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Rabindran B, Corben AD. Wide-field optical coherence tomography for microstructural analysis of key tissue types: a proof-of-concept evaluation. Pathol Oncol Res 2023; 29:1611167. [PMID: 37521364 PMCID: PMC10374948 DOI: 10.3389/pore.2023.1611167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
Introduction: The presence of positive margins following tumor resection is a frequent cause of re-excision surgery. Nondestructive, real-time intraoperative histopathological imaging methods may improve margin status assessment at the time of surgery; optical coherence tomography (OCT) has been identified as a potential solution but has not been tested with the most common tissue types in surgical oncology using a single, standardized platform. Methods: This was a proof-of-concept evaluation of a novel device that employs wide-field OCT (WF-OCT; OTIS 2.0 System) to image tissue specimens. Various cadaveric tissues were obtained from a single autopsy and were imaged with WF-OCT then processed for permanent histology. The quality and resolution of the WF-OCT images were evaluated and compared to histology and with images in previous literature. Results: A total of 30 specimens were collected and tissue-specific microarchitecture consistent with previous literature were identified on both WF-OCT images and histology slides for all specimens, and corresponding sections were correlated. Application of vacuum pressure during scanning did not affect specimen integrity. On average, specimens were scanned at a speed of 10.3 s/cm2 with approximately three features observed per tissue type. Conclusion: The WF-OCT images captured in this study displayed the key features of the most common human tissue types encountered in surgical oncology with utility comparable to histology, confirming the utility of an FDA-cleared imaging platform. With further study, WF-OCT may have the potential to bridge the gap between the immediate information needs of the operating room and the longer timeline inherent to histology workflow.
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Affiliation(s)
| | - Adriana D. Corben
- Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, United States
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2
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Zijlker LP, Eggermont AMM, van Akkooi ACJ. The end of wide local excision (WLE) margins for melanoma ? Eur J Cancer 2023; 178:82-87. [PMID: 36423526 DOI: 10.1016/j.ejca.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/22/2022]
Abstract
CLINICAL QUESTION Is there nowadays any benefit of continuing the practice of routine wide local excision (WLE) for primary stage I/II cutaneous melanoma? BACKGROUND WLE aims to eradicate potential microsatellites around melanomas and thereby reduce local recurrence rates and improve overall survival. Six large prospective randomised trials investigated WLE versus wider WLE, they all failed to show any effect on overall survival (OS). METHODS A literature search was performed to identify data on outcome after omitting WLE. Additionally circumstantial evidence was gathered from pathology studies and outcomes of modified surgical techniques, as well as publications on morbidity. RESULTS No prospective and one retrospective study was found. The retrospective study showed no difference in OS after correction for confounding factors. Pathology studies showed a low incidence of residual melanoma in WLE specimen (0-4.2%). Mohs surgery does not show a difference in recurrence rates or OS. WLE is associated with considerable postoperative morbidity, which increases with wider excision margins. CONCLUSION There is no solid prospective evidence to support the classic dogma of a 2-step approach with the use of WLE for primary cutaneous melanoma that has been completely excised on diagnostic excision biopsy. We recommend to setup and conduct a prospective randomised trial to compare the classical 2-step approach with WLE to a complete diagnostic excision only to abolish the routine practice of WLE in the future.
