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Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous colon and rectal lesions. For larger lesions ( .20mm) that are not amenable to endoscopic mucosal resection, superficial biopsies are typically taken prior to referral for ESD. The aim of this study was to evaluate the degree of concordance between superficial forceps biopsies and ESD pathology. Method(s): A retrospective medical record review was performed including consecutive patients who underwent ESD of colon and rectal lesions at a tertiary care center between 10/2018 and 11/2021. Pathology results from outside hospital and same institution pre-ESD superficial forceps biopsies were compared to ESD pathology results. The primary outcome was the number of patients found to have higher disease severity on ESD pathology compared with superficial forceps biopsies. Result(s): Of the 84 patients who underwent ESD of colon or rectal lesions, 72 had pre-ESD superficial forceps biopsies which were taken at an outside hospital (n=48) or at the same institution (n=36). The average length of time between outside hospital superficial forceps biopsies and ESD was 91 days compared to 75 days for those performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic prolonging time between procedures. Pathology findings after ESD differed from superficial forceps biopsies in 31/72 patients (43%) with 21 patients receiving upgraded disease severity and 6 patients receiving a new cancer diagnosis based on ESD pathology. Patients who received a new cancer diagnosis had more days between superficial forceps biopsies and ESD compared with the whole cohort (86 vs 75, respectively). Conclusion(s): While superficial forceps biopsies of colon and rectal lesions were typically concordant with ESD pathology, 29% of patients in this cohort received upgraded disease severity based on ESD pathology. This shows that while superficial forceps biopsies can aid in diagnosis, en bloc resection via ESD remains critical for accurate diagnosis of large colon and rectal lesions. These results also show that ESD is not only diagnostic but therapeutic given 75% of the patients in this cohort achieved R0 resection.
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A giant cell tumor is a common, benign but locally aggressive bone tumor faced by orthopedic surgeons. The proximal humerus is a rare site of occurrence for this tumor, and the challenges posed while approaching such a case are discussed in this report of a 29-year-old male who presented with pain, swelling, and restricted motion at the left shoulder. Plain radiographs and MRI were suggestive of an aggressive giant cell tumor of the proximal humerus, which was confirmed on histopathological examination. Due to the lesion's extensive soft-tissue involvement, en-bloc resection with reconstruction was planned, but due to the COVID-19 pandemic, surgery was delayed. During the same period, the patient had trivial trauma to the same shoulder, following which the size of the lesion began increasing. The patient was operated on with en-bloc resection and reconstruction with a custom megaprosthesis; following the surgery, there was a complete resolution of pain and improvement in the range of motion. En bloc resection and replacement with a customized megaprosthesis, though technically demanding, offer a safe and cost-effective modality for limb salvage surgery for large giant cell tumors, with good functional outcomes and decreased chances of recurrence.
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DDW 2022 Author Disclosures: Daniel Scanlon: NO financial relationship with a commercial interest ;Brianna Shinn: NO financial relationship with a commercial interest ;Zachary Lieb: NO financial relationship with a commercial interest ;Brian Jacobs: NO financial relationship with a commercial interest ;Divya Chalikonda: NO financial relationship with a commercial interest ;Jason Ho: NO financial relationship with a commercial interest ;Abhishek Agnihotri: NO financial relationship with a commercial interest ;Anand Kumar: YES financial relationship with a commercial interest;Olympus:Consulting ;Anthony Infantolino: NO financial relationship with a commercial interest ;Christina Tofani: NO financial relationship with a commercial interest ;Alexander Schlachterman: NO financial relationship with a commercial interest Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous esophageal lesions. Many of these lesions arise in a background of Barrett’s esophagus (BE) which is a known precursor of dysplasia and adenocarcinoma. Large lesions not amenable to endoscopic mucosal resection often have superficial forceps biopsies taken prior to referral for ESD. This study aims to evaluate the accuracy of superficial forceps biopsies