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We performed a systematic review and meta-analysis to determine the effect of positive surgical margins in patients undergoing a partial nephrectomy regarging survival. We found that positive margin increases the risk of local recurrence, recurrence, and metastasis-free survival. Background: To determine the effect of positive surgical margins in patients who undergo a partial nephrectomy regarding recurrence, overall survival, disease-free survival, recurrence and progression-free survival, and metastasis-free survival. Methods: We performed a systematic review accomplishing with Cochrane recommendations. We searched in Medline, Embase, and central. We also looked for unpublished literature. There was no language or setting restrictions. We performed a random-effects meta-analysis for all outcomes. Results: We included 44 studies for qualitative and quantitative analysis. We found that positive margins increase the risk of local recurrence (RR 4.14 95%CI 2.75-6.24), recurrence (RR 4.8 95%CI 3.38-6.62), mortality (RR 1.83 95%CI 1.08-3.1), metastasis (RR 8.1 95%CI 3.88-16.92), and improved the recurrence/progression-free survival (HR 2.9 95%CI 1.88-4.49) and metastasis-free survival (HR 2.91 95%CI 1.25-6.79) with moderate, moderate, very low, very low, and high certainty of the evidence, respectively. We found no change in overall survival (HR 1.48 95%CI 0.98-2.22) with very low certainty of evidence. Conclusions: A positive margin is an independent predictor of local recurrence, recurrence, mortality, metastasis, with no effect on overall survival. Therefore, a tailored intense and prolonged follow-up is mandatory. [ABSTRACT FROM AUTHOR]

The standard management for residual osteomyelitis following amputation in a diabetic foot infection includes a prolonged course of intravenous antibiotic agents. The purpose of this analysis was to investigate whether oral antibiotic therapy led to treatment failure more than intravenous antibiotic therapy for this indication. The primary endpoint was treatment failure within one year of the initial amputation, defined by re-operation for residual osteomyelitic infection or a remaining nonhealing wound at the surgical site. All patients received at least 4 weeks of antibiotics and were chosen for oral or intravenous route of administration by infectious disease specialists. Characteristics including age, sex, hemoglobin A1c, BMI, tobacco use, PVD, homelessness and IDSA classification were also assessed for influence on antibiotic success and failure. Of the 65 patients meeting inclusion criteria, treatment failure occurred in 32 and treatment success occurred in 33. Of the treatment failures, 17 (53%) were in the intravenous group, and 15 (47%) were in the oral group. The differences between the modalities of antibiotic administration and their failure rates were not found to be statistically significant (p =.28 (proportional difference: -14%, 95% confidence interval [CI]:−36% to 10%)). [ABSTRACT FROM AUTHOR]

Adjuvant chemotherapy or chemoradiation is often recommended for resected pancreatic adenocarcinoma. We sought to examine the impact of these therapies on R1 resected pancreatic cancer. Utilizing the National Cancer Database we identified patients who underwent pancreatic resection for adenocarcinoma. Patients were stratified by resection status and adjuvant therapy. We identified 28,440 patients who underwent pancreatic resection. Patients with tumor size >2 cm were more likely to undergo R1 resections, p < 0.001. Adjuvant therapy improved survival in all patients with median and 5-year survival: adjuvant chemotherapy (21.7 months, 17.45%), chemoradiation (23.3 months, 20.9%) vs no adjuvant therapy (19.5 months, 19.1%), p < 0.001. In the R1 resection cohort survival was also improved with adjuvant therapy with chemoradiation demonstrating the most significant improvement: adjuvant chemotherapy (15.9 months, 6.5%), chemoradiation (18.7 months, 11.2%) vs no adjuvant therapy (12.5 months, 8.7%), p < 0.001. Chemoradiation but not adjuvant chemotherapy improved survival in the R1 node negative, p < 0.004, and node positive, p < 0.001. Adjuvant chemotherapy benefited survival in R1 node positive patients, p < 0.001. Patients with pancreatic cancer who undergo R1 resection have significant improvement in survival when treated with adjuvant chemoradiation and adjuvant chemotherapy. However, benefits were greater in those receiving adjuvant chemoradiation. [ABSTRACT FROM AUTHOR]

