Carcinoma of the laryngeal margin

The laryngeal margin constitutes an anatomic and clinical entity that differs from what is commonly referred to as supraglottic. The present retrospective study reviews 189 cases of carcinomas occurring in this specifically defined region. Local, nodal, and distant metastatic spread of these tumors varied depending on whether the initial tumor site was located in the anterior or lateral margin. Treatment regimens were planned according to the tumor's origin. Primary tumor site surgery associated with a modified or radical neck dissection according to N staging, followed by postoperative radiation is advocated for treatment of these tumors. Cervical nodal metastases are frequent and often bilateral (36%) in cases of anterior margin carcinoma suggesting that bilateral neck dissection sparing two jugular veins for N₀ staged carcinoma and one jugular vein when there is evidence of a palpable node, be routinely used. Nodal involvement in cases of lateral margin carcinoma is also frequent but is almost exclusively confined to the ipsilateral nodes. It is suggested that homolateral neck dissection therefore be systematically associated with primary tumor site surgery for these tumors. The various anatomical aspects and pathways of extension of laryngeal margin carcinoma are discussed and a modified TNM classification is proposed.     

The surgical margin in soft-tissue sarcoma

In a retrospective review of 231 patients who were referred to Princess Margaret Hospital because of a soft-tissue sarcoma in an extremity, 100 patients were identified who had no metastases when they were first seen and who had been treated by local resection and adjuvant radiation therapy. Complete data were collected for each patient for the following variables: age; sex; location of the tumor and its size, grade, depth, and compartmental status; chemotherapy; and dose of radiation. The surgical margins were characterized as positive or negative for histological evidence of disease on the basis of an independent review of the pathological and operative reports by a surgeon and a radiation oncologist who were experienced in the management of sarcoma. Cox multivariate analysis was used to determine which of these variables contributed to local recurrence and evidence of systemic disease. Adequacy of the margin of resection was the only variable that was associated with local relapse (p = 0.0004). The size of the tumor (p = 0.0008) was the major determinant of the risk of systemic disease.     

Paget's disease of the anal margin

A follow-up study of 22 patients with Paget's disease of the anal margin was conducted to determine the prevalence of invasive disease and coexisting visceral carcinomas, cure and survival rates. Seventy-three per cent of the patients suffered from persistent pruritus ani. Seven (32 per cent) patients had malignancy (invasive Paget's disease (n = 5) and coexisting visceral carcinoma (n = 2] and six (27 per cent) developed malignancy (invasive Paget's disease (n = 4) and coexisting visceral carcinoma (n = 2] during follow-up, giving an overall occurrence of malignancies of 59 per cent (95 per cent confidence limits: 36-79). The median follow-up period was 9 (range 0.5-25) years. No difference in length of history could be found between patients with or without malignancy. The estimated cure rate by actuarial analysis among radically treated patients was 64 per cent (95 per cent confidence limits: 43-91) at 1 year and 45 per cent (95 per cent confidence limits: 18-72) at 8 years after primary treatment. The 5- and 10-year crude survival rates of 54 per cent and 45 per cent, respectively, were significantly lower than the corresponding values of 84 per cent and 60 per cent for the normal population (P less than 0.01). Patients with persistent pruritus ani and a perianal skin lesion should be biopsied frequently. If Paget's disease is diagnosed, physical examination of the patient and anorectal region must be done carefully and repeatedly.     

The proximal margin of resected hilar cholangiocarcinoma: the effect of microscopic positive margin on long-term survival

Achieving an R0 resection can be difficult for hilar cholangiocarcinoma (HC) because of the anatomic structures of the hepatic hilum and frequent tumor infiltration. The aim of this study was to evaluate the margin status of bile duct resected in HC and prognostic impact of R1 resection. Between 2000 and 2009, 245 patients underwent operation for HC at Asan Medical Center. We retrospectively analyzed the clinicopathologic features and surgical outcomes, focusing on the proximal margin status, of 162 cases of patients with curative intention. Curative resections were achieved in 125 (52.1%) patients, and R1 resections were performed in 43 (26.5%). Proximal ductal margin states were classified as free margin (73.5%), carcinoma in situ (3.7%), and invasive carcinoma (22.8%). The 3- and 5-year survival rates of the R1 group (39.5% and 34.9%) were not significantly different from the rates of the R0 group (55.5% and 44.5%, respectively). Multivariate analysis showed lymph node metastasis (P = 0.001) and histologic differentiation (P = 0.001) were independent predictors of patient survival. The aggressive surgical approach based on liver resection including caudate lobe may increase the number of patients eligible for a curative chance and improve long-term survival even if the microscopically positive margin is still achieved.     

Surgical margin status after radical retropubic prostatectomy

This month there are two mini-reviews on aspects of prostate cancer. The first, from the USA, presents the implications of surgical margin status after radical prostatectomy and the potential role of adjuvant radiation therapy. The second, from the USA and Belgium, discusses the use of hormonal therapy for PSA-only recurrence of prostate cancer after previous local therapy. In the third mini-review, the condition known as hypoactive sexual desire disorder is described, and that it is often ignored or erroneously treated as erectile dysfunction suggests to the authors that education of doctors and patients is required. Finally, there is a mini-review of conventional and alternative methods for providing analgesia in renal colic.     

