Evaluating the Effect of MarginProbe® Use on Re-excisions After Partial Mastectomy: A Single-Institution Analysis.

BACKGROUND: Breast conservation therapy is a widely accepted approach in treating breast cancer, yet the average re-excision rates are approximately 25% despite surgical advancements. The Food and Drug Administration (FDA)-approved MarginProbe® device uses radiofrequency spectroscopy for intraoperative margin assessment, potentially reducing re-excision rates. This study evaluated the effectiveness of MarginProbe® in reducing re-excisions compared with standard of care (SOC). METHODS: A prospective cohort with MarginProbe® usage during partial mastectomies from June 2019 to July 2023 (153 patients) was compared with a retrospective control group without the device from January 2015 to May 2019 (300 patients). Both groups underwent partial mastectomies performed by two breast surgeons. Positive margins were defined as tumor on ink for invasive cancers and within 2 mm for ductal carcinoma in situ. RESULTS: When control was used for patient demographics and tumor characteristics, the findings showed that MarginProbe® significantly decreased the probability of re-excision by 58% (p < 0.001), although it led to a higher shave volume, with an average of 9.8 cc additional tissue removed compared with SOC (p < 0.001). Human epidermal growth factor 2 (HER2) positivity was significantly associated with increased odds of re-excision (p = 0.036). MarginProbe® demonstrated a sensitivity of 70.1% and a specificity of 47.5%. CONCLUSIONS: MarginProbe® is an effective adjunct for intraoperative margin assessment to decrease re-excision rates. However, patient selection is paramount. Given its significant increase in shave volume, women with small breasts may be at higher risk for poor cosmesis. Surgeons should exercise clinical judgement when determining the suitability of MarginProbe® use for patients undergoing breast conservation. Further research is necessary to refine MarginProbe®'s specificity and to optimize its clinical application.

Intraoperative evaluation of surgical margins in breast cancer.

Achieving clear resection margins at the time of lumpectomy is essential for optimal patient outcomes. Margin status is traditionally determined by pathologic evaluation of the specimen and often is difficult or impossible for the surgeon to definitively know at the time of surgery, resulting in the need for re-operation to obtain clear surgical margins. Numerous techniques have been investigated to enhance the accuracy of intraoperative margin and are reviewed in this manuscript.

Clinical Impact and Accuracy of Shave Biopsy for Initial Diagnosis of Cutaneous Melanoma.

INTRODUCTION: Effective treatment of malignant melanomas is dependent upon accurate histopathological staging of preoperative biopsy specimens. While narrow excision is the gold standard for melanoma diagnosis, superficial shave biopsies have become the preferred method by dermatologists but may transect the lesion and result in inaccurate Breslow thickness assessment. This is a retrospective cohort study evaluating an initial method of biopsy for diagnosis of cutaneous melanoma and indication for reoperation based on inaccurate initial T-staging. METHODS: We retrospectively analyzed consecutive patients referred to the Medical College of Wisconsin, a tertiary cancer center, with a diagnosis of primary cutaneous melanoma. Adult patients seen between 2015 and 2018 were included. Fisher's exact test was used to assess the association between method of initial biopsy and need for unplanned reoperation. RESULTS: Three hundred twenty three patients with cutaneous melanoma from the head and neck (H&N, n = 101, 31%), trunk (n = 90, 15%), upper extremity (n = 84, 26%), and lower extremity (n = 48, 28%) were analyzed. Median Breslow thickness was 0.54 mm (interquartile range = 0.65). Shave biopsy was the method of initial biopsy in 244 (76%), excision in 23 (7%), and punch biopsy in 56 (17%). Thirty nine (33%) shave biopsies had a positive deep margin, as did seven (23%) punch biopsies and 0 excisional biopsies. Residual melanoma at definitive excision was found in 131 (42.5%) of all surgical specimens: 95 (40.6%) shave biopsy patients, 32 (60.4%) punch biopsy patients, and four (19.0%) excision biopsy patients. Recommendations for excision margin or sentinel lymph node biopsy changed in 15 (6%) shave biopsy patients and five (9%) punch biopsy patients. CONCLUSIONS: Shave biopsy is the most frequent method of diagnosis of cutaneous melanoma in the modern era. While shave and punch biopsies may underestimate true T-stage, there was no difference in need for reoperation due to T-upstaging based on initial biopsy type, supporting current diagnostic practices. Partial biopsies can thus be used to guide appropriate treatment and definitive wide local excision when adjusting for understaging.