• Several studies indicated that margins < 1 mm should be classified as positive margins in OCSCC. • Margin < 1 mm exhibited distinct clinicopathological characteristics and a more favorable prognosis. • Positive margins should remain a high risk factor, whereas margins < 1 mm could be considered an intermediate risk factor. While several studies have indicated that a margin status of < 1 mm should be classified as a positive margin in oral cavity squamous cell carcinoma (OCSCC), there is a lack of extensive cohort studies comparing the clinical outcomes between patients with positive margins and margins < 1 mm. Between 2011 and 2020, we identified 18,416 Taiwanese OCSCC patients who underwent tumor resection and neck dissection. Of these, 311 had margins < 1 mm and 1013 had positive margins. To compare patients with margins < 1 mm and those with positive margins, a propensity score (PS)-matched analysis (n = 253 in each group) was conducted. The group with margins < 1 mm displayed a notably higher prevalence of several variables: 1) tongue subsite, 2) younger age, 3) smaller depth of invasion), 4) early tumor stage, and 5) treatment with surgery alone. Patients with margins < 1 mm demonstrated significantly better disease-specific survival (DSS) and overall survival (OS) rates compared to those with positive margins (74 % versus 53 %, 65 % versus 43 %, both p < 0.0001). Multivariable analysis further confirmed that positive margins were an independent predictor of worse 5-year DSS (hazard ratio [HR] = 1.38, p = 0.0103) and OS (HR = 1.28, p = 0.0222). In the PS-matched cohort, the 5-year outcomes for patients with margins < 1 mm compared to positive margins were as follows: DSS, 71 % versus 59 %, respectively (p = 0.0127) and OS, 60 % versus 48 %, respectively (p = 0.0398). OCSCC patients with a margin status < 1 mm exhibited distinct clinicopathological characteristics and a more favorable prognosis compared to those with positive resection margins. [ABSTRACT FROM AUTHOR]

It remains unclear whether patients with positive surgical margins or extracapsular extension benefit from adjuvant radiotherapy following radical prostatectomy. To compare the effectiveness and tolerability of adjuvant radiotherapy following radical prostatectomy. This was a randomised, open-label, parallel-group trial. A total of 250 patients were enrolled between April 2004 and October 2012 in eight Finnish hospitals, with pT2 with positive margins or pT3a, pN0, M0 cancer without seminal vesicle invasion. A total of 126 patients received adjuvant radiotherapy at 66.6 Gy. The primary endpoint was biochemical recurrence-free survival, which we analysed using the Kaplan-Meier method and Cox proportional hazard regression. Overall survival, cancer-specific survival, local recurrence, and adverse events were secondary endpoints. The median follow-up time for patients who were alive when the follow-up ended was 9.3 yr in the adjuvant group and 8.6 yr in the observation group. The 10-yr survival for biochemical recurrence was 82% in the adjuvant group and 61% in the observation group (hazard ratio [HR] 0.26 [95% confidence interval {CI} 0.14–0.48], p < 0.001), and for overall survival 92% and 87%, respectively (HR 0.69 [95% CI 0.29–1.60], p = 0.4). Two and four metastatic cancers occurred, respectively. Out of the 43 patients with biochemical recurrence in the observation group, 37 patients received salvage radiotherapy. In the adjuvant group, 56% experienced grade 3 adverse events, versus 40% in the observation group (p = 0.016). Only one grade 4 adverse event occurred (adjuvant group). A limitation of this study was the number of patients. Adjuvant radiotherapy following radical prostatectomy is generally well tolerated and prolongs biochemical recurrence-free survival compared with radical prostatectomy alone in patients with positive margins or extracapsular extension. Radiotherapy given immediately after prostate cancer surgery prolongs prostate-specific antigen progression-free survival, but causes more adverse events, when compared with surgery alone. In a randomised setting of patients with positive margins or extracapsular extension, adjuvant radiotherapy following radical prostatectomy significantly improved biochemical recurrence-free survival compared with radical prostatectomy alone. More adverse events occurred in the radiotherapy group, although radiotherapy was generally well tolerated. [ABSTRACT FROM AUTHOR]

Highlights • Desmoid tumor or aggressive fibromatosis (AF) is a benign tumor of borderline malignant condition, it is infiltrative, deep-seated and muscoloapo neurotic in nature. • AF is commonly found among children below 15 years of age, affecting males more as compared to females. • Primary surgery is not the treatment choice among patients with positive margins as the risk of recurrence is higher after surgery. However, radiation and chemotherapy may assist in maintaining local control of these tumors in such patients. • Primary surgery with negative margins is the treatment choice for children with AF. Abstract Introduction Aggressive fibromatosis or Desmoid fibromatosis is a benign tumor which originated form mesenchymal tissues of the body. This tumor has strong potential of recurrence and infiltration but it does not metastasize to other organs of the body. This case series is focused to determine the treatment outcomes for pediatric patients of aggressive fibromatosis. Methodology It is a retrospective case series conducted on 7 patients presented to section of Orthopedics, department of surgery of our institute in Karachi. We included all the cases of pediatric patients from 1 to 16 years, with biopsy proven fibromatosis from January 2000 to December 2015. Presentation of Cases Out of 7 pediatric patients, there were 6 (85.7%) males and 1 (14.3%) female patient. The median age was 6 years IQR (5–11) years. Gluteal region was the most common site of disease. Four patients (57.1%) had positive tumor margins while three (42.9%) had negative margins. Out of 7 patients, 4 patients (57.1%) had recurrent disease and they had positive margins. The median Disease Free survival time was 14 months and there was no expiry of patients. Conclusion & recommendation The conclusion of our study was that aggressive fibromatosis is more prevalent in children below 15 years of age and disease burden is higher in male gender. Positive margins after surgery indicate a high risk for disease recurrence therefore; primary surgery with negative margins is the treatment of choice for children with AF. However, we recommend that multicenter trials should be conducted in the future to clarify the role of adjuvant treatment for patients with pediatric AF. [ABSTRACT FROM AUTHOR]

