Wide-field Resection Research Articles

Virtual scale endoscope-assisted wide-field resection of large sessile serrated lesions.

Large sessile serrated lesions (SSLs) are associated with a very high risk of incomplete resection. The CARE study found almost 50 % incomplete resections among 10 to 20-mm SSLs [1]. Wide-field cold snare resection with submucosal injection (cap-assisted endoscopic mucosal resection, C-EMR) has been proposed as an effective method to prevent incomplete resection since distinguishing SSL margins during resection is difficult [2] [3] [4]. In contrast to a hot snare, a more extended resection field is recommended for a cold snare [5]. However, quantification of the resection field extent in comparison to polyp size has been challenging in the past. The novel virtual scale endoscope (VSE; SCALE EYE, Fujifilm, Tokyo, Japan) can be used as dedicated technology to measure polyp size before resection and to ensure adequate post-resection defect size. The VSE allows polyp size measurement during live colonoscopies by emitting a laser beam onto the mucosa to measure distance. This permits superimposition of a linear/circular ruler that changes in size depending on distance of the endoscope to the laser point ([Fig. 1]).

Positive surgical margins after radical nephrectomy for localized kidney cancer: Impact on survival.

676 Background: Impact of positive surgical margins (PSM) in patients undergoing radical nephrectomy (RN) in localized renal cell carcinoma (RCC) is poorly understood. We sought to understand the impact of PSM for on overall survival (OS) after RN in clinically localized RCC. Methods: Retrospective analysis of patients from the US National Cancer Database who RN for clinically localized (cT1a-cT2b cN0M0) RCC between 2003-13, were stratified into their pathological stage group [pT1a, pT1b, pT2a, pT2b, and pT3a ( = Upstaged)] and analyzed by final margin status. Cox Regression Multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on OS. Kaplan-Meier analysis (KMA) of OS was performed for PSM verses NSM for the overall cohort and by stage. Results: 37,656 RN events [14312 (38%) pT1a, 13598 (36.1%) pT1b, 6551 (17.4%) pT2a, 2937 (7.8%) pT2b, and 4286 (11.3%) with pT3a upstaging]. PSM rate was 0.9% overall (0.4% pT1a, 0.4% pT1b, 0.4% pT2a, 0.4% pT2b, and 4.7% pT3a upstaged). On MVA for all-cause mortality, PSM was independently predictive for decreased OS (HR 1.51, p < 0.001), along with increasing age (HR 1.04, p < 0.001), non-Caucasian race (HR 1.199, p < 0.001), increasing charlson score (HR 2.23, p < 0.001), non-private insurance (HR 1.61, p = 0.001), high grade histology (HR 1.21, p = 0.001), and sarcomatoid histology (HR 3.61, p < 0.001). Pathologic T-stage was also predictive of decreased OS (Referent pT1a, HR 1.17, 1.47, 1.74, and 1.93, for pT1b, pT2a, pT2b, pT3a, respectively; all p < 0.001). KMA revealed worsened 5-year OS for PSM vs. NSM for the overall cohort (62.4% vs. 81%, p < 0.001), pT2a (61% vs. 79.4%, p = 0.013), and pT3a (50% vs. 68.3%, p < 0.001) groups. Conclusions: PSM is a rare event after RN, but is associated with worsened OS, particularly in pT2 and pT3a upstaged patients. Mechanism of decreased OS cannot be clarified given limitations of the NCDB, these suggest that PSM may pose increased oncologic risks in higher pathological stage. Consideration of further definitive strategies (ex: preemptive wide field resection) may be warranted in select circumstances. Furthermore, our findings call for re-consideration of exclusion of PSM patients from adjuvant therapy trials.

Barrett's esophagus: review of diagnosis and treatment.

Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.

Endoscopic management of Barrett esophagus

Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.

