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Lisa A Newman - One of the best experts on this subject based on the ideXlab platform.
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residual disease after re Excision lumpectomy for close margins
Journal of Surgical Oncology, 2009Co-Authors: Michael S Sabel, Tara M Breslin, Kendra Rogers, Kent A Griffith, Reshma Jagsi, Celina G Kleer, Kathleen A Diehl, Vincent M Cimmino, Alfred E Chang, Lisa A NewmanAbstract:Introduction: While a positive margin after an attempt at breast conservation therapy (BCT) is a reason for concern, there is more controversy regarding close margins. When re-Excisions are performed, there is often no residual disease in the new specimen, calling into question the need for the procedure. We sought to examine the incidence of residual disease after re-Excision for close margins and to identify predictive factors that may better select patients for re-Excision. Methods: Our IRB-approved prospective breast cancer database was queried for all breast cancer patients who underwent a re-Excision lumpectomy for either close or positive margins after an attempt at BCT. Close margins are defined as � 2 mm for invasive carcinoma and � 3m m for DCIS. Clinicopathologic features were correlated with the presence of residual disease in the re-Excision specimen. Results: Three hundred three patients (32%) underwent re-operation for either close (173) or positive (130) margins. Overall, 33% had residual disease identified, 42% of DCIS patients and 29% of patients with invasive disease, nearly identical to patients with positive margins. For patients with DCIS, only younger age was significantly related to residual disease. For patients with invasive cancer, only multifocality was significantly associated with residual disease (OR 3.64 [1.26‐10.48]). However, patients without multifocality still had a substantial risk of residual disease. Discussion: The presence of residual disease appears equal between re-Excisions for close and positive margins. No subset of patients with either DCIS or invasive cancer could be identified with a substantially lower risk of residual disease. J. Surg. Oncol. 2009;99:99–103. 2008 Wiley-Liss, Inc.
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predictors of re Excision among women undergoing breast conserving surgery for cancer
Annals of Surgical Oncology, 2008Co-Authors: Jennifer F Waljee, Lisa A Newman, Amy K AldermanAbstract:Up to 60% of breast cancer patients who undergo breast-conserving surgery (BCS) require re-Excision to obtain clear margins, causing delays in adjuvant treatment and poor aesthetic results. However, patient and treatment-related factors associated with re-Excision are not well defined. We surveyed all women undergoing breast conserving surgery between January 2002 and May 2006 regarding their breast disease (n = 714, response rate = 79.5%). The medical record was reviewed to determine the receipt of re-Excision lumpectomy following BCS, and obtain tumor stage, histology, and biopsy method (surgical versus needle biopsy). Patient age, breast size, tumor location in the breast, and receipt of chemotherapy were self-reported. Logistic regression was used to determine significant predictors of re-Excision lumpectomy. In this sample, 51.4% of women required only one breast Excision, 41.9% required two breast Excisions, and 6.6% required three breast Excisions. Overall, 10.8% of women required a mastectomy following initial attempt at BCS. Factors significantly correlated with re-Excision lumpectomy included smaller breast size (A cup: OR = 2.7; 95%CI: 1.32–5.52; B cup: 1.63; 95%CI: 1.02–2.62), lobular histology (OR = 1.93; 95%CI: 1.15–3.25), and receipt of surgical biopsy (OR = 3.35; 95%CI: 2.24–5.02). Women who received adjuvant chemotherapy (OR = 2.49; 95%CI: 1.19–5.22) were more likely to require re-Excision compared with women who received neoadjuvant chemotherapy. Re-Excision lumpectomy is common, and is significantly correlated with smaller breast size, lobular histology, surgical biopsy, and chemotherapy timing. Attention to these risk factors can improve the quality of care delivered to BCS patients by decreasing the cost and morbidity associated with multiple re-Excision procedures.
Benjamin K Potter - One of the best experts on this subject based on the ideXlab platform.
