Positive Margins

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Is Postmastectomy Radiation Therapy Indicated in Patients with Close or Positive Margins?

Is Postmastectomy Radiation Therapy Indicated in Patients with Close or Positive Margins?

Background: The indications for Post Mastectomy Radiation Therapy (PMRT) for positive or close margins are unclear. We examined the indications for PMRT in mastectomy patients with close or positive margins and determined patterns for relapse and survival. Methods: The pathology re- ports of 610 patients treated with a mastectomy from 1999-2012 were reviewed. Of these, 72 pa- tients had a positive or <2 mm margin. Demographic, tumor characteristics, treatments and sur- vival were compared between women treated with and without PMRT. Results: The mean follow up was 4.1 years. Patients who received PMRT were younger (p = 0.03) and more likely to receive chemotherapy (p = 0.03). Patients with lymphovascular invasion (LVI) were more likely to un- dergo PMRT (p = 0.02). Seven patients who did not receive PMRT recurred. There was no correla- tion with locoregional failure. The disease free survival was better in the PMRT group (p = 0.03), but the overall survival was the same. Conclusion: We found that women with a close or positive margin who were younger, had LVI, and who received chemotherapy received PMRT. The disease free survival was better in the PMRT cohort, but the overall survival was similar. Long-term follow up of patients is warranted to see if PMRT offers a survival advantage.
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<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

<p>Positive margins (R1) risk factors in breast cancer conservative surgery</p>

Results: Positive margins (R1) rate was 10.2% (147 cases out of 1440). Overall survival was 95% at 5 years and 89% at 10 years. No differences in mortality and local recurrence rate between R0 and R1 patients were found. Half of the R1 patients underwent secondary surgery with enlargement of margins, while in the other half we performed direct mastect- omy. Among the analyzed variables, age, histological size, histological type, grading, multi- focality, lympho-vascular invasion and lymph node status were signi fi cantly correlated with the R1 status. The multivariate analysis shows the association of age and surgical technique (oncoplastic) with R1 status.
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Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins

Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins

The initial query included all patients with pancreatic cancer diagnosed between the years of 2004 and 2013, which yielded 309 709 patients (online supplementary figure 1). Patients with clinical stage II or III disease were selected for analysis (44 852). Stage refers to clinical stage throughout the analysis unless otherwise specified. Patients were first separated into groups by treatment strategy: surgery alone (Surg), NAT followed by surgery, AT following surgery and no surgery (chemotherapy or CRT alone) to ascertain whether there were differences between the treatment groups that might explain poten- tial survival differences. The primary outcome variable was survival based on surgical resection and margin status. Survival was compared between patients who underwent no surgery, surgery with negative margins (R0), surgery with microscopically positive margins (R1) and surgery with macroscopically positive margins (R2) using univar- iate (UVA) Cox proportional hazards modelling. A P value of 0.05 was required for significance.
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The Effectiveness of Intraoperative Frozen Section Analysis of Safety Margins in Breast Conserving Surgery and the Role of Surgeon in Decreasing the Rate of Positive Margins

The Effectiveness of Intraoperative Frozen Section Analysis of Safety Margins in Breast Conserving Surgery and the Role of Surgeon in Decreasing the Rate of Positive Margins

In our work we depend mainly on the preoperative radiological and clinical assessment for intraoperative resection guide and frozen section to be sure of clear safety margin with discussion of other surgical option with patient preope- ratively if we need it. Our result revealed that intraoperative frozen section anal- ysis confirmed negative margin for residual malignancy in 183 patients (83.6%) positive for residual malignancy need more remargin in 36 patients (16.4%). For other patients with positive margins; intraoperative decision for re-excision was applied for 29 patients (13.2%) for attempt to gain another negative safety mar- gin guided by intraoperative frozen section analysis which was successful in this issue, modified radical mastectomy was offered for 4 patients (1.8%) due to ei- ther patient desire or extensive DCIS or due to the breast being small in volume not allowing more resection of margins, while nipple sparing mastectomy with immediate breast reconstruction using latissimus dorsi flap was offered for 3 pa- tients (1.4%). Our rate of positive margin was low (16.4%) in comparison to other authors in literature e.g. 57% [13], 30.3% [16] and 25% [15].
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Pretreatment predictors of adjuvant chemoradiation in patients receiving transoral robotic surgery for squamous cell carcinoma of the oropharynx: a case control study

Pretreatment predictors of adjuvant chemoradiation in patients receiving transoral robotic surgery for squamous cell carcinoma of the oropharynx: a case control study