Objectives: Subgroup analysis from two randomized trials showed a survival benefit for adjuvant chemoradiation (CRT) over radiation alone (RT) in patients with extracapsular spread (ECS) of involved lymph nodes and/or positive margins (PM) in resected head and neck cancer (HNSCC). However, results were not analyzed separately for patients with ECS or PM and were not stratified by tumor subsite/HPV status. We therefore sought to determine whether adjuvant CRT is associated with a survival benefit, separately among patients with ECS or PM and stratified by subsite/HPV status.Methods: Using the National Cancer Database (NCDB), we identified 6948 patients diagnosed with HNSCC between 2010 and 13 who underwent surgical resection and had either ECS or PM. The impact of adjuvant therapy on OS from surgery was evaluated using Cox proportional hazards regression adjusting for clinical and demographic factors.Results: Adjuvant CRT was associated with a significant survival benefit over RT alone among patients with ECS (aHR 0.83, 95%CI 0.71-0.97) but not among those with PM (aHR 0.89, 95%CI 0.77-1.04). In patients with HPV-negative tumors, CRT was associated with a benefit over RT alone in the setting of ECS (aHR 0.83, 95%CI 0.70-0.98) but not PM (aHR 0.91, 95%CI 0.78-1.06). However, in patients with HPV-positive oropharynx tumors, CRT was not associated with a benefit over RT in ECS (aHR 0.94, 95%CI 0.47-1.88) but appeared beneficial in PM (aHR 0.54, 95%CI 0.32-0.90).Conclusions: CRT appears beneficial over RT in ECS among patients with HPV-negative tumors, and beneficial in PM among patients with HPV-positive tumors. [ABSTRACT FROM AUTHOR]

Background: The Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group recently published a consensus statement that incompletely excised moderately dysplastic nevi (MDN) without clinical residual pigmentation can be observed and not re-excised. However, data regarding recurrence of MDN with positive histologic margins are quite scant.Objective: We sought to extend the reported findings with a study to determine the recurrence rate of MDN with positive histologic margins.Methods: We performed a retrospective study on MDN with positive histologic margins that were not re-excised and for which at least 1 year of clinical follow-up was available.Results: We found a total of 147 such nevi from January 1, 2007, to December 31, 2013. Six MDN (5 compound and 1 junctional) or 4% recurred with an average recurrence time of 1.7 years. All of these MDN were evaluated by shave biopsies.Limitations: Subjectivity in grading of atypia is a limitation of this study.Conclusion: These data from a large study focusing exclusively on recurrence of MDN with positive histologic margins support the conclusion of the Pigmented Lesion Subcommittee that incompletely excised MDN do not require re-excision. [ABSTRACT FROM AUTHOR]

Background Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP). Objective To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy. Design, setting, and participants This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results–Medicare linked data. Intervention RARP versus ORP. Outcome measurements and statistical analysis Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach. Results and limitations In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66–0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59–0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63–0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69–0.81), 12 mo (OR: 0.73; 95% CI, 0.62–0.86), and 24 mo (OR: 0.67; 95% CI, 0.57–0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence. Conclusions RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs. Patient summary Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Re-excision is a necessary procedure in obtaining clean margins for breast-conserving surgery (BCS)-treated patients. Re-excision rates vary widely among different breast cancer management procedures. The aim of this study was to evaluate the efficacy of ultrasound (US)-guided BCS to decrease the re-excision rate in patients with US-detectable breast cancer, as well as the relationship between positive margins and ultrasonographic characteristics of tumor. Methods: Between 2008 and 2009, we identified consecutive patients who underwent initial US-guided BCS for breast in situ or invasive carcinoma, which was preoperatively detected using US examination and on the basis of image-guided biopsy findings. The margins achieved after BCS were separately assessed by performing frozen section analysis of shaved margins. The negative margin and positive margin groups were compared for clinicopathological features and ultrasonographic findings. Results: Of 381 patients undergoing US-guided BCS, 126 (33.1%) had palpable tumors and 255 (66.9%) had nonpalpable tumors. Positive margins were noted in 35 patients (9.2%). These patients underwent re-excision and were margin-free; no further surgery was required for these patients. There were no significant intergroup differences in clinicopathological features and ultrasonographic findings. Conclusion: Breast US is an effective modality for intraoperative tumor localization and can thus help obtain clean margins and reduce the re-excision rate in cases in which breast-conserving therapy has been performed. Furthermore, frozen section analysis of cavity shaved margins is a feasible method for minimizing the need for further surgery. [Copyright &y& Elsevier]

