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Positive Margins (positive + margin)
Selected AbstractsSurgical margin determination in head and neck oncology: Current clinical practice.HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 11 2005Neck Society Member Survey, The results of an International American Head Abstract Background. Our aim was to investigate the ways in which surgeons who perform head and neck ablative procedures on a regular basis define margins, how they use frozen sections to evaluate margins, and the effect of chemoradiation on determining tumor margins. Methods. A custom-designed questionnaire was mailed to members of the American Head and Neck Society asking members how they evaluate and define tumor margins. Results. Of 1500 surveys mailed, 476 completed surveys were received. The most common response for distance of a clear pathologic margin was >5 mm on microscopic evaluation. A margin containing carcinoma in situ was considered a positive margin by most, but most did not consider a margin containing dysplasia a positive margin. When initial frozen section margins are positive for tumor and further resection results in negative frozen section margins, 90% consider the patient's margin negative. Most surgeons sample the frozen section from the surgical bed rather than from the main specimen. Nearly half use wider margins when resecting tumors treated with neoadjuvant therapy. When resecting recurrent or residual tumors treated with previous chemoradiation therapy, most resect to the pretreatment margin. Conclusions. No uniform criteria to define a clear surgical margin exist among practicing head and neck surgeons. Most head and neck surgeons consider margins clear if resection completed after an initial positive frozen section margin reveals negative margins, but this view is not shared by all. Most surgeons take frozen sections from the surgical bed; however, error may occur when identifying the positive margin within the surgical bed. The definition of a clear tumor margin after chemoradiation is unclear. These questions could be addressed in a multicenter prospective trial. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX,XXX, 2005 [source] Financial Impact of Emergency Department UltrasoundACADEMIC EMERGENCY MEDICINE, Issue 7 2009Olanrewaju A. Soremekun MD Abstract Objectives:, There is limited information on the financial implications of an emergency department ultrasound (ED US) program. The authors sought to perform a fiscal analysis of an integrated ED US program. Methods:, A retrospective review of billing data was performed for fiscal year (FY) 2007 for an urban academic ED with an ED US program. The ED had an annual census of 80,000 visits and 1,101 ED trauma activations. The ED is a core teaching site for a 4-year emergency medicine (EM) residency, has 35 faculty members, and has 24-hour availability of all radiology services including formal US. ED US is utilized as part of evaluation of all trauma activations and for ED procedures. As actual billing charges and reimbursement rates are institution-specific and proprietary information, relative value units (RVUs) and reimbursement based on the Centers for Medicare & Medicaid Services (CMS) 2007 fee schedule (adjusted for fixed diagnosis-related group [DRG] payments and bad debt) was used to determine revenue generated from ED US. To estimate potential volume, assumptions were made on improvement in documentation rate for diagnostic scans (current documentation rates based on billed volume versus diagnostic studies in diagnostic image database), with no improvements assumed for procedural ED US. Expenses consist of three components,capital costs, training costs, and ongoing operational costs,and were determined by institutional experience. Training costs were considered sunken expenses by this institution and were thus not included in the original return on investment (ROI) calculation, although for this article a second ROI calculation was done with training cost estimates included. For the purposes of analysis, certain key assumptions were made. We utilized a collection rate of 45% and hospitalization rates (used to adjust for fixed DRG payments) of 33% for all diagnostic scans, 100% for vascular access, and 10% for needle placement. An optimal documentation rate of 95% was used to estimate potential revenue. Results:, In FY 2007, 486 limited echo exams of abdomen (current procedural terminology [CPT] 76705) and 480 limited echo cardiac exams were performed (CPT 93308) while there were 78 exams for US-guided vascular access (CPT 76937) and 36 US-guided needle placements when performing paracentesis, thoracentesis, or location of abscess for drainage (CPT 76492). Applying the 2007 CMS fee schedule and above assumptions, the revenue generated was 578 RVUs and $35,541 ($12,934 in professional physician fees and $22,607 in facility fees). Assuming optimal documentation rates for diagnostic ED US scans, ED US could have generated 1,487 RVUs and $94,593 ($33,953 in professional physician fees and $60,640 in facility fees). Program expenses include an initial capital expense (estimated at $120,000 for two US machines) and ongoing operational costs ($68,640 per year to cover image