Comparison of the quality of total mesorectal excision after robotic and laparoscopic surgery for rectal cancer: a multicenter, propensity score-matched study

Purpose: This study aimed to evaluate and compare the quality of total mesorectal excision (TME) and disease-free and overall survival rates between robotic and laparoscopic surgeries for rectal cancer.Methods: From January 2015 to December 2018, 234 patients underwent curative robotic or laparoscopic surgery for rectal cancer at two centers. Ultimately, 201 patients were enrolled. To control for different demographic factors in the two groups, propensity score matching was used at a 1:1 ratio. Propensity scores were generated with the baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, tumor location, preoperative chemotherapy, and preoperative radiation. Finally, 134 patients were matched with 67 patients in the robotic surgery group and 67 patients in the laparoscopic surgery group.Results: There was no significant difference in the pathologic stages between the robotic and laparoscopic surgery groups. Distal margin involvement was only observed in the robotic surgery group (1/67, 1.5%). Circumferential resection margin involvement was not different between the robotic surgery and laparoscopic surgery groups (3/67 [4.5%] and 4/67 [6.0%], respectively, P = 1.000). The quality of TME (complete, nearly complete, and incomplete) was similar between the robotic surgery and laparoscopic surgery groups (88.0%, 6.0%, 6.0% and 79.1%, 9.0%, 11.9%, respectively, P = 0.358). The disease-free and overall survival rates were not significantly different between the groups.Conclusion: The quality of TME and disease-free and overall survival rates between the two surgeries were similar. There was no oncologic advantage of robotic surgery for rectal cancer compared to laparoscopic surgery.

Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer

Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE.Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement.Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038).Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.

309 Does Anaesthetic Type Effect Positive Excision Margin Rate for Non-Melanoma Skin Cancers?

Aim Australia has the highest incidence of Non-melanoma skin cancers (NMSC) in the world estimated to be 2448/100,000 population with the state of Queensland carrying the highest burden. Surgical excision is the primary treatment and makes up a large proportion of general surgical lists in regional Queensland where they are typically removed using either local anaesthetic (LA) alone, local anaesthetic and sedation (LAS), or general anaesthesia (GA). There is little in the literature to suggest if anaesthetic type effects the rate of involved margins. The purpose of this study is to establish if anaesthetic type impacts the rate of positive excision margins in regional hospitals in Queensland. Method A retrospective audit was performed, incorporating a total of 194 squamous and basal cell carcinoma lesions excised between October 2019 and October 2020 at two hospitals in regional Australia. Data was recorded for the type of anaesthetic used and the histopathology of the lesions including type of lesion and microscopic margin involvement. Results Of the 194 excised lesions 39 of them had involved margins (20.1%). The rate of involved margins under LA, GA and LAS were found to be 19.79%, 18.52% and 22.73% respectively. When comparing these modalities with each other: LA vs GA, LAS vs GA and LA vs LAS no significant difference was found in involved margins for excision of NMSC with p-values (<0.05) of 1, 0.624 and 0.8225 respectively. Conclusions Modality of anaesthetic used for excision of NMSC does not affect the outcome of margin involvement.

Clinicopathological Factors that Predict Endocervical Margin Involvement of CIN2+ after Cervical Conization Procedure in the Tertiary Center, Rajavithi Hospital, Thailand

