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Background Objectives Methods Results Conclusions Reflectance confocal microscopy (RCM) has shown promise in predicting surgical outcomes by non‐invasively detecting subclinical lentigo maligna (melanoma) (LM/LMM).To assess the effects of presurgical mapping using handheld RCM (HH‐RCM) on surgical treatment, follow‐up outcomes and management decisions.A total of 117 consecutive LM/LMM cases (2015–2023) were included. The diagnostic accuracy of HH‐RCM in detecting subclinical LM and invasive components was evaluated. The primary endpoints included histological margin status and changes in management based on the outcomes of the HH‐RCM mapping procedure. Margin and follow‐up outcomes were compared to a historical cohort before HH‐RCM was introduced in our center (n = 94) (2003–2014).HH‐RCM detected subclinical LM in 60% (n = 60) of cases. The median mapping duration was 14 min (range 4–50). In 27% (n = 33), the mapping procedure resulted in modified management, the majority consisting of limited surgery with adjuvant imiquimod (n = 15) or imiquimod monotherapy (n = 14). The remaining cases (n = 84) underwent HH‐RCM‐assisted surgery. Histological margins were cleared in 96.5% of the patients with a median histological margin of 3.0 mm, significantly higher than 81% in the historical cohort (median 2.0 mm) (p = 0.001). The sensitivity and specificity for detecting the extent of subclinical LM were 94% (95% CI 80.4–99.3) and 84% (95% CI 70.3–92.7), respectively. The negative predictive value for the detection of LMM was 94% (95% CI 84.4–97.7), and 75% of the initially missed LMM (n = 12) were identified during the HH‐RCM mapping procedure. The study cohort had a 1.6% local recurrence rate compared with 25% in the historical cohort.Integrating HH‐RCM as the standard of care could lead to more personalized treatment strategies for LM/LMM and allows for the selection of patients suitable for nonsurgical treatment. [ABSTRACT FROM AUTHOR]