Remarkable efficiency of surgical shave excision of keloids followed by intralesional injection of Bleomycin. A retrospective study of 314 cases.

The aim of this study was to determine the efficiency of a keloid treatment consisting of intradermal surgical shave excision followed by intralesional injections of Bleomycin. A retrospective study performed in the Department of Dermatology, CHU UCL Namur Sainte Elisabeth Clinic, Belgium between 2018 and 2019, on 314 patients with keloids-average age: 32 years (range 19-62). Patients were treated first by surgical shave excision and then after reepithelialization, monthly Bleomycin injections were used until the itching and/or pain ceased and the keloid disappeared. The satisfaction index based on Vancouver Scar Scale on the 314 patients was as follows: 87% of the patients were very satisfied with complete flattening (276 patients), 11% were moderated satisfied with significant flattening (32 patients), and 2% show recurrences (6 patients). Pain and itching disappear totally (100% of patients) based on Visual Analogue Scale. The absence of recurrence within 24 months of the last injection, leads us to believe that this can be a first choice and low-cost treatment, whatever the phototype and the size of the lesion. This treatment can be given in all regions of the world, including in non-industrialized or developing countries.

Prognostic factors for residual occult disease in shave margins during partial mastectomy.

PURPOSE: Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins. METHODS: Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors. RESULTS: 166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28 months (9-50 months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS. CONCLUSION: Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.

[Long-term healing of a therapy-refractory venous leg ulcer after crural fasciectomy and split skin graft transplantation]. / Langfristige Abheilung eines therapierefraktären Ulcus cruris venosum nach kruraler Fasziektomie und Spalthauttransplantation.

A 59-year-old obese woman had been suffering from a painful, chronic leg ulcer since 1986. We diagnosed a venous leg ulcer due to functional chronic venous insufficiency in the context of obesity per magna (dependency syndrome) and arthrogenic congestion syndrome due to immobility. Although a high ligation and stripping of the great saphenous vein and several so-called shave therapies with split skin transplantation after appropriate wound bed preparation had been previously performed, the wound persisted. In 2012, the patient wanted to amputate her leg because the course of wound healing was so refractory to therapy and she suffered from severe pain. As an alternative to amputation, we performed a crural fascietomy and, after a wound bed preparation with two cycles of negative pressure wound therapy, we covered the defect with a split skin graft using the mesh graft technique. The surgery could be performed without complications and the skin healed completely. At the current presentation 7 years after the intervention, complete healing of the previously therapy-refractory venous leg ulcer was shown despite the persistent obesity per magna and immobility. This case report shows that a crural fasciectomy should be considered, especially in the case of otherwise therapy-refractory courses of venous leg ulcers.

Preputial melanoma.

BACKGROUND: Melanomas of the glans penis, prepuce, and the corpus of the penis account for less than 1% of all melanoma cases. Due to this rarity, there is currently no standard treatment approach. CASE DESCRIPTION: We present the case of a 59-year-old patient with tumorous formations in the prepuce area. Histology was lacking at presentation. Medical history contained excision of a single formation with the character of a viral wart in the same area 1 year previously, with electrodesiccation for relapse a few months later. Due to the appearance of new bumps, the patient presented to the Onkoderma polyclinic. Dermatological examination revealed two nodular tumor formations: one with an erosive surface in the area of the prepuce and one subcutaneous lesion in the area of the right cavernous body. Differential diagnosis included Merkel carcinoma, dermatofibrosarcoma protuberans, anaplastic T/B cell lymphoma, and achromatic melanoma. Histology showed epithelioid cell infiltration and immunohistochemistry was positive for S100 protein, HMB 45, and melan A. Achromatic preputial malignant melanoma was diagnosed. The subcutaneous formation in the area of the cavernous body was defined as an in-transit metastasis. Penectomy under spinal anesthesia was planned. CONCLUSION: The prognosis for penile melanoma patients is currently poor, probably because of delays in diagnosis. Histopathologic evaluation after excision should be standard to prevent possible severe consequences such as penectomy and partial penile amputation.

Impact of systematic cavity shave margins in breast-conserving surgery at a large community hospital with a low baseline re-excision rate.

