Residual cancer burden in two-stage nipple sparing mastectomy after first stage lumpectomy and devascularization of the nipple areolar complex.

PURPOSE: Ischemic complications after nipple-sparing mastectomy (NSM) can be ameliorated by 2-stage procedures wherein devascularization of the nipple-areolar complex (NAC) and lumpectomy with or without nodal staging surgery is performed first (1S), weeks prior to a completion NSM (2S). We report the time interval between procedures in relation to the presence of residual carcinoma at 2S NSM. METHODS: Women with breast cancer who received 2S NSM from 2015 to 2022 were identified. Both patient level and breast level analyses were conducted. Clinical staging at presentation, pathologic staging at 1S and residual disease at 2S pathology are noted. Residual disease was classified as microscopic (1-2 mm), minimal (3-10 mm), and moderate (> 10 mm). RESULTS: 59 patients (108 breasts) underwent 2S NSM. The median time interval between 1 and 2S for all patients was 34 days: 31 days for upfront surgery invasive cancer, 41 days for upfront DCIS surgery and 31 days for those receiving neoadjuvant therapy. Completion NSM was performed within 6 weeks for 72% of the breasts analyzed. Of the 53 breasts with invasive cancer on 1S pathology, 35% (19/53) had no residual invasive disease and 24.5% (13/53) had neither residual invasive nor in situ carcinoma on final 2S. Among the 50 women who had upfront surgery, 16 (32%) had residual invasive cancer found at 2S NSM, 9 of which had less than or equal to 1 cm disease. CONCLUSION: Invasive cancers were completely resected during 1S procedure in 65% of breasts. Residual disease was minimal and there was only one case of upstaging at 2S. Added time of two-stage surgery is offset by a reduction in ischemic mastectomy flap complications.

Nipple-areola-complex preservation and obesity-Successful in stages.

BACKGROUND: The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS: Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS: Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS: Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies.

BACKGROUND: Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. METHODS: O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. RESULTS: Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m2. Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7 g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. CONCLUSIONS: The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Trastuzumab Emtansine for Residual Invasive HER2-Positive Breast Cancer.

BACKGROUND: Patients who have residual invasive breast cancer after receiving neoadjuvant chemotherapy plus human epidermal growth factor receptor 2 (HER2)-targeted therapy have a worse prognosis than those who have no residual cancer. Trastuzumab emtansine (T-DM1), an antibody-drug conjugate of trastuzumab and the cytotoxic agent emtansine (DM1), a maytansine derivative and microtubule inhibitor, provides benefit in patients with metastatic breast cancer that was previously treated with chemotherapy plus HER2-targeted therapy. METHODS: We conducted a phase 3, open-label trial involving patients with HER2-positive early breast cancer who were found to have residual invasive disease in the breast or axilla at surgery after receiving neoadjuvant therapy containing a taxane (with or without anthracycline) and trastuzumab. Patients were randomly assigned to receive adjuvant T-DM1 or trastuzumab for 14 cycles. The primary end point was invasive disease-free survival (defined as freedom from ipsilateral invasive breast tumor recurrence, ipsilateral locoregional invasive breast cancer recurrence, contralateral invasive breast cancer, distant recurrence, or death from any cause). RESULTS: At the interim analysis, among 1486 randomly assigned patients (743 in the T-DM1 group and 743 in the trastuzumab group), invasive disease or death had occurred in 91 patients in the T-DM1 group (12.2%) and 165 patients in the trastuzumab group (22.2%). The estimated percentage of patients who were free of invasive disease at 3 years was 88.3% in the T-DM1 group and 77.0% in the trastuzumab group. Invasive disease-free survival was significantly higher in the T-DM1 group than in the trastuzumab group (hazard ratio for invasive disease or death, 0.50; 95% confidence interval, 0.39 to 0.64; P<0.001). Distant recurrence as the first invasive-disease event occurred in 10.5% of patients in the T-DM1 group and 15.9% of those in the trastuzumab group. The safety data were consistent with the known safety profile of T-DM1, with more adverse events associated with T-DM1 than with trastuzumab alone. CONCLUSIONS: Among patients with HER2-positive early breast cancer who had residual invasive disease after completion of neoadjuvant therapy, the risk of recurrence of invasive breast cancer or death was 50% lower with adjuvant T-DM1 than with trastuzumab alone. (Funded by F. Hoffmann-La Roche/Genentech; KATHERINE ClinicalTrials.gov number, NCT01772472 .).