Skull Base Surgery for the Management of Deeply Invasive Scalp Cancer

Skin cancer involving the scalp is a common malignancy in the "sun belt areas of the United States." Most early lesions are well managed by primary care physicians and dermatologists. Occasionally we encounter basal cell, squamous cell, and rarely Merkel cell carcinomas that have failed local therapy and present with large tumors invading full thickness scalp, calvarium, and even underlying dura. We describe our experience with 52 such tumors and illustrate their resections and reconstruction. For full thickness lesions we generally do a wide field resection of skin and underlying calvarium followed by dural resection. Reconstruction is usually with dural replacement, calvarial reconstruction with titanium mesh, and cutaneous reconstruction with a musculocutaneous free flap or muscular free flap with an overlying skin graft. Complications, survival rates, and recurrence rates will be presented.

Resection Deep Invasion of Scalp Carcinoma Using Skull Base Techniques

Skin cancer involving the scalp is a common malignancy in the sunbelt areas of the United States. Most early lesions are well managed by primary care physicians and dermatologists. Occasionally, we encounter basal cell, squamous cell, and, rarely, Merkel cell carcinomas that have failed local therapy and present with large tumors invading the full thickness scalp, calvarium, and occasionally the underlying brain. We describe our experience with 12 such tumors and illustrate their resections and reconstruction. For full thickness lesions, we generally do a wide field resection of the skull and underlying calvarium followed by dural resection and that of the underlying brain, if affected in ineloquent regions. Reconstruction is usually with dural replacement, calvarial reconstruction with titanium mesh, and cutaneous reconstruction with a musculocutaneous free flap or muscular free flap with an overlying skin graft. Complications, survival rates, and recurrence rates will be presented.

Extra-abdominal fibromatosis invading the mandible: Case report

Extra-abdominal fibromatosis (desmoid tumour) is a rare aggressive neoplasm with a tendency to infiltrate local structures but rarely metastasises or undergoes spontaneous malignant transformation. The treatment of choice is surgery, however, recurrences have been reported even after wide-field resection. This article presents a case of extra-abdominal fibromatosis that had extensively invaded the mandible.

Safety of total thyroidectomy: review of 100 consecutive cases.

During a 6-year period (June 1982 to June 1988), 100 consecutive total thyroidectomies were performed at Mount Sinai Hospital, University of Toronto, for benign and malignant disease. There were five permanent complications: one deliberate sacrifice of the recurrent laryngeal nerve and four cases of persistent hypoparathyroidism. Four of these five complications occurred in extracapsular carcinoma and resulted from oncologic wide-field resection and/or deliberate sacrifice. One patient with benign disease suffered initially transient hypoparathyroidism which has now become permanent. Interestingly, two patients actually underwent deliberate sacrifice of a recurrent laryngeal nerve; one patient has made a surprising recovery at 16 months postoperative and now has full vocal cord mobility. Our experience suggests that the morbidity of total thyroidectomy relates primarily to the stage of malignancy and extracapsular extension, necessitating en bloc excision accompanied by additional lymph node dissection. The low incidence of permanent complications in benign thyroid disease suggests the feasibility of total thyroidectomy as the operation of choice when surgeons are familiar with the technique and indications.

Nonsurgical Treatment of Aggressive Fibromatosis in the Head and Neck

Aggressive fibromatosis is a poorly defined, locally aggressive, yet histologically benign fibroblastic proliferative lesion that may occur in the head and neck. The lesion is highly cellular and locally infiltrative and has a propensity to invade and erode bone, compromising vital structures within the head and neck. However, it is not a true malignancy because it does not have malignant cytologic characteristics nor does it metastasize. We present two cases of aggressive fibromatosis occurring in young adult men. The first case involved a rapidly enlarging mass of the anterior maxilla that involved the upper lip, nasal alae, nasal septum, inferior turbinates, and hard palate. The patient underwent incisional biopsy to confirm the diagnosis. Because of difficulty in determining the actual margins of this extensive lesion and the significant morbidity that would have resulted from surgical resection, we elected to treat this patient with chemotherapy and radiation therapy. The second case was an extensive lesion involving the right temporal bone, pterygomaxillary space, and infratemporal, temporal, and middle cranial fossae. Incisional biopsy confirmed the diagnosis. Because of the lack of functional and cosmetic deficits and the unavoidable morbidity of a surgical resection, this patient was treated with radiation therapy. Although wide field resection is the most satisfactory form of treatment, in situations in which this modality would result in unacceptable morbidity or if surgical margins are positive, then radiation therapy and chemotherapy should be considered. Support for these therapeutic modalities is found in larger series of cases outside the head and neck.