Systematic cavity shave margins (CSM) can decrease rate of positive margins and re-excision beyond that of selective CSM. The objective of this study was to determine whether systematic CSM decreased re-excision rate in a population with a low baseline re-excision rate. We conducted a retrospective chart review of patients who underwent breast-conserving surgery (BCS) from November 2013 to November 2017. Primary end points were re-excision rate and margin status. Secondary end points were total volume of tissue excised, operative time, and concordance of core needle biopsy (CNB) pathology with final surgical pathology. The re-excision rates were 14.29% in the no shave margin group; 15.38% in the selective CSM; and 14.59% in the systematic CSM (P = .985). Odds of re-excision with ductal carcinoma in situ (DCIS) was 5.04 times greater than with invasive cancer (INV) and 1.94 times higher than with INV and DCIS. There was no significant difference in positive margins between groups (P = .362). Mean specimen volume was lowest in the systematic CSM group (64.6 cm3 ), compared to no CSM and selective CSM (94.6 cm3 and 91.8 cm3 , respectively). With inclusion of shave margin volumes, total volume removed was not significantly different between no shave margin group (94.6 cm3 ) and systematic CSM (89.7 cm3 ) (P = .949). For patients with invasive ductal carcinoma (IDC) alone on their initial biopsy pathology, 69% were discovered to also have DCIS upon final pathology. Re-excision rate and specimen volume between all groups were not statistically different. There was a higher re-excision rate when DCIS was present, especially when not identified on CNB. As systematic CSM is most impactful when DCIS is involved, it is important to establish its presence for proper surgical planning.

Prospective study of pigmented lesions managed by shave excision with no deep margin transection of melanomas.

Shave excision is a simple and cost-effective technique for the removal of suitable skin lesions. We performed a prospective study over six months, collecting data from pigmented lesions that were treated with shave excision by dermatologists. Only shave excisions with the intent to remove the lesion in toto were included. A total of 349 lesions were included in this study, 50 (14%) of these were melanomas and no melanoma diagnosed had deep margin involvement, while 13 (26%) had lateral margin involvement.

Think before you shave: Factors influencing choice of biopsy technique for invasive melanoma and effect on definitive management.

BACKGROUND/OBJECTIVE: Partial biopsies are sometimes used for melanoma diagnosis with anticipated time and cost savings compared to excisional biopsy. However, their impact on subsequent melanoma management is unknown. Determine factors related to choice of partial over excisional biopsy to diagnose invasive melanoma and examine the effect of partial biopsies on definitive melanoma management. METHOD: Retrospective repeated cross-sectional population-based study through the Victorian Cancer Registry of diagnosed melanomas in 2005, 2010 and 2015. A random sample of 400 patients per year, stratified by tumour thickness, was selected. RESULTS: A total of 1200 patients had 833 excisional and 337 partial biopsies. Omission of suspected diagnosis on pathology requests affected 46% (532/1151) of all diagnostic biopsies. Diagnostic suspicion did not influence preference for partial over excisional biopsy [Odds Ratio (OR) 1.2, 95%CI 0.8-1.7; P = 0.40]. The partial:excisional biopsy usage ratio was higher in patients aged > 50 years than patients aged <50 years [relative risk ratios (RRR) 1.5; 95%CI 1.0 to 2.2; P = 0.03]. In 34% and 17% of tumours diagnosed with punch and shave, respectively, three procedures were required for definitive excision instead of two, compared with 5% of excisional biopsies When partial biopsy was used, patients were at greater risk of requiring three-staged excisions when controlled for age, anatomical site, melanoma subtype and thickness (RRR 6.7; 95%CI 4.4-10.1; P < 0.001). CONCLUSION: Diagnostic suspicion does not appear to be a major factor influencing choice of biopsy technique. Using partial biopsy to diagnose melanoma often leads to an extra procedure for definitive treatment compared with excisional biopsy.

Assessment of Shave Removal Without Further Excision in the Treatment of Spitz Nevi: A Retrospective Study of 58 Cases.

BACKGROUND: Spitz nevi (or tumors) are noncancerous growths that are found particularly in the pediatric population. Their histologic features overlap with melanoma, but they have a favorable prognosis, even when showing atypical features. OBJECTIVES: The aim of this research is to examine whether Spitz nevi can be sufficiently removed by adequate shave excisions without a subsequent excision. METHODS: Melan-A stained shave removal specimens (SRS) were obtained for 58 consecutively diagnosed Spitz nevi, along with slides of their postshave excision specimens. The SRS were reviewed for negative (clear) margins, defined as no neoplastic melanocytes detected within <0.2 mm of the deep and lateral margins of the specimen. Postshave excision specimens were reviewed for residual or recurrent lesions. RESULTS: The 15 shave excision specimens with negative margins had no corresponding residual lesions on postshave specimens. There were no recurrences in any of the cases in an average of 17 months of follow-up. CONCLUSIONS: Observation may be a logical approach for the management of Spitz nevi when shave removal achieves clear margins and the lesion lacks atypical features.