Patient perspectives on window of opportunity clinical trials in early-stage breast cancer.

PURPOSE: Window of opportunity trials (WOT) are increasingly common in oncology research. In WOT participants receive a drug between diagnosis and anti-cancer treatment, usually for the purpose of investigating that drugs effect on cancer biology. This qualitative study aimed to understand patient perspectives on WOT. METHODS: We recruited adults diagnosed with early-stage breast cancer awaiting definitive therapy at a single-academic medical center to participate in semi-structured interviews. Thematic and content analyses were performed to identify attitudes and factors that would influence decisions about WOT participation. RESULTS: We interviewed 25 women diagnosed with early-stage breast cancer. The most common positive attitudes toward trial participation were a desire to contribute to research and a hope for personal benefit, while the most common concerns were the potential for side effects and how they might impact fitness for planned treatment. Participants indicated family would be an important normative factor in decision-making and, during the COVID-19 pandemic, deemed the absence of family members during clinic visits a barrier to enrollment. Factors that could hinder participation included delay in standard treatment and the requirement for additional visits or procedures. Ultimately, most interviewees stated they would participate in a WOT if offered (N = 17/25). CONCLUSION: In this qualitative study, interviewees weighed altruism and hypothetical personal benefit against the possibility of side effect from a WOT. In-person family presence during trial discussion, challenging during COVID-19, was important for many. Our results may inform trial design and communication approaches in future window of opportunity efforts.

Minimizing Postoperative Pain in Autologous Breast Reconstruction With the Omental Fat-Augmented Free Flap.

INTRODUCTION: The omental fat-augmented free flap (O-FAFF) is a recently developed technique for autologous breast reconstruction. Our aim of the study is to evaluate the outcomes of our early case series. We assess the O-FAFF donor site morbidity in terms of postoperative pain, narcotic, and antiemetic use. METHODS: A retrospective analysis of patients undergoing O-FAFF from 2019 to 2021 was performed. Patients were evaluated for demographic data, operative time, hospital course, and complications. Mean pain scores (1-10 scale) and narcotic pain medication use in oral morphine equivalents and doses of antiemetic medications during their hospital course were analyzed. We compared outcomes of our O-FAFF group with those of a control group of patients who underwent breast reconstruction with traditional free abdominal tissue transfer. RESULTS: A total of 14 patients underwent O-FAFF breast reconstruction, representing 23 breasts. Patients had an average age of 48.5 years (±2.3 years) and body mass index of 22.6 kg/m 2 (±1.09 kg/m 2 ). Average follow-up was 232 days (±51 days). Average mastectomy weight was 245.6 g (±30.2 g) and average O-FAFF weight was 271 g (±31.7 g). Average pain scores on postoperative day 1 (POD1), POD2, and POD3 were 3.1 (±0.28), 2.8 (±0.21), and 2.1 (±0.35), respectively. The average narcotic use by patients in oral morphine equivalents on POD1, POD2, and POD3 are 24.3 (±5.5), 21.9 (±4.6), and 6.2 (±2.4), respectively. Total narcotic use during hospital stay was 79.4 mg (±11.1 mg). Average pain scores and narcotic use are significantly lower when compared with a previously published cohort of patients who underwent autologous breast reconstruction with free abdominal tissue transfer ( P < 0.05). Average antiemetic use was lower in the O-FAFF group compared with the control group: 3.5 versus 4.8 doses ( P = 0.6). Hospital length of stay was 3.0 days (±0.0 days). No complications were noted (0%). Patients were universally satisfied with their reconstructive outcome (100%). CONCLUSIONS: The O-FAFF is proven to be a viable method of autologous breast reconstruction. Early series of patients undergoing O-FAFF reconstruction suggest a lower donor site morbidity as demonstrated by lower postoperative pain scores and lower consumptions of narcotic pain medications.

Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss.

BACKGROUND: Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM. METHODS: Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses. RESULTS: From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75). CONCLUSIONS: Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

Skin angiography assisted mastectomy in secondary breast angiosarcoma: Complete clinical response after neoadjuvant immunotherapy.

Radiation-induced breast angiosarcoma, or secondary angiosarcoma (SAS), is a rare entity with a high risk of metastatic recurrence. Herein, we describe the use of intraoperative fluorescence-based skin angiography to guide surgical resection following a novel immunotherapy-based regimen for SAS resulting in a complete pathological response.

Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study.

BACKGROUND: Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage. METHODS: We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure. RESULTS: Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group. CONCLUSIONS: Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

Dilemma in management of hemorrhagic myositis in dermatomyositis.

Dermatomyositis (DM) is a rare inflammatory disorder affecting the muscle and skin. DM patients can present with spontaneous muscle hemorrhage, a potentially fatal complication. The best practice for management of hemorrhagic myositis in these patients remains unclear. Here we discuss the case of a patient who presented with progressive muscle weakness and intermittent rash that was diagnosed with dermatomyositis. During admission, she developed spontaneous hemorrhagic myositis of the right pectoralis major treated with surgical evacuation. She also developed a spontaneous left anterior thigh hematoma which was treated conservatively. She recovered and showed no evidence of recurrent bleeding at either location. We performed a literature review and identified ten cases of spontaneous hemorrhage in DM patients, with a 60% mortality rate among reported cases. Given the high mortality rate associated with spontaneous hemorrhage in DM patients, it is important for physicians to be aware of the diagnosis, workup, and management strategies.

Pretreatment Tattoo Marking of Suspicious Axillary Lymph Nodes: Reliability and Correlation with Sentinel Lymph Node.

BACKGROUND: Tattooing is an alternative method for marking biopsied axillary lymph nodes (ALNs) before initiation of treatments for newly diagnosed breast cancer. Detection of black ink-stained nodes is performed under direct visualization at surgery and is combined with sentinel node (SLN) mapping procedures. METHODS: Women with newly diagnosed breast cancer who underwent fine or core-needle biopsy of suspicious ALNs were recruited. The nodal cortex and perinodal soft tissue was injected with 0.1-1.0 ml of Spot™ (GI Supply) black ink under ultrasound guidance. Intraoperatively, black stained nodes were removed along with SLNs, noting concordance between the two. RESULTS: Sixty-six evaluable patients were enrolled (2013-2017). Nineteen received surgery first (Group 1) and 47 neoadjuvant therapy (NAT, Group 2). The average number of nodes tattooed was 1.16 for Group 1 and 1.04 for Group 2. The average interval from tattoo to surgery was 21 days (range 1-62) for Group 1 and 148 days (range 71-257) for Group 2. The tattooed node(s) were visually identified at surgery and corresponded to the sentinel lymph node(s) in 98.5% of cases (18/19 in Group 1 and 47/47 in Group 2). Of the 14 patients in Group 2 whose nodes remained positive following NAT, the tattooed node was the SLN associated with carcinoma. CONCLUSIONS: Tattooing is an alternative method for marking biopsied ALNs. Tattooed nodes coincided with SLNs in 98.5% of cases. This technique is advantageous, because it allows for fewer procedures and lower costs compared with other methods.

Current Strategies for the Management of Locoregional Breast Cancer Recurrence.

