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We investigated whether peppermint oil (PO) is useful for endoscopic diagnosis of gastric tumors without magnifying endoscopy. Twenty-six patients diagnosed with gastric tumors were examined. Endoscopic images were recorded by white light (WL) and narrow band imaging (NBI) without magnifying endoscopy. After PO administration, images were recorded again by WL and NBI (PO+WL and PO+NBI). The clarity of tumor margins and the effect of PO on the clarity of tumor margins were scored. The mean scores for clarity of tumor margins were 3.6 points in WL, 4 in NBI, 4.3 in PO+WL, and 4.3 in PO+NBI. The scores of WL and NBI showed a tendency to rise by PO. The mean scores for the effect of PO on the clarity of tumor margins were 2.7 in WL and 2.5 in NBI. Therefore, we conclude that PO is useful for endoscopic diagnosis of the margin of gastric tumors.

Object The authors prospectively analyzed volume changes in vestibular schwannomas (VSs) after Gamma Knife surgery (GKS). Methods Among 104 VSs treated by GKS at the Chiba Cardiovascular Center between 1998 and 2004, 87 consecutively treated unilateral VSs observed on follow-up MR imaging for at least 5 years were analyzed. These lesions were harbored by 31 men and 56 women, with a mean age of 58.6 years (range 29–80 years). The Gd-enhanced volume of each lesion was measured serially every 3 months during the 1st year and every 6 months thereafter using GammaPlan or SurgiPlan. The frequency and degree of volume shrinkage were documented and possible prognostic factors were analyzed. Results The mean tumor volume at GKS was 2.5 cm3 (range 0.1–13.2 cm3). The lesions were irradiated by directing a mean dose of 12.0 Gy (range 10.5–13.0 Gy) to the tumor margin, which was located at the mean 52.2% isodose line (range 50%–67% isodose line). The mean follow-up period was 7.5 years (range 5.0–11.1 years). Peak tumor volume expansion was most frequently observed at 8.6 months after GKS and averaged 58% (range 0%–613%). Five years after GKS, the mean reduction in tumor volume was 31%, and 9 tumors still remained larger than their initial volumes. Tumors that homogeneously enhanced on MR images displayed less shrinkage than other tumors. Conclusions Most VSs exhibit shrinkage 5 years after GKS. The mean volume reduction in this series was 31%. These results indicate that careful serial follow-up is necessary for patients who harbor tumors that display homogeneous enhancement on MR images and patients whose tumors continue to expand in size after GKS.

BACKGROUND The hallmark of Mohs micrographic surgery is using tangential tissue sections that theoretically allow 100% of the tissue margin to be examined, but when taking additional layers for second and subsequent Mohs stages, no detailed methods have been described to ensure that 100% of the tissue margins are analyzed. METHOD A rectangular or a crescent-shaped layer is often used to take second and subsequent stages. Here we compare the two techniques for their theoretic advantages and disadvantages. SUMMARY The advantage of the rectangular shape has been ease of processing, as well as built in vertical "nicks" that automatically mark the border of the tissue removed, but the rectangular layer may not provide 100% evaluation of the tumor margin because the vertical edges of the rectangular layer are not always completely analyzed, and thus tumor cells cannot be visualized in the vertical margins of these layers. This might result in a false-negative margin reading, which can be avoided by using the crescent layer. CONCLUSION We propose taking second and subsequent Mohs layers with only a crescent shape, which allows true 100% tissue margin assessment.

Confocal microscopy is a new imaging modality for noninvasive real-time tissue imaging with high resolution and contrast comparable with conventional histology. Application of this technology to skin imaging during the last decade has been an exciting advance in dermatology, allowing a virtual widow into living skin without the need for a conventional biopsy or histologic processing of tissue. High-resolution noninvasive skin imaging with confocal microscopy has potential broad applications in the clinical and research arenas, including differentiating between benign and malignant skin lesions, tumor margin mapping, monitoring response to medical or surgical treatments, and pathophysiologic study of inflammatory processes.

Mohs micrographic surgery (MMS), a surgical and histopathological technique that permits histologic analysis of the entire deep and superficial tumor margin, has been used successfully to treat many types of cutaneous malignancy. MMS results in cure rates as high as 99% for nonmelanoma skin cancer and is particularly useful in areas where standard surgical margins would result in cosmetic and functional deficits. The use of MMS for the treatment of melanoma has been controversial. This controversy stems from the perceived difficulty of diagnosing melanoma in frozen sections and a lack of prospective studies documenting equivalence or superiority to standard wide excision. We review the Mohs technique, detail the challenges facing MMS in the treatment of melanoma and discuss the evidence supporting its use. Despite the challenges, we find evidence of the effectiveness of MMS in the treatment of melanoma, particularly lentigo maligna of the face.