Minimally invasive transoral robotic surgery (TORS) has been rapidly adopted across the country for the treat- ment of oropharyngeal squamous cell carcinoma (OPSCC) [1]. The outcomes following TORS have been encouraging, with less morbidity than conventional sur- gery [2, 3]. However, the use of adjuvant therapy after TORS remains high [4]. Based on the landmark studies by the RTOG and EORTC, the addition of cisplatin chemotherapy is indicated in patients with extracapsular extension (ECE) of metastatic lymph nodes or positive surgical margins [5–7]. Although recent analysis has called into question the validity of these guidelines [8], adjuvant chemoradiation remains the standard of care for these high-risk patients, pending further clinical trials. Additionally, positive margins and nodal ECE are indications for dose escalation of radiation therapy [9].
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Classification of positive surgical margins and tumor recurrence after nephron-sparing surgery for small renal masses

Classification of positive surgical margins and tumor recurrence after nephron-sparing surgery for small renal masses

There were a total of 600 cases collected for the current survey from four centers, including 20 cases with positive margins on final pathological examination. The average positive margin rate was found to be 3.3%. All patients with or without PSMs were followed up for a median duration of 56 months. The follow-up was specific to each institution’s practice with a physical examination and a CT scan of the abdomen usually included. There were 20 patients with recur- rence events (3 with PSMs and 17 with NSMs). None of the patients developed metastatic progression, with only one case of in situ recurrence detected, which was connected with NSMs (Table 1). On the basis of the analytical observations of the sections for pathological examination, we raised a set of new classification criteria: 1) false PSMs, which could be further divided into three subtypes: i) no standard processing was performed on the pathological specimens, leading to false positives (Type A; Figure 1); ii) incidental incision into the tumor during the operative procedure, with the tumor bed noted to be free of any tumor residues (Type B; Figures 2 and 3); iii) part of tumor pseudocapsule remained in the tumor bed, with no sign of tumor residue (Type C; Figure 4). 2) True PSMs, which could be further subdivided into two subtypes: i) a large number of residual tumor cells at the margin, as well as the tumor bed (Type D; Figure 5); ii) incision of satel- lite tumor nodules in the vicinity of a large tumor, resulting in positive margins (Type E; Figure 6). The pathological and clinical data of 20 cases with PSMs were summarized (Table 2). Five patients had true PSMs on final pathological examination, with two cases of tumor recurrence. Fifteen patients were detected to have false PSMs, with one case of recurrence. The relapse rates after NSS between patients with
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Ki-67 expression predicts biochemical recurrence after radical prostatectomy in the setting of positive surgical margins

Ki-67 expression predicts biochemical recurrence after radical prostatectomy in the setting of positive surgical margins

risk stratification of the positive margins have failed. Neither the number nor the sites of positive margins were found to have a significant impact on PSA recur- rence [2]. More recently, Udo et al. showed that the linear length of positive surgical margins (PSM) in milli- meters (LLOM) and highest Gleason grade or score at PSM are associated with progression. However, sub- categorization of surgical margins based on these param- eters failed to add to predictive models using margin status alone [3].

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Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study

Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study

et al., have recently published a systematic review of the literature covering the last ten years, on positive surgical margins after radical prostatectomy evaluating also their oncologic impacts [22]. The authors concluded that the long term impact of positive margins on cancer progres- sion and specific survival is highly variable and largely dependent on additional risk modifiers. In fact, they noted that while all the revised studies showed a significant asso- ciation between positive margins and biochemical recur- rence, the data pertaining to metastatic progression and death were less consistent with only two studies indicating that PSMs were significantly associated with an increased risk of prostate cancer-specific mortality [15,23]. In the Surveillance, Epidemiology and End Results (SEER) data analysis, Wright et al., found a 2.6-fold increased un- adjusted risk of prostate cancer-specific mortality that remained significant also after adjusting for grade, stage, additional radiotherapy, age, race, registry and year of diagnosis. However, when stratified by adverse patho- logical features of the tumour these findings held only for those with higher grade or pT3 tumours [15]. In a more recent study on a single surgeon cohort, Chalfin et al., showed that PSM had a statistically significant, but mod- est, adverse effect on prostate cancer-specific mortality in
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Oncoplasty’s Contribution in Breast Cancers: About 48 Cases

Oncoplasty’s Contribution in Breast Cancers: About 48 Cases

Introduction: Oncoplasty has developed for 20 years in order to avoid potentially major deforma- tions of conservative treatment. We report the results of our oncoplastic breast operations. Pa- tients and Methods: We conducted a descriptive and retrospective study of 48 patients treated by oncoplastic technique in the national center of burn and plastic surgery in the U.H. IBN-ROCHD of Casablanca between 2011 and 2014. Patient and tumor characteristics, as well as information on the procedures and complications, were collected from clinical records. Results: Forty-eight cases were reviewed. The tumors were processed for the majority of invasive ductal carcinoma pT2. Seven patients had an inadequate surgical margin. About histology, the rate of recovery for non-positive margins was significantly lower in the CCI alone than that in other types. Morbidity was 14.5% and the average delayed to adjuvant treatment of 72 days. The symmetrization rate was 24%. In terms of oncological results, during a median follow-up of 22 months, the rate of local recurrences was 13%. Conclusion: The oncoplastic operations offer tools for breast conservation in patients and otherwise is destined for mastectomy or poor esthetic outcome. This study shows that the goal of surgical therapy is to identify patients who are suitable for oncoplastic surgery. Proper pre-operative evaluation and diagnosis, surgical planning, adequacy of resection, and pa- thological evaluation are essential.
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<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