quality assurance review, continuing education, and program maintenance). Based on current revenue, there would be an annual operating loss, and thus an ROI cannot be calculated. However, if potential revenue is achieved, the annual operating income will be $22,846 per year with an ROI of 4.9 years to break even with initial investment. Conclusions:, Determining an ROI is a required procedure for any business plan for establishing an ED US program. Our analysis demonstrates that an ED US program that captures charges for trauma and procedural US and achieves the potential billing volume breaks even in less than 5 years, at which point it would generate a positive margin. [source] Effect of inflammation on positive margins of basal cell carcinomasAUSTRALASIAN JOURNAL OF DERMATOLOGY, Issue 2 2010Neil Macpherson ABSTRACT Background/Objectives:, The use of preparations such as imiquimod in the treatment of basal cell carcinoma is well accepted. Imiquimod induces interferon-,, other cytokines, antigen-presenting cells and innate immunity, against tumour cells. The current study investigated whether the inflammation induced from a surgical procedure could have a similar effect on removing residual tumour after an excision. Method:, A retrospective audit was carried out on basal cell carcinoma removed in the Dermatology Clinic of the Royal Newcastle Centre in 2007. The end-point focussed on the features of those tumours which initially had a positive margin, but were found to have no remaining tumour on subsequent excision. Result:, A linear regression was carried out, revealing two significant predictors of outcome. These were the location of the basal cell carcinoma excision and the excision type. Punch biopsies and excisional biopsy had a greater number of histopathologically negative wider excisions despite initial positive margins. Facial lesions had a greater number of negative wider excisions. Conclusion:, The study has shown the majority of negative re-excisions were from lesions on the head which had had an initial surgical procedure. However, the evidence is not strong enough to advocate a protocol for dealing with positive margins. A larger sample size that encompassed all three factors that affect outcome, that is, the location of lesion, type of lesion and type of excision carried out, would be required in order to make a more definitive statement on protocol change for treatment of basal cell carcinoma. [source] Oncological control after radical prostatectomy in men with clinical T3 prostate cancer: a single-centre experienceBJU INTERNATIONAL, Issue 9 2009Evanguelos Xylinas OBJECTIVE To determine the effectiveness of cancer control afforded by radical prostatectomy (RP) in patients with clinical stage T3 prostate cancer. PATIENTS AND METHODS We retrospectively reviewed data for patients treated by RP for clinical stage T3 prostate cancer between 1995 and 2005. The following case characteristics were analysed: patient age, clinical presentation, preoperative prostate-specific antigen (PSA) level, Gleason score, tumour stage (2002 Tumour-Node-Metastasis), surgical procedure, pathological data, margin and lymph node status, and recurrence. Biochemical recurrence was defined as an increase in PSA level of >0.2 ng/mL after surgery. Kaplan-Meier survival curves were generated, and prognostic factors were evaluated. RESULTS Overall, 100 patients were included; only 79% of them had pT3 disease based on the pathological specimen. The median follow-up after RP was 69 months. The RP was open in 77 and laparoscopic in 23, with no significant difference between these approaches (P = 0.38). The 5-year PSA-free survival after surgery was 45%, and 5-year cancer-specific survival was 90%. On univariable analysis, Gleason score >7 (P = 0.01), pathological stage (pT2-T3a vs T3b) (P < 0.001), positive lymph node (P < 0.001), and positive margin (P < 0.001) were associated with recurrence. On multivariable analysis, lymph node, margin status and Gleason score were also significant (P < 0.05). CONCLUSIONS RP can be recommended as an alternative primary treatment that results in acceptable cancer control for clinical stage T3 prostate cancer in selected cases. However, the patient should be warned that surgery alone might not be sufficient to control the cancer, and that adjuvant therapy might be needed during the course of the disease. [source] 7 Positive margin rates in patients with a single positive core on extended TRUS biopsyBJU INTERNATIONAL, Issue 2006D. DANGERFIELD Introduction:, Extended TRUS biopsy (12 biopsies or more) is now a standard technique performed in many centres. The management of small volume prostate cancer (<0.05cc) found in a single TRUS biopsy is controversial and may have implications in nerve-sparing versus non-nerve sparing radical prostatectomy. The aims of this study are: , To assess the incidence of prostate cancer in the unaffected contralateral prostate lobe on final histopathology , To assess the incidence of extracapsular extension and margin status in the ipsilateral and contralateral lobes Patients and methods:, Of 897 radical prostatectomy specimens examined through Sullivan Nicolaides Pathology between 2002 and 2005, 78 had a single positive core in