Multidisciplinary management of a quickly growing pediatric atypical Spitz nevus, mimicking melanoma, during the COVID-19 pandemic

Spitzoid melanoma is very rare tumour in the pediatric population, with clinical and non-uniform behaviour, different from adult melanoma [1]. It can be difficult to differentiate an atypical Spitz nevus from a Spitzoid melanoma, resulting in diagnostic problems. In addition, in our clinical case, the COVID-19pandemiccaused significant delays both in the diagnosis and in the surgical treatment of our patient. We present the clinical case of a 4-year-old child suffering from a localized polypoid cutaneous neoformation on the dorsum of the left hand, which started immediately before the lockdown and steadily increased during the COVID-19 pandemic. After a general clinical framing, the child underwent an excisional biopsy at our Department of Plastic and Reconstructive Surgery, at the Policlinico of Foggia. Subsequently, two independent anatomic pathology groups examined the specimen. Definitive diagnosis was made only after careful genetic analysis in combination with supporting histological and immunohistochemical examinations. This clinical case shows how during the pandemic we have been facing advanced forms of tumours, compared to the previous period and highlight show an interdisciplinary and multicenter collaboration allowed a quick diagnosis of certainty, demonstrating the utility of molecular pathology as a fundamental aid in clinical/surgical practice. © 2022 The Authors

Moderate hypofractionated radiotherapy after prostatectomy in the context of the COVID19

Purpose or Objective We designed a hypofractionated radiotherapy protocol for adjuvant or salvage treatment after radical prostatectomy. In this first report we present the implementation of this protocol in the context of a COVID-19 pandemic. Materials and Methods Patients meeting the inclusion criteria (high-risk features on histopathology or biochemical recurrence) received radiotherapy to the prostate bed 51 Gy in 17 fractions, elective treatment of the pelvis at a dose of 36 Gy in 12 fractions was permited. Acute gastrointestinal (GI) and genitourinary (GU) toxicity was evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events versión 4.03. The disease-related quality of life, urinary, gastrointestinal, sexual and hormonal function were evaluated with the Expanded Prostate Cancer Index Composite (EPIC), QLQc30 and PR25 questionnaires at baseline before the start of radiotherapy and at one month after radiotherapy, then every six monts for two years. In addition, the incidence of COVID-19 cases was reported in the patients recruited in the trial and in those who underwent standard fractionation treatment (1.8-2.0 Gy per fraction), and in health personnel involved in the treatment of patients in study period. Results From August 2020 to March 2021, 22 patients have been registered. Fourteen patients have completed treatment and are included in this report. The median age was 64 years and most had a Gleason 3 + 4 (50%), with a pT3a (35.7%) and negative surgical margins (71.4%). Three patients (21.4%) were staged as pN1. Most patients were treated for salvage (57.1%), with an median PSA prior to the start of RT of 0,29 ng/ml. Most patients report minimal or low acute radiation effects in terms of GI and GU toxicity, with an acute toxicity grade 2 GI and GU of 50% and 14.3%, respectively. Without Grade 3 or higher GI / GU toxicity. Of the 14 patients who received the trial protocol, none had a clinical of COVID-19 infection, while one patient who received treatment with conventional fractionation development a COVID-19 infection. Conclusion We present the implementation of an protocol of hypofractionated schedule of postoperative prostate radiotherapy in an academic center in a developing country in the context of a COVID-19 pandemic. Preliminary results show the absence of COVID infection in the included patients, and low GU and GI toxicity.

Partial breast irradiation with IORT using Xoft®. Experience at Catalan Institute of Oncology