To retrospectively determine the safety and effectiveness of percutaneous cryoablation, monitored with computed tomography (CT), for the treatment of solid renal masses.This study was compliant with the Health Insurance Portability and Accountability Act and had institutional review board approval; informed consent was waived. From March 12, 2003, through August 4, 2005, 23 men and 17 women (mean age, 76 years +/- 9.7 [standard deviation]; range, 53-92 years), each with a single renal tumor, underwent one percutaneous cryoablation treatment session that combined ultrasonographic (US) guidance and CT monitoring. Technical success was defined as extension of the visible ice ball 5 mm beyond the tumor margin. Local tumor progression was defined as any tumor with intralesional enhancement or a serial increase in tumor size when compared with that on images obtained immediately after ablation. Tumor characteristics, complications, and follow-up were evaluated.The maximum diameter of the 40 treated lesions ranged from 1.5 to 7.2 cm (mean, 3.4 cm +/- 1.3). Twenty (50%) of 40 tumors were 3 cm or larger in diameter. Nineteen tumors (48%) extended into the renal sinus fat. One complication (2%) conformed to a grade 3 event, as determined with the Common Terminology Criteria for Adverse Events (version 3.0) of the National Cancer Institute; the overall complication rate was 8%. Thirty-eight (95%) of 40 cryoablation procedures were technically successful. Twenty-nine patients underwent follow-up (mean, 8.0 months +/- 4.3; range, 1.2-18.4 months); no local tumor recurrence was found.Percutaneous cryoablation with US guidance and CT monitoring is safe and effective for the treatment of solid renal tumors. Longer follow-up should provide further proof of the effectiveness of this technique.

AIM: To investigate the feasibility of cold snare polypectomy (CSP) in Japan. METHODS: The outcomes of 234 non-pedunculated polyps smaller than 10 mm in 61 patients who underwent CSP in a Japanese referral center were retrospectively analyzed. The cold snare polypectomies were performed by nine endoscopists with no prior experience in CSP using an electrosurgical snare without electrocautery. RESULTS: CSPs were completed for 232 of the 234 polyps. Two (0.9%) polyps could not be removed without electrocautery. Immediate postpolypectomy bleeding requiring endoscopic hemostasis occurred in eight lesions (3.4%; 95%CI: 1.1%-5.8%), but all were easily managed. The incidence of immediate bleeding after CSP for small polyps (6-9 mm) was significantly higher than that of diminutive polyps (≤ 5 mm; 15% vs 1%, respectively). Three (5%) patients complained of minor bleeding after the procedure but required no intervention. The incidence of delayed bleeding requiring endoscopic intervention was 0.0% (95%CI: 0.0%-1.7%). In total, 12% of the resected lesions could not be retrieved for pathological examination. Tumor involvement in the lateral margin could not be histologically assessed in 70 (40%) lesions. CONCLUSION: CSP is feasible in Japan. However, immediate bleeding, retrieval failure and uncertain assessment of the lateral tumor margin should not be underestimated. Careful endoscopic diagnosis before and evaluation of the tumor residue after CSP are recommended when implementing CSP in Japan.

The quantized vibration of chemical bonds provides a way of detecting specific molecules in a complex tissue environment. Unlike pure optical methods, for which imaging depth is limited to a few hundred micrometers by significant optical scattering, photoacoustic detection of vibrational absorption breaks through the optical diffusion limit by taking advantage of diffused photons and weak acoustic scattering. Key features of this method include both high scalability of imaging depth from a few millimeters to a few centimeters and chemical bond selectivity as a novel contrast mechanism for photoacoustic imaging. Its biomedical applications spans detection of white matter loss and regeneration, assessment of breast tumor margins, and diagnosis of vulnerable atherosclerotic plaques. This review provides an overview of the recent advances made in vibration-based photoacoustic imaging and various biomedical applications enabled by this new technology.

The objective of our study was to determine whether CT findings, including texture analysis, can differentiate sarcomatoid renal cell carcinoma (RCC) from clear cell RCC.A retrospective case-control study was performed of consecutive patients with a histologic diagnosis of sarcomatoid RCC (n = 20) and clear cell RCC (n = 25) who underwent preoperative CT over a 3-year period. The CT images were independently reviewed by two blinded abdominal radiologists; they evaluated the following: tumor heterogeneity, tumor margin, calcification, intratumoral neovascularity, peritumoral neovascularity, renal sinus invasion, renal vein invasion, and adjacent organ invasion. Interobserver agreement was assessed using the Cohen kappa coefficient, and results were compared between groups using an independent Student t test and the chi-square test with a Bonferroni correction. For texture analysis, gray-level co-occurrence and run-length matrix features were extracted and compared using Mann-Whitney U tests. ROC curves for each tumor were constructed, and AUCs were calculated.Overall, sarcomatoid RCCs were larger than clear cell RCCs, measuring 77 ± 27 mm (mean ± SD) compared with 50 ± 29 mm (p = 0.003), respectively; however, there was no difference in tumor size between the tumors that were compared using texture analysis or subjective analysis (p = 0.06 and 0.03, respectively). From the subjective analysis, only peritumoral neovascularity (readers 1 and 2: 70% and 70% sarcomatoid RCCs vs 0% and 41.6% clear cell RCCs, respectively; p = 0.001) and the size of the peritumoral vessels (p0.001) differed between sarcomatoid RCCs and clear cell RCCs, and interobserver agreement was fair (κ = 0.38). Other subjective imaging features did not differ between the tumors (p0.005). There was greater run-length nonuniformity and greater gray-level nonuniformity in sarcomatoid RCCs than in clear cell RCCs (p = 0.03 and p = 0.04, respectively). The combined textural features identified sarcomatoid RCC with an AUC of 0.81 ± 0.08 (standard error) (p0.0001).Large tumor size, the presence of peritumoral neovascularity, and larger peritumoral vessels are features that are more commonly associated with sarcomatoid RCCs than with clear cell RCCs. Sarcomatoid RCCs are also more heterogeneous by texture analysis than clear cell RCCs.