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local recurrence of disease after unplanned Excisions of high grade soft tissue sarcomas
Clinical Orthopaedics and Related Research, 2008Co-Authors: Benjamin K Potter, David J Pitcher, Sheila C Adams, Thomas H TempleAbstract:Unplanned Excisions of soft tissue sarcomas occur with alarming frequency and result in high rates of residual disease, potentially affecting patient prognosis. To determine if unplanned Excisions and residual disease status at tumor bed Excision increased local recurrence rates and predicted disease-specific patient survival, we retrospectively reviewed 203 consecutive patients with high-grade soft tissue sarcomas treated operatively and followed for at least 2 years (mean, 4.8 years) or until patient death. Among the 64 patients (32%) who had undergone previous unplanned Excisions, six had gross residual disease and 40 of the remaining 58 (69%) had microscopic residual disease in the tumor bed. We observed subsequent local recurrence in nine of the 139 patients (6%) after planned Excision compared with 22 patients (34%) after unplanned Excision. More patients with unplanned Excisions who underwent limb salvage procedures required flap coverage and/or skin grafting with their definitive resection (30% versus 5%). In the unplanned Excision cohort, residual disease status at tumor bed Excision predicted increased rates of local recurrence and decreased disease-specific survival. Unplanned Excisions of high-grade soft tissue sarcomas resulted in increased rates of local recurrence but not disease-specific survival. Residual disease at reExcision predicted the likelihood of local recurrence. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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soft tissue sarcomas of the foot and ankle impact of unplanned Excision limb salvage and multimodality therapy
Foot & Ankle International, 2008Co-Authors: Mihir M Thacker, Benjamin K Potter, David J Pitcher, Thomas H TempleAbstract:Background: Foot and ankle sarcomas have historically been treated with amputation because of the difficulty in achieving local disease control and maintaining a functional foot. Potential opportunities for limb salvage may be further compromised by unplanned Excisions. Materials and Methods: We reviewed 52 consecutive patients with soft tissue sarcomas of the foot and ankle and analyzed the impact of planned versus unplanned initial Excision, limb salvage, and multimodality therapy on treatment and outcomes. Results: Unplanned Excisions had been performed in 29 (55.8%) patients. Limb salvage was performed in 38 patients, with 14 requiring free soft tissue transfers. At an average followup of 99 (range, 24 to 216) months, the 5-year overall survival estimate was 76.3%. Although not statistically significant, we noted clinically relevant potential differences in local recurrence-free, disease-free, and oncologic survival between the planned and unplanned Excision groups. Seven patients (13.5%) had a local ...
John R. T. Monson - One of the best experts on this subject based on the ideXlab platform.
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Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal Excision of the rectum.
Diseases of the colon and rectum, 2012Co-Authors: Muhammad Tayyab, Abhiram Sharma, Joseph L. Ragg, Alastair W. Macdonald, James Gunn, John E. Hartley, John R. T. MonsonAbstract:Background Abdominoperineal Excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated. Objectives This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jackknife position might improve Excision margins and oncological outcomes. Methods A single-institution review of a prospectively maintained database comparing the quality of Excision and oncological outcomes after abdominoperineal Excision in conventional and prone position was performed. Consecutive abdominoperineal Excisions performed for adenocarcinoma of the rectum between January 1999 and April 2008 were included. Results Abdominoperineal Excision cases were assessed including 63 in the Lloyd-Davies position and 58 in the prone jackknife position. The 5-year local recurrence rate was 5% in the prone jackknife group in comparison with 23% in the Lloyd-Davies group (p = 0.03) by life table analysis. For local recurrence, the most significant and independent risk factors were a favorable effect of having the patient in the prone jackknife position for the perineal phase of abdominoperineal Excision (HR 0.2; 95% CI 0.04-0.81) and, unfavorably, a positive circumferential resection margin (HR 7.1; 95% CI 2.4-20). Lymph node involvement (N2) was an independent risk factor for overall survival (HR 4.6; 95% CI 2.1-9.5) and relapse of disease (HR 4.0; 95% CI 0.7-9.4). Limitations This study has some limitations because it is a retrospective review of a prospective database. Conclusion These data suggest that the rate of local recurrence after abdominoperineal Excision may be lowered by adaptation of the prone jackknife position.
Jonathan S Zager - One of the best experts on this subject based on the ideXlab platform.
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surgical management of melanoma in situ using a staged marginal and central Excision technique
Annals of Surgical Oncology, 2009Co-Authors: Mecker G Moller, Effie Pappaspolitis, Jonathan S Zager, Luis A Santiago, Amy V Prakash, Adam Kinal, Graham S Clark, Weiwei Zhu, Christopher A PuleoAbstract:Melanoma-in-situ (MIS) represents 45% of all melanomas. The margins of MIS are often poorly defined with extensive subclinical disease. Standard fusiform Excision with 5-mm margins results in positive margins in up to a third of cases. To decrease the incidence of involved margins, we use a staged Excision approach for MIS. First, patients undergo Excision under local anesthesia of a 2- to 3-mm "contoured" rim of tissue optimally 5 mm beyond the visible extent of the lesion. Formalin-fixed paraffin-embedded en face sections from this Excision are then evaluated, if necessary with the aid of immunohistochemical stains. Any positive margins are further excised. When all margins are negative, the central area is then excised and reconstructed. A total of 61 patients with MIS or lentigo maligna melanoma underwent staged contoured Excisions from 2004 to 2007 at Moffitt Cancer Center. We analyzed data only from patients with MIS of the head and neck. Patients with known invasive melanoma or non-head and neck primary disease were excluded. Demographics, tumor characteristics, margin status, number of stages, and type of reconstruction and recurrences were evaluated. Forty-nine patients with MIS of the head and neck, 28 (57%) male and 21 (43%) female, 42 to 88-years-old (median 72; mean 70), underwent staged contoured margin Excision before definitive central tumor Excision and reconstruction. The final surgical defect size ranged from 2 to 130 cm(2) (median 16 cm(2)). Twelve patients (24%) required reExcision of at least one margin; the median number of reExcisions was 1 (range 1-2). There seemed to be a positive association between lesion size and margin status (as well as number of Excisions needed to clear the margin). Unsuspected invasive melanoma was found in the central specimen in six patients (12%). Even small tumors could have unsuspected invasive melanoma: invasive cancer was seen in 4 (21%) of 19 tumors 2 cm, respectively. Surgical defects were reconstructed with flaps in 18 (37%), full-thickness grafts in 20 (41%), and split-thickness grafts in 10 patients (20%). Median time from first margin Excision to completion/final reconstruction was 7 days (range 7-63 days). No local recurrences have been reported at a median follow-up of 14 months (range 1-36 months). This technique allows for careful margin analysis and subsequent central tumor Excision with simultaneous reconstruction. This approach minimizes the need for a second major operation, which would have been necessary in 24% of our patients if treated by a one-stage Excisional approach. It is noteworthy that 12% of MIS patients had invasive melanoma in the final Excision specimen. This reinforces the importance of adequate full-thickness biopsies of suspicious pigmented lesions before any type of surgical management. With short follow-up, local control has been achieved by this technique in 100% of cases.