Surgery is one of the most common curative modalities in prostate cancer. Unfortunately, as with any therapy, patients can suffer recurrence. Postoperative adjuvant therapy has been shown to prevent or delay recurrence. The presence of positive margins puts the patient at a high risk for recurrence. Additional risk factors have been identified that can predict for recurrence, but it is still uncertain as to who warrants immediate treatment. We reviewed the extensive surgical literature for prognostic factors for recurrence in addition to positive margins. We attempted to be exhaustive, first searching PubMed and Medline for all papers for radical prostatectomy and then checking the articles cited in those papers. We sought out papers that reviewed the effect of positive margins and its modifying factors on outcome. With the supposition that patients with >70% risk of failure is enough to consider additional treatment, we were able to identify the factors that appear to consistently place patients at or above that level of recurrence. For patients with positive margins, any one of these factors places the patients at a very high risk of recurrence: positive lymph nodes or seminal vesicles, preoperative PSA > 20 ng/ml, or a Gleason score > 7. Many Gleason 7 patients with positive margins fall into the >70% risk of failure category, especially if they have additional risk factors (i.e., those with extraprostatic extension). While there are no absolutes, all these patients should be strongly considered for adjuvant therapy in addition to radical prostatectomy. [ABSTRACT FROM AUTHOR]

Purpose: Radical prostatectomy for invasive prostate cancer is associated with positive margin rates in 10% to 50% of resected specimens. Postoperative radiation therapy may benefit patients who have organ-confined prostate cancer with positive margins. Methods and Materials: We performed a retrospective analysis to examine whether adjunctive radiation therapy enhanced long-term survival for prostate cancer patients who underwent prostatectomy for localized prostate cancer but with positive margins. We used the Hoag Cancer Center database to identify patients diagnosed with invasive prostate cancer. Relative and overall survival rates were calculated. Results: Among 1,474 patients diagnosed with localized invasive prostate cancer during the years 1990 to 2006 and undergoing prostatectomy, 113 (7.7%) were identified who had positive margins and did not have local extension of disease, positive lymph nodes, or distant metastases. A total of 17 patients received adjunctive radiation therapy (Group A), whereas 96 did not (Group B; 3 received hormonal therapy). Both groups had a median age of 64 years and median follow-up of 7.5 years. In Group A, no patients have died as of last follow-up, but in Group B, 18 have died. Estimated 10-year and 15-year overall survival rates were both 100% for Group A compared with 85% and 57% respectively for Group B (p 2 = 0.050, log rank). Relative 10- and 15 year survival rates were both 100% for Group A compared with 100% and 79% respectively for Group B. Conclusions: This retrospective analysis suggests that prostate cancer patients with localized disease but positive margins do derive a survival benefit from adjuvant radiation therapy. [ABSTRACT FROM AUTHOR]

Purpose: For patients with an extremity soft tissue sarcoma (STS) treated with preoperative radiotherapy and surgically excised with positive margins, we retrospectively reviewed whether a postoperative radiation boost reduced the risk of local recurrence (LR). Methods and Materials: A total of 216 patients with positive margins after resection of an extremity STS treated between 1986 and 2003 were identified from our institution''s prospectively collected database. Patient demographics, radiation therapy parameters including timing and dose, classification of positive margin status, reasons for not administering a postoperative boost, and oncologic outcome were collected and evaluated. Results: Of the 216 patients with a positive surgical margin, 52 patients were treated with preoperative radiation therapy alone (50 Gy), whereas 41 received preoperative radiation therapy plus a postoperative boost (80% received 16 Gy postoperatively for a total of 66 Gy). There was no difference in baseline tumor characteristics between the two groups. Six of 52 patients in the group receiving preoperative radiation alone developed a LR compared with 9 of 41 in the boost group. Five-year estimated LR-free survivals were 90.4% and 73.8%, respectively (p = 0.13). Conclusions: We found that including the postoperative radiation boost after preoperative radiation and a margin-positive excision did not provide an advantage in preventing LR for patients treated with external beam radiotherapy. Given that higher radiation doses placed patients at greater risk for late complications such as fracture, fibrosis, edema, and joint stiffness, judicious avoidance of the postoperative boost while maintaining an equivalent rate of local control can reduce the risk of these difficult-to-treat morbidities. [Copyright &y& Elsevier]