Background: Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients. Materials and Methods: A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records. Results: The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm 3 (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. Conclusion: The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.

Background. Whether presurgical curettage (PC), light curettage performed before Mohs surgery to delineate tumor margin, is appropriate or causes unnecessary removal of normal tissue has not been well established. Objective. We aim to determine histologically whether PC appropriately increases the size of the stage I specimen or causes unnecessary removal of healthy tissue. Methods. Before a surgical margin guided by PC was taken, a hypothetical margin determined by visual and tactile assessment alone (no curettage [NC]) was marked outside the clinically defined tumor. Histologic analysis at the NC and the PC margins revealed whether the increase in the stage I specimen as a result of PC was appropriate. Results. PC appropriately increased the stage I specimen in 21 cases and unnecessarily removed normal tissue in only 1 case. The estimation of tumor margins with PC was 15 times more accurate than with NC (p value = .0012). Conclusion. For basal cell and squamous cell carcinomas at least 4 mm in diameter, light curettage performed prior to Mohs surgery could better delineate subclinical extensions of the tumor margin and appropriately increase the size of the stage I specimen.

Background Preoperative combined-modality therapy (CMT) is considered the treatment approach of choice for rectal cancer. To examine the effect of CMT on distal intramural spread (DIS), we determined the extent of DIS in rectal cancer specimens after CMT. Methods Specimens from 20 patients after preoperative CMT and total mesorectal excision for rectal cancer were analyzed for extent of DIS. Specimens were washed, fixed in formalin, and sectioned in 5-mm cuts from the distal border of the residual tumor to the distal resection margin. Results Eleven patients (55%) had DIS. Two patients had a complete pathologic response (10%). The mean extent of DIS was 0.50 cm (standard deviation, 0.64 cm; range, 0.0 to 2.5 cm). Only 1 patient in the study had DIS beyond 1 cm from the residual tumor. Six of the patients have died at a median of 30.4 months after operation (range, 19.0 to 51.1 months). No correlation was found between the extent of residual DIS and survival. Conclusions Our study shows that the vast majority of patients with rectal cancer after neoadjuvant CMT have no tumor cells beyond 1 cm from the residual tumor. Our data suggest that a 2-cm margin of resection when feasible from the macroscopic tumor margin after neoadjuvant CMT is adequate.

Rationale and Objectives To evaluate the clinical acceptability of semiautomated methods for the measurement of mesothelioma tumor thickness in computed tomography (CT) scans. Materials and Methods A computer interface was developed to allow the acquisition of semiautomated mesothelioma tumor thickness measurements, which require the manual selection of a point along the outer margin of the tumor in a CT section. After application of an automated lung segmentation method, the computer automatically identifies a corresponding point along the inner margin of the tumor (as represented by the lung boundary), constructs a line segment between the manually selected outer tumor margin point and the computer-determined inner tumor margin point, and computes tumor thickness as the length of this line segment. Three radiologists and oncologists independently reviewed line segments representing the semiautomated measurements generated by three different algorithms at 134 measurement sites in the CT scans of 22 mesothelioma patients. The observers either accepted a measurement line segment or modified it through the interface. Differences between the initial semiautomated measurements and the measurements as modified by the observers were analyzed. Results The frequency with which observers accepted the semiautomated measurements without modification was as high as 86%. Of all measurements across all observers and methods (1,206 measurements), 89% were changed by 2 mm or less. Conclusion We have developed semiautomated methods to measure mesothelioma tumor thickness. The potential of these methods has been demonstrated through an observer study. We expect these methods to become important tools for the efficient quantification of tumor extent.

This retrospective study consisted of 17 consecutive patients with oligodendrogliomas. We qualitatively and quantitatively assessed the diagnostic value of fluid-attenuated inversion-recovery (FLAIR) images compared with T2-weighted fast spin-echo (FSE) images for evaluating intracranial oligodendrogliomas. Qualitative evaluations of signal intensity, tumor conspicuity, definition of tumor margin, distinction between solid and cystic-like parts within tumor, and calcification were performed. Quantitative criteria comparing FLAIR to T2-weighted FSE images included tumor-to-background contrast and contrast-to-noise ratio (CNR) and tumor-to-cerebrospinal fluid (CSF) contrast and CNR. Our results demonstrate that the FLAIR sequence can replace the T2-weighted FSE sequence for evaluating oligodendrogliomas.

During neurosurgical procedures the objective of the neurosurgeon is to achieve the resection of as much diseased tissue as possible while achieving the preservation of healthy brain tissue. The restricted capacity of the conventional operating room to enable the surgeon to visualize critical healthy brain structures and tumor margin has lead, over the past decade, to the development of sophisticated intraoperative imaging techniques to enhance visualization. However, both rigid motion due to patient placement and nonrigid deformations occurring as a consequence of the surgical intervention disrupt the correspondence between preoperative data used to plan surgery and the intraoperative configuration of the patient's brain. Similar challenges are faced in other interventional therapies, such as in cryoablation of the liver, or biopsy of the prostate. We have developed algorithms to model the motion of key anatomical structures and system implementations that enable us to estimate the deformation of the critical anatomy from sequences of volumetric images and to prepare updated fused visualizations of preoperative and intraoperative images at a rate compatible with surgical decision making. This paper reviews the experience at Brigham and Women's Hospital through the process of developing and applying novel algorithms for capturing intraoperative deformations in support of image guided therapy.