preoperative TRUS biopsy. Histopathalogy, PSA and Gleason sum were reviewed. Results:, For patients with a Gleason sum of 6 on TRUS biopsy the mean PSA was 7.00 mcgm/dl. A majority (85%) of the positive cores had low volume disease with tumour occupying less than 30% of the core. Of those with Gleason 3 + 3 = 6 on TRUS biopsy, 34% had their Gleason sum upgraded on final histopathology. Ipsilateral positive margin was seen in 14% of cases. Contralateral positive margin was present in only 2.8% of cases despite tumour being found in 61% of cases in the contralateral lobe on final histopathology. Conclusion:, This study shows that in patients with a single positive core of low volume disease, the incidence of contralateral margin involvement on final histopathology is very low. This data is useful in counselling patients who intend to undergo nerve sparing radical prostatectomy. [source] Recurrent salivary gland carcinomas treated by surgery with or without intraoperative radiation therapyHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 1 2008Allen M. Chen MD Abstract Background. The optimal treatment for patients with locally recurrent carcinomas of the salivary glands is unclear. Methods. Ninety-nine patients underwent salvage surgery for locally recurrent salivary gland carcinomas. Eighty-one (82%) had previously received radiation. Thirty-seven patients (37%) received intraoperative radiation therapy (IORT) to a median dose of 15 Gy (range, 12,18 Gy) at the time of salvage. Results. The 1-, 3-, and 5-year estimates of local control after salvage surgery were 88%, 75%, and 69%, respectively. A Cox proportional hazard model identified positive margins (0.01) and the omission of IORT (p = .001) as independent predictors of local failure. The 5-year overall survival was 34%. Distant metastasis was the most common site of subsequent failure, occurring in 42% of patients. Conclusions. IORT significantly improves disease control for patients with locally recurrent carcinomas of the salivary glands. The high rate of distant metastasis emphasizes the need for effective systemic therapies. © 2007 Wiley Periodicals, Inc. Head Neck, 2008 [source] Anterior skull base surgery for malignant tumors: A multivariate analysis of 27 years of experience,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 7 2003Brandon G. Bentz MD Abstract Introduction. Few studies have examined prognostic factors that have an impact on outcomes in anterior skull base surgery by multivariate analysis. Methods. We retrospectively examined our institution's skull base experience from 1973,2000. Results. During this time, 166 patients underwent an anterior skull base resection for malignancy (median age, 53 years; range, 6,92 years). The 5-year relapse-free and disease-specific survival was 41% and 57% (median follow-up, 53 months). Multivariate analysis found that dural invasion, primary histologic diagnosis, and margin status had a significant impact on relapse-free and disease-specific survival. Conclusions. These data indicate that patients with anterior skull base malignancies are treated successfully with skull base surgery. Patients demonstrating adverse prognostic variables such as dural invasion, adverse histologic findings, and/or positive margins should be considered for the addition of adjuvant therapy or innovative therapies as they become available in the future. © 2003 Wiley Periodicals, Inc. Head Neck 25: 515,520, 2003 [source] Significance of clinical stage, extent of surgery, and pathologic findings in metastatic cutaneous squamous carcinoma of the parotid gland,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 5 2002Christopher J. O'Brien MS, FRACS Abstract Background Metastatic cutaneous cancer is the most common parotid malignancy in Australia, with metastatic squamous carcinoma (SCC) occurring most frequently. There are limitations in the current TNM staging system for metastatic cutaneous malignancy, because all patients with nodal metastases are simply designated N1, irrespective of the extent of disease. The aim of this study was to analyze the influence of clinical stage, extent of surgery, and pathologic findings on outcome after parotidectomy for metastatic SCC by applying a new staging system that separates metastatic disease in the parotid from metastatic disease in the neck. Methods A prospectively documented series of 87 patients treated by one of the authors (COB) over 12 years for clinical metastatic cutaneous SCC involving the parotid gland and a minimum of 2 years follow-up was analyzed. These patients were all previously untreated and were restaged according to the clinical extent of disease in the parotid gland in the following manner. P1, metastatic SCC of the parotid up to 3 cm in diameter; P2, tumor greater than 3 cm up to 6 cm in diameter or multiple metastatic parotid nodes; P3, tumor greater than 6 cm in diameter, VII nerve palsy, or skull base invasion. Neck disease was staged in the following manner: N0, no clinical metastatic disease in the neck; N1, a single ipsilateral metastatic neck node less than 3 cm in diameter; N2, multiple metastatic nodes or any node greater than 3 cm in diameter. Results Clinical P stages were P1, 43 patients; P2, 35 patients; and P3, 