Abstract: Background: A significant proportion of patients undergoing breast conservation therapy require additional operations to obtain clear margins. The aim of this study was to assess the impact of initial margins and residual carcinoma found on second surgery on the outcomes of breast cancer patients. Methods: In this retrospective study, Cox proportional-hazard regression analysis was performed to evaluate data from 437 patients with stage I to IIIA breast cancer who underwent initial breast-conserving surgery between 1994 and 2004. Results: The distant recurrence rate was higher among patients with initial positive margins than among those with initial negative margins (15.5% vs 4.9%; hazard ratio, 3.6; 95% confidence interval 1.5–8.7; P = .003). For patients who had underwent second surgery, the finding of a residual invasive carcinoma was associated with increased risk for distant recurrence (22.8% vs 6.6%; hazard ratio, 3.5; 95% confidence interval, 1.8–7.4; P = .0001). Conclusion: Invasive residual carcinoma found during subsequent surgery after initial compromised margins is an important prognostic marker for distant recurrence. [Copyright &y& Elsevier]

Abstract: Background: The accuracy of magnetic resonance imaging (MRI) in identifying residual disease after breast conservation therapy (BCT) is unclear. Method: Review of an institutional database identified patients with positive or close (≤2 mm) margins undergoing MRI before re-excision. Histopathologic correlation was performed. Results: Forty-three women underwent MRI after BCT. MRI suggested residual disease in 29 patients, of whom 20 (69%) had residual carcinoma pathologically. Nine patients had false-positive MRI as seen by benign pathology findings. Fourteen MRIs indicated no residual disease, of which 6 had residual disease pathologically. The sensitivity and positive predictive value of MRI was 77% and 69%, respectively. MRI conducted within 28 days of the original surgery was 85% sensitive. MRI performed after 28 days was 69% sensitive. Conclusions: MRI is able to detect residual disease among most patients undergoing re-excision. False-positive results may be caused by inflammatory processes that resemble residual disease. [Copyright &y& Elsevier]

Abstract: Background: The study''s aim was to identify technical factors that are predictive of negative margins after breast-conserving surgery (BCS). Methods: This was a retrospective, cohort study of patients who underwent BCS for early-stage cancer from 2000 to 2002. Pathological and specific surgical factors were compared with margin status. Univariate and multivariate regression analyses were performed. Results: Four hundred eighty-nine cases were reviewed. The positive margin rate after the initial surgery was 26%. In univariate analysis, lobular histology, size, grade, multifocality, and the presence of EIC and LVI were associated with positive margins (P < .05). The absence of cavity margin dissection and specimen orientation labeling, the absence of a confirmed diagnosis, and smaller volumes of excision were also associated with positive margins (P < .05). In multivariate analysis, confirmed diagnosis, small tumor size, ductal histology, absence of LVI and multifocality, palpability, cavity margin dissection, and larger volumes of excision were predictors of negative margins. Conclusions: This study shows that specific surgical factors are predictive of margin status. Both tumor and technical factors should be considered when planning BCS. [Copyright &y& Elsevier]

Abstract: Introduction: Inability to accurately determine extracapsular extension (ECE) and neurovascular bundle (NVB) tumor involvement prior to or during radical prostatectomy (RP) remains problematic. Laparoscopic prostatectomy has the additional challenge of lack of tactile tumor assessment. Our goal is to determine the impact of preoperative endorectal magnetic resonance imaging (eMRI) staging upon NVB sparing aggressiveness and the RP surgical margin rate. Methods: Sixty-two patients who underwent RP (46 laparoscopic and 16 open retropubic) from March 2002 to February 2005 and had preoperative eMRI staging were evaluated to determine the impact of apparent ECE upon NVB sparing aggressiveness and subsequent RP margin positivity. Results: Thirty-four (83%) of 41 pathologic stage T2 tumors and 8 (38%) of 21 pathologic stage T3 tumors were accurately classified by eMRI. Eighty-three percent of eMRI stage T2 classified tumors underwent bilateral NVB sparing, whereas only 55% of laparoscopic (P = 0.09) and 75% of open RP (P = 1.0) tumors classified as eMRI stage T3 underwent bilateral NVB sparing. The overall surgical margin positive rate was 30% for laparoscopic and 25% for open RPs. Pathologic T3 tumors erroneously classified as T2 demonstrated a trend towards greater positive margin rate (54% vs. 13% [P = 0.07], 63% vs. 14% laparoscopic RP [P = 0.12]). Eighty percent of clinical T1c, Gleason score 6, pathologic T3 tumors classified erroneously as T2 by eMRI had positive margins. Conclusions: The usefulness of endorectal MRI in detecting ECE is limited. Patients with eMRIs suggesting no ECE demonstrated a trend towards more aggressive NVB sparing and an increased positive surgical margin rate at laparoscopic prostatectomy. [Copyright &y& Elsevier]