Radiation therapy in the treatment of aggressive fibromatoses (desmoid tumors)

Twenty-five patients with aggressive fibromatoses (desmoid tumors) have been treated or followed in the Department of Radiation Medicine at the Massachusetts General Hospital between 1972 and 1982. Seventeen patients were treated by radiation, 4 for primary and 13 for recurrent disease. Seven patients were treated in conjunction with surgery. Partial or complete regression was achieved in 76%, and 59% are without evidence of disease (NED) at 9 to 94 months follow-up. Eight of ten patients treated primarily with radiation have achieved complete response without an attempt at resection (five) or have achieved stabilization (three) of their disease after some regression. Consistent complete control was seen with doses above 60 Gy. Periods to 27 months were required to observe complete responses. Only three failures within the radiation field were observed, two after low doses (22 and 24 Gy, respectively). Eight patients were seen after resection but with uncertain or histologically minimum positive margins, and were followed regularly and not treated. One patient has failed to date and is NED after resection. Radiation therapy is recommended in those situations where wide-field resection without significant morbidity is not possible for gross local disease. If minimally positive margins exist after resection in a patient who may be followed carefully, frequent follow-up and prompt treatment at recurrence may be an effective alternative to immediate radiation therapy.

Prognostic and therapeutic use of microstaging of cutaneous squamous cell carcinoma of the trunk and extremities

Cutaneous squamous cell carcinomas (SCC) arising in actinically damaged skin, unassociated with chronic inflammation or injury, are generally regarded as nonaggressive lesions. These tumors occasionally recur or metastasize, however, as do de novo SCC. The authors reviewed 63 patients with cutaneous SCC of the trunk or extremities, excluding lesions that developed in known high risk settings, in order to explore the potential of histologic microstaging as a prognostic indicator. Fifty-four patients (86%) were free of recurrence following primary surgical therapy. Nine patients (14%) had either local recurrence or metastases; five of these (8% of the entire series) died of their tumors. Tumor behavior correlated best with the level of dermal invasion and the vertical tumor thickness. All tumors that recurred were 4 mm or more thick and involved the deep half of the dermis or deeper structures. All tumors that proved fatal were at least 10 mm in maximum thickness, and the four lethal lesions that could be evaluated for level of invasion extended into subcutaneous tissue or deeper structures. The thickness and level of invasion of cutaneous SCC appear to represent important prognostic factors and may be relevant indicators for wide field resection and/or elective lymph node dissection.

Carcinoma in a Zenker's diverticulum

Zenker's diverticulum is a common developmental anomaly seen usually in the elderly. Carcinoma in this pharyngoesophageal outpouching has been reported in only 23 instances. A 55-year-old woman is presented whose only symptoms were dysphagia and periodic regurgitation of bloodstained material. Barium swallow and esophagoscopy confirmed the presence of a neoplasm, and biopsy revealed an epidermoid carcinoma. Wide field resection was followed by a full course of irradiation and secondary pharyngoesophageal reconstruction. The patient was free of disease at three-year follow-up.

Fibrosarcoma of the head and neck: a clinical analysis of forty cases.

This paper is a clinical analysis of 40 patients with fibrosarcoma of the head and neck treated at the Washington University Medical School, St. Louis, Missouri. Follow-up ranged from 6 to 25 years in 31 patients. Treatment consisted of widefield surgical excision, surgery and irradiation, narrowfield surgery, and irradiation alone. Histological classification of the tumors correlates well with the prognosis. In the well differentiated tumor group 12 out of 16 patients treated for a cure were free of tumor. In the poorly differentiated group only one out of five treated for a cure was free of tumor. Widefield surgical excision is the treatment of choice. Prophylactic radical neck dissection is not indicated. Narrowfield surgical excision resulted in a high recurrence rate although the salvage rate was excellent with subsequent widefield resection. Irradiation therapy produced good palliative results in those patients treated by irradiation alone and has a definite role in the management of this disease.