A Surgeon’s Role in the Management of Early Esophageal, EGJ and Gastric Lesions

Background: Endoscopic mucosal resection and submucosal dissection (ESD) are indicated in a majority of mucosal esophageal, esophagogastric junction and gastric cancers (GC), and selected cases of submucosal cancers as well. Summary: The presence of lymph node metastases in early esophageal cancer (EC) has been proven in up to 50% of patients with sm3 cancers treated with surgical resection, and up to 18.5 and 30.5% in sm1 and sm2 cancer respectively. The presence of lymphovascular invasion (LVI), tumor depth >500 μm and poor tumor differentiation seem to be a common predictor of worse outcomes in literature reports. In case of early esophagogastric junction cancer (EGJC) these predictors include LVI, tumor size >3 cm, Barrett’s origin of the tumor and ulcerative tumor appearance. Extended indications for ESD in early GC are already adopted in high volume centers with high success rates (up to 98%). Jet, positive resection margins after ESD, LVI and poor tumor differentiation carry high metastatic potential, therefore advocating surgery. Limited resections and cooperative laparoscopic endoscopic approach may be implemented in cases of early EGJC and GC. Key Messages: The presence of LVI, depth of submucosal invasion, and poor tumor differentiation in cases of early EC, EGJC, and GC favor surgical treatment despite improvements in endoscopic techniques.

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Prognostic factors in patients with nonmetastatic gastric cancer treated with contemporary multimodality strategies.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.451 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 451-451

Author(s):

Ariceli Alfaro ◽

Tuyen Hoang ◽

Jasmine Huynh ◽

Jingran Ji ◽

Andrew H. Ko ◽

...

Keyword(s):

Prognostic Factors ◽

Cox Regression ◽

Cancer Recurrence ◽

High Volume ◽

Multimodality Therapy ◽

Resection Margins ◽

Study Cohort ◽

Curative Intent ◽

California Cancer Registry ◽

Positive Resection Margins

451 Background: We conducted a retrospective study to evaluate clinical outcomes in patients with non-metastatic gastric adenocarcinoma (nmGA) treated at two high-volume academic institutions within the University of California (UC) system. Methods: Electronic Health Records and California Cancer Registry of demographic and clinical data were collected for pts with nmGA who underwent surgery with curative intent from 2010-2017. Medical chart reviews were conducted to validate outcomes. We used multivariate Cox regression to determine prognostic factors for cancer recurrence and overall survival. Results: Demographics of study cohort (n = 406): mean age 65 years; 71% male; 58% Caucasian, 26% Asian, 13% Latino. There was an even distribution between pts with locoregionally advanced (defined as pT4 or pN1+) vs. localized (pT1-3, pN0) disease. Tumor histology: 49% intestinal, 19% diffuse, 13% mixed, 19% unknown. Type of surgery: 27% open gastrectomy, 59% laparoscopic, 14% unknown. Multimodality therapy: 29% received perioperative systemic rx alone (48% adjuvant only, 52% neoadjuvant +/- adjuvant), 35% received perioperative systemic rx plus radiation (40% adjuvant only, 60% neoadjuvant +/- adjuvant), 36% underwent surgery only. With median f/u time after surgery of 5 years, 21% of pts developed cancer recurrence and 43% had died. Weight loss prior to diagnosis, locoregional stage, and positive resection margins were a/w recurrence (HR = 1.6-2.5, p < .05). Only locoregional stage was prognostic for worse survival (HR = 2.7, p < .0001). Positive resection margins were seen in 6% of pts and were a/w diffuse histology and tumor size > 4cm (odds ratio = 2.9-8.8, p < .02). Multimodality therapy was not a/w recurrence but was a/w longer survival after adjusting for stage (HR = 0.3, p < .0001). Addition of radiation to systemic rx did not confer further improvements in either recurrence or survival. Conclusions: This study highlights contemporary practice patterns for pts with nmGA and demonstrates a survival benefit with multimodality rx. Additional data are being gathered from other UC medical centers to confirm these findings and explore differences across institutions and ethnicities.