睑缘切口内眦赘皮矫治术的临床应用

目的 针对内眦赘皮的病理解剖学成因设计,以不行复杂的皮瓣转移为特点的内眦赘皮矫治术式,不在内眦区形成明显瘢痕.方法 通过内眦部上下睑缘切口,将内眦赘皮与眼轮匝肌及内眦韧带浅头充分游离,去除异位的内眦韧带浅头和增厚的眼轮匝肌,显露原内眦角及泪阜,修剪多余皮肤,缝合睑缘切口.结果 122例内眦赘皮包括：上睑型67例（54.9%）、睑板型51例（41.8%）、反向型4例（3.3%）,未发现眉型.术后无感染及其他并发症的出现,内眦赘皮矫治效果满意,术后切口痕迹隐蔽,未出现内眦赘皮复发.结论 睑缘切口内眦赘皮矫正术设计灵活、操作简单、矫治效果满意,值得推广.     

A mechanical device for costal margin retraction

A mechanical device for optimal retraction of the costal margin is described. Ribs are displaced simultaneously in the three directions of motion occurring in normal inspiration, providing atraumatic retraction since pressure is absorbed by costovertebral joints instead of rib body. The instrument relieves the surgical assistant of exhaustive retraction in anterior, lateral, and posterior thoracoabdominal surgery.     

The unsatisfactory margin in breast cancer surgery

BACKGROUND: Surgical margin involvement with breast cancer usually results in obligatory reexcision or mastectomy. While unalterable occult host and pathologic factors may interfere with margin clearance during the initial excision, it is possible that alterations in surgical technique might increase the likelihood of obtaining satisfactory margins. METHODS: Two hundred and thirty-five patients who were candidates for breast conservation therapy were identified for 1991 and 1996 using the Tumor Registry. Margins were defined as "unsatisfactory" if there was microscopic involvement with tumor or the margin was close at initial excisional biopsy and the surgeon opted for reexcision. Multiple logistic regression analyses of factors associated with margin status were performed. RESULTS: One hundred thirty-two (56%) patients had positive or close (unsatisfactory) margins; this rate increased from 51% in 1991 to 59% in 1996. Patients with unsatisfactory margins underwent more procedures (mean 2.0 versus 1.2; P <0.0001) than patients whose margins were satisfactory. The breast conservation rate for patients with unsatisfactory margins was 64% compared with 99% for patients with satisfactory margins. A multiple logistic regression demonstrated that patients with unsatisfactory margins were 67 times more likely to have a mastectomy than patients whose margins were satisfactory after adjusting for other significant factors (P <0.0001). The practice of fine needle aspiration biopsy, orientation of specimen margins by the surgeon, and reexcision of tumor at the first operation were statistically significant technical factors in obtaining satisfactory margins. Significant pathology factors were extensive intraductal component (EIC), lobular or ductal extension, and tumor size. CONCLUSION: These data show that technical factors in the surgical management of breast cancer, as well as biological factors such as EIC, can influence the success of breast conservation.     

Intraoperative margin re-resection for colorectal liver metastases

OBJECTIVE: Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases. DESIGN: Retrospective analysis. SETTING: University Hospital, Cincinnati, Ohio. Academic medical center. PARTICIPANTS: Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21). RESULTS: Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant. CONCLUSION: Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.     

Population-based determinants of radical prostatectomy surgical margin positivity

Study Type – Prognosis (cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Prior population and single‐centre studies have assessed incidence of positive surgical margins. The current study derived population‐based positive surgical margin cut‐offs in order to help identify underperforming surgeons who may benefit from further courses and/or self study to improve outcomes.

OBJECTIVE

? To characterize factors associated with positive surgical margins (PSMs) and derive population‐based PSM cutoffs to evaluate surgeon performance in radical prostatectomy (RP).

PATIENTS AND METHODS

? SEER‐Medicare data were used to identify 4247 men diagnosed with prostate cancer during 2004–2005 who underwent RP up to 2006. ? We performed logistic regression to assess the impact of tumour characteristics, surgeon volume and surgical approach on the likelihood of PSMs for pT2 and PT3a disease. ? Moreover, we derived 25th and 10th percentile cutoffs from binomial distribution equations.

RESULTS

? Overall, 19.4% of men experienced PSMs with a pT2 vs pT3a PSM rate of 14.9% vs 42% (P < 0.001). Extrapolating from our population‐based results, a surgeon incurring more than three PSMs in 10 cases of pT2 disease performed below the 25th percentile. ? There was a trend for fewer PSMs with minimally invasive vs open RP (17.4% vs 20.1%, P= 0.086), and the PSM rate also decreased over the study period from 21.3% in 2004 to 16.6% in 2006 (P= 0.028) with significant geographic variation (P < 0.001). ? In adjusted analyses, temporal and geographic variation in PSM persisted, and men with high (odds ratio 3.68, 95% CI 2.82–4.81) and intermediate (odds ratio 2.52, 95% CI 2.03–3.13) vs low‐risk disease were at greater odds to experience PSMs. Notably, neither surgical approach nor surgeon volume was significantly associated with PSMs.