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surgical management of melanoma in situ using a staged marginal and central Excision technique
Annals of Surgical Oncology, 2009Co-Authors: Mecker G Moller, Effie Pappaspolitis, Jonathan S Zager, Luis A Santiago, Amy V Prakash, Adam Kinal, Daohai Yu, Graham S ClarkAbstract:Melanoma-in-situ (MIS) represents 45% of all melanomas. The margins of MIS are often poorly defined with extensive subclinical disease. Standard fusiform Excision with 5-mm margins results in positive margins in up to a third of cases. To decrease the incidence of involved margins, we use a staged Excision approach for MIS. First, patients undergo Excision under local anesthesia of a 2- to 3-mm “contoured” rim of tissue optimally 5 mm beyond the visible extent of the lesion. Formalin-fixed paraffin-embedded en face sections from this Excision are then evaluated, if necessary with the aid of immunohistochemical stains. Any positive margins are further excised. When all margins are negative, the central area is then excised and reconstructed. A total of 61 patients with MIS or lentigo maligna melanoma underwent staged contoured Excisions from 2004 to 2007 at Moffitt Cancer Center. We analyzed data only from patients with MIS of the head and neck. Patients with known invasive melanoma or non–head and neck primary disease were excluded. Demographics, tumor characteristics, margin status, number of stages, and type of reconstruction and recurrences were evaluated. Forty-nine patients with MIS of the head and neck, 28 (57%) male and 21 (43%) female, 42 to 88-years-old (median 72; mean 70), underwent staged contoured margin Excision before definitive central tumor Excision and reconstruction. The final surgical defect size ranged from 2 to 130 cm2 (median 16 cm2). Twelve patients (24%) required reExcision of at least one margin; the median number of reExcisions was 1 (range 1–2). There seemed to be a positive association between lesion size and margin status (as well as number of Excisions needed to clear the margin). Unsuspected invasive melanoma was found in the central specimen in six patients (12%). Even small tumors could have unsuspected invasive melanoma: invasive cancer was seen in 4 (21%) of 19 tumors ≤2 cm in greatest dimension and 2 (7%) of 30 > 2 cm, respectively. Surgical defects were reconstructed with flaps in 18 (37%), full-thickness grafts in 20 (41%), and split-thickness grafts in 10 patients (20%). Median time from first margin Excision to completion/final reconstruction was 7 days (range 7–63 days). No local recurrences have been reported at a median follow-up of 14 months (range 1–36 months). This technique allows for careful margin analysis and subsequent central tumor Excision with simultaneous reconstruction. This approach minimizes the need for a second major operation, which would have been necessary in 24% of our patients if treated by a one-stage Excisional approach. It is noteworthy that 12% of MIS patients had invasive melanoma in the final Excision specimen. This reinforces the importance of adequate full-thickness biopsies of suspicious pigmented lesions before any type of surgical management. With short follow-up, local control has been achieved by this technique in 100% of cases.
Leila Moayed Alaei - One of the best experts on this subject based on the ideXlab platform.
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punch biopsy is best avoided for clinically suspicious pigmented lesions
Journal of general practice, 2019Co-Authors: Dariush Adybeik, Dominico Ciranni, Leila Moayed AlaeiAbstract:Two patients had suspicious pigmented lesions that were partially punch biopsied by their primary care physicians, resulting in sampling error and subsequent pathology misdiagnosis. These cases emphasise that an Excision biopsy with a 2 mm margin is recommended as the standard biopsy technique used for suspicious pigmented lesions. Punch biopsies are best avoided. Situations in which standard Excisions may not be practical, and the alternative options available, are also discussed.