Object. The authors describe their experience in treating patients with hemangioblastoma, especially multiple lesions, with gamma knife surgery (GKS). Methods.Nine patients with 84 hemangioblastomas underwent GKS between July 1992 and May 2003. Three patients harbored a single lesion and six patients had multiple lesions. Of the six patients with multifocal tumors, a diagnosis of von Hippel—Lindau disease had been established in five. In the patients with multiple lesions, the mean radiation dose delivered to the tumor margin was 16.6 Gy (range 12.8–29.75 Gy). The mean margin isodose was 60% (range 40–95%). Three of the 84 lesions failed to be controlled after a mean follow-up period of 4.3 years (range 8.6–141 months). One patient who had undergone two GKS treatments suffered delayed radiation-induced complications, and posterior fossa decompression and ventriculoperitoneal shunt insertion were required. Conclusions. To achieve tumor control and avoid morbidity, the surgeon should keep in mind minimizing field overlapping by using a small-diameter collimator or applying a steep dose gradient, and by accurate dose prescription.

Purpose We aimed to determine the presence of the "shoulder" sign in prediction of pericolonic fat invasion on double-contrast barium enema (DCBE) studies in colorectal cancer. Materials and methods Patients at our institution with apparent colorectal cancer were identified from a computer search of both radiological and surgical pathology records during a recent 30-month period. The presence of a shoulder sign was defined as a tumor margin having an abrupt transition from the intraluminal component to the adjacent normal mucosa, forming a shouldered edge on barium studies. Results A total of 49 patients (53 lesions) for whom the DCBE studies and surgical pathology records were available for review were proven to have colorectal carcinomas. DCBE studies revealed that 45 patients with lesions (85%) presented with a "shoulder" sign. All of these lesions were correctly diagnosed as colorectal cancer. Of these, 89% had pericolonic fat invasion and 44% had regional lymph node metastases. Of lesions without a shoulder sign, 25% had pericolonic fat invasion and 25% had nodal metastases. Conclusion The presence of shoulder sign detected with barium enema can be a useful predictor of pericolonic fat invasion in colorectal cancer.

Three-dimensional (3-D) endosonography is a new method of staging anal carcinoma that has not yet been validated in comparison with two-dimensional (2-D) endosonography, the latter using only a single scan plane. The aim of this study was to investigate the differences between the two endosonographic techniques. Thirty patients with an endosonographically detectable anal tumor were examined with a 10 MHz rotating endoprobe. Cross-sectional images of the anal sphincters were stored on a 3-D system during retraction of the endoprobe through the anal canal. Afterwards, any projection could be reconstructed. Cross-sectional images (2-D) were compared with reconstructed projections (3-D) according to five parameters concerning tumor spread and presence of regional lymph nodes. In this study, a scale of 0 to 5 points on critical issues was used; ideally, the results should be identical in 2-D and 3-D endosonography. The 3-D method detected a median of 5 diagnostic findings, compared with a median of 4 findings with the 2-D method (P = 0.001). In eight patients the lateral tumor margin was visualized only by 3-D endosonography. The median number of lymph nodes visualized in 3-D was 1 (range, 0-13), in 2-D the median number was 0 (range, 0-6), P = 0.002. Use of 3-D endosonography in patients with anal carcinoma improves detection of perirectal lymph nodes and may improve that of tumor invasion, compared with 2-D endosonography. This may affect local tumor staging and thus planning of treatment. A study with histopathologic correlation is needed to verify this endosonographic study.

Laparoscopic renal cryosurgery provides a minimally invasive alternative for the treatment of small renal lesions of undefined malignant potential. We report on our series of patients treated with laparoscopic renal cryosurgery.Fifteen patients underwent laparoscopic renal cryoablation of peripheral, exophytic unifocal renal lesions. Patients were managed with a 4-port transperitoneal approach for anteromedial tumors and 3 to 4-port retroperitoneal approach for posterolateral tumors. All lesions were biopsied and sent to pathology for permanent section. A 4.8 mm cryoprobe (CMS cryoprobe, 4.8 mm x 2 cm x 40 cm, Cryomedical Sciences Inc., Ewing, New Jersey) was placed into the tumor using visual and ultrasonographic guidance, and a double freeze-passive thaw cycle was performed. The iceball was extended at least 1 cm beyond the tumor margin under ultrasound guidance. Followup biopsies were performed on all consenting patients with renal cell carcinoma at least 3 months after cryosurgery was performed.Laparoscopic renal cryosurgery was successfully performed on all 15 patients (6 male and 9 female). Of the 15 patients 10 had renal cell carcinoma. Mean age was 68.5 years (range 49 to 86). Mean tumor size was 2.15 cm (range 1.2 to 3.2) and mean estimated blood loss was 67 cc (range 15 to 125). There were 2 perioperative complications. Mean hospital stay was 3.5 days (range 1 to 11). Patients returned to work after 16.5 days (range 7 to 28). Radiographic followup revealed stable cryoablative lesions in all patients. Mean radiographic followup was 453 days (range 147 to 816). Mean preoperative creatinine was 1.25 mg/dl (range 0.8 to 4.3) and mean postoperative creatinine obtained 1 month postoperatively was 1.36 (range 0.8 to 4.8). There was 1 treatment failure, although another patient had a positive biopsy outside the ablated area. The failure occurred in the largest tumor treated (3.2 cm) and was due to incomplete treatment of the periphery of the lesion. The other patient had a successfully treated tumor but a positive followup biopsy due to multifocal papillary renal cell carcinoma and required nephrectomy.Laparoscopic renal cryosurgery appears to be a safe and effective minimally invasive alternative for the treatment of small renal masses. Careful selection of patients with lesions that are less than 3.0 cm and close monitoring of the iceball is necessary to treat these patients successfully.