Abstract: Background: This randomized, double-arm trial was designed to study the benefit of a novel device (MarginProbe, Dune Medical Devices, Caesarea, Israel) in intraoperative margin assessment for breast-conserving surgery (BCS) and the associated reduction in reoperations. Methods: In the device group, the probe was applied to the lumpectomy specimen and additional tissue was excised according to device readings. Study arms were compared by reoperation rates and by correct surgical reaction confirmed by histology. Results: Three hundred patients were enrolled. Device use was associated with improved correct surgical reaction, defined as additional re-excision in all histologically detected positive margins, with tumor within 1 mm of inked margin. The repeat lumpectomy rate was significantly reduced by 56% in the device arm: 5.6% versus 12.7% in the control arm. There were no differences in excised tissue volume or cosmetic outcome. Conclusions: Intraoperative use of the MarginProbe for positive margin detection is safe and effective in BCS and decreases the rate of repeat operations. [Copyright &y& Elsevier]

Purpose: Positive margins (PM) remain after surgery in some soft-tissue sarcoma (STS) patients. We investigated the efficacy of radiation therapy (RT) in STS patients with PM. Methods and Materials: A retrospective chart review was performed on 154 patients with STS at various anatomic sites with PM, defined as tumor on ink, who underwent RT with curative intent between 1970 and 2001. Local control (LC), disease-free survival (DFS), and overall survival (OS) rates were evaluated by univariate (log–rank) and multivariate analysis of prognostic and treatment factors. Results: At 5 years, actuarial LC, DFS, and OS rates were: 76%, 46.7%, and 65.2%, respectively. LC was highest with extremity lesions (p < 0.01), radiation dose >64 Gy (p < 0.05), microscopically (vs. grossly visible) positive margin (p = 0.03), and superficial lesions (p = 0.05). Patients receiving >64 Gy had higher 5-year LC, DFS, and OS rates of 85%, 52.1%, and 67.8% vs. 66.1%, 41.8%, and 62.9% if ≤64 Gy, p < 0.04. OS was worse in patients with G2/G3 tumors with local failure (LF), p < 0.001. Other known prognostic factors, including grade, stage, size, and age (>50), also significantly influenced OS. By multivariate analysis, the best predictors of LC were site (extremity vs. other), p < 0.01 and dose (>64 vs. ≤64 Gy), p < 0.05; the best predictors for OS were size, p < 0.001, gross vs. microscopic PM, p < 0.05, and LF, p < 0.01. Conclusion: Local control is achieved in most PM STS patients undergoing RT. Doses >64 Gy, superficial location, and extremity site are associated with improved LC. OS is worse in patients with tumors with lesions >5 cm, grossly positive margins, and after local failure. [Copyright &y& Elsevier]

Abstract: Introduction: Robotic-assisted laparoscopic radical prostatectomy (RLRP) is increasingly becoming an alternative to open and laparoscopic radical prostatectomy in the treatment of localized prostate cancer. RLRP has been associated with low morbidity, short convalescence and comparable oncologic and functional outcomes. We report our initial experience of 300 consecutive cases with selective use of interfascial nerve preservation (IFNP). Methods: Between February 2003 and September 2005, 300 consecutive men underwent RLRP at our institution. Patients were followed prospectively with validated questionnaires. Results: Mean operative time was 282 minutes with an estimated blood loss of 273ml. The intra-operative complication rate was 2.3% with no mortality. Return to baseline (RTB) urinary function and subjective continence at 12 months were 71% and 90.2%, respectively. RTB sexual function and subjective potency at 12 months were 53% and 80.4%, respectively. Overall, the positive surgical margin (PSM) rate was 20.9%: 15.1% for pT2 and 52.1% for pT3 disease and 93.1% had an undetectable PSA (<0.1ng/mL) with a mean follow-up of 17.3 months. Fifty-four percent of PSMs occured in a poster-lateral (PL) location. Retrospectively, IFNP was performed in 86.5% and 62.5% of pT2 and pT3 PSMs, respectively. Pathologic-T3 PSMs were found to occur significantly more often in a PL location when ipsilateral IFNP was performed when compared to non-IFNP (73% vs 33%, p =0.05). Conclusions: IFNP appears to result in favorable return of potency, however, postero-lateral PSMs appear to occur more frequently with this technique. Proper patient selection for robotic surgery and nerve-preservation appears to be critical in order to reduce PSM and optimize the oncologic efficacy of this technololgy. [Copyright &y& Elsevier]

Abstract: Introduction: In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy. Methods: A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy. Results: When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing “postprostatectomy anatomical hazard” debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin. Discussion: Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra. [Copyright &y& Elsevier]