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Radiation-Associated Angiosarcoma of the Breast and Chest Wall Treated with Thermography-Controlled, Contactless wIRA-Hyperthermia and Hypofractionated Re-Irradiation

Cancers ◽

10.3390/cancers13153911 ◽

2021 ◽

Vol 13 (15) ◽

pp. 3911

Author(s):

Markus Notter ◽

Emanuel Stutz ◽

Andreas R. Thomsen ◽

Peter Vaupel

Keyword(s):

Local Recurrence ◽

Background Radiation ◽

Definitive Treatment ◽

Resection Margins ◽

Recurrence Rates ◽

Rate Dependent ◽

Angiosarcoma Of The Breast ◽

Positive Resection Margins ◽

Locally Recurrent ◽

Tumor Extent

Background: Radiation-associated angiosarcoma of the breast (RAASB) is a rare, challenging disease, with surgery being the accepted basic therapeutic approach. In contrast, the role of adjuvant and systemic therapies is a subject of some controversy. Local recurrence rates reported in the literature are mostly heterogeneous and are highly dependent on the extent of surgery. In cases of locally recurrent or unresectable RAASB, prognosis is very poor. Methods: We retrospectively report on 10 consecutive RAASB patients, most of them presenting with locally recurrent or unresectable RAASB, which were treated with thermography-controlled water-filtered infrared-A (wIRA) superficial hyperthermia (HT) immediately followed by re-irradiation (re-RT). Patients with RAASB were graded based on their tumor extent before onset of radiotherapy (RT). Results: We recorded a local control (LC) rate dependent on tumor extent ranging from a high LC rate of 100% (two of two patients) in the adjuvant setting with an R0 or R2 resection to a limited LC rate of 33% (one of three patients) in patients with inoperable, macroscopic tumor lesions. Conclusion: Combined HT and re-RT should be considered as an option (a) for adjuvant treatment of RAASB, especially in cases with positive resection margins and after surgery of local recurrence (LR), and (b) for definitive treatment of unresectable RAASB.

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Predicting Surgical Margins in Patients With Borderline Resectable and Locally Advanced Pancreatic Cancer Undergoing Resection

The American Surgeon ◽

10.1177/00031348211011129 ◽

2021 ◽

pp. 000313482110111

Author(s):

Weizheng Ren ◽

Dimitrios Xourafas ◽

Stanley W. Ashley ◽

Thomas E. Clancy

Keyword(s):