Object Stereotactic radiosurgery (SRS) has become an important treatment option for patients with intracranial meningiomas. The author reviews the 12-year experience at a single institution and discusses the relative strengths and weakness of this management approach. Methods Between January 1990 and December 2002, 330 patients (with 356 tumors) underwent radiosurgery for intracranial meningiomas. One hundred thirty-eight patients (42%) harbored recurrent/residual tumors after having already undergone resection; 192 patients (58%) underwent radiosurgery as primary treatment. The majority of patients (70%) harbored skull base tumors. The median tumor volume was 7.3 cm3 (range 0.5–50.5 cm3). The median tumor margin dose was 16 Gy (range 12–20 Gy). In 278 patients with 297 lesions the mean clinical and imaging follow-up period was 43 months (range 2–138 months). Two hundred seventy-eight tumors (94%) remained stable or decreased in size, and 19 tumors progressed in size. Factors associated with progression were tumor histological type and prior surgery. Treatment-related complications occurred in 8% of the patients and included cranial neuropathies, symptomatic edema, cyst formation, and stenosis of the internal carotid artery. In three patients (1%) tumor dedifferentiation was noted after SRS. Conclusions Radiosurgical treatment of meningioma is safe and it has become the primary treatment for patients with small skull base tumors. Further study is needed to determine the long-term tumor control rates after such treatment, especially for patients treated with doses of 14 Gy or less.

Angiosarcoma of the scalp is a relatively rare malignant endothelial tumor. We experienced a case of angiosarcoma treated by wide local excision. An 85-year-old man was admitted to our hospital with a tumor which had appeared 1 month before on his left temporal region. The diagnosis of angiosarcoma was made based on the clinical features and histopathological finding of the lesions on the skin by a former institution. We performed wide local excision immediately circumferentially to a distance of more than 3-5cm from the tumor margin. At present, 13 months after surgery, no recurrence or metastasis has been observed. [Skin Cancer (Japan) 2003; 18: 51-55]

Purpose : we performed laparoscopic partial nephrectomy in 8 cases. We will report the operative technique and the results.Methods : After retroperitoneal cavity was expanded by balloon, which was replaced by a Hasson type trocar of 12 mm and two or three trocars were inserted. The tumor was separated and the coagulation line was set 5 to 8 mm apart from the tumor margin. The renal capsule was marked using an electric scalpel use at intervals of 5-8 mm. A needle electrode was inserted, and coagulation was done at 60-80 watt for 30-40 seconds and detachment for 10-15 seconds.Results : The mean operation time was 170 minutes. The mean blood loss during operation was 71 mL. There was no major complication associated with laparoscopic procedure.

PURPOSE To describe a combined transcranial-orbital approach for en bloc resection of optic nerve gliomas with preservation of the annulus of Zinn that minimizes recurrence and prevents postoperative paralytic ptosis. METHODS DESIGN A retrospective, noncomparative, interventional case series. STUDY POPULATION All patients who underwent optic nerve glioma resections using this technique with the authors between 1994 and 2010. PROCEDURE A transcranial-orbital approach is used to resect the intracranial segment of the optic nerve glioma from 2 mm anterior to the chiasm to the posterior extent of annulus of Zinn. The proximal transected edge of the nerve is examined intraoperatively for tumor margin clearance. Through a superior orbitotomy exposure, the entire retrobulbar segment of the tumor is transected from the globe to the annulus of Zinn. A simulation of the procedure in a cadaver and en bloc resection of the orbital apex are performed to demonstrate the subdural plane of dissection within the annulus of Zinn. MAIN OUTCOME MEASURES Postoperative outcome measures include: health of the ipsilateral globe, paralytic ptosis, postoperative complications, and tumor recurrence. RESULTS Eleven patients underwent resection of optic nerve gliomas using this technique. No patients had tumor recurrence or developed postoperative paralytic ptosis. CONCLUSIONS The combined transcranial-orbital approach with preservation of the annulus of Zinn is a safe and effective way to remove optic nerve gliomas and ensure tumor clearance while avoiding paralytic ptosis.

Facial nerve schwannomas (FNS) are rare tumors, and their appropriate management remains the subject of considerable debate. This report details the results of a series of patients with FNS treated with stereotactic radiosurgery (SRS) at the University of Virginia.We performed a retrospective review of the clinical and imaging outcomes of 5 patients who underwent Gamma Knife RS (GKRS) for small-to-medium-sized (5 mL) FNS at our institution. The study population consisted of 3 males and 2 females with a median age of 35 years. All patients presented with varying degrees of facial palsy and/or hearing dysfunction. Tumor volumes at GKRS ranged from 0.1 to 5 (median=0.8) mL. The median maximum radiosurgical dose and tumor margin dose were 24 Gy and 12 Gy, respectively.After a median follow-up period of 12 (range, 6-36) months, three tumors were radiographically smaller and two remained stable. Facial function improved in three patients, remained stable in one patient, and slightly declined from House-Brackmann grade I to II in one patient. Hearing function was preserved in three patients and deteriorated in two patients, one from Gardner-Robertson grade I to II and the other from serviceable hearing grade II to III.SRS appears to offer a reasonable rate of facial nerve preservation and tumor control for patients with small-to-medium-sized FNS. Considering the published outcomes achieved with resection, RS may be the preferred first-line treatment for these tumors.