Abstract: Introduction: A technical modification of nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with preservation of the puboprostatic ligaments is presented and compared to a previous techniique. Materials and methods: nsEERPE was performed in 100 men with clinically localized adenocarcinoma of the prostate from March 2004 through February 2005. Patients were divided into two groups: Group A included patients in whom a standard nsEERPE was performed (n =50), and group B included patients in whom a puboprostatic ligament sparing nsEERPE was performed (n =50). The postoperative follow-up was 2 weeks and 3 months evaluating preliminary effects on early continence and positive margins. Results: The early return to continence at 2 weeks postoperatively was achieved by 6 patients (12%) in group A, and 12 patients (24%) in group B. Three months after the procedure 24 (48%) and 38 (76%) patients were continent, in groups A and B respectively. Cli.nical outcome (early continence) was significantly better for Group B patients, at 2 weeks (chi-square test, p =0.0019) and at 3 months (chi-square test, p =0.0347) following surgery. No cases of complete or severe incontinence (more than 5pads/day) were observed at 3 months after surgery, in either groups. Groups A and B did not exhibit significant differences regarding their histological status. In group A, positive margins were detected in 6.5% and 26.3% of patients with pT2 and pT3, respectively. In group B, positive margins were found in 3.2% and 15.8% of patients with pT2 and pT3, respectively Conclusion: We propose the use of puboprostatic ligament-sparing nsEERPE as an intriguing method to ascertain recuperation of early continence after nerve sparing procedures, without hindering the final oncological outcome [Copyright &y& Elsevier]

Purpose: Positive surgical margins adversely influence local tumor control in breast conservation therapy (BCT). However, reports have conflicted regarding whether an increased radiation dose can overcome this poor prognostic factor. In this study, we evaluated the influence of an increased radiation dose on tumor control in women with positive surgical margins undergoing BCT.Methods and Materials: Between 1978 and 1994, 733 women with pathologic Stage I-II breast cancer and known surgical margin status were treated at Thomas Jefferson University Hospital with BCT. Of these 733 patients, 641 women had a minimal tumor bed dose of 60 Gy and had documentation of their margin status; 509 had negative surgical margins, and 132 had positive surgical margins before definitive radiotherapy. Complete gross excision of the tumor and axillary lymph node sampling was obtained in all patients. The median radiation dose to the primary site was 65.0 Gy (range 60–76). Of the women with positive margins (n = 132), the influence of higher doses of radiotherapy was evaluated. The median follow-up time was 52 months.Results: The local tumor control rate for patients with negative margins at 5 and 10 years was 94% and 88%, respectively, compared with 85% and 67%, respectively, for those women with positive margins (p = 0.001). The disease-free survival rate for the negative margin group at 5 and 10 years was 91% and 82%, respectively, compared with 76% and 71%, respectively, for the positive margin group (p = 0.001). The overall survival rate of women with negative margins at 5 and 10 years was 95% and 90%, respectively. By comparison, for women with positive surgical margins, the overall survival rate at 5 and 10 years was 86% and 79%, respectively (p = 0.008). A comparison of the positive and negative margin groups revealed that an increased radiation dose (whether entered as a dichotomous or a continuous variable) >65.0 Gy did not improve local tumor control (p = 0.776). On Cox multivariate analysis, margin status and menopausal status had prognostic significance for local tumor control and DFS.Conclusion: Patients with positive surgical margins have a higher risk of local tumor recurrence and worse survival when undergoing BCT. Higher doses of radiation are unable to provide an adequate level of local control in patients with positive margins. [Copyright &y& Elsevier]

Purpose: Sarcomas are rare tumours of mesenchymal origin that are often treated with surgical resection and radiation to prevent local recurrence (LR). Surveillance for LR after surgical resection is often done with contrast-enhanced MRI, however, the optimal frequency of surveillance imaging is unknown. The aims of this study are to calculate LR growth, and to evaluate the factors that affect LR growth and to use this data to predict the optimal imaging surveillance frequency.Method: Retrospective cohort study of patients with sarcoma who were treated at a tertiary care academic institution between 01/01/2007 and 01/03/2020 identified 34 patients with 60 histologically confirmed LRs. The maximum LR length was measured on each surveillance MRI. Linear mixed-effects models were used to calculate the maximum LR length growth rate. We evaluated whether age, sex, primary sarcoma tumour size, sarcoma grade, margins, chemotherapy or radiation therapy affected the growth rate of the maximum LR length.Results: One patient had 6 LRs (2.9 %), two patients (5.9 %) had 5 LRs, two patients (5.9 %) had 4 LRs, two patients (5.9 %) had 3 LRs, three patients (8.8 %) had 2 LRs, and twenty-four patients (70.6 %) had 1 LR. Most patients had high grade (Grade II/III) disease (88.2 %). 41.2 % of the patients had microscopically positive surgical margins. The median time (range) from surgery to LR was 264 days (17 - 8013) days, and 90 % occurred within 42.8 months (1284 days). Microscopically positive margins were associated with faster growth of the maximum LR length (P = 0.036). Assuming that a 1 cm sarcoma LR is actionable and that the previous surveillance MRI was negative, the data predicts that patients with microscopically positive margins should have surveillance MRIs every 6.2 months when LRs are expected to achieve a length of 1.0 cm (95 % CI (0.4-2.3 cm)).Conclusions: Patients with microscopically positive resection margins had LRs that grew faster than patients with negative margins. Surveillance imaging with contrast-enhanced MRI could be conservatively performed every 6 months when LRs are expected to be just less than 1.0 cm in length. [ABSTRACT FROM AUTHOR]