Purpose or Objective external beam whole breast irradiation (WBI) for low-risk early-stage breast cancer patients after breast conserving surgery. We present the experience at our center treating patients with PBI using an IORT technic with Xoft® Axxent® Electronic Brachytherapy (eBx®) System®. Materials and Methods Between April 2019 and August 2021, 44 patients diagnosed with low-risk early-stage breast cancer who met international criteria for PBI, received IORT in a single fraction of 20 Gy to the tumor bed after lumpectomy. Toxicities and follow up were prospectively registered. Results 3 of the 44 initial patients were discarded for IORT due to non-compliance with the minimum safety distance (<1 cm) between the applicator and the skin. Of the remaining patients, 32/41 patients (78%) received a PBI, while 9/41 (22%) required adjuvant WBI due to adverse prognostic factors identified on the definitive biopsy. The most frequent risk factor was close resection margins (<2mm), present in 8/9 patients (88,8%). Two patients additionally presented sentinel node involvement and in 1 case no axillary sample was obtained. The most used IORT applicator was the 3-4 cm balloon, with most likely filling volumes between 30cc and 40 cc. For all treatments, the mean filling volume of the applicator was 45 cc and there were no complications during the irradiation procedure. Surgical bed seroma was the most common acute effect, observed in 29/41 patients (70,7%), although only 8/29 (27,5%) required drainage. We observed wound dehiscence in 7/41 cases (17%), inflammatory complications requiring antibiotics in 9/41 cases (19,5%), and 4/41 cases of hematoma (9,7%). Regarding late toxicity, at the time of the analysis it was only assessable for 37 patients. We observed low rates of local grade I fibrosis (21,6%) and only 1 case of tumor bed G2 fibrosis. Hyperpigmentation G1 was observed in 8,1% of patients and 10,8% presented occasional mild local discomfort. With median follow-up of 17.14 months (range 4-29 months), no relapses were observed, but 1 patient died from covid-19 pneumonia. Conclusion Intra operative PBI with Xoft® Axxent® Electronic Brachytherapy (eBx®) System® is a feasible approach to treat low-risk early-stage breast cancer patients. Our preliminary results show that it presents advantages over conventional WBI allowing for less toxic and shortened treatment courses while maintaining good local tumor control.

Villis Marshall Presentation

We compared outcomes between two groups: a) High PSA testing (screening) group which included men who received two or more PSA tests that were at least one year apart and b) Low PSA testing group. B Methods: b Using the Medicare Statistics Reports tool, the Medicare Benefit Schedule number for screening & diagnostic tests for prostate cancer were analyzed over a 6-year period (2015 - 2020). Presentation Type: Villis Marshall Theme: Other Urological imaging trends in Australia and the impact of COVID-19: A ten-year analysis of nat... EMMA CLAREBROUGH SP 1 sp , ANDREW O'BRIEN SP 1 sp , ROHAN HALL SP 1 sp SP I 1 i sp I Bendigo Hospital, Bendigo, Australia i B Introduction & Objectives: b During the COVID-19 pandemic there has been a drastic shift in access and utilisation of healthcare resources globally. [Extracted from the article] Copyright of BJU International is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

COVID-19 and the impact on oncological general surgery at a district general hospital

Introduction: Covid-19 has had a significant impact on all aspects of healthcare. We aimed to characterise our experience of oncological general surgery during the first 4-months of the pandemic and compare with the same period in 2019. Method: A prospective cohort study was performed from 23/03/20 to 08/ 07/20. All elective oncological operations were included. Data on patient demographics, waiting times, inpatient characteristics and oncological outcomes were recorded. Statistical analysis was used to compare with retrospective data from 2019. Results: 78 patients were included in total, 38 in 2019 and 40 in 2020. There were no differences in length of stay (2.5 vs 3.5 days, p=0.355) or waiting list time (27.2 vs 24.2 days, p=0.574). Oncological outcomes were comparable with no statistical difference in clear resection margin status (94.4 vs 84.6%, p=0.168) or positive nodal status (24.1 vs 37.1%, p=0.298). The percentage of staging CT scans requested externally was higher in 2020 (4 vs 32%, p=<0.05). There was no difference in time from urgent referral to first assessment (30.5 vs 26.4 days, p=0.384) or time to operation (96.6 vs 85.7 days, p= 0.618). Conclusions: Oncological surgery during Covid-19 can be performed safely with favourable oncological outcomes. The longer-term effects from delayed diagnoses remain to be evaluated.

Correlation between imaging and histopathology in head and neck oncology – A retrospective study

Introduction: Tumour size, depth of invasion, type and extent of nodal metastasis are some of the key prognostic indicators in operable head and neck cancers. Initial Imaging with USS of neck and FNAC or core biopsy has been established to have a high sensitivity and specificity. In addition, CT neck and thorax and MRI scan of the primary tumour are recommended as part of staging scans. Information from this work up guides the MDT and patients towards a tailored management plan. We aimed to compare preoperative imaging work up and TNM staging with post-operative histopathology. Methods: We retrospectively reviewed 48 patients who underwent resection and selective neck dissection from January 2020 to August 2021, assessing their initial work up and its adherence to current guidelines. We also evaluated its correlation to final histopathology. Results: 100% compliance was noted with USS and FNAC, 94% compliance with CT and MRI and 96% had incisional biopsy. USS showed a 80 % specificity and a 55% sensitivity. CT had a specificity of 62.5% and sensitivity of 75%. MRI specificity was 58.8% and sensitivity 73.6%. Conclusions: Our results compare favourably to other published data on imaging correlation to histopathology in head and neck oncology. Time lapse between preoperative work-up and surgical resection during COVID pandemic may have led to advanced disease that is not evident on preoperative staging scans. Newer modalities including real time imaging and in-vivo surgical margin assessment remain to be explored.