Pancreatic Ductal Adenocarcinoma ◽

Univariate Analysis ◽

Locally Advanced ◽

Advanced Pancreatic Cancer ◽

Ductal Adenocarcinoma ◽

Resection Margins ◽

Borderline Resectable ◽

Stepwise Selection ◽

R1 Resection ◽

Positive Resection Margins

Background Many patients with borderline resectable/locally advanced pancreatic ductal adenocarcinoma (borderline resectable [BR]/locally advanced [LA] pancreatic ductal adenocarcinoma [PDAC]) undergoing resection will have positive resection margins (R1), which is associated with poor prognosis. It might be useful to preoperatively predict the margin (R) status. Methods Data from patients with BR/LA PDAC who underwent a pancreatectomy between 2008 and 2018 at Brigham and Women’s Hospital were retrospectively reviewed. Logistic regression analysis was used to evaluate the association between R status and relevant preoperative factors. Significant predictors of R1 resection on univariate analysis ( P < .1) were entered into a stepwise selection using the Akaike information criterion to define the final model. Results A total of 142 patients with BR/LA PDAC were included in the analysis, 60(42.3%) had R1 resections. In stepwise selection, the following factors were identified as positive predictors of an R1 resection: evidence of lymphadenopathy at diagnosis (OR = 2.06, 95% CI: 0.99-4.36, P = .056), the need for pancreaticoduodenectomy (OR = 3.81, 96% CI: 1.15-15.70, P = .040), extent of portal vein/superior mesenteric vein involvement at restaging (<180°, OR = 3.57, 95% CI: 1.00-17.00, P = .069, ≥180°, OR = 7,32, 95% CI: 1.75-39.87, P = .010), stable CA 19-9 serum levels (less than 50% decrease from diagnosis to restaging, OR = 2.27, 95% CI: 0.84-6.36 P = .107), and no preoperative FOLFIRINOX (OR = 2.17, 95% CI: 0.86-5.64, P = .103). The prognostic nomogram based on this model yielded a probability of achieving an R1 resection ranging from <5% (0 factors) to >70% (all 5 factors). Conclusions Relevant preoperative clinicopathological characteristics accurately predict positive resection margins in patients with BR/LA PDAC before resection. With further development, this model might be used to preoperatively guide surgical decision-making in patients with BR/LA PDAC.

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RAS Mutation Predicts Positive Resection Margins and Narrower Resection Margins in Patients Undergoing Resection of Colorectal Liver Metastases

Annals of Surgical Oncology ◽

10.1245/s10434-016-5187-2 ◽

2016 ◽

Vol 23 (8) ◽

pp. 2635-2643 ◽

Cited By ~ 48

Author(s):

Kristoffer Watten Brudvik ◽

Yoshihiro Mise ◽

Michael Hsiang Chung ◽

Yun Shin Chun ◽

Scott E. Kopetz ◽

...

Keyword(s):

Liver Metastases ◽

Colorectal Liver Metastases ◽

Resection Margins ◽

Ras Mutation ◽

Positive Resection Margins

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Predictors of adjuvant treatment for pancreatic adenocarcinoma at the population level

Current Oncology ◽

10.3747/co.23.3205 ◽

2016 ◽

Vol 23 (5) ◽

pp. 334 ◽

Cited By ~ 7

Author(s):

D.J. Kagedan ◽

M.E. Dixon ◽

R.S. Raju ◽

Q. Li ◽

M. Elmi ◽

...

Keyword(s):

Pancreatic Adenocarcinoma ◽

Adjuvant Treatment ◽

Population Level ◽

Universal Coverage ◽

High Volume ◽

Geographic Region ◽

Administrative Databases ◽

Resection Margins ◽

Curative Intent ◽

Comorbidity Burden

Background In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use.Methods In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005–2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt.Results Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 (p = 0.002), multivariate analysis revealed widespread variation between the treating hospitals (p = 0.001), and even between high-volume hepatopancreatobiliary hospitals (p = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx.Conclusions Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.

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Chondrosarcoma of the Nasal Septum—A Rare Subsite: Case Report with Review of Literature

Indian Journal of Medical and Paediatric Oncology ◽

10.1055/s-0041-1736210 ◽

2021 ◽

Vol 42 (05) ◽

pp. 506-509

Author(s):

Nidhi Gupta ◽

Awadhesh Kumar Pandey ◽

Kislay Dimri ◽

Surinder K Singhal ◽

Neeraj Rathee ◽

...

Keyword(s):