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Affiliation(s)
- Lisanne P Zijlker
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Alexander M M Eggermont
- Faculty of Medicine University Medical Center Utrecht, the Netherlands; Princess Máxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center Munich, Germany, Technical University Munich & Ldwig Maximiliaan University, Munich, Germany
| | - Alexander C J van Akkooi
- Melanoma Institute Australia, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
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Ramachandran V, Phan K. Mohs micrographic surgery versus wide local excision for eyelid melanoma: An analysis of a national database. J Plast Reconstr Aesthet Surg 2022; 75:4410-4415. [PMID: 36257889 DOI: 10.1016/j.bjps.2022.08.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 06/18/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although eyelid melanomas represent less than 1% of eyelid neoplasms, they have the worst prognosis. Wide local excision (WLE) and Mohs micrographic surgery (MMS) are mainstay treatment options. We conducted a retrospective analysis to assess all-cause and cause-specific mortality rates in patients undergoing WLE or MMS for eyelid melanoma. METHODS A retrospective analysis of Surveillance, Epidemiology, and End Results (SEER) registry was performed for eyelid melanoma treated with WLE or MMS. Cases were limited to American Joint Committee on Cancer (AJCC) stage T1 primary malignancies. RESULTS A total of 45 cases of WLE were identified along with 48 cases of MMS for eyelid melanoma. There was no significant difference between subgroups in age group, sex, race, ethnicity, marital status at diagnosis, AJCC N stage, AJCC M stage, melanoma histology, chemotherapy use, and radiotherapy use. Among the cohort, all tumors were unilateral. Kaplan-Meier analysis with log-rank demonstrated no significant difference between MMS and WLE subgroups with regard to overall survival (P = 0.662) and cancer-specific survival (P = 0.494). Cox regression adjusting for variables with α<0.10 and found no significant difference in all-cause mortality (HR, 0.923; 95% CI 0.310-2.747; P = 0.885) or cancer-specific mortality (HR, 0.518; 95% CI 0.047-5.711; P = 0.591) when patients who underwent MMS were compared to those who underwent WLE. CONCLUSION While our study is limited by a small number of patients, our analysis demonstrated no significant difference in all-cause or cause-specific survival for patients with eyelid melanoma treated with MMS compared with WLE. In areas requiring preservation of tissue due to cosmetic or functional purposes, MMS is a reasonable surgical approach.
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Affiliation(s)
| | - Kevin Phan
- Department of Dermatology, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales (UNSW), Liverpool, Sydney, Australia
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4
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Ramiscal JAB, Stern SL, Wilson AK, Lorimer PD, Lee NA, Goldfarb MR, Foshag LJ, Fischer TD. Does Residual Invasive Disease in Wide Local Excision after Diagnosis with Partial Biopsy Technique Influence Survival in Melanoma? Matched-Pair Analysis of Multicenter Selective Lymphadenectomy Trial I and II. J Am Coll Surg 2022; 235:49-59. [PMID: 35703962 DOI: 10.1097/xcs.0000000000000263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current guidelines recommend excisional/complete biopsy for melanoma diagnosis, owing to high rates of residual disease found at wide local excision (WLE) after partial biopsy techniques. We sought to determine any survival disadvantage associated with the presence of residual invasive melanoma in the WLE after diagnosis with a partial biopsy technique. STUDY DESIGN Data were examined from Multicenter Selective Lymphadenectomy Trials I and II (MSLT-I and -II), 2 large melanoma trials. Patients diagnosed with excisional/complete biopsy were excluded. Clinicopathologic characteristics, melanoma-specific survival (MSS), distant disease-free survival (DDFS), and disease-free survival (DFS) of those with residual invasive melanoma in the definitive WLE and those with no residual melanoma were compared. Matched pairing was used to reduce variability between groups. RESULTS From 1994 through 2014, 3,939 patients were enrolled in these trials and 874 (22%) were diagnosed using partial biopsy techniques. Of these, 399 (46%) had residual tumor in the WLE. Only 6 patients had residual tumor in their WLE resulting in T-upstaging of their tumor. Match-pairing formed two cohorts (1:1) of patients with and without residual invasive tumor after WLE. A total of 514 patients were paired; 288 (56%) males, 148 (28.8%) aged 60 or older, 192 (37.4%) with truncal melanomas, 214 (41.6%) had Breslow thickness 2 mm or greater, and 376 (73.2%) had positive sentinel nodes. Kaplan-Meier analysis showed no statistical difference in 10-year MSS (73.6% ± 3.3% vs 73.9% ± 3.7%, p = 0.891), DDFS (68.7% ± 3.4% vs 65.3% ± 4.0%, p = 0.548), or DFS (59.6% ± 3.7% vs 59.4% ± 3.9%, p = 0.783). CONCLUSIONS Survival in patients with primary melanoma does not appear to be worse in patients who undergo a partial biopsy technique and are later found to have residual invasive tumor in the WLE specimen.