Strategies for breast cancer surgery during & after COVID-19 pandemic

Goals: COVD-19 global pandemic has seriously affected many health systems around the world, particularly in countries extremely hit remarkably such as Italy, Spain and the UK. As a response, hospitals had to reduce access to elective patients to avoid the spread of infectious disease, and many international societies and groups of experts have published clinical guidelines and recommendations about surgical management of breast cancer patients in this time of crisis and Issued COVID guidelines to prioritize surgery for whom time is critical and cannot be deferred. Methods:We performed a comprehensive review from November 1, 2019 to October 25, 2020 of the published literature in English language on COVID-19. Keywords used were: Coronavirus, COVID-19, nCoV, Breast Cancer, Corona crisis, Breast Surgery. Studies were included if they fulfilled specific eligibility criteria such as combination of keywords to focus the subject of COVID-19 and breast surgery. Non-scientific commentary, reports, and news articleswere excluded from the analysis. Results: Among the 118 research articles included in the analysis, 9 articles were included. Based on the review and experts opinions;therewere strong supportive arguments to support providing surgery in breast cancer services, therefore we proposed a strategy to be implemented to resume and to keep providing breast cancer surgery during the pandemic: Provide a one stop triple assessment clinic for patients with a high suspicion of cancer, agreed MDT treatment decisions, provide a single pre-op consultation, perform Breast surgery under day case setup, offer routine wider margin excision where feasible, oncoplastic and reconstructive breast surgery in carefully selected patient, single post op results consultation with follow up phone/Teleconsultation as needed, regular locoregional guidelines review, surgery prioritizing to be escalated or de-escalated according to the level of pandemic with regular revision of pooled waiting lists. Conclusion(s): COVID-19 may live with us for many months and years, we still face the uncertainty to the course of the pandemic and the challenges of the future waves with a considerable concern over the impact on cancer patients, Including accumulated untreated cases. To avoid such additional impact and deaths from breast cancer, new protocols under new norms to are of paramount importance to continue to deliver breast cancer surgery safely. Conflict of Interest: No significant relationships.

Trainee perspective in sarcoma care

Aim: Soft tissue sarcomas (STS) are rare and aggressive tumours. Appropriate multidisciplinary management requires robust knowledge of best practice and understanding of current guidelines. Plastic surgery trainees must therefore be proficient in the assessment, investigation, and treatment of patients with STS. We aimed to evaluate trainee education, confidence, and competence in managing patients with STS. Method: All plastic surgery trainees in Wales completed an online questionnaire and written assessment. This was designed by the lead for STS and TPD. Formal training, knowledge of national guidelines and excision margins for different types of STS and skin cancer was assessed using short answer questions. A five-point Likert scale was used to assess trainee confidence in STS and skin cancer management and follow-up. Volume and type of teaching in sarcoma and skin cancer was also quantified. Results: Trainees received less sarcoma training and were less confident in STS assessment and follow-up, in comparison to skin cancer. More senior trainees or those with formal sarcoma training were more confident in skin cancer management (mean confidence rating 4.4 vs 2.2) and performed better in the written assessment of excision margins (mean score 100% vs 61.45%) Conclusions: Trainees receive less training in sarcoma with a significant impact on their competence and confidence in sarcoma care. We believe this is consistent across the United Kingdom as evidenced by just two sarcoma webinars held during the COVID-19 pandemic. Formal national evaluation of sarcoma teaching should be carried out to inform ongoing efforts to improve educational resources on this important topic for trainees.

Powered articulation by the SigniaTM stapling system for stapling position adjustments: optimizing safe surgical margins in thoracoscopic sublobar resection.

Accumulation of experience and advances in techniques and instruments have enabled surgeons to perform video-assisted thoracic surgery (VATS) safely for sublobar resection, including segmentectomy and wedge resection. A key to successful VATS sublobar resection is to have adequate resection margins and the appropriate use of articulated surgical staplers is essential for this purpose. The SigniaTM stapling system (Covidien Japan, Tokyo) has been used extensively in the fields of thoracic surgery. Its features include high maneuverability with fully powered articulation, rotation, clamping, and firing, which the surgeon can control with one hand. We introduce the "sliding technique" using the SigniaTM system, which allows for adjustment of the resection lines of the pulmonary parenchyma to optimize safe surgical margins with minimal stapler movement, and without repetitively moving the stapler in and out of the pleural cavity, during VATS sublobar resection.