Complete Tissue Submission to Increase Lymph Node Detection in Pelvic Lymph Node Packets Submitted for Patients Undergoing Radical Prostatectomy and Radical Cystectomy.

BACKGROUND: Pelvic lymphadenectomy has prognostic and therapeutic implications in both bladder and prostate cancer. Pelvic lymphadenectomy specimens are fatty and identification of lymph nodes (LNs) can be difficult during the grossing process. We investigated the benefit of a new grossing method requiring entire LN packet submission. MATERIALS/METHODS: We introduced a new grossing protocol requiring total submission of LN packets for patients undergoing radical prostatectomy (RP) or radical cystectomy (RC). A retrospective review was performed to evaluate clinical and pathologic data for RP (n = 59) and RC (n = 56) cases performed 18 months prior to and 18 months following implementation of the new lymphadenectomy grossing protocol. RESULTS: For RP and RC cases, significantly more LNs were found when total LN packets were submitted with the new technique: mean 14.1 versus 8.7, and mean 25.2 versus 15.9, respectively ( P = .007, P = .011). For RP cases, there was no significant change in the number of LN packets submitted for evaluation from the operating room ( P = .76). For RC cases, more LNs were found with the new technique despite a significantly fewer number of LN packets sent from the operating room in the cohort that were processed with the new technique: mean 2.2 versus 4.0 LN packets ( P < .001). Significantly more paraffin blocks were required using the new grossing method for both RP and RC: mean 13.53 versus 6.9 and mean 19.0 versus 12.4, respectively ( P < .001, P = .018). CONCLUSIONS: Submitting all additional fatty tissue after palpable identification of LNs can significantly increase the detection of LNs in RP and RC cases.

Outcomes after surgical salvage for recurrent oropharyngeal squamous cell carcinoma.

OBJECTIVE: Compare human papillomavirus (HPV) status and outcomes in patients undergoing salvage surgical resection for a recurrent oropharyngeal squamous cell carcinoma (OPSCC). METHODS: Case series with chart review (2005-2013). RESULTS: Sixty-nine patients were identified who underwent salvage surgical resection for a recurrent OPSCC after primary radiation therapy. There was no difference in the incidence of HPV negative (52%; n=36) and HPV positive (48%; n=33) tumors. The mean time from completion of radiation therapy to salvage surgery was 2.4years. At the time of salvage operation, there was no correlation with HPV status, as assessed by p16 immunohistochemistry, and lymph node metastases (p=0.21), T classification (p=0.22), tracheostomy dependence (p=0.59), gastrostomy tube dependence (p=0.82), or duration from radiation therapy (p=0.63). The majority of patients were either current or former tobacco users (75%) and of the HPV positive patients, 66% were tobacco users. Development of a new recurrence after salvage surgical resection occurred in 33% of patients (n=26), with a higher incidence in patients with HPV negative disease (52%, n=17/33; p=0.05). The overall 2- and 5-year survival rates were 0.47 and 0.23. There was no difference in overall survival rates when stratified by HPV status or tobacco use. Decreased overall 5-year survival rates did correlate with cervical lymph node metastases (p=0.01), advanced tumor stage (p=0.04) and dependence on gastrostomy tube postoperatively (p=0.04). CONCLUSIONS: This study found cervical lymph node metastases, clinical stage, and dependence on gastrostomy tube for nutrition to have the greatest impact on overall survival for patients with recurrent OPSCC.

Frozen section: guiding the hands of surgeons?

Frozen section (FS) analysis is a powerful tool that can provide a rapid diagnosis, directing operative management. However, FSs can also be misused. We consider an FS to be "inappropriate" when it does not influence operative management or immediate patient care. Not only can inappropriate FSs compromise diagnostic material, they can impact turnaround time of other FSs. We evaluated the utilization of FSs at our institution and assessed influence on intraoperative management. Frozen sections performed at the University of Alabama at Birmingham Hospital in 2013 were stratified by surgical subspecialty. Operative, clinical, and pathology notes were reviewed to determine the rationale for sending each FS and to determine impact on intraoperative management. Cases lacking operative notes were excluded. A total of 4104 FSs were performed in 1896 cases. Surgical subspecialties included cardiothoracic, otolaryngology, breast, surgical oncology, gynecology, gastrointestinal, hepatobiliary, urology, transplant, and orthopedics. 42.5% of FSs evaluated margin status, 34.8% confirmed or excluded malignancy, 9.5% were for tumor classification, 6.7% assessed adequacy for diagnosis, 1.9% were to confirm or exclude infection, 2.8% were for transplant, and 1.8% were for lymphoma workup. Twelve percent (491/4104) of FSs did not influence operative management. This was most common among cardiothoracic surgeries (34%). No inappropriate FSs were sent for any transplant surgeries. Otolaryngology used the most FSs and had less than 1% that were inappropriate. Most FSs influence operative management. The rationale for sending an FS and its influence on operative management was subspecialty dependent. Interdepartmental discussions of FS utilization might be helpful in the elimination of unnecessary FSs.