9 patients. A total of 21 patients (24%) had clinically positive neck nodes. Among these, 11 were N1, and 10 were N2. Conservative parotidectomies were carried out in 71 of 87 patients (82%), and 8 of these had involved surgical margins (11%). Radical parotidectomy sacrificing the facial nerve was performed in 16 patients, and 6 (38%) had positive margins, (p < .01 compared with conservative resections). Margins were positive in 12% of patients staged P1, 14% of those staged P2, and 44% of those staged P3 (p < .05). Multivariate analysis demonstrated that increasing P stage, positive margins, and a failure to have postoperative radiotherapy independently predicted for decreased control in the parotid region. Survival did not correlate with P stage; however, many patients staged P1 and P2 also had metastatic disease in the neck. Clinical and pathologic N stage both significantly influenced survival, and patients with N2 disease had a much worse prognosis than patients with negative necks or only a single positive node. Independent risk factors for survival by multivariate analysis were positive surgical margins and the presence of advanced (N2) clinical and pathologic neck disease. Conclusions The results of this study demonstrate that patients with metastatic cutaneous SCC in both the parotid gland and neck have a significantly worse prognosis than those with disease in the parotid gland alone. Furthermore, patients with cervical nodes larger than 3 cm in diameter or with multiple positive neck nodes have a significantly worse prognosis than those with only a single positive node. Also, the extent of metastatic disease in the parotid gland correlated with the local control rate. The authors recommend that the clinical staging system for cutaneous SCC of the head and neck should separate parotid (P) and neck disease (N) and that the proposed staging system should be tested in a larger study population. © 2002 Wiley Periodicals, Inc. [source] A new method of margin evaluation in breast conservation surgery using an adjustable mould during fixationHISTOPATHOLOGY, Issue 1 2001S Ichihara A new method of margin evaluation in breast conservation surgery using an adjustable mould during fixation Aims:,We have developed a new method of breast resection margin assessment in quadrantectomy using an adjustable mould to prevent the three-dimensional specimen from distorting during fixation. Methods and results:,The new method has been applied to 10 consecutive quadrantectomies (six invasive duct carcinomas, four duct carcinoma in situ with or without microinvasion). The precise configuration of the fixed specimen enabled pathologists to examine the side slices, the 5 mm thick slices cut parallel to the flat lateral margins of the specimen, permitting the separation of margin evaluation from tumour characterization. Eight cases with negative margins by our method would also be negative by assessment of inked margins since the margin widths were estimated to be from 5 to 30 mm (average 16.3 mm); two cases with positive margins would also be positive by inked margins. Conclusions:,Our new method was as reliable as the inked margins employing sequential slicing of the entire tissue, although it reduced the number of blocks by more than half in invasive carcinomas. A further advantage of this method is that the accuracy in margin evaluation is not influenced by the extent of tumour sampling. In addition, our system can pinpoint the positive margins facilitating re-excision to obtain tumour-free margins. [source] Adenoid cystic carcinoma: A retrospective clinical reviewINTERNATIONAL JOURNAL OF CANCER, Issue 3 2001Atif J. Khan M.D. Abstract Adenoid cystic carcinoma (ACC) are uncommon tumors, representing about 10% to 15% of head and neck tumors. We compare the survival and control rates at our institution with those reported in the literature, and examine putative predictors of outcome. All patients registered with the tumor registry as having had ACC were identified. Demographic and survival variables were retrieved from the database. Additionally, a chart review of all patients was done to obtain specific information. Minor gland tumors were staged using the American Joint Committee on Cancer's criteria for squamous cell carcinomas in identical sites. Histopathologic variables retrieved included grade of the tumor, margins, and perineural invasion. Treatment modalities, field sizes, and radiation doses were recorded in applicable cases. An effort to retrieve archival tumor specimens for immunohistochemical analysis was undertaken. A total of 69 patients were treated for ACC from 1955 to 1999. One patient, who presented with fatal brain metastasis, was excluded from further analysis. Of the remaining 68 patients, 30 were men and 38 were women. The average age at diagnosis was 52 years, and mean follow-up was 13.2 years. Mean survival was 7.7 years. Overall survival (OS) rates at 5, 10, and 15 years were 72%, 44%, and 34%, and cause-specific survival was 83%, 71%, and 55%, respectively. Recurrence-free survival rates were 65%, 52%, and 30% at 5, 10, and 15 years, with a total of 29 of 68 (43%) eventually suffering a recurrence. Overall survival was adversely affected by advancing T and AJCC stage. Higher