The objective of our study was to prospectively investigate whether nonsmooth margins detected on multiphasic CT images correlate with the presence and location of microvascular invasion (MVI) in hepatocellular carcinoma (HCC).A total of 102 patients with preoperative CT findings of solitary HCC were prospectively enrolled. Tumor size, tumor capsule, tumor margins, and peritumoral enhancement on preoperative CT images were assessed. Histopathologic results including the following were also recorded: tumor differentiation; liver fibrosis score; presence or absence of MVI; and, if present, the location of MVI. Correlation between tumor margin on preoperative CT images and histopathologic location of MVI was determined.Pathologic examination revealed MVI in 60 of the 102 HCC specimens. Although the results of the univariate analysis showed that tumor size, higher Edmondson-Steiner grade, and nonsmooth tumor margins were associated with MVI, multivariate analysis revealed that only nonsmooth margins correlated with the presence of MVI in HCC (p0.001). Of the 60 HCC specimens with histopathologic evidence of MVI, 40 exhibited focal nonsmooth margins. In addition, the locations of the nonsmooth margins and MVI were similar in 36 of the 40 specimens.Nonsmooth tumor margins correlated with the histopathologic presence and location of MVI. Therefore, nonsmooth margins detected on multiphasic CT may be predictive of MVI in HCC.

Anterior exposure for cervical chordomas remains challenging because of the anatomical complexities and the restoration of the dimensional balance of the atlanto-axial region. In this report, we describe and analyze the transmandibular transoral approach and multilevel spinal reconstruction for upper cervical chordomas. We report two cases of cervical chordomas (C2 and C2-C4) that were treated by marginal en bloc resection with a transmandibular approach and anterior-posterior multilevel spinal reconstruction/fixation. Both patients showed clinical improvement. Postoperative imaging was negative for any residual tumor and revealed adequate reconstruction and stabilization. Marginal resection requires more extensive exposure to allow the surgeon access to the entire pathology, as an inadequate tumor margin is the main factor that negatively affects the prognosis. Anterior and posterior reconstruction provides a rigid reconstruction that protects the medulla and decreases axial pain by properly stabilizing the cervical spine.

Sandeep S Hedgire,1 Mari Mino-Kenudson,2 Azadeh Elmi,1 Sarah Thayer,3 Carlos Fernandez-del Castillo,3 Mukesh G Harisinghani11Department of Abdominal Imaging and Intervention, 2Department of Pathology, 3Department of Surgery, Massachusetts General Hospital, Boston, MA, USAPurpose: To evaluate the role of ferumoxytol-enhanced magnetic resonance imaging (MRI) in delineating primary pancreatic tumors in patients undergoing preoperative neoadjuvant therapy.Materials and methods: Eight patients with pancreatic adenocarcinoma were enrolled in this study, and underwent MRI scans at baseline, immediate post, and at the 48 hour time point after ferumoxytol injection with quantitative T2* sequences. The patients were categorized into two groups; group A received preoperative neoadjuvant therapy and group B did not. The T2* of the primary pancreatic tumor and adjacent parenchyma was recorded at baseline and the 48 hour time point. After surgery, the primary tumors were assessed histopathologically for fibrosis and inflammation.Results: The mean T2* of the primary tumor and adjacent parenchyma at 48 hours in group A were 22.11 ms and 16.34 ms, respectively; in group B, these values were 23.96 ms and 23.26 ms, respectively. The T2* difference between the tumor and adjacent parenchyma in group A was more pronounced compared to in group B. The tumor margins were subjectively more distinct in group A compared to group B. Histopathologic evaluation showed a rim of dense fibrosis with atrophic acini at the periphery of the lesion in group A. Conversely, intact tumor cells/glands were present at the periphery of the tumor in group B.Conclusion: Ferumoxytol-enhanced MRI scans in patients receiving preoperative neoadjuvant therapy may offer enhanced primary tumor delineation, contributing towards achieving disease-free margin at the time of surgery, and thus improving the prognosis of pancreatic carcinomas.Keywords: pancreatic cancer, tumor margin, neoadjuvant therapy, borderline resectable pancreatic cancer

Gliomas are extremely infiltrative type of brain cancers, the borders of which are difficult to locate. Gliomas largely consist of tumors of astrocytic or oligodendroglial lineage. Usually stereotactic surgery is performed to obtain tumor tissue sample. Complete excision of these tumors with preservation of uninvolved normal areas is important during brain tumor surgeries. The present study was undertaken to explore feasibility of classifying abnormal and normal glioma tissues with Raman spectroscopy (RS). RS is a nondestructive vibrational spectroscopic technique, which provides information about molecular composition, molecular structures and molecular interactions in tissue. Postoperated 33 (20-abnormal and 13-normal) gliomas tissue samples of different grades were collected under clinical supervision. Five micron section from tissue sample was used for confirmatory histopathological diagnosis while the remaining tissue was placed on CaF2 window and spectra were acquired using a fiberoptic-probe-coupled HE-785 Raman-spectrometer. Spectral acquisition parameters were laser power-80mW, integration-20s and averaged over 3 accumulations. Spectra were pre-processed and subjected to unsupervised Principal-Component Analysis (PCA) to identify trends of classification. Supervised PC-LDA (Principal-Component-Linear-Discriminant Analysis) was used to develop standard-models using spectra of 12 normal and abnormal specimens each. Leave-one-out crossvalidation yielded classification-efficiency of 90% and 80% for normal and abnormal conditions, respectively. Evaluation with an independent-test data-set comprising of 135 spectra of 9 samples provided sensitivity of 100% and specificity of 70%. Findings of this preliminary study may pave way for objective tumor margin assessment during brain surgery.

