Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

Objectives: Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear. Study Design: retrospective study. Setting: Multicentric. Subjects and Methods: We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors. Results: A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors. Conclusions: Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

Alteration of Tissue Marking Dyes Depends on Used Chromogen during Immunohistochemistry

Pathological biopsy protocols require tissue marking dye (TMD) for orientation. In some cases (e.g., close margin), additional immunohistochemical analyses can be necessary. Therefore, the correlation between the applied TMD during macroscopy and the examined TMD during microscopy is crucial for the correct orientation, the residual tumour status and the subsequent therapeutic regime. In this context, our group observed colour changes during routine immunohistochemistry. Tissue specimens were marked with various TMD and processed by two different methods. TMD (blue, red, black, yellow and green) obtained from three different providers (A, B and C, and Whiteout/Tipp-Ex®) were used. Immunohistochemistry was performed manually via stepwise omission of reagents to identify the colour changing mechanism. Blue colour from provider A changed during immunohistochemistry into black, when 3,3′-Diaminobenzidine-tetrahydrochloride-dihydrate (DAB) and H2O2 was applied as an immunoperoxidase-based terminal colour signal. No other applied reagents, nor tissue texture or processing showed any influence on the colour. The remaining colours from provider A and the other colours did not show any changes during immunohistochemistry. Our results demonstrate an interesting and important pitfall in routine immunohistochemistry-based diagnostics that pathologists should be aware of. Furthermore, the chemical rationale behind the observed misleading colour change is discussed.

Metaplastic Breast Carcinoma: Experience of a Tertiary Cancer Center in the Middle East

Background: Metaplastic breast cancer (MetBC) represents a therapeutic challenge. We evaluated the impact of clinicopathological characteristics and treatment modalities on outcomes among MetBC patients treated at our center. Methods: Women with stage I-III MetBC were reviewed from our database from 2005-2018. Kaplan-Meier method was used to calculate locoregional-failure-free survival (LRFFS), overall-survival (OS) and distant-metastases-free survival (DMFS). We assessed associations with survival outcomes by log-rank tests. Multivariate Cox proportional-hazards models were used to identify independent predictors of LRFFS, OS and DMFS. Results: 81 patients were eligible for the study. Median age at diagnosis was 48 years. 90.1% had G-III tumors, 64.2% were pathologically node negative and lympho-vascular invasion (LVI) was absent in 72.8%. 67.8% were triple negative, and 7.4% were HER2-neu positive. Most (66.7%) patients underwent mastectomy. Free margins were achieved in the entire cohort, however, 17.3% had close margin (<2 mm). Almost all patients received chemotherapy. 75.3% received radiotherapy, 23.5% received hormonal therapy and 6.2% received Trastuzumab. With a median follow-up of 54 months, 18.5% developed loco-regional recurrence and 34.6% relapsed distally. Five-year OS was 66.0%. On multivariate analysis: adjuvant radiotherapy correlated with better OS ( P < .0001), and tumor size >5 cm, nodal involvement and LVI correlated with worse OS, ( P = .019, P = .021, P = .028, respectively). There were no survival differences with respect to age, triple negativity, and morphologic subtype. Conclusion: We report the largest single institutional series on MetBC in the Middle East region. MetBC confers worse survival outcomes, and more aggressive local and systemic treatment strategies should be investigated.

“Pull-through” Resection for Total and Subtotal Glossectomy Involving the Posterior Third of Tongue

The lower lip-splitting incision associated with different types of mandibulotomy, in order to obtain wide access to total or subtotal glossectomy, is described. In those cases, high rates of functional and aesthetic deficit and postoperative morbidity (more in cases of patients in which adjuvant radiotherapy has been performed) are described. We present our experience in the treatment of patients undergoing total or subtotal glossectomy and contemporary reconstruction with flaps, and without lip-splitting incision and mandibulotomy. Materials and Methods: Data about patients affected by malignant tumors requiring total or subtotal (posterior third of the tongue) resection that were treated at our department from January 2004 to December 2014 were retrospectively reviewed. Data evaluated included: T and N stage, resection margins, operation time, and post-operative complications, such as fistula and flap necrosis. Results: 41 patients were identified. In two cases microscopic infiltration of one margin was found (R1); in one case a close margin was identified. In 26 cases reconstruction was performed using free flaps, and in the remaining cases a pectoralis major flap was used. In three cases postoperative complications were observed. Discussion and conclusions: In theory, lip-splitting and mandible discontinuity could allow for increased access and tumor visualization, and could facilitate flap positioning. Nevertheless, in our experience, it is not necessary in the case of total or subtotal glossectomy.