tumor grades were also associated with decreased OS, although the numbers compared were small. Primaries of the nasosinal region fared poorly when compared with other locations. Total recurrence-free survival, local and distant recurrence rates were distinctly better in primaries of the oral cavity/oropharynx when compared with those in other locations. Reduced distant recurrence-free survival was significantly associated with increasing stage. No other variables were predictive for recurrence. Additionally, we found that nasosinal tumors were more likely to display higher stage at presentation, and were more often associated with perineural invasion. Also of interest was the association of perineural invasion with margin status, with 15 of 20 patients with positive margins displaying perineural invasion, while only 5 of 17 with negative margins showed nerve invasion (P = 0.02). On immunohistochemistry, 2 cases of the 29 (7%) tumor specimens found displayed HER-2/neu positivity. No correlation between clinical behavior and positive staining could be demonstrated. Our data concur with previous reports on ACC in terms of survival and recurrence statistics. Stage and site of primary were important determinants of outcome. Grade may still serve a role in decision making. We could not demonstrate any differences attributable to primary modality of therapy, perhaps due to the nonrandomization of patients into the various treatment tracks and the inclusion of palliative cases. Similarly, perineural invasion, radiation dose and field size, and HER-2/neu positivity did not prove to be important factors in our experience. © 2001 Wiley-Liss, Inc. [source] Autofluorescence and diffuse reflectance spectroscopy and spectral imaging for breast surgical margin analysisLASERS IN SURGERY AND MEDICINE, Issue 1 2010Matthew D. Keller MS Abstract Background and Objective Most women with early stage breast cancer have the option of breast conserving therapy, which involves a partial mastectomy for removal of the primary tumor, usually followed by radiotherapy. The presence of tumor at or near the margin is strongly correlated with the risk of local tumor recurrence, so there is a need for a non-invasive, real-time tool to evaluate margin status. This study examined the use of autofluorescence and diffuse reflectance spectroscopy and spectral imaging to evaluate margin status intraoperatively. Materials and Methods Spectral measurements were taken from the surface of the tissue mass immediately following removal during partial mastectomies and/or from tissues immediately after sectioning by surgical pathology. A total of 145 normal spectra were obtained from 28 patients, and 34 tumor spectra were obtained from 12 patients. Results After correlation with histopathology, a multivariate statistical algorithm classified the spectra as normal (negative margins) or tumor (positive margins) with 85% sensitivity and 96% specificity. A separate algorithm achieved 100% classification between neo-adjuvant chemotherapy-treated tissues and non-treated tissues. Fluorescence and reflectance-based spectral images were able to demarcate a calcified lesion on the surface of a resected specimen as well. Conclusion Fluorescence and reflectance spectroscopy could be a valuable tool for examining the superficial margin status of excised breast tumor specimens, particularly in the form of spectral imaging to examine entire margins in a single acquisition. Lasers Surg. Med. 42:15,23, 2010. © 2010 Wiley-Liss, Inc. [source] The value of postoperative radiotherapy in childhood nonrhabdomyosarcoma soft tissue sarcoma,PEDIATRIC BLOOD & CANCER, Issue 5 2004Arnold C. Paulino MD Abstract Objective To determine the value of postoperative radiotherapy (RT) in the management of nonrhabdomyosarcoma soft tissue sarcoma (NRSTS) of childhood. Procedure From 1964 to 2000, 62 children with a median age of 14 years were seen at the University of Iowa and underwent a wide local excision for non-metastatic NRSTS. Tumors were high grade in 36 (58%) and >5 cm in 24 (39%). Margins of resection were negative (Group I) in 37 (60%) and positive (Group II) in 25 (40%). Postoperative RT was delivered to 20 patients (32%); eight of 37 (22%) Group I and 12 of 25 (48%) Group II children received postoperative RT. Chemotherapy was employed in 19 patients (31%). Median follow-up was 9.6 years. Results The 5- and 10-year overall survival rates for Group I were 69 and 63% and for Group II were 66 and 60%. The 5- and 10-year local control rate was 66%. On multivariate analysis, size of tumor (P,<,0.001) and postoperative RT (P,=,0.017) were prognostic factors for local control. All 13 Group I children with low grade, ,5 cm tumors were locally controlled without RT. For Group II patients, 2- and 5-year local control rates were 92 and 82% with postoperative RT and 51 and 43% for no RT (P,=,0.0426). Conclusions Local control was improved by the addition of postoperative RT in tumors with positive margins of resection. © 2004 Wiley-Liss, Inc. [source] Total Pharyngolaryngectomy for Squamous Cell Carcinoma of the Hypopharynx: A ReviewTHE LARYNGOSCOPE, Issue 5 2005FRACS, Ronaldo Bova MS Abstract Objectives: To evaluate our experience with total pharyngolaryngectomy