Objective: To identify clinicopathological factors that predict endocervical margin involvement of CIN2+ after cervical conization. Methods: 464 patients undergoing LEEP at Department of Obstetrics and Gynecology, Rajavithi Hospital, Thailand between January 2014 and June 2019 were analysed retrospectively. The patients were divided into two groups as a negative and positive endocervical margin of CIN2+. Clinical factors and the cyto-pathological characteristic were included. Univariate and multivariate analysis were used to identify the risk factors predicted positive endocervical margin. Results: 150 (32.3%, 150/464) women had endocervical margin involvement of CIN2+. Mean age in positive endocervical margin group was significant older than negative endocervical margin group (47.8 ± 12.9 versus 40.8 ± 11.5 years old, p <0.001). There are more significant post-menopausal women in positive endocervical margin group (p<0.001). In positive endocervical margin group, there were significant higher grade on cervical cytology, higher grade on histology of LEEP specimen, and glandular involvement of LEEP specimen. In univariate analysis, age of ≥ 50 years old, post-menopausal status, ≥ HSIL on cervical cytology, and glandular involvement of LEEP specimens were independent risk factors for predicting endocervical margin involvement. Moreover, in multivariate analysis, age of ≥ 50 years old and glandular involvement of LEEP specimen show significant difference between two groups. In endocervical margin involvement of CIN2+ group has 2.84 (95% CI: 1.23-6.56, p = 0.015) and 2.41 (95% CI: 1.58-3.66, p <0.01) times more age ≥ 50 years old and glandular involvement of LEEP specimen respectively. Conclusions: The age of ≥50 years old is the only pre-operative variable in this study. This finding is consistent with many previous studies. Therefore, performing LEEP in the women with the age of ≥50 years old should be aware the result of positive endocervical margin

Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome

Objective This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy. Methods A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed. Results Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7–92.3% for up to 24 mm cone height and 100% from 25 mm. Conclusion Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.

Clinical Aspects and Prognostic Factors for Survival in Patients with Recurrent Cervical Cancer after Radical Hysterectomy and Adjuvant Radiochemotherapy

Purpose To investigate the recurrence patterns and prognostic factors of patients with recurrent cervical cancer after radical hysterectomy with node dissection (RHND) followed by adjuvant radiotherapy (RT)/concurrent radiochemotherapy (CCRT). Methods Between January 1, 2012 and May 31, 2018, the medical records of 153 patients with pre-operative FIGO stage IB-IIA disease treated with RHND followed by adjuvant RT/CCRT in Liaoning Cancer Hospital were retrospectively analyzed. Results The median disease progression-free survival (PFS) time was 16 months. 75.2% (115/153) patients had disease relapse within 2 years. The survival of patients with recurrences in multiple organs was signifificantly lower in comparison to those with recurrences in single organ ( P <0.001). The survival rate of patients with distant metastasis (DM) and distant metastasis with local recurrence (LR) was significantly lower than that of patients with simple LR ( P =0.006, P <0.001). Furthermore, the survival rate of patients with LR+DM was significantly lower than that of patients with simple DM ( P =0.046).The multivariate analysis showed that resection margin involvement, para-aortic and common iliac lymph node metastasis, DM, no treatment after disease relapse and early disease relapse were independent prognostic fators asscociated with poor survivals. Conclusion Most cervical cancer patients who received initial RHND followed by adjuvant RT/CCRT occurred disease relapse within 2 years. Resection margin involvement, para-aortic and common iliac lymph node metastasis, DM, no treatment after recurrence and early disease relapse were found to be prognostic factors in patients with recurrent cervical cancer after RHND followed by adjuvant RT/CCRT.

The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study

Background This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS). Methods Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008–2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved. Results Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33–0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68–4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03–1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07–12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69–7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01–3.40) were independently associated with positive resection margins after BCS. Conclusions Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = − 191.35 (− 238.12, − 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.

Detection of involved margins in breast specimens with X-ray phase-contrast computed tomography

Margins of wide local excisions in breast conserving surgery are tested through histology, which can delay results by days and lead to second operations. Detection of margin involvement intraoperatively would allow the removal of additional tissue during the same intervention. X-ray phase contrast imaging (XPCI) provides soft tissue sensitivity superior to conventional X-rays: we propose its use to detect margin involvement intraoperatively. We have developed a system that can perform phase-based computed tomography (CT) scans in minutes, used it to image 101 specimens approximately half of which contained neoplastic lesions, and compared results against those of a commercial system. Histological analysis was carried out on all specimens and used as the gold standard. XPCI-CT showed higher sensitivity (83%, 95% CI 69–92%) than conventional specimen imaging (32%, 95% CI 20–49%) for detection of lesions at margin, and comparable specificity (83%, 95% CI 70–92% vs 86%, 95% CI 73–93%). Within the limits of this study, in particular that specimens obtained from surplus tissue typically contain small lesions which makes detection more difficult for both methods, we believe it likely that the observed increase in sensitivity will lead to a comparable reduction in the number of re-operations.