The aim of this study is to use the Resonance Raman (RR) and fluorescence spectroscopic technique for tumor margin detection with high accuracy based on native molecular fingerprints of breast and gastrointestinal (GI) tissues. This tumor margins detection method utilizes advantages of RR spectroscopic technique in situ and in real-time to diagnose tumor changes providing powerful tools for clinical guiding intraoperative margin assessments and postoperative treatments. The tumor margin detection procedures by RR spectroscopy were taken by scanning lesion from center or around tumor region in ex-vivo to find the changes in cancerous tissues with the rim of normal tissues using the native molecular fingerprints. The specimens used to analyze tumor margins include breast and GI carcinoma and normal tissues. The sharp margin of the tumor was found by the changes of RR spectral peaks within 2 mm distance. The result was verified using fluorescence spectra with 300 nm, 320 nm and 340 nm excitation, in a typical specimen of gastric cancerous tissue within a positive margin in comparison with normal gastric tissues. This study demonstrates the potential of RR and fluorescence spectroscopy as new approaches with labeling free to determine the intraoperative margin assessment.

Optical coherence tomography (OCT) provides significant advantages of high resolution (approaching the histopathology level) real-time imaging of tissues without use of contrast agents. Based on these advantages, the microstructural features of tumors can be visualized and detected intra-operatively. However, it is still not clinically accepted for tumor margin delineation due to poor specificity and accuracy. In contrast, Raman spectroscopy (RS) can obtain tissue information at the molecular level, but does not provide real-time imaging capability. Therefore, combining OCT and RS could provide synergy. To this end, we present a tissue analysis and classification method using both the slope of OCT intensity signal vs depth and the principle components from the RS spectrum as the indicators for tissue characterization. The goal of this study was to understand prediction accuracy of OCT and combined OCT/RS method for classification of optically similar tissues and organs. Our pilot experiments were performed on mouse kidneys, livers, and small intestines (SIs). The prediction accuracy with five-fold cross validation of the method has been evaluated by the support vector machine (SVM) method. The results demonstrate that tissue characterization based on the OCT/RS method was superior compared to using OCT structural information alone. This combined OCT/RS method is potentially useful as a noninvasive optical biopsy technique for rapid and automatic tissue characterization during surgery.

During the past 10 years from 1988 to 1997, 68 lesions in 68 patients were treated by local resection for early gastric cancers at Akita Red Cross Hospital. The criteria for local resection were 1) intramucosal gastric carcinoma (m-carcinoma) within 30mm in size and having a clear tumor margin, and 2) submucosal gastric carcinoma (sm-carcinoma) within 20mm in size and having an intolerance for major surgery. Local resection was performed to all layer resection (AR) and submucosectomy (SM). Of 51 patients, 42 with m-carcinoma and 9 with sm-carcinoma were treated by AR. Forty-five of them were treated successfully by AR, and the rest underwent additional intervention. Of 17 patients, 14 with m-carcinoma and 3 with sm-carcinoma were treated successfully by SM. There were no recurrences of lymph node and distant metastases. The 5-year survival rate was 100% except for other causes of death, and no cancer deaths. These local resections of early gastric cancers were thought to be effective in improving the postoperative QOL of patients without loss of survival benefit.

Purpose: To spare normal tissue for SBRT lung/liver patients, especially for patients with significant tumor motion, image guided respiratory motion management has been widely implemented in clinical practice. The purpose of this study was to evaluate imaging coordination of cone beam CT, on-board X-ray image conjunction with optical image guidance for SBRT treatment with motion management. Methods: Currently in our clinic a Varian Novlis Tx was utilized for treating SBRT patients implementing CBCT. A BrainLAB X-ray ExacTrac imaging system in conjunction with optical guidance was primarily used for SRS patients. CBCT and X-ray imaging system were independently calibrated with 1.0 mm tolerance. For SBRT lung/liver patients, the magnitude of tumor motion was measured based-on 4DCT and the measurement was analyzed to determine if patients would be beneficial with respiratory motion management. For patients eligible for motion management, an additional CT with breath holding would be scanned and used as primary planning CT and as reference images for Cone beam CT. During the SBRT treatment, a CBCT with pause and continuing technology would be performed with patients holding breath, which may require 3–4 partially scanned CBCT to combine as a whole CBCT depending on how long patients capable of holding breath. After patients being setup by CBCT images, the ExactTrac X-ray imaging system was implemented with patients’ on-board X-ray images compared to breath holding CT-based DRR. Results: For breath holding patients SBRT treatment, after initially localizing patients with CBCT, we then position patients with ExacTrac X-ray and optical imaging system. The observed deviations of real-time optical guided position average at 3.0, 2.5 and 1.5 mm in longitudinal, vertical and lateral respectively based on 35 treatments. Conclusion: The respiratory motion management clinical practice improved our physician confidence level to give tighter tumor margin for sparing normal tissue for SBRT lung/liver patients.