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Affiliation(s)
- Judi Anne B Ramiscal
- From Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA
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5
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Santandrea G, Valli R, Ragazzi M, Castagnetti F, Lai M, Longo C, Piana S. Clinically unquestionable but histologically deceptive melanomas in acral skin grafts: PRAME confirms its role. Br J Dermatol 2022; 187:804-806. [PMID: 35762291 DOI: 10.1111/bjd.21715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Giacomo Santandrea
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121, Modena, Italy
| | - Riccardo Valli
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Moira Ragazzi
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Fabio Castagnetti
- Surgery Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Michela Lai
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy. Viale Risorgimento 80, 42123, Reggio Emilia, Italy.,Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Caterina Longo
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy. Viale Risorgimento 80, 42123, Reggio Emilia, Italy.,Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Simonetta Piana
- Pathology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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Jackett LA, Satgunaseelan L, Roper E, Lo SN, Thompson JF, Scolyer RA. Residual melanoma in wide local excision specimens after 'complete' excision of primary cutaneous in situ and invasive melanomas. Pathology 2022; 54:71-78. [PMID: 34392983 DOI: 10.1016/j.pathol.2021.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 11/18/2022]
Abstract
Wide local excision (WLE) to achieve adequate clearance margins is the standard initial definitive treatment for patients with biopsy-proven primary cutaneous melanoma. Residual melanoma in WLE specimens after prior complete excision-biopsy (CEB) is reported in 0-6.3% of cases. However, studies evaluating the prevalence, clinicopathological features and relevance of persistent disease in WLE specimens are limited. This study sought to determine the frequency of and clinicopathological characteristics associated with residual melanoma in WLE specimens performed after a CEB of primary cutaneous or acral melanoma (in situ or invasive) with clinically and histologically tumour-free margins, and assess its relevance. A review of the research database and pathology archives of a large Australian tertiary referral melanoma treatment centre was performed. Eligible patients were those for whom a definitive WLE was performed after CEB of a primary melanoma (in situ or invasive) with negative clinical and histological margins, between May 2013 and May 2015. All partial biopsies were excluded. Of 640 eligible patients, 510 (79.7%) had invasive melanoma and 130 (20.3%) had melanoma in situ. Residual disease was identified in 20 cases (20/640, 3.1%), of which three (15%) were melanoma in situ on CEB and 17 (85%) were invasive melanoma. On univariate analysis, the presence of residual disease in WLE specimens was associated with lentigo maligna (LM)/LM melanoma (LMM) subtype [odds ratio (OR) 10.33; 95% confidence interval (CI) 2.84-37.54; p=0.004], nodular melanoma (NM) subtype (OR 4.92; 95% CI 1.53-15.85; p=0.0076) and, for invasive tumours, higher tumour mitotic rate (mean 7.7, SD 7.51 vs 3.4, SD 4.83; OR 1.11; 95% CI 1.04-1.18; p=0.0014). Breslow thickness >4 mm was associated with a higher risk of residual disease (OR 7.30; 95% CI 1.88, 28.26; p=0.004). Cases with residual disease had primary tumours with a significantly larger diameter (median 14 mm, range 4-25) than those without residual disease (median 9 mm, range 2-60), (OR 1.07; 95% CI 1.03-1.11; p≤0.001) and were also more likely to be amelanotic (38% vs 14%), (OR 3.69; 95% CI 1.17, 11.60; p=0.026). Residual disease was associated with assessment of >3 slides of tissue (OR 6.98; 95% CI 1.54-31.62; p=0.0118) and complete blocking of the scar (OR 31.69; 95% CI 3.98-252.21; p=0.0011). Residual melanoma in WLE specimens is an infrequent occurrence. Risk factors for residual disease are LM/LMM and NM melanoma subtypes, higher mitotic rate, larger lesion diameter and amelanosis. Tumours with these features warrant more extensive pathological sampling. WLE after CEB for melanoma remains an important procedure to reduce local recurrence; however, limited pathological sampling of the WLE scar is probably appropriate for cases lacking high risk features.
