of factors were therefore examined regarding their influence upon therapeutic success in a consecutive series of 129 localization biopsies. Factors included type of radiological abnormality, method and accuracy of wire localization and pre-operative cytology. Primary malignancy was detected at initial localization in 64 cases (malignant:benign ratio, 1.11:1); 26 (41%) achieving adequate local tumour excision margins without further surgery, and 38 undergoing further surgery to clear margins (mastectomy in 23, further wide excision in 15). Therapeutic success was related to the accuracy of pre-operative needle localization (needle hook within 1 cm of target lesion in 26/26 (100%) therapeutic biopsies, compared to 29/38 (76%) non-therapeutic biopsies (P<0.01, Fisher's exact test)); and to pre-operative cytology (suspicious/malignant cytology in 15/24 therapeutic, compared with only 9/29 non-therapeutic biopsies (P=0.013, chi-squared)). Localization biopsy has a high diagnostic success rate and a therapeutic value dependent upon accurate pre-operative cytological diagnosis, supplemented by precise needle localization of the target lesion.