The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer–related deaths, but treatment is usually curative following early ...detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.
To report the first use of a novel projected augmented reality (AR) system in open sinonasal tumor resections in preclinical models and to compare the AR approach with an advanced intraoperative ...navigation (IN) system.
Four tumor models were created. Five head and neck surgeons participated in the study performing virtual osteotomies. Unguided, AR, IN, and AR + IN simulations were performed. Statistical comparisons between approaches were obtained. Intratumoral cut rate was the main outcome. The groups were also compared in terms of percentage of intratumoral, close, adequate, and excessive distances from the tumor. Information on a wearable gaze tracker headset and NASA Task Load Index questionnaire results were analyzed as well.
A total of 335 cuts were simulated. Intratumoral cuts were observed in 20.7%, 9.4%, 1.2,% and 0% of the unguided, AR, IN, and AR + IN simulations, respectively (p < 0.0001). The AR was superior than the unguided approach in univariate and multivariate models. The percentage of time looking at the screen during the procedures was 55.5% for the unguided approaches and 0%, 78.5%, and 61.8% in AR, IN, and AR + IN, respectively (p < 0.001). The combined approach significantly reduced the screen time compared with the IN procedure alone.
We reported the use of a novel AR system for oncological resections in open sinonasal approaches, with improved margin delineation compared with unguided techniques. AR improved the gaze-toggling drawback of IN. Further refinements of the AR system are needed before translating our experience to clinical practice.
•A D2 LND is preferred for curative intent resection with ≥16 LNs assessed for staging.•Gastric cancer surgery should aim to achieve an RO resection margin.•In the metastatic setting, surgery should ...only be considered for palliation of symptoms.•Patients should be referred to higher volume centres.•Laparoscopic resections should be performed to the same standards as open resections.
Gastric adenocarcinoma accounted for 6.8% of new cancer cases and 8.8% of cancer deaths worldwide in 2012. Although resection is the cornerstone for cure, several aspects of surgical intervention remain controversial or sub-optimally applied at the population level. These include staging, extent of lymph node dissection (LND), optimal requirements of LN assessment, minimum resection margins, surgical technique (laparoscopic vs. open), relationship between surgical volumes and patient outcomes, and resection of stage IV gastric cancer.
A systematic review was conducted to inform surgical care.
The evidence included in this systematic review consists of one guideline, seven systematic reviews and 48 primary studies.
All patients should be discussed at a multidisciplinary team meeting and a staging CT of the chest and abdomen should always be performed. Diagnostic laparoscopy should be performed in patients at risk for stage IV disease. A D2 LND is preferred for curative-intent resection in advanced non-metastatic gastric cancer. At least 16 LNs should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an RO resection margin. In the metastatic setting, surgery should only be considered for palliation of symptoms. Patients should be referred to higher volume centres, and those with adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as open resections.
Background: Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive superficial soft tissue tumor that can occur in many parts of the body. Surgical resection with a wide margin of ...safety is the main treatment modality of this rare tumor of the breast. According to the postoperative pathology report, the patient can be followed up or adjuvant radiotherapy (RT) can be added.
Case presentation: A 22-year-old woman presented with a mass filling the lower inner quadrant of her right breast. Tru-cut biopsy revealed a mesenchymal tumor, but excision was recommended for definitive diagnosis. A right breast quadrantectomy was performed. The result came as DFSP. Tumor diameter was 10x9x6.5 cm and the tumor was positive in most of the surgical margins. The patient underwent re-resection and a residual tumor with a diameter of 0.2 cm was detected at a distance of 3.3 cm from the surgical margin. Although the surgical margins were negative, the distance of the posterior surgical margin, in particular, could not be assured. Because of the uncertainty of surgical margins, 60 Gy RT was planned.
Conclusion: The localization of DFSP in the breast is extremely rare and surgery is the primary treatment. RT should be added as an adjuvant when safe surgical margins cannot be obtained.
Objectives
To summarize the current evidence on Retzius‐sparing (RS)‐robot‐assisted radical prostatectomy (RARP) and to compare its oncological, peri‐operative and functional outcomes with those of ...standard retropubic RARP (S‐RARP).
Materials and Methods
After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the ‘PICO‘ (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure RS‐RARP vs S‐RARP) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri‐operative and functional outcomes were recorded and analysed.
Results
A shorter operating time was associated with RS‐RARP (weighted mean difference WMD 14.7 min, 95% confidence interval CI −28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI −31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio OR 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S‐RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS‐RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004).
Conclusion
Our analysis confirms that RS‐RARP is a safe and feasible alternative to S‐RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.
Background:
India Ink is the most commonly used ink in surgical pathology. The main disadvantages of India Ink are longer drying time, monochrome, toxicity and cost. Because of these disadvantages, ...alternative materials have been suggested to replace India ink. The aim of this study is to evaluate the effectiveness of nail enamel for inking of surgical margin and to compare it with India ink.
Materials and methods:
N
= 20, which included 10 mucosal and 10 skin samples. Each selected margin is divided into 2 equal halves and one is inked with India ink and the other with nail enamel (Vernis A Ongles: Dark green). After routine processing and staining, the effectiveness of nail enamel and India ink were compared based on macroscopic and microscopic parameters.