<p>Positive or close margins: reoperation rate and second conservative resection or total mastectomy?</p>

Re-excision rates for BCS are extremely variable across the literature. This is mainly due to no clear consensus regard- ing the definition of a negative margin, different preoperative and intraoperative tumor localizing methods, differences in intraoperative imaging techniques, specimen inking by surgeons or pathologists, the use of shave margins, tumor vs lumpectomy size, oncoplastic resections, volume of breast surgery per year by surgeons, and surgeon threshold to offer re-excision vs mastectomy for positive margins. 13,18,19

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Transoral endoscopic head and neck surgery (eHNS) for minor salivary gland tumors of the oropharynx

Transoral endoscopic head and neck surgery (eHNS) for minor salivary gland tumors of the oropharynx

Most patients with adenoid cystic carcinomas (86%) had negative margins on final pathology, and all received postoperative radiation. One of these patients with a clinical T4, pathological T2 adenoid cystic carcinoma involving the base of tongue and floor of mouth was resected by TORS, found to have positive margins on final pathology, underwent postoperative radi- ation therapy, and was alive with no evidence of disease at 12.8 months of follow-up. Another patient with a T2 ade- noid cystic carcinoma of the tonsil and soft palate devel- oped distant disease in the lungs after surgery with negative margins received postoperative radiation therapy; this patient was alive with known pulmonary metastatic disease at 24 months of follow-up.
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Infraorbital cutaneous angiosarcoma: a diagnostic and therapeutic dilemma

Infraorbital cutaneous angiosarcoma: a diagnostic and therapeutic dilemma

the tumour was removed by wide local surgical excision (Figure 3) and the defect was temporarily covered by Epi- gard. Despite negative intraoperative frozen section mar- gins, positive margins were repeatedly detected later on permanent sections. Negative margins on permanent sec- tion were finally reached after three resections and infraorbital soft tissue was plastically reconstructed with a buccal rotation flap. After surgery, chemotherapy fol- lowed with six cycles of alpha-interferon.

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HER 2 positive breast cancer is associated with an increased risk of positive cavity margins after initial lumpectomy

HER 2 positive breast cancer is associated with an increased risk of positive cavity margins after initial lumpectomy

Many studies have demonstrated that patients with HER-2 overexpression and TN BCs are at increased risk of developing LR following BCS [6,13,14]. Does the higher risk of LR in the two subtypes result from an increased microscopic invasive tumor burden that could be indicated by margin status after lumpectomy? We have no definite answer at present. Positive margins were reported to be significantly associated with large tumor size, young age, positive nodes, presence of lym- phovascular invasion (LVI), and presence of an extensive intraductal component (EIC) [15-17]. In addition to the above analyzed clinical and pathologic variables, molecu- lar phenotype may be a relevant factor of positive margins. The purpose of this study was to determine whether BC subtype approximation is associated with positive mar- gins after initial lumpectomy and the extent of initial surgery that should be considered according to molecular subtypes.
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<p>The Significance of Adjuvant Therapy for Extrahepatic Cholangiocarcinoma After Surgery</p>

<p>The Significance of Adjuvant Therapy for Extrahepatic Cholangiocarcinoma After Surgery</p>

Abstract: Extrahepatic cholangiocarcinoma (EHCC) is a rare malignant tumor, and current treatment methods are also relatively limited. Radical surgery is the only potentially curative method for the long survival time. However, despite undergoing radical resection, prognosis remained poor due to the high recurrence rate and distant metastasis. Therefore, adjuvant chemotherapy and radiotherapy should be offered to patients who have undergone surgery. Unfortunately, the low incidence of this disease has resulted in a lack of high-level evidence to con fi rm the importance of adjuvant chemotherapy or radiotherapy. At present, it is still controversial whether adjuvant therapy can prolong the survival of patients after operation, especially patients with negative margins or lymph nodes. Furthermore, standard regimens of adjuvant have not been identi fi ed. This review summarizes the currently available evidence of the effect of adjuvant therapy in the management of EHCC. Ultimately, we concluded that adjuvant therapy may improve survival in high-risk (positive margin or lymph node or advanced stage) patients and adjuvant concurrent chemoradiotherapy followed by che- motherapy may be the optimum selection for them. This needs to be veri fi ed by randomized prospective clinical trials.
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Surgeons’ Experience In Breast Conserving Surgery: Does It Influence Surgical Margin?