Background Surgical treatment options for facial melanomas include conventional excision with postoperative margin assessment, Mohs micrographic surgery (MMS) with immunostains (MMS-I), and slow MMS. Patient preferences for these surgical options have not been studied. Objectives To evaluate patient preferences for surgical treatment of facial melanoma and to determine how patients value the relative importance of different surgical attributes. Methods Participants completed a 2-part study consisting of a stated preference survey and a choice-based conjoint analysis experiment. Results Patients overwhelmingly (94.3%) rated local recurrence risk as very important and ranked it as the most important attribute of surgical treatment for facial melanoma. Via choice-based conjoint analysis, patients ranked the following surgical attributes from highest to lowest in importance: local recurrence rate, out-of-pocket cost, chance of second surgical visit, timing of reconstruction, travel time, and time in office for the procedure. Consistent with their prioritization of low local recurrence rates, more than 73% of respondents selected MMS-I or slow MMS as their preferred treatment option for a facial melanoma. Limitations Data were obtained from a single health system. Conclusion Patients prefer surgical treatment options that minimize risk for local recurrence. Logistics for travel and treatment have less influence on patient preferences. Most survey participants chose MMS-I to maximize local cure and convenience of care. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship of race and margin status among patients undergoing robotic partial nephrectomy (RPN) for T1 renal tumors from a contemporary population-based cohort.Methods: Using the National Cancer Database, we identified patients with localized renal cell carcinoma (RCC) (clinical T1N0M0) who underwent RPN from 2010 to 2013. The primary outcome was positive surgical margins (PSM). Multivariable logistic regression analyses were used to assess the association between race and PSM adjusting for patient clinicopathologic and hospital factors.Results: Among 12,515 patients undergoing RPN in our cohort, 8.3% had PSM (n = 1,045). When compared to white patients undergoing RPN for T1 RCC with PSM (7.9%), we observed a higher proportion of PSM among African American (AA) (10.8%; P = 0.005) and Hispanic/Latino patients (8.8%; P = 0.005), respectively. On multivariable analysis, AA patients had higher odds of PSM compared to white patients (odds ratio = 1.40; P = 0.008). Other factors associated with higher odds of PSM were treatment at nonacademic centers relative to academic centers (10.4% vs. 6.9%; odds ratio = 1.57; P<0.001).Conclusions: In this contemporary population-based cohort, AA patients undergoing RPN for localized RCC tumors are at higher risk for PSM. These results suggest potential differences in quality of care and patient selection of RPN by race. [ABSTRACT FROM AUTHOR]

Background: Positive or equivocal margins after wide local excision (WLE) complicate surgical management of cutaneous melanoma.Objective: To identify the frequency of and risk factors for positive or equivocal margins after WLE of cutaneous melanoma.Methods: Retrospective, single-center, cross-sectional study of 1345 consecutive melanomas treated with WLE.Results: The overall frequency of positive or equivocal margins was 4.2% (56/1345), ranging from 2.2% to 22.6%, depending on the size of the surgical margins, patient characteristics, biopsy history, and the clinicopathology of the melanoma. In descending order, independent risk factors associated with the greatest odds for positive or equivocal margins after multivariate analysis were noncompliance with recommended surgical margins (odds ratio [OR] 5.57, P = .002); anatomic location on the head, neck, hands, feet, genitals, or pretibial leg (OR 5.07, P < .001); histologic regression (OR 2.78, P = .007); in situ melanoma (OR 2.27, P = .011); multiple biopsies at the tumor site before WLE (OR 1.92 [per biopsy], P = .004); and increasing age (OR 1.049 [per year], P < .001).Limitations: This was a single-site, retrospective observational study.Conclusions: Clinicopathologic factors, especially location in cosmetically or functionally sensitive areas and noncompliance with recommended surgical margins, identified melanomas at increased risk for positive or equivocal margins after WLE. [ABSTRACT FROM AUTHOR]