in the treatment of hypopharyngeal squamous cell carcinoma. Study Design: Retrospective analysis of consecutively treated patients in an academic otolaryngology, head and neck department. Methods: One hundred eighty patients who had total pharyngolaryngectomy performed for hypopharyngeal carcinoma were included in this study. Patients with a history of previous head and neck cancer were excluded. Clinicopathologic parameters were recorded and survival calculated using the Kaplan-Meier method. Results: One hundred sixty-two (90%) of the patients were male, and the patients had a mean age of 62 years. The majority (91%) of patients had advanced overall clinical stage disease (stage 3,4). Thirty-one (17.8%) and 43 (24%) patients developed locoregional and metastatic disease recurrence, respectively. The 2- and 5-year disease-specific survival rates were 72% and 52%, respectively. Advanced nodal stage, perineural invasion, lymphovascular invasion, and positive margins were predictors of poor survival on univariate analysis, and lymphovascular invasion was an independent prognostic factor on multivariate analysis. Conclusion: Surgery and postoperative radiotherapy remains the treatment against which other modalities should be compared for advanced stage hypopharyngeal squamous cell carcinoma. [source] Role for Postoperative Radiation Therapy in Adenoid Cystic Carcinoma of the Head and Neck,THE LARYNGOSCOPE, Issue 7 2004Damon A. Silverman MD Objective: Clarify the role for postoperative radiation for adenoid cystic carcinoma (ACC) of the head and neck as it relates to tumor site, T-stage, and surgical margin status. Study Design: Retrospective cohort study at an academic tertiary care hospital. Methods: A review of 129 patients with biopsy-proven ACC was performed. Previous treatment failures and nonoperative candidates were excluded, with 75 patients considered eligible for further study. Patients were grouped according to treatment modality and Kaplan-Meier estimates of overall survival, locoregional control, and distant control were compared using log-rank tests. Patients were also stratified according to tumor site, T-stage, and surgical margin status, and pair-wise comparisons of treatment outcome within each group were performed using Wald tests from Cox proportional hazards models. Results: Twenty-five patients were treated with surgery alone, and 50 were treated with surgery and postoperative radiation. There was no significant difference in outcome between treatment groups when correlated with tumor site (P = .89). However, postoperative radiation was associated with improved overall survival for advanced T-stage (T4) tumors (P = .019) and greater locoregional control for patients with microscopically positive margins (P = .018). There was no demonstrated benefit of postoperative radiation for patients with microscopically negative margins (P = .93). Conclusions: The findings of this study suggest that advanced T-stage and positive microscopic margins are important factors in determining the necessity for postoperative radiation therapy for ACC of the head and neck and that radiation therapy may not be necessary for patients with early T-stage tumors and negative surgical margins. [source] Effect of inflammation on positive margins of basal cell carcinomasAUSTRALASIAN JOURNAL OF DERMATOLOGY, Issue 2 2010Neil Macpherson ABSTRACT Background/Objectives:, The use of preparations such as imiquimod in the treatment of basal cell carcinoma is well accepted. Imiquimod induces interferon-,, other cytokines, antigen-presenting cells and innate immunity, against tumour cells. The current study investigated whether the inflammation induced from a surgical procedure could have a similar effect on removing residual tumour after an excision. Method:, A retrospective audit was carried out on basal cell carcinoma removed in the Dermatology Clinic of the Royal Newcastle Centre in 2007. The end-point focussed on the features of those tumours which initially had a positive margin, but were found to have no remaining tumour on subsequent excision. Result:, A linear regression was carried out, revealing two significant predictors of outcome. These were the location of the basal cell carcinoma excision and the excision type. Punch biopsies and excisional biopsy had a greater number of histopathologically negative wider excisions despite initial positive margins. Facial lesions had a greater number of negative wider excisions. Conclusion:, The study has shown the majority of negative re-excisions were from lesions on the head which had had an initial surgical procedure. However, the evidence is not strong enough to advocate a protocol for dealing with positive margins. A larger sample size that encompassed all three factors that affect outcome, that is, the location of lesion, type of lesion and type of excision carried out, would be required in order to make a more definitive statement on protocol change for treatment of basal cell carcinoma. [source] Evaluation of modern pathological criteria for positive margins in radical prostatectomy specimens and their use for predicting biochemical recurrenceBJU INTERNATIONAL, Issue 3 2009Gary W. Bong OBJECTIVES To assess the interpretation of modern