During 4 years we have treated 202 patients with meningiomas using the Leksell γ knife. The results in 156 patients with a postoperative follow-up of at least 6 months were assessed. Collateral edema after radiosurgery occurred in 16 patients (10.3%), and in 8 patients it was asymptomatic. The collateral postirradiation edema gradually improved in 14 patients. The tumor volume increased in 10 patients. In seven patients, enlargement caused by intratumoral edema was temporary and a subsequent decrease in tumor volume was observed. In three patients there was real growth after radiosurgery; in two cases the meningioma was malignant and in one patient the tumor volume was underestimated for radiosurgery. Shrinkage of the tumor was observed in 59 patients (38%). An improvement in the clinical state was observed in 48 patients (31%). An impairment of neurodeficit was observed in 10 patients (6.4%), in 6 patients after the antiedematic corticotherapy neurodeficit gradually improved. An average dose of 13.5 Gy to the tumor margin was applied. The optimal marginal dose for meningioma seems to be in the range of 12–16 Gy. Radiosurgery is a noninvasive treatment method suitable as an alternative treatment for meningiomas when the immediate decompressive effect of open neurosurgery is not necessary.

To evaluate and compare perioperative outcomes of robotic partial nephrectomy (RPN) using robotic and laparoscopic ultrasound probe for tumor identification.Data from 75 consecutive RPN procedures using a laparoscopic ultrasound probe (January 2009- November 2010) and 75 consecutive RPN procedures using a robotic ultrasound probe (November 2010- November 2011) were collected. Perioperative outcomes of the two groups were retrospectively analyzed.A total of 72 patients underwent 75 consecutive RPN using the laparoscopic ultrasound probe followed by 73 patients who underwent 75 consecutive RPNs using the robotic ultrasound probe. Characteristics were similar between groups, and tumors had a similar complexity (mean nephrometry score 6.6 vs. 6.8, p=0.534), mean operating room time (234 vs. 218 min, p=0.095), mean console time (173 vs. 156 min, p=0.071), mean blood loss (171 mL vs. 164 mL, p=0.79), and positive tumor margin rates (1.2% vs. 2.2%, p=1) did not achieve significance. All patients are free of cancer recurrence after a mean follow up of 25.7 months in the laparoscopic probe group and of 10.2 months in the robotic probe group.Robotic ultrasound probes for tumor identification during RPN had comparable perioperative outcomes and surgical margin rates as a laparoscopic ultrasound probe, but with the advantage of surgeon autonomy.

So far only on examples of small tumors in which the excised tumor specimen fitted completely in the device for histological sectioning were discussed. If tumors are larger due to their advanced growth or larger safety margins, the resulting specimen may not fit completely onto the devices used for histological sectioning. In these cases, the excised specimens have to be divided in parts small enough to be sectioned by either cryo-sectioning or paraffin sectioning raising new complex issues of topographical orientation which will be discussed in the following.

The management of a full 3D histology needs a tight communication between the surgeon and the pathologist. Clear and safe rules are necessary to enable both the surgeon and the pathologist to point out areas of incomplete tumor excisions very precisely. In Mohs’ micrographic surgery, the surgeon and pathologist is the same person. This has advantages because a communication with other institutions is not necessary.

Soft tissue sarcomas appear to be an ideal tumor type for delivering preoperative therapy. The rationale for preoperative therapy is that it is delivered to undisturbed tissue planes with well-oxygenated tissue. This is of great benefit for radiation therapy, because with new computed tomography scan treatment planning it is possible to completely delineate the tumor without surgical clips or postoperative hematoma (or both) obscuring the tumor margin.

A 68-year-old woman was admitted to the hospital because of a hard tumor on the right anteriorthoracic wall. Chest CT revealed an expansively growing tumor attached to the 5th rib. Ga scintigraphydemonstrated a high uptake lesion at the tumor. Histological diagnosis could not be made with theincisional biopsy performed prior to the radical operation. The whole thoracic wall containing the tumorwas resected sufficiently apart from the tumor margin. Malignant fibrous histiocytoma (MFH) showinga striform-pleomorphic pattern was recognized histologically with the resected specimen. MFH commonly arises in the soft tissues of the extremities, but rarely in those of the chest. This paper also presentsa review of 22 reported cases of MFH originated from the thoracic soft tissues in Japan.

The authors describe a method of using the C7-T3 spinous processes visualized on MRI as landmarks for localizing thoracic spinal lesions in 19 cases. This method included six steps. First, the “spinous process nearest to the lesion that was visible on the MRI image” was identified. Second, a dashed line was drawn on the image through the tip of the identified spinous process perpendicular to the skin surface. Third, two additional dashed lines parallel to the first dashed line were drawn from the upper and lower margins of the lesion. Fourth, the distances between the identified process and the two additional dashed lines were measured. Fifth, the same “spinous process nearest to the lesion” was identified by palpation and marked on the patient’s skin. Sixth, the upper and lower margins of the lesion were marked on the skin according to the two distances measured in step 4. After the lesion was exposed, the deviations of the lesion margins were measured. All 19 cases of the thoracic spinal lesions were localized correctly using the C7-T3 spinous processes visualized on the MRI images as landmarks without any other evaluation methods. The deviation value for the localization of the tumor margin was 4.1 ± 1.47 mm. Using the C7-T3 spinous processes as landmarks is an accurate, simple, and economic method for lesion localization during thoracic spinal surgery.