CONCLUSION

? Our population‐based PSM benchmarks allow identification of under‐performing outliers who may seek courses or video self‐study to improve outcomes. There was significant temporal and geographic variation in PSMs but neither surgeon volume nor surgical approach was associated with PSMs.     

Factors influencing circumferential resection margin in rectal cancer

Aim Abdominoperineal excision (APR) has been associated with higher circumferential resection margin (CRM) involvement and local recurrence rates than extralevator APR for low rectal cancer. This study aimed to evaluate the CRMs in APR and low anterior resection (LAR) specimens and to identify factors influencing CRM involvement. Method All pathological specimens from consecutive patients with rectal cancer who underwent curative resection at the Cleveland Clinic Florida, from January 2000 to July 2010, were reviewed by two pathologists. Demographics, tumour characteristics, operative data, postoperative pathology and Dworak’s tumour regression grade were compared between specimens with positive and negative CRMs. Results One‐hundred and fifty‐four patients underwent curative APR (n = 65) or LAR (n = 69). Mean tumour size was 3.6 cm, and mean distance from the dentate line was 5.4 cm. Nine (6.8%) patients had a positive CRM (n = 6 APR, n = 3 LAR), which was associated with tumour size > 5.9 cm (P = 0.002), a distance of ≤ 2.6 cm from the dentate line (P = 0.013), microvascular invasion (P = 0.009), perineural invasion (P < 0.001), number of positive lymph nodes (P = 0.046) and incomplete total mesorectal excision (TME) (P < 0.001). APR specimens were three times more likely than LAR specimens to have an incomplete mesorectum (9.8%vs 2.9%, P = 0.322). Conclusions Factors associated with a positive CRM were tumour size > 5.9 cm, a distance of ≤ 2.6 cm from the dentate line, incomplete TME, number of positive nodes and microvascular and perineural invasion. The incidence of a positive CRM was not significantly different between LAR and APR (n = 3 LAR and n = 6 APR).     

侧唇唇缘红唇肌瓣再造双侧唇裂患者唇珠及唇缘

目的:利用侧唇重要的解剖学指标,再造双侧唇裂人中部唇缘及唇珠,探求一种有效的功能性修复双侧唇裂唇缘及唇珠的方法。方法:2000年～2005年本院收治的唇裂患者中,双侧唇裂患者76例,男性54例,女性22例。年龄最大19岁,最小4/12岁。通过设计侧唇唇缘红唇肌瓣,旋转于前唇下方重建唇弓缘,该瓣末端红唇粘膜肌瓣再造唇珠的方法修复。结果:术后患者无1例裂开,无明显的口哨畸形,口轮匝肌连续完整,唇弓缘连续,唇弓自然生动,形态好。红唇丰满,红线连续,唇珠突翘明显。结论:唇缘红唇肌瓣可以较好地修复双侧唇裂下部重要解剖结构,唇缘红唇肌瓣的设计切取是手术成功的关键。     

保乳手术确定标本边缘的探讨

目的 探讨保留乳房的乳腺癌切除术如何确定标本边缘.方法 选择符合保留乳房标准的乳腺癌111例,实施保乳手术,手术标本边缘按照肿瘤周围1cm正常组织切除.术后根据病理、临床分期制定个体化的综合治疗,定期随访患者局部和全身情况.结果 111例乳腺癌符合保乳手术治疗标准,实施了保乳手术治疗并能接受定期随访,1例出现局部区域复发.结论 按照肿瘤周围1cm正常组织切除,取其左、右、上、下、基底5个面作冰冻切片,证实标本边缘无肿瘤浸润.绝大多数患者可获满意的美容效果,提高了早期乳腺癌患者的生存质量.     

胰十二指肠切除标本腹膜后切缘的界定

胰十二指肠切除(PD)标本的胰腺、胆道、胃肠切缘的界定和检查已成为常规.然而,对于PD标本重要切缘——腹膜后切缘却关注较少,其定义也无统一标准.这可能是PD治疗壶腹部周围恶性肿瘤疗效评价不一致的原因之一.本文就腹膜后切缘的定义、界定标准和重要意义,以及与R0、R1切除率和生存率之间的关系进行了分析.本文阐明了我们对PD...     

Intraoperative margin re-resection for colorectal cancer liver metastases

One of the basic tenets of surgical oncology is the achievement of margin-negative resection. The importance of surgical margins in hepatic resection for colorectal cancer liver metastases (CRCLM) is reflected in the abundance of literature written about this topic. However, the definition of the ideal surgical margin has evolved in parallel with advances in systemic chemotherapy, biologic therapy and surgical technology. A better understanding of the biology of liver metastasis is of critical importance in the context of surgical strategy for CRCLM. The value of intraoperative margin re-resection to achieve R0 status for CRCLM is addressed, taking into consideration current understandings of cancer biology.Key Words: Colorectal cancer liver metastasis, intraoperative margins, colorectal cancer, margin re-resection, liver metastasis