Wound Care With a Porcine Extracellular Matrix After Surgical Treatment of Rhinophyma.

BACKGROUND: Rhinophyma surgery is commonly associated with prolonged wound healing and the need for multiple wound dressings. OBJECTIVES: To evaluate clinical outcome with a porcine extracellular matrix (ECM) after shave excision of rhinophyma compared with common wound care procedure. MATERIALS AND METHODS: Retrospective analysis of patients with common dressings (CD) compared with patients with additional ECM (OASIS) application. Clinical findings were assessed prior to treatment and at follow-up visit using the Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale (VSS), and Rhinophyma Severity Index (RHISI). RESULTS: Overall, 28 patients (67.5 ±9.0 years) with a mean wound area of 33.9 (±8.5) cm² were included. After a mean follow-up period of 132 (±73) days, scales of POSAS, VSS, and RHISI showed significant (P< .0001) reductions of 47.0% (±11.1), 56.0% (±12.0), and 62.3% (±14.3), respectively. Subgroup analysis showed no significant differences of aforementioned parameters between the ECM group (n= 17) and CD group (n= 11). In contrast, the number of dressing changes were significantly (P< .006) less in the ECM group (1.4 ±0.8) compared with CD group (4.1 ±2.6). The ECM group showed a significant (P< .017) shorter time to re-epithelization (10.5 ±1.7 days) than the CD group (13.1 ±2.2 days). CONCLUSIONS: The application of porcine ECM is practicable and reduces the number of dressing changes and time to re-epithelization clearly. Crusts are scaling off spontaneously without any aggressive action needed. Our findings indicate that ECM application is a promising approach for rhinophyma wound care.

Facial Feminization Surgery: A Review of 220 Consecutive Patients.

Background Facial feminization surgery (FFS) is a combination of facial bony and soft tissue surgeries designed to modify and convert a masculine face to feminine. One's face plays a very central role in gender incongruence and FFS helps patients overcome this. There are prominent differences between the male and the female facial anatomy (bony and soft tissue) which can be surgically altered to change the visual perception of the face. Methods The author presents the method used at his center for treating 220 patients of gender incongruence requesting FFS from June 2016 to June 2019. The alterations to known methods of forehead contouring, hairline lowering, and jaw shave adopted by his team are discussed. He also presents the logic of performing the entire FFS in two stages at an interval of 7 to 10 days. Results A total of 220 cases of FFS are presented, along with surgical details of techniques used, the sequence and staging of procedures performed, and the results obtained. A two-staged approach to FFS is proposed to maximize the recovery and minimize complications and promote faster healing. Different methods of forehead contouring are also explained in detail. Conclusions FFS is a very rewarding surgery for the plastic surgeon and has high patient satisfaction rate. With proper training in craniomaxillofacial and soft tissue surgery, it is possible for the plastic surgeon to be the main team leader for this procedure. A two-stage approach is highly recommended.

Modified shave surgery combined with nail window technique for the treatment of longitudinal melanonychia: Evaluation of the method on a series of 67 cases.

BACKGROUND: Nail matrix histopathologic examination is still the criterion standard to diagnose longitudinal melanonychia (LM). OBJECTIVE: To introduce modified shave surgery combined with the nail window technique for managing LM and evaluate the postoperative outcome of the procedure. METHODS: We retrospectively reviewed the medical records of 67 patients with LM who underwent shave surgery combined with the longitudinal-strip nail window technique at our institution from March 2015 to June 2018. RESULTS: Pathologic diagnosis was accessible in all cases, and 60 cases were assessable for the postoperative outcomes. A total of 45 cases (75.0%) had no postoperative nail dystrophy, and recurrence of nail pigmentation was found in only 8 cases (13.3%). LIMITATIONS: This was a retrospective study. CONCLUSION: Modified shave surgery combined with the nail window technique is the preferable management for LM cases, with limited postoperative nail dystrophy and recurrence of pigmentation.

Accuracy of partial biopsies in the management of cutaneous melanoma.