Advances in the treatment of breast cancer have decreased the rate of isolated locoregional recurrences (ILRRs) over time. Surgery, radiation therapy, and systemic therapies are used to manage these failure events and their associated poor prognosis. Operable ipsilateral breast tumor recurrences (IBTRs) are treated by either salvage mastectomy or, in select cases, repeat lumpectomy. Axillary nodal recurrences and postmastectomy chest wall relapses are commonly amenable to surgical resection, too. Repeat sentinel node mapping may be undertaken after IBTRs and chest wall recurrences. Aberrant lymphatic drainage, especially after previous mastectomy, is frequently observed. Adjuvant radiation is recommended for most ILRR cases; the dose and volume must be adjusted for prior to receipt of therapy. Implementation of adjuvant systemic therapies after ILRR should be based on the expression of molecular markers in the recurrent tumor. Administration of chemotherapy for estrogen receptor-negative ILRR is indicated, since it significantly decreases the rate of distant metastases.

Will oncotype DX DCIS testing guide therapy? A single-institution correlation of oncotype DX DCIS results with histopathologic findings and clinical management decisions.

Given the increased detection rates of ductal carcinoma in situ (DCIS) and the limited overall survival benefit from adjuvant breast irradiation after breast-conserving surgery, there is interest in identifying subsets of patients who have low rates of ipsilateral breast tumor recurrence such that they might safely forgo radiation. The Oncotype DCIS score is a reverse transcription-PCR (RT-PCR)-based assay that was validated to predict which DCIS cases are most likely to recur. Clinically, these results may be used to assist in selecting which patients with DCIS might safely forgo radiation therapy after breast-conserving surgery; however, little is currently published on how this test is being used in practice. Our study examines traditional histopathologic features used in predicting DCIS risk with Oncotype DCIS results and how these results affect clinical decision-making at our academic institution. Histopathologic features and management decisions for 37 cases with Oncotype DCIS results over the past 4 years were collected. Necrosis, high nuclear grade, biopsy site change, estrogen receptor and progesterone receptor positivity <90% on immunohistochemistry, and Van Nuys Prognostic Index score of 8 or greater were significant predictors of an intermediate-high recurrence score on multivariate regression analysis (P<0.02). Low Oncotype DCIS scores and low nuclear grade were associated with lower rate of radiation therapy (P<0.008). There were seven cases (19%) with Oncotype DCIS results that we considered unexpected in relation to the histopathologic findings (ie, high nuclear grade with comedonecrosis and a low Oncotype score, or hormone receptor discrepancies). Overall, pathologic features correlate with Oncotype DCIS scores but unexpected results do occur, making individual recommendations sometimes challenging.

Axillary reverse mapping with indocyanine green or isosulfan blue demonstrate similar crossover rates to radiotracer identified sentinel nodes.

BACKGROUND: Sentinel lymph node (SLN) resection is imperative for breast cancer staging. Axillary reverse mapping (ARM) can preserve arm draining nodes and lymphatics during surgery. ARM is generally performed with isosulfan blue (ISB), restricting its use for concurrent SLN biopsy. Indocyanine green (ICG) could serve as an alternative to ISB for ARM procedures. METHODS: SLN mapping and biopsy was performed via periareolar injection of 99 technetium-sulfur colloid (99m TcSc, TSC). ISB and ICG were injected in the upper arm. Blue-stained lymphatics or nodes were visualized in the axilla; ICG was identified using the SPY Elite® system. RESULTS: Twenty-three patients underwent SLN biopsy with or without axillary node dissection and ARM procedures. Twenty of these patients had at least one hot node; 12 patients had SLNs that were only hot, 6 hot/blue/fluorescent, and 2 hot/fluorescent. Overall, crossover of ARM agents with SLNs occurred in 8 cases. Inspection of the axillary cavity after SLN biopsy revealed fluorescent lymphatics and nodes remaining in 14 and 7 patients, respectively. Blue lymphatics and blue nodes were detected in fewer cases. CONCLUSION: Nearly one-third of patients showed crossover between breast and arm draining nodes, which provides insight as to why some patients develop lymphedema symptoms after SLN biopsy. ICG and ISB identify similar numbers of SLNs. As such ICG could substitute for ISB in ARM procedures.