compared with pathology from ESD. Methods: A retrospective medical record review was performed that included consecutive patients who underwent ESD for esophageal lesions at a tertiary care center between 6/2018 and 9/2021. Pathology results from outside hospital and same institution superficial forceps biopsies as well as ESD pathology reports were reviewed. The primary outcome measured was the number of patients found to have higher disease severity on ESD pathology compared with pre-ESD superficial forceps biopsies. Results: The 28 patients included in the study received superficial forceps biopsies at outside hospitals (n=9), the same institution (n=14), or both (n=5). An average of 99 days occurred between outside hospital superficial forceps biopsies and ESD compared with an average of 30 days between superficial forceps biopsies and ESD performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic leading to prolonged time between procedures. In the entire cohort, ESD pathology differed from superficial forceps biopsies in 13/28 patients (46%). 10 patients (36%) had their disease severity upgraded and 3 were newly diagnosed with cancer on ESD pathology. Findings were similar for patients with lesions arising in a background of BE (21/28) (Table 1). Of those with BE, 9/21 (43%) patients had ESD pathology that differed from superficial forceps biopsies with 6 patients (29%) receiving increased disease severity and 2 patients receiving a new cancer diagnosis on ESD pathology. Conclusion: Superficial forceps biopsies taken prior to resection of esophageal lesions via ESD were concordant with ESD pathology in the majority of cases, however 36% of patients received upgraded disease severity on ESD pathology. Findings were similar for patients with or without a background of Barrett’s esophagus. These results highlight the importance of en bloc resection not only for therapeutic benefit (60% of patients in this cohort achieved R0 resection), but for accurate staging of esophageal lesions. [Formula presented]
ABSTRACT
Introduction & Objectives: The HoLERBT (Holmium Laser En-bloc Resection) has emerged as an alternative to classical TURBT (Transurethral Resection of Bladder Tumor) by using the en-bloc tumor resection technique. So far, the tumors in previous studies were mostly <3cm. We performed a previous pilot study with tumors >3cm (3-8cm) submitted to HoLERBT in 2019. All samples had detrusor muscle present and there were no peri-operative complications. These results support the present study to establish the best approach to endoscopic treatment of large bladder tumors. The objectives are to analyze differences between HoLERBT and TURBT in terms of presence of detrusor muscle in the histopathological analysis, intra-operative and peri-operative complications and oncological outcomes in large bladder tumors. Materials & Methods: This is a single-institution, randomized, single-blinded, prospective, controlled trial (RCT). The expected duration is of 24 months. The sample size calculated is 47 patients per group (n = 94). The study was approved by the Institutional Ethical Board and was submitted to the Brazilian Registry of Clinical Trials (ReBEC). Inclusion criteria is bladder tumor >3cm by CT or MRI. The exclusion criteria are diagnosis of invasive tumor on image examination (CT, MRI), urethral stenosis, systemic or intra-vesical chemotherapy or previous radiotherapy. The outcomes analyzed are quality of detrusor muscle, intra-operative and immediate post-operative complications, length of hospital stay (LOS);clinical progression, recurrence-free, overall and cancer-specific survival at 24 months. Results: This is an ongoing trial that began in January 2020, was suspended for 5 months due to Covid-19, restarted recruitment in September 2020 and currently has 9 patients in the group HoLERBT and 11 patients in the group TURBT. The first surgery was in 01/21/20. The current data represents 22% of the estimated sample and the analysis is partial. The median age (years) was 55.8 (29-83) and 65.5 (46-84), the median tumor size (cm) was 3.4 (2.1-5.4) and 3.1 (2.1-5.7), the median time of surgery (min) was 29 (16-49) and 37.6 (13-60), the LOS (days) was 1.25 (1-3) and 2.0 (1-4), complications rates Clavien I was 11% and 36% and Clavien >I was 0% and 9% for HoLERBT and TURBT. The presence of detrusor was 80% in both groups. The interim analysis will be made with 50% of the sample estimated to occur in June 2021 and the final analysis with 2 years of follow up is estimated to occur in January 2023. Conclusions: This is a RCT comparing HoLERBT and TURBT evolving large tumors, with a 2-year follow-up proposal. The initial analysis give support to continue the study in order to assess the real role of laser resection in high volume bladder tumor.