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Affiliation(s)
- Louise A Jackett
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
| | - Laveniya Satgunaseelan
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
| | - Edward Roper
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia.
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7
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Nan Y, Gu Y, Liu Z, Zhou Q, Zhao W, Xu W. Versatile quantitative biopsy: an approach for cost-effective detection of hydrogen peroxide in tissue specimens. NEW J CHEM 2021. [DOI: 10.1039/d0nj05569g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In the presence of H2O2, the amylose released by the micelles is converted into glucose by glucoamylase and detected by a PGM.
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Affiliation(s)
- Yanxia Nan
- State Key Laboratory of Chemo/Biosensing and Chemometrics
- College of Chemistry and Chemical Engineering
- Hunan University
- Changsha
- China
| | - Yu Gu
- State Key Laboratory of Chemo/Biosensing and Chemometrics
- College of Chemistry and Chemical Engineering
- Hunan University
- Changsha
- China
| | - Zhen Liu
- State Key Laboratory of Chemo/Biosensing and Chemometrics
- College of Chemistry and Chemical Engineering
- Hunan University
- Changsha
- China
| | - Qiulan Zhou
- State Key Laboratory of Chemo/Biosensing and Chemometrics
- College of Chemistry and Chemical Engineering
- Hunan University
- Changsha
- China
| | - Wenjie Zhao
- College of Chemistry and Chemical Engineering
- Inner Mongolia University
- Hohhot
- China
| | - Weijian Xu
- State Key Laboratory of Chemo/Biosensing and Chemometrics
- College of Chemistry and Chemical Engineering
- Hunan University
- Changsha
- China
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8
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de Menezes SL, Wolfe R, Kelly JW, Farrugia H, Mar VJ. Think before you shave: Factors influencing choice of biopsy technique for invasive melanoma and effect on definitive management. Australas J Dermatol 2020; 61:134-139. [PMID: 31869446 DOI: 10.1111/ajd.13227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Sara Lee de Menezes
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John William Kelly
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Farrugia
- Victorian Cancer Registry, Cancer Council Australia, Melbourne, Australia
| | - Victoria Jane Mar
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Skin Health Institute, Melbourne, Australia
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Impact of Immediate Surgical Reconstruction Following Wide Local Excision of Malignant Head and Neck Melanoma. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2661. [PMID: 32309102 PMCID: PMC7159960 DOI: 10.1097/gox.0000000000002661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/17/2019] [Indexed: 10/27/2022]
Abstract
Background The role of surgical reconstruction following melanoma extirpation is well recognized. Although technical considerations depend on patient anatomy and surgeon preference, the optimal timing of reconstruction remains unclear. This study aims to evaluate clinical and oncologic outcomes in melanoma extirpation followed by immediate reconstruction. Methods We retrospectively identified patients who underwent immediate reconstruction following head and neck melanoma excision at our institution between January 2013 and December 2016. Demographic and clinical characteristics, operative variables, and outcome data were extracted. Results Overall, 197 patients (male 70.6%) underwent excision followed by immediate reconstruction. Of the 70 patients with a history of cutaneous malignancy, 46 (65.7%) had a prior melanoma and 26 (37.1%) had 2 or more types of skin cancers. Of the 202 lesions resected, 138 (68.3%) were invasive, whereas 64 (31.7%) were in situ. The most frequent anatomic location involved was the cheek (34.2%), followed by scalp (31.2%). Reconstruction technique varied, with 116 (57.4%) lesions repaired by adjacent tissue transfer, 24 (11.9%) by full-thickness skin graft, 23 (11.4%) by complex primary closure, 17 (8.4%) by split-thickness skin graft, and 22 (10.9%) by more than 1 technique. On postoperative pathologic assessment, 2 patients had positive margins and 5 experienced local recurrence (mean follow-up: 2.3 years). In an unadjusted bivariate analysis, history of melanoma (P = 0.015) was significantly associated with local recurrence. Conclusions Reconstruction at time of excision is an oncologically safe approach for the management of patients with malignant melanoma. A prior history of melanoma may be associated with local recurrence.