Rising Bilateral Mastectomy Rates Among Neoadjuvant Chemotherapy Recipients in California From 1998 to 2012.

OBJECTIVE: To study the impact of rising bilateral mastectomy rates among neoadjuvant chemotherapy (NAC) recipients in California. BACKGROUND: NAC for operable breast cancer (BC) can downstage disease and facilitate breast conservation. We assessed trends in NAC use and surgical procedures in California from January 1, 1998 to December 31, 2012 using statewide population-based cancer registry data. METHODS: A total of 236,797 females diagnosed with stage I-III BC were studied. Information regarding NAC, adjuvant chemotherapy (aCT), breast conserving surgery (BCS), bilateral mastectomy (BLM), and unilateral mastectomy (ULM) was abstracted from the medical records. Multivariable polytomous logistic regression was used to estimate odds ratios (OR) of receiving NAC and of type of surgery after NAC. RESULTS: Approximately, 40.1% (94,980) of patients received chemotherapy: 87% (82,588) aCT and 13.0% (12,392) NAC. NAC use more than doubled over time and increased with stage (Stage I, 0.7%; Stage III, 29.9%). Multivariable predictors of NAC treatment were stage (III), younger age (<40 yrs), Black or Hispanic race/ethnicity versus non-Hispanic White (OR 1.10, 95% confidence interval (CI) 1.05-1.16), and care at a National Cancer Institute (NCI)-designated center (OR 1.70, CI 1.58-1.82). Most NAC recipients (68.4%) had mastectomies, and 14.3% of them underwent BLM. In contrast, 47.9% aCT patients had mastectomies with 7.3% BLM. The only independent predictor of BCS after NAC was care at a NCI-designated center (OR 1.28, CI 1.10-1.49), and of BLM, age <40 years versus 50 to 64 years (OR 2.59, CI 2.21-3.03), or residence in the highest socioeconomic neighborhood quintile versus lowest (OR 2.10, CI 1.67-2.64). CONCLUSIONS: NAC use remains low. Predictors of surgery type after NAC were sociodemographic rather than clinical, raising concern for disparities in care access.

Oncologic Procedures Amenable to Fluorescence-guided Surgery.

OBJECTIVE: Although fluorescence imaging is being applied to a wide range of cancers, it remains unclear which disease populations will benefit greatest. Therefore, we review the potential of this technology to improve outcomes in surgical oncology with attention to the various surgical procedures while exploring trial endpoints that may be optimal for each tumor type. BACKGROUND: For many tumors, primary treatment is surgical resection with negative margins, which corresponds to improved survival and a reduction in subsequent adjuvant therapies. Despite unfavorable effect on patient outcomes, margin positivity rate has not changed significantly over the years. Thus, patients often experience high rates of re-excision, radical resections, and overtreatment. However, fluorescence-guided surgery (FGS) has brought forth new light by allowing detection of subclinical disease not readily visible with the naked eye. METHODS: We performed a systematic review of clinicatrials.gov using search terms "fluorescence," "image-guided surgery," and "near-infrared imaging" to identify trials utilizing FGS for those received on or before May 2016. INCLUSION CRITERIA: fluorescence surgery for tumor debulking, wide local excision, whole-organ resection, and peritoneal metastases. EXCLUSION CRITERIA: fluorescence in situ hybridization, fluorescence imaging for lymph node mapping, nonmalignant lesions, nonsurgical purposes, or image guidance without fluorescence. RESULTS: Initial search produced 844 entries, which was narrowed down to 68 trials. Review of literature and clinical trials identified 3 primary resection methods for utilizing FGS: (1) debulking, (2) wide local excision, and (3) whole organ excision. CONCLUSIONS: The use of FGS as a surgical guide enhancement has the potential to improve survival and quality of life outcomes for patients. And, as the number of clinical trials rise each year, it is apparent that FGS has great potential for a broad range of clinical applications.