criteria for evaluating surgical margins (SMs), by examining the incidence of positive SMs (PSMs) and subsequent biochemical recurrence in a single-surgeon series of radical prostatectomy (RP) at two institutions, as the criteria for determining PSMs after RP are subject to individual interpretation, and this might explain some of the variability in biochemical recurrence rates with different rates of PSMs. PATIENTS AND METHODS We reviewed 301 consecutive perineal RPs by one surgeon (T.K.) at Emory University Hospital (EUH) and the Medical University of South Carolina (MUSC), with each pathology department using modern criteria to evaluate the SMs. The SM status and biochemical recurrence (BCR) were analysed, the latter defined as a prostate-specific antigen level of ,0.2 ng/mL. RESULTS There were 158 perineal RPs at EUH followed by 143 at MUSC. PSMs were reported in 39 patients (24.7%) at EUH, whereas six (4.2%) were positive at MUSC. The overall BCR rates were similar between the groups, but BCR within margin-positive cases was 100% at MUSC vs 25.6% at EUH (P < 0.01). The presence of tumour at <1 mm from the margin did not increase the rate of BCR compared to those with obvious negative SMs (P = 0.731). CONCLUSION In this single-surgeon series, using the same criteria to evaluate the SMs resulted in significantly different PSM rates and margin-positive BCR rates between the institutions. Although the reason for these differences is difficult to determine, the study shows clearly that tumour within 1 mm of the margin should not be classified as margin-positive. [source] Impact of tumour volume on surgical and pathological outcomes after robot-assisted radical cystectomyBJU INTERNATIONAL, Issue 7 2008Bertram Yuh OBJECTIVE To report on the influence that bladder tumour volume has on operative and pathological outcomes after robotic-assisted radical cystectomy (RARC, a minimally invasive alternative to open cystectomy for treating bladder cancer), as with the lack of tactile feedback in RARC tumour volume might compromise the outcome. PATIENTS AND METHODS Between 2005 and 2007, 54 consecutive patients had RARC at one institution. CT urograms were obtained in all patients for staging purposes and to evaluate hydronephrosis. Patients were separated into two groups based on pathological tumour dimensions. Once selected into two-dimensional (2D, flat) or 3D (bulky) tumour groups the patients were compared for operative and pathological variables. RESULTS The mean age of all patients was 67 years; 19 had tumours classified as 2D and 35 as 3D. There were no statistical differences in age, sex, body mass index, American Society of Anesthesiologists score, previous surgery, mean hospital stay, or estimated blood loss between the groups. The difference in operative duration for bladder removal was almost statistically significant (P = 0.077). Intraoperative transfusion was more common in the 3D group (P = 0.044); 43% of patients in the 3D group had hydronephrosis, vs only 16% in the 2D group. 3D tumours were more likely to be higher stage (P = 0.051). All positive margins in the patient were in the 3D group (P = 0.04); no patients with ,T2 disease had a positive surgical margin. CONCLUSIONS Bulky tumours removed with RARC might be associated with an increased rate of intraoperative transfusion, higher stage disease, and higher rate of margin positivity. In patients with large-volume tumours on preoperative assessment, wider dissection of perivesical tissue might decrease the margin-positive rates. [source] Training for renal ablative technique using an agarose-based renal tumour-mimic modelBJU INTERNATIONAL, Issue 1 2006GRANT D. TAYLOR OBJECTIVE To assess whether a recently developed porcine tumour-mimic model can serve as a training model for radiofrequency ablation (RFA) of renal masses, as the increased diagnosis of small occult renal masses has led to the development of nephron-sparing treatments, including RFA, and the techniques required for effective tumour ablation can be difficult to master. MATERIALS AND METHODS Tumour mimics were created by injecting 0.7 mL of an agarose mixture into the parenchyma of a porcine kidney, producing 1-cm spherical lesions which were hyperechoic on ultrasonography (US). The ex vivo experiment included creating 40 tumour mimics followed by RFA using US-guided needle placement. The ablation diameter was set to 15 mm to produce a margin of grossly ablated tissue around the mimic lesions. The in vivo portion involved creating 20 tumour mimics and ablating them under direct laparoscopic vision with US-guided probe placement. In each case, the mimic lesion size by US and gross examination, ablation diameter, and completion (accuracy) of ablations were recorded. RESULTS Accurate placing of the RFA needle by US guidance was difficult to learn, as all tumour-mimic lesions were either endophytic or completely intraparenchymal. The ex vivo model required ,,15 ablations before the needle was placed consistently into the lesions. The in vivo model was equally difficult to learn, with five positive margins by gross examination in the first 10 ablations, while the subsequent 10 had no positive margins. CONCLUSION The agarose-based tumour mimic is a useful target model