Background: Neoadjuvant ipilimumab plus nivolumab has yielded high response rates in patients with macroscopic stage III melanoma. These response rates translated to high short-term survival rates. However, data on long-term survival and disease recurrence are lacking., Patients and Methods: In OpACIN, 20 patients with macroscopic stage III melanoma were randomized to ipilimumab 3 mg/kg plus nivolumab 1 mg/kg q3w four cycles of adjuvant or split two cycles of neoadjuvant and two adjuvant. In OpACIN-neo, 86 patients with macroscopic stage III melanoma were randomized to arm A (2× ipilimumab 3 mg/kg plus nivolumab 1 mg/kg q3w; n = 30), arm B (2× ipilimumab 1 mg/kg plus nivolumab 3 mg/kg q3w; n = 30), or arm C (2× ipilimumab 3 mg/kg q3w plus 2× nivolumab 3 mg/kg q2w; n = 26) followed by surgery., Results: The median recurrence-free survival (RFS) and overall survival (OS) were not reached in either trial. After a median follow-up of 69 months for OpACIN, 1/7 patients with a pathologic response to neoadjuvant therapy had disease recurrence. The estimated 5-year RFS and OS rates for the neoadjuvant arm were 70% and 90% versus 60% and 70% for the adjuvant arm. After a median follow-up of 47 months for OpACIN-neo, the estimated 3-year RFS and OS rates were 82% and 92%, respectively. The estimated 3-year RFS rate for OpACIN-neo was 95% for patients with a pathologic response versus 37% for patients without a pathologic response (P < 0.001). In multiple regression analyses, pathologic response was the strongest predictor of disease recurrence. Of the 12 patients with distant disease recurrence after neoadjuvant therapy, 5 responded to subsequent anti-PD-1 and 8 to targeted therapy, although 7 patients showed progression after the initial response., Conclusions: Updated data confirm the high survival rates after neoadjuvant combination checkpoint inhibition in macroscopic stage III melanoma, especially for patients with a pathologic response. Pathologic response is the strongest surrogate marker for long-term outcome., Competing Interests: Disclosure AMM reports an advisory role for Bristol-Myers Squibb, MSD Oncology, Novartis, Pierre Fabre, QBiotics, and Roche. RPMS reports an advisory role for Merck Sharpe & Dohme, Novartis, and QBiotics; and was a speaker for Bristol-Myers Squibb. WJvH reports an advisory role for Amgen, Bristol-Myers Squibb, and Sanofi. BAvdW reports employment with Bristol-Myers Squibb. RAS reports an advisory role for Amgen, Bristol-Myers Squibb, Evaxion Biotech, GlaxoSmithKline, Merck Sharp & Dohme, Myriad Genetics, NeraCare GmbH, Novartis Australia, Novartis, Provectus Biopharmaceuticals Australia, QBiotics, and Roche; has received compensation for travel expenses from Bristol-Myers Squibb and Novartis Australia; has received honoraria from GlaxoSmithKline, Harvard Medical School, and Wake Forest School of Medicine; and has received research funding from the Australian National Health and Medical Research Council. JBAGH reports an advisory role for Achilles Therapeutics, BioNTech, Bristol-Myers Squibb, Immunocore, Instil Bio, Iovance Biotherapeutics, Ipsen, Molecular Partners, MSD Oncology, Neogene Therapeutics, Novartis, PokeAcell, Roche/Genentech, Sanofi, Third Rock Ventures, and T-Knife; has received research funding, paid to the institute, from Amgen, Asher Biotherapeutics, BioNTech, Bristol-Myers Squibb, MSD, Neon Therapeutics, and Novartis; and is stockowner of Neogene Therapeutics. TNS reports an advisory role for Allogene Therapeutics, Asher Bio, Celsius, Merus, Neogene Therapeutics, Scenic Biotech, and Third Rock Ventures; and is stockowner of Allogene Therapeutics, Asher Bio, Celsius, Merus, Neogene Therapeutics, Scenic Biotech, and Third Rock Ventures. ACJvA reports an advisory role for 4SC, Bristol-Myers Squibb, Amgen, Merck/Pfizer, Novartis, MSD Oncology, Pierre Fabre, Provectus, Sanofi, and Sirius Medical; and received research funding, all paid to the institute, from Amgen and Merck/Pfizer. GVL reports an advisory role for Agenus, Amgen, Array BioPharma, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Evaxion Biotech A/S, Hexal, Highlight Therapeutics, Innovent Biologics, Merck Sharp & Dohme, Novartis, OncoSec, PHMR Ltd, Pierre Fabre, Provectus Australia, QBiotics, and Regeneron; and has received honorarium from Bristol-Myers Squibb and Pierre Fabre. CUB reports research funding from Bristol-Myers Squibb, Novartis, and NanoString, all paid to the institute; has an advisory role for Bristol-Myers Squibb, MSD Oncology, Roche/Genentech, Novartis, GlaxoSmithKline, AstraZeneca, Pfizer, Lilly, Genmab, Pierre Fabre, and Third Rock Ventures; and is stockowner of Uniti Cars and Immagene. All other authors have declared no conflicts of interest., (Copyright © 2023 European Society for Medical Oncology. Published by Elsevier Ltd. All rights reserved.)