Results:
Less drying time and visibility on paraffin wax block were excellent for nail enamel. Microscopic visibility of nail enamel was comparable with that of India ink. However, processing fluids contamination is the main drawback of nail enamel.
Conclusion:
Nail enamel can be used as an alternative to India ink because of its less drying time, ease of application, good visibility on wax blocks and microscopically, availability in multiple colours, cost effectiveness and non-toxicity.
There are no clinical guidelines on the management of dysplastic nevus (DN). The aims of this study were to determine the percentage of dermatologists in the center-Spain section of the Spanish ...Academy of Dermatology and Venereology (AEDV) who would manage a histologically confirmed DN with a watch-and-wait approach or with wider surgical margins and to investigate whether their attitudes would vary depending on whether or not the patient had a personal and/or family history of melanoma.
We collected data from an anonymous survey sent to 738 dermatologists between June 15 and July 31, 2022. The independent variables were degree of dysplasia (low vs. high), margin status (positive vs. negative), and a personal or family history of melanoma (yes vs. no in both cases). The dependent variables were attitude towards management (watch-and-wait vs. re-excision with a surgical margin of 1 to 4 mm or re-excision with a surgical margin of 5 to 10 mm).
We obtained 86 responses to the questionnaire. When pathology indicated a low-grade DN, 60.5% of dermatologists stated they would obtain a surgical margin of 1 to 4 mm if the first margins were positive, and 97.7% would watch and wait if the report described negative margins. For high-grade DNs, 1.2% of dermatologists would watch and wait to manage DN with positive margins; 68.8% would use this approach for negative margins. A family or personal history of melanoma had no influence on most of the dermatologists' attitudes.
Management strategies for DN among dermatologists from the center-Spain section of the AEDV varied, particularly when faced with low-grade DN with positive margins and high-grade DN with negative margins. A family or personal history of melanoma did not influence clinical attitudes in most cases.
To provide a perspective on the significance of recent reports for optimizing cancer free surgical margins that have challenged standard practices.
We conducted a review of the recent literature ...(2012–2018) using the keywords surgical margin analysis, frozen and paraffin section techniques, head and neck cancer, spectroscopy and molecular markers.
Of significance are the reports indicating superiority of tumor specimen directed sampling of margins compared to patient directed (tumor bed) sampling for frozen section control of oral cancers. With reference to optimal distance between tumor and the surgical margin, recent reports recommended cutoffs less than 5mm. Employment of new technologies such as light spectroscopy and molecular analysis of tissues, provide opportunities for a “real time” assessment of surgical margins.
The commonly practiced method of patient directed margin sampling involving previous studies raises concern over conclusions made regarding the efficacy of frozen section margin control. The recent studies that challenge the optimal distance for clear surgical margins are retrospective and address patient cohorts with inherently confounding factors. The use of novel ancillary techniques require further refinements, clinical trial validation, and justification based on the additional resources.
Aim
To present the experience from collective data regarding patients with retroperitoneal sarcomas that have been operated in and followed up by the University General Hospital of Patras in Rion, ...Greece, between 2009 and 2020.
Methods A retrospective analysis of adult patients treated at our hospital with a diagnosis of primary retroperitoneal sarcoma who underwent tumour resection.
Results
Data from 29 patients were analysed. The mean age at diagnosis was 56.1 years; 55.2% of patients were male (n=16). Liposarcomas (on histology) were identified in 19 (65.5%) patients, leiomyosarcoma six (20.7%), and other histologic subtypes in four (13.8%) patients. Tumours >5cm were presented in 27 (93.1%) patients. Negative margins were attained in 13 (44.8%) of all patients who underwent surgical resection. Five (17.2%) patients received neoadjuvant radiation, four (13.8%) postoperative radiation, and three (10.3%) patients received both chemotherapy and radiation
prior to surgery with the rest of the patients being treated with surgical excision alone. A 3-year follow-up was successful in 21 (72.4%) patients; five (23.8%) patients died. In total, 16 (55.2%) patients were found to have a local recurrence, with no significant difference in patients' age, gender, tumour size, histology, negative surgical margin (Ro) resection, neoadjuvant chemotherapy, or radiation therapy. There was a significant difference in the 3-year survival rate between patients having positive or negative surgical margins (p=0.027).
Conclusion
The higher 3-year survival rate in patients with retroperitoneal sarcomas when achieving Ro resection warrant further
investigation with a larger sample size across different institutions.
Positive surgical margin rates remain high in head and neck cancer surgery. Relocation is challenging given the complex, three-dimensional (3D) anatomy.
Prospective, multi-institutional study to ...determine accuracy of head and neck surgeons and pathologists relocating margins on virtual 3D specimen models using written descriptions from pathology reports. Using 3D models of 10 head and neck surgical specimens, each participant relocated 20 mucosal margins (10 perpendicular, 10 shave).
A total of 32 participants, 23 surgeons and 9 pathologists, marked 640 margins. Of the 320 marked perpendicular margins, 49.7% were greater than 1 centimeter from the true margin with a mean relocation error of 10.2 mm. Marked shave margins overlapped with the true margin a mean 54% of the time, with no overlap in 44 of 320 (13.8%) shave margins.
Surgical margin relocation is imprecise and challenging even for experienced surgeons and pathologists. New communication technologies are needed.
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