Feasibility of intraoperative radiotherapy with X-rays for the treatment of superior sulcus tumours

Background Preoperative concurrent chemoradiotherapy (CCRT) followed by surgery has become the standard treatment for potentially resectable superior sulcus (SS) tumours. To date, intraoperative radiotherapy (IORT) for SS tumour treatment is primarily performed via brachytherapy; it achieves high local control, but has no influence on overall survival. Therefore, a novel therapy is required to increase the local control of SS tumours. The purpose of this study was to evaluate the feasibility and safety of IORT with low-energy X-rays for treating SS tumours. Methods Patients diagnosed with stage IIB-IIIA SS tumours with chest wall invasion and scheduled to undergo surgery were eligible for this prospective pilot study. Every patient was discussed at a lung cancer multidisciplinary team meeting. Patients with potentially resectable tumour were scheduled for neoadjuvant chemoradiotherapy followed by surgery, while those with resectable tumour were scheduled to receive surgery alone. Neoadjuvant chemotherapy consisted of two cycles of platinum-based doublet chemotherapy. Concurrent radiotherapy of 50 Gy in 25 fractions over 5 weeks was performed via intensity-modulated radiation therapy. IORT was administered to the tumour bed with close margin. The primary endpoint was acute toxicity and secondary endpoints were late spinal cord and brachial plexus toxicity. Results Between August 22, 2014 and November 30, 2017, we enrolled nine patients (seven males and two females). Anaemia was the most common acute complication, with grade 3 anaemia occurring in three patients who received preoperative CCRT. Other side effects included pneumonia (1 patient), prolonged air leakage (1), and grade 1 brachial plexus injury (1). The average follow-up period was 29.4 (range; 13.3-50.4) months. All patients are alive. Distant metastasis was observed in two patients, one with contralateral lung metastasis and another with pericardial metastasis. Conclusions IORT with low-energy X-rays is a technically feasible and relatively safe treatment modality for patients with superior pulmonary sulcus tumours.

Wire Guided Wide Local Excision of Clinically Undetectable Breast Cancer - Initial Experience in Bangladesh

Background: With the rise of awareness of breast cancer and better screening mammography, there are increasing number of breast cancers detected before becoming clinically evident. These cancers are mostly treated by wide local excision under guidance of a wire which is put with mammogram and/or USG. In Bangladesh this procedure has never been done. We started it in Surgical Oncology Division in BSMMU with the collaboration of Department of Radiology. Methods: We have performed the procedure on 7 patients within 19 months. All of them had USG and mammography detected small lesions. The average size being 7.24mm. From needle biopsy 3 cases showed suspicious cytology, 4 had IDCC, and 1 had DCIS. Wire was put in all cases under USG guidance. Wire Guided Wide Local Excision was performed in all cases. $ patients underwent SLNB. Results: The age range was between 26 to 55 years with the average age of 43.86 years. 4 of them being post-menopausal. One case came benign. Other were malignant with clear margins. One case had close margin, which was later re-excised. All cases were sent for adjuvant therapy. Histopathology showed 4 patients of invasive ductal carcinoma, 1 patient each of invasive lobular carcinoma, DCIS and 1 being benign. Conclusion: This well-established procedure can be performed in Bangladesh to meet the goal of ensuring adequate treatment and cosmesis of the patients with impalpable cancer, amidst constrained facilities. Journal of Surgical Sciences (2019) Vol. 23(2): 81-86

The approach to an isolated close anterior margin in breast conserving surgery

Introduction Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. Methods All patients having breast conserving surgery at St Vincent’s University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. Results A total of 930 patients were included with an average age of 65 years (range 29–94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. Conclusion The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.