Background: Guidelines for pathological evaluation of neoadjuvant specimens and pathological response categories have been developed by the International Neoadjuvant Melanoma Consortium (INMC). As part of the Optimal Neo-adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) clinical trial of neoadjuvant combination anti-programmed cell death protein 1/anti-cytotoxic T-lymphocyte-associated protein 4 immunotherapy for stage III melanoma, we sought to determine interobserver reproducibility of INMC histopathological assessment principles, identify specific tumour bed histopathological features of immunotherapeutic response that correlated with recurrence and relapse-free survival (RFS) and evaluate proposed INMC pathological response categories for predicting recurrence and RFS., Patients and Methods: Clinicopathological characteristics of lymph node dissection specimens of 83 patients enrolled in the OpACIN-neo clinical trial were evaluated. Two methods of assessing histological features of immunotherapeutic response were evaluated: the previously described immune-related pathologic response (irPR) score and our novel immunotherapeutic response score (ITRS). For a subset of cases (n = 29), cellular composition of the tumour bed was analysed by flow cytometry., Results: There was strong interobserver reproducibility in assessment of pathological response (κ = 0.879) and percentage residual viable melanoma (intraclass correlation coefficient = 0.965). The immunotherapeutic response subtype with high fibrosis had the strongest association with lack of recurrence (P = 0.008) and prolonged RFS (P = 0.019). Amongst patients with criteria for pathological non-response (pNR, >50% viable tumour), all who recurred had ≥70% viable melanoma. Higher ITRS and irPR scores correlated with lack of recurrence in the entire cohort (P = 0.002 and P ≤ 0.0001). The number of B lymphocytes was significantly increased in patients with a high fibrosis subtype of treatment response (P = 0.046)., Conclusions: There is strong reproducibility for assessment of pathological response using INMC criteria. Immunotherapeutic response of fibrosis subtype correlated with improved RFS, and may represent a biomarker. Potential B-cell contribution to fibrosis development warrants further study. Reclassification of pNR to a threshold of ≥70% viable melanoma and incorporating additional criteria of <10% fibrosis subtype of response may identify those at highest risk of recurrence, but requires validation., Competing Interests: Disclosure EAR received travel support from Merck Sharpe & Dohme (MSD) and NanoString. AMM reports personal fees as a consultant advisor for Bristol Myers Squibb (BMS), MSD, Novartis, Roche, Pierre Fabre and QBiotics. ACJvA reports personal fees as a consultant advisor for Amgen, BMS, Novartis, MSD Merck, Merck–Pfizer, Sanofi and 4SC, and received grant support from Amgen, BMS and Novartis all paid to the institution (The Netherlands Cancer Institute). ADG received travel support from Merck KgA and Sun Pharma and has served as a consultant advisor for BMS, Pfizer, Merck KgA, Regeneron and Sun Pharma. MTT reports Advisory Board with Merck, Myriad Genetics, Novartis, Seattle Genetics and NanoString. RPMS has received honoraria for advisory board participation from MSD, Novartis and QBiotics and speaking honoraria from BMS. AJS has received honoraria for advisory board participation from QBiotics and Stryker. CUB reports personal fees as a consultant advisor for BMS, MSD, Roche, Novartis, Lilly, Pfizer, GSK, GenMab and Pierre Fabre for which the institution (The Netherlands Cancer Institute) received funding, has received research grants from BMS, Novartis and NanoString all paid to the institution (The Netherlands Cancer Institute), is shareholder of Unity Cars and co-founder of Immagene BV and received personal compensation as consultant advisor from Third Rock Ventures. GVL reports personal fees as a consultant advisor to Aduro Biotech Inc, Amgen Inc, Array Biopharma Inc, Boehringer Ingelheim International GmbH, BMS, Highlight Therapeutics S.L., MSD, Novartis Pharma AG, QBiotics Group Limited, Regeneron Pharmaceuticals Inc, and SkylineDx B.V. (all not related to this work). BAvdW reports advisory role for BMS. RAS has received professional services fees from QBiotics, Merck Sharp Dohme, BMS, Novartis, GlaxoSmithKline, Myriad and NeraCare (not related to this work). WJvH reports personal fees as a consultant advisor for Amgen and Sanofi. JH received (institutional fees for advisory roles in Achilles Tx, BioNTech, BMS, Ipsen, Immunocore, MSD, Merck Serono, Molecular Partners, PokeAcel, Pfizer, Roche, Sanofi, T-knife, Third Rock Ventures. JH received personal fees for advisory role in Neogene Tx. JH received institutional grant support from Amgen, BioNTech US, BMS, MSD, Neogene Therapeutics, Novartis. All other authors have declared no conflicts of interest., (Copyright © 2021 European Society for Medical Oncology. All rights reserved.)

Objectives: Feeding tubes are placed unnecessarily in a proportion of head and neck cancer (HNC) patients treated with chemoradiotherapy (CRT) when prophylactic tube placement protocols are used. This may have a negative impact on the risk of long-term dysphagia. Reactive tube placement protocols, on the other hand, might result in weight loss and treatment interruption. The objective of this study is to identify patients at risk for prolonged tube dependency in order to implement a personalized strategy regarding proactive tube placement., Materials and Methods: A retrospective study was performed in a consecutive cohort of HNC patients treated with primary CRT for whom a reactive tube placement protocol was used. A prediction model was developed to predict prolonged (> 90 days) feeding tube dependency. Model performance and clinical net benefit of the model were assessed., Results: Of the 336 included patients, 229 (68%) needed a feeding tube during CRT and 151 (45%) were prolonged feeding tube dependent. The prediction model includes the predictors pretreatment BMI, weight loss, Functional Oral Intake Scale and T-stage. Discriminatory ability is fair (area under the ROC-curve of 0.69) and calibration is adequate (Hosmer and Lemeshow test p = .254). The model shows net benefit over current practice for probability thresholds from 35 to 80%., Conclusion: The developed model can be used to select patients for proactive feeding tube placement during primary CRT for HNC. The nomogram with easily obtainable parameters is a useful tool for clinicians to support shared decision making regarding proactive tube placement., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

A 65-year-old man presented with an anomaly in his left ear. He had no complaints, but was ashamed of the lesion. On physical examination a pigmented, pedunculated, polypoid tumour of approximately 2 x 2.5 cm was seen, which filled the whole cavum conchae. After excision, histopathological examination showed a verruca seborrhoica.