Surgeons’ Experience In Breast Conserving Surgery: Does It Influence Surgical Margin?

A surgeon’s experience plays an important role in breast conserving surgery (BCS). The common conception is that, the more junior is the operating surgeon, the surgical margin will be wider or closer to the tumour edge. Thus the aim of this study is to look into the adequacy of surgical margin performed by different level of surgeons’ experience in patients whom underwent wide local excision (WLE) and hook-wire localization (HWL) in our surgical unit. The surgical experience of the operating surgeon and their surgical margins will be analyzed. This is a retrospective study from January 2000 to December 2012. Eighty-eight patients with early breast cancer underwent WLE and HWL by 3 different groups of surgeons (breast surgeons, junior surgeons and surgical registrars) were included. The surgical margins were analyzed for involved-margin, closed-margin or excessed-margin.The incidence of involved-margin, closed-margin and excessed-margin is the lowest among breast surgeons compared to other groups. However, the results were not statistically significant. The incidence of involved surgical margin is significantly higher within junior surgeons for HWL compared to the breast surgeons. The incidence of involved, closed or excessed surgical margin were lowest when performed by breast surgeon but not significantly different between the three groups. However, for HWL the breast surgeons significantly better compared to the other groups.
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Urinary Continence after Robot Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

Urinary Continence after Robot Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

neoadjuvant or adjuvant hormonal or radiation therapy were not included in the present analysis. Two experienced uroradi- ologists performed transrectal ultrasonography (TRUS) and TRUS biopsy, and a single experienced uropathologist the ex- amined prostate specimen. We assessed pathologic stage, pathologic Gleason score, extracapsular extension, seminal vesicle invasion, lymph node invasion, and positive surgical margin according to IPP status.

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Professions at the margins

Professions at the margins

While some occupational groups have succeeded in achieving high levels of social recognition, others have found themselves languishing at the margins and striving to legitimize their work as professionals. Examples of such marginalization include the way that medical doctors have attained a prestigious professional status, whereas radiologists, nurses and midwives have struggled to acquire the same kind of social and economic rewards from their work (Freidson, 2007; Scott, 2008). Similarly, airline pilots have managed to secure for themselves an esteemed professional image – which continues today even though most of the actual flying is fully automated – whereas cabin personnel and air traffic controllers have found it difficult to gain respect for their work, although they are also responsible for a great deal of the safety in the air (Ashcraft, 2005; 2007; Hopkins, 1998). We tend to agree with commentators who suggest that the study of professions at the margins may offer considerable insight into issues around occupational development, regulation and closure. As McKenna notes (2007: 208), ‘the specific reasons behind the institutional failures of these potential professions are far more instructive than the subsequent explanations of institutional success’. This is because the progress of thriving professions, such as medicine or piloting, can be misleading because the process of professionalization for these occupational groups seems inevitable and unproblematic. Examining professions at the margins, by contrast, serves to illuminate the kinds of institutional power struggles, social inequalities, and race- and gender-based exclusions that lie at the heart of the system of professions.
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Professions at the margins

Professions at the margins

When professions on the margins attempt to mirror a particular professionalism – such as this example in which massage seeks to align itself with bureaucratic professionalism[r]

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Two new species of Nototelmatoscopus (Jozifekia), with records of three other species from Thailand (Diptera: Psychodidae)

Two new species of Nototelmatoscopus (Jozifekia), with records of three other species from Thailand (Diptera: Psychodidae)

Most species of Nototelmatoscopus Satchell, 1953 have been described from the Australian Region, with the exception of Nototelmatoscopus (Jozifekia) sasakawai Ježek, 2010 from Sa- bah, Malaysia (Borneo). Telmatoscopus obtusalus Quate, 1966 from the Ryuku Islands, Japan, may also belong in Nototelmatoscopus (Jozifekia); however, the description and illustrations are insuffi cient for a positive identifi cation. In the present paper we record Nototelmatoscopus and the subgenus Jozifekia, as well as three additional species of Psychodinae for the fi rst time from Thailand.

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The usefulness of MR in establishing the diagnosis of parotid pleomorphic adenoma

The usefulness of MR in establishing the diagnosis of parotid pleomorphic adenoma

The sensitivity, specificity, positive predictive value, and negative predictive value for the ho- mogeneity of the lesion, signal intensity on T2-weighted images, signal intensity on T1- weighted images, adenopathy, and irregularity of fat are given in Tables 2 and 3. All pleomor- phic adenomas had a signal intensity equal to or higher than fatty tissue on T2-weighted images and most (95%) had a signal intensity equal to or lower than muscle on T1-weighted images. Pleomorphic adenomas were inhomogeneous in 31 of 38 cases. None of the pleomorphic adenomas had infiltration of the surrounding
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