Nasal Septum ◽

Malignant Tumors ◽

Surgical Excision ◽

Metastatic Potential ◽

Young Female ◽

Resection Margins ◽

Diagnostic Dilemma ◽

Complete Surgical Excision ◽

Grade Ii ◽

Common Primary Malignant Bone

AbstractChondrosarcomas are the second most common primary malignant bone tumors. Head and neck chondrosarcomas constitute less than 10% of these tumors, rarely arising from the nasal septum. These are locally aggressive malignant tumors arising from the cartilaginous framework of the nasal septum. Rarity of the tumor coupled with nonspecific symptoms makes it a diagnostic dilemma. Diagnosis requires endoscopy, radiology, and final histopathology for confirmation. Treatment is mainly surgical, requiring complete surgical excision with clear margins. Radiation has a role in unresectable tumors or for tumors with positive margins after surgery. Survival depends on the grade of tumor that predicts the metastatic potential of the tumor. We present a rare case of chondrosarcoma arising from the nasal septum in a 29-year-old young female presenting with complaints of nasal obstruction. Computed tomography was suggestive of a calcified cartilaginous tumor arising from the nasal septum. Endoscopic excision was done and postoperative histopathology showed grade II chondrosarcoma with clear margins. No adjuvant treatment was given to our patient and 2 years post-excision patient is disease free.To conclude, chondrosarcoma of the nasal septum is a rare tumor, with nonspecific symptoms. Surgery with clear margins remains the treatment of choice. Prognosis depends on the extent of tumor at presentation, resection margins, and grade of tumor.

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Identification of Preoperative Magnetic Resonance Imaging Features Associated with Positive Resection Margins in Breast Cancer: A Retrospective Study

Korean Journal of Radiology ◽

10.3348/kjr.2018.19.5.897 ◽

2018 ◽

Vol 19 (5) ◽

pp. 897 ◽

Cited By ~ 5

Author(s):

Jung-Hyun Kang ◽

Ji Hyun Youk ◽

Jeong-Ah Kim ◽

Hye Mi Gweon ◽

Na Lae Eun ◽

...

Keyword(s):

Breast Cancer ◽

Magnetic Resonance Imaging ◽

Retrospective Study ◽

Magnetic Resonance ◽

Preoperative Magnetic Resonance Imaging ◽

Resection Margins ◽

Imaging Features ◽

Resonance Imaging ◽

Positive Resection Margins ◽

Preoperative Magnetic Resonance

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Outcomes of precut sphincterotomy techniques in cases of difficult biliary access

Frontline Gastroenterology ◽

10.1136/flgastro-2019-101380 ◽

2020 ◽

pp. flgastro-2019-101380

Author(s):

Jared Rejeski ◽

Marc Hines ◽

Jason Jones ◽

Jason Conway ◽

Girish Mishra ◽

...

Keyword(s):

High Volume ◽

Complication Rates ◽

Success Rates ◽

Biliary Cannulation ◽

Pancreatic Duct Stenting ◽

Significant Difference ◽

Effective Option ◽

Needle Knife ◽

Precut Sphincterotomy ◽

Rectal Indomethacin

GoalsOur study aims to define success and complication rates of precut sphincterotomy with the needle-knife and transpancreatic papillary septotomy (TPS) techniques as experienced at a single, high-volume endoscopy centre.BackgroundComplication rates rise with increasing number of failed attempts at biliary cannulation; therefore, early precut sphincterotomy (PS) has been recommended. Selecting the ideal method for PS can be challenging and there is a paucity of data to help guide this decision.StudyWe performed a retrospective analysis over 37 months of endoscopic retrograde cholangiopancreatography (ERCP) experience at a single institution. We identified all ERCPs performed and stratified based on the presence of PS; if PS occurred, a thorough chart review was performed to identify success and complication rates. Patients received guideline-driven management for post-ERCP pancreatitis including rectal indomethacin and pancreatic duct stenting when appropriate.ResultsWe identified 1808 ERCP procedures performed during this time. Successful biliary cannulation was achieved in 1748 cases, yielding a success rate of 96.7% (Grades I–IV ERCP difficulty/complexity). PS was required in 232 cases (12.8%); we identified 88 TPS cases and 114 needle-knife precut sphincterotomy (NKPS) cases. Complications following PS procedures occurred in 9.1% of TPS patients and 11.4% of NKPS patients. Success rates for TPS and NKPS were 97.7% and 81.6%, respectively—a statistically significant difference (p<0.001).ConclusionThis data supports TPS as a safe and effective option for biliary access in difficult cannulation settings when performed by experienced advanced endoscopists.

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