Objectives: To examine health utilities in patients with cT1-2 oral cavity squamous cell carcinoma following different diagnostic and treatment modalities for the neck and to investigate the relation between shoulder morbidity and health utility., Design: Cross-sectional survey., Setting: Two Dutch hospitals., Participants: Four subgroups of patients with oral cavity cancer who underwent watchful waiting, sentinel lymph node biopsy, elective supraomohyoid neck dissection or therapeutic modified radical neck dissection., Main Outcome Measures: Patients received the EuroQol-5D-3L questionnaire and the shoulder disability questionnaire. Mean health utility, visual analogue scale and shoulder disability scores were calculated., Results: A total of 181 patients (62%) returned the questionnaires. Mean health utilities, adjusted for age, gender and time since treatment were 0.804, 0.863, 0.834 and 0.794 for the watchful waiting, sentinel lymph node biopsy, supraomohyoid neck dissection and modified radical neck dissection subgroups, respectively. Mean shoulder disability scores (higher score means more shoulder complaints) for these subgroups were 8.64, 10.57, 18.92 and 33.66. Patients with shoulder complaints had a mean utility of 0.78 while patients without shoulder complaints had a mean utility of 0.90., Conclusions: This study shows that more invasive procedures appear to result in lower health utility. The high health utility for patients after sentinel lymph node biopsy supports a role for this procedure in patients with oral cancer., (© 2015 John Wiley & Sons Ltd.)

Purpose: Recent innovations such as preoperative SPECT/CT, intraoperative imaging using portable devices and a hybrid tracer were evaluated in a multimodality approach for sentinel node (SN) mapping and biopsy in head and neck malignancies., Material and Methods: The evaluation included 25 consecutive patients with head and neck malignancies (16 melanomas and 9 oral cavity squamous cell carcinomas). Patients were peritumorally injected with the hybrid tracer ICG-(99m)Tc-nanocolloid. SNs were initially identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT/CT) 2 hours after tracer administration. During surgery a portable gamma camera in combination with a near-infrared fluorescence camera was used in addition to a handheld gamma ray detection probe to locate the SNs., Results: In all patients the use of conventional lymphoscintigraphy, SPECT/CT and the additional help of the portable gamma camera in one case were able to depict a total of 67 SNs (55 of them visualized on planar images, 11 additional on SPECT/CT and 1 additional with the portable gamma camera). A total of 67 of the preoperatively defined SNs together with 22 additional SNs were removed intraoperatively; 12 out of the 22 additional SNs found during operation were located in the vicinity of the injection site in anatomical areas such as the periauricular or submental regions. The other 10 additional SNs were found by radioguided post-resection control of the excision SN site., Conclusion: In the present series 26% additional SNs were found using the multimodal approach, that incorporates SPECT/CT and intraoperative imaging to the conventional procedure. This approach appears to be useful in malignancies located close to the area of lymphatic drainage such as the periauricular area and the oral cavity., (Copyright © 2013 Elsevier España, S.L.U. and SEMNIM. All rights reserved.)

A 35-year-old man with morbid obesity was admitted to our hospital to undergo gastric banding gastroplasty by the laparoscopic approach. Aside from his morbid adiposity, with a body mass index (BMI) of 49.9 kg/m2, the patient was healthy. During the procedure, he developed ventricular fibrillation (VF) while a diathermic knife was being used. After defibrillation, his heart rate returned to normal. The postoperative clinical course was uneventful, and there was no evidence of permanent heart failure. Although the VF could have been caused by patient- or material-related variables, it was most likely the result of unwanted electrical effects. Specifically, the occurrence of an arc between the patient's tissue and the tip of the electrode during cutting in the coagulation mode can lead to low-frequency current. The modified low-frequency current may produce arrhythmias. Thus, the use of the coagulation mode to cut tissue in the cardiac region during laparoscopic procedures could increase the risk for arrhythmias. An understanding of the physical principles of electrosurgery, as well as familiarity with the equipment and its various functions, is essential for the patient's safety. In addition, cardioversion equipment should be readily available on every surgical unit.