for learning and improving US-guided ablative techniques in both the ex vivo and in vivo settings. The tumour-mimic allows the surgeon to assess targeting accuracy in an animal model. Further studies are needed to determine this model's utility as a clinical training aid. [source] A prospective study of concurrent cyclophosphamide/methotrexate/5-fluorouracil and reduced-dose radiotherapy in patients with early-stage breast carcinomaCANCER, Issue 7 2004Jennifer R. Bellon M.D. Abstract BACKGROUND Concurrent administration of chemotherapy and radiotherapy has the potential advantage of delaying neither treatment and providing radiation sensitization. However, the optimal approach to concurrent treatment in women with early-stage breast carcinoma remains undefined. We present updated results of a prospective protocol of concurrent cyclophosphamide/methotrexate/5-fluorouracil (CMF) and reduced-dose radiotherapy, focusing on tumor control and patient tolerance. METHODS One hundred twelve women with AJCC Stage I or Stage II breast carcinoma with 0,3 positive axillary lymph nodes were enrolled in a prospective single-arm study of concurrent CMF and reduced-dose radiotherapy (39.6 gray [Gy] to the whole breast, 16-Gy boost). A high proportion of women had risk factors associated with an increased risk of local disease recurrence, including age < 40 (32%), close or positive margins (37%), or lymphatic/vascular invasion (51%). The median follow-up period was 94 months. RESULTS The 5-year overall survival rate was 94%. By 60 months, 5 patients (4%) experienced local disease recurrence and 19 patients (17%) experienced distant metastasis. There were no isolated regional lymph node recurrences. Local disease recurrence occurred in 1 of 25 patients (4%), 1 of 16 patients (6%), and 3 of 70 patients (4%) with positive, close (< 1 mm), and negative margins, respectively. One patient developed acute myelogenous leukemia. An additional patient developed Grade 2 pneumonitis. Cosmetic results were not recorded uniformly for all patients and therefore could not be reliably analyzed. CONCLUSIONS Concurrent CMF and reduced-dose radiotherapy resulted in a low level of late toxicity and excellent local tumor control, despite the large proportion of patients with substantial risk factors for local disease recurrence. Future studies of concurrent regimens, particularly in patients at high risk of local disease recurrence, are warranted. Cancer 2004;100:1358,64. © 2004 American Cancer Society. [source] Low recurrence rate after surgery for dermatofibrosarcoma protuberansCANCER, Issue 5 2004A multidisciplinary approach from a single institution Abstract BACKGROUND Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma with a propensity for local recurrence. Treatments with wide excision, Mohs surgery, and other approaches have been reported with widely variable local control rates. The objective of this study was to review the experience with a multidisciplinary approach employing wide excision and Mohs surgery selectively in the treatment of patients with DFSP at a single academic institution over the past 10 years. METHODS The records of 62 patients with 63 DFSP tumors who underwent wide excision, Mohs surgery, or a multidisciplinary combination approach from January 1991 to December 2000 were reviewed retrospectively. Primary endpoints included the ability to extirpate the DFSP lesion completely, the tumor recurrence rate, and the need for skin grafts or local tissue flaps. Additional objectives included defining surgical practice patterns at the authors' institution. RESULTS Sixty-three DFSP lesions were removed from 62 patients. At a median follow-up of 4.4 years, no local or distant recurrences were detected in any patient. Forty-three lesions were treated with wide local excision, 11 lesions were treated with Mohs surgery, and 9 lesions were treated with a combination approach. Ninety-five percent of lesions that were approached initially with wide local excision were cleared histologically. Two patients (5%) received postoperative radiation for positive margins after undergoing maximal excision. Eighty-five percent of lesions that were approached initially with Mohs surgery were cleared histologically. The remaining 15% of lesions subsequently were cleared surgically with a wide excision. DFSP lesions that were approached initially with Mohs surgery tended to be smaller. Patients with head and neck lesions most often underwent Mohs surgery or were treated with a multidisciplinary combination approach (87%). CONCLUSIONS Wide local excision with careful pathologic analysis of margins was found to have a very low recurrence rate and was used for the majority of patients with DFSP lesions at the authors' institution. Wide local excision, Mohs surgery, and a multidisciplinary combination approach, selected based on both tumor and patient factors, were capable of achieving very high local control rates in the treatment of DFSP. The evolution of a multidisciplinary approach has provided a level of expertise that no single individual could achieve for the treatment of the full spectrum of DFSP lesions at the authors' institution. Cancer 2004;100:1008,16. © 2004 American Cancer Society. [source] | ||||||||||