BACKGROUND: The recommended method for histopathological diagnosis of cutaneous melanoma is excisional biopsy, although partial biopsies (shave and punch) are often used. Following a partial biopsy, treatment guidelines recommend a narrow excisional biopsy to plan definitive management. There is limited evidence on the benefits of direct wide local excision (WLE) following diagnostic partial biopsies. METHODS: Retrospective cohort study of cutaneous melanoma cases, from two tertiary referral centres from January 2013 to December 2015. Demographic and histopathological data, including tumour thickness (T-stage) from initial biopsy and subsequent excisions, were collected. Logistic regression was used to examine histopathological T-staging between biopsy and subsequent excisions (upstaging). RESULTS: 2304 melanomas (2157 patients) were identified; 455 shave, 308 punch, 14 incisional and 1527 excisional biopsies. Out of 1527, 5 (<1%) excisional biopsies were upstaged from original biopsy T-stage to final WLE; compared to 28/455 (6%) for shave, 45/308 (15%) for punch and 2/14 (14%) for incisional biopsies. Histopathology upstaging were increased with punch (OR, 52.1; 95% CI, 20.5-132.4. P < 0.001) and shave biopsy (OR, 20.0; 95% CI, 7.7-52.0. P < 0.001) compared to excisional biopsy. Upstaging rates of 9.4% for desmoplastic (OR, 6.9; 95% CI, 2.4-19.7. P < 0.001) and 21.9% for acral lentiginous (OR, 18.4; 95% CI, 6.9-49.2. P < 0.001) melanomas were elevated compared to 1.4% for superficial spreading melanoma. CONCLUSIONS: In most cases, partial biopsy (particularly shave biopsy) can provide sufficient information to plan for definitive surgical melanoma management. Punch and incisional biopsies have elevated upstaging rates, a consideration in planning therapy. Partial biopsies of desmoplastic or acral lentiginous melanomas have high rates of upstaging and should have a complete excision prior to definitive treatment.

Initial Misidentification of Thumb Poroma by Shave Biopsy.

Poromas are benign adnexal neoplasms originating from the intraepidermal portion of sweat gland ducts. With the possibility of malignant transformation, accurate clinical diagnosis and treatment are crucial. Numerous reports of hand poroma lesions have been reported. We present an unusual case of a distal thumb poroma originally identified as a squamous cell lesion in a shave biopsy and eventually accurately identified after excisional biopsy. This report highlights the limitations of shave biopsy associated with soft tissue hand lesions and the need to consider poroma when evaluating a soft tissue lesion of the hand.

The impact of preoperative magnetic resonance imaging and lumpectomy cavity shavings on re-excision rate in pure ductal carcinoma in situ-A single institution's experience.

BACKGROUND AND OBJECTIVES: The impact of preoperative magnetic resonance imaging (pMRI) and cavity shave margins (CSM) on re-excision rate (RR) in DCIS is unclear. We investigated whether either modality was associated with RR in DCIS. METHODS: This is a single-institution retrospective study of 295 women undergoing breast conservation surgery for pure DCIS (2010-2013). CSM were the systematic resection of 4-6 margins during lumpectomy whereas selective shave margins (SSM) were the selective resection of 1-3 margins. Patient demographics and clinical characteristics were abstracted. RR was analyzed according to the use of pMRI, SSM, or CSM with respect to three high-volume breast surgeons at our institution. RESULTS: RR was not associated with the use of pMRI (P = 0.87). Any shave margins (P = 0.05), DCIS size (P < 0.001), and DCIS grade (P = 0.14) associated with a lower RR. Of our high-volume surgeons, RR was lower for Surgeon A (P = 0.02). Multivariate analyses showed larger DCIS (OR 1.35, P = 0.005) and practices specific to surgeons B (OR 3.23, P = 0.04) and C (OR 3.57, P = 0.04) increased re-excision odds. CONCLUSIONS: SSM/CSM and pMRI use varied among surgeons. Our results suggested the routine use of CSM, not pMRI, could lower re-excision rate, which highlighted a quality improvement opportunity at our institution.

Wound infection after inpatient pediatric skin biopsy.

Punch and shave biopsies are important dermatologic procedures in the inpatient setting but have a risk of wound infection. Data on the incidence of infection in this setting are limited and conflicting. This retrospective study of 127 pediatric inpatients at two tertiary care centers who underwent biopsy demonstrated a low overall risk of infection (n = 1, 0.8%). Twenty-five (19.7%) were neutropenic, and 51 (40.2%) were not taking systemic antibiotics at the time of biopsy; none of these patients developed a wound infection. The overall low rate of infection should reassure physicians who are balancing the risks and benefits of performing a skin biopsy in children in the inpatient setting and suggests that physicians should not defer clinically indicated biopsies because of concern about infection.