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Schmidt H, Connolly C, Jaffer S, Oza T, Weltz CR, Port ER, Corben A. Evaluation of surgically excised breast tissue microstructure using wide-field optical coherence tomography. Breast J 2019; 26:917-923. [PMID: 31612563 DOI: 10.1111/tbj.13663] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, positive margins at lumpectomy contribute to health care cost, patient anxiety, and treatment delay. Multiple technology solutions are being explored with the aim of lowering re-excision rates for breast-conserving surgery (BCS). We examined wide-field optical coherence tomography (WF-OCT), an innovative adjunct intraoperative imaging tool for tissue visualization of margins. METHODS This IRB-approved pilot study included women with invasive or in situ carcinoma scheduled for primary BCS. Lumpectomy specimens and any final/revised margins were imaged by optical coherence tomography immediately prior to standard histological processing. The optical coherence tomography used provided two-dimensional, cross-sectional, real-time depth visualization of the margin widths around excised specimens. A volume of images was captured for 10 × 10 cm tissue surface at high resolution (sub-30 μm) to a depth of 2 mm. Integrated interpretation was performed incorporating final pathology linked with the optical image data for correlation. RESULTS Wide-field optical coherence tomography was performed on 185 tissue samples (50 lumpectomy specimens and 135 additional margin shaves) in 50 subjects. Initial diagnosis was invasive ductal carcinoma (IDC) in 10, ductal carcinoma in situ (DCIS) in 14, IDC/DCIS in 22, invasive lobular carcinoma (ILC) in 2, ILC/DCIS in 1, and sarcoma in 1. Optical coherence tomography was concordant with final pathology in 178/185 tissue samples for overall accuracy of 86% and 96.2% (main specimen alone and main specimen + shave margins). Of seven samples that were discordant, 57% (4/7) were considered close (DCIS < 2 mm from margin) per final pathology. CONCLUSION Wide-field optical coherence tomography demonstrated concordance with histology at tissue margins, supporting its potential for use as a real-time adjunct intraoperative imaging tool for margin assessment. Further studies are needed for comprehensive evaluation in the intraoperative setting.
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Affiliation(s)
- Hank Schmidt
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Courtney Connolly
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Shabnam Jaffer
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Twisha Oza
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Christina R Weltz
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Elisa R Port
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
| | - Adriana Corben
- Dubin Breast Center of the Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
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11
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Kunishige JH, Doan L, Brodland DG, Zitelli JA. Comparison of surgical margins for lentigo maligna versus melanoma in situ. J Am Acad Dermatol 2019; 81:204-212. [PMID: 31014825 DOI: 10.1016/j.jaad.2019.01.051] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/04/2018] [Accepted: 01/19/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple studies have shown a 5-mm surgical margin to be inadequate for excision of melanoma in situ. Some have suggested that a wider margin is needed only for the lentigo maligna subtype. OBJECTIVE To compare subclinical extension of lentigo maligna with that of melanoma in situ. The secondary objective was to investigate the effect of other factors on extent of subclinical extension. METHODS A prospectively collected series of noninvasive melanomas was studied. Original pathology reports were used to identify lentigo maligna and compare data for that subtype with data for the remaining melanomas in situ. RESULTS A total of 1506 lentigo maligna cases and 829 melanomas in situ were included. To obtain a 97% clearance rate, both lentigo maligna and melanoma in situ required a 12-mm margin on the head and neck and a 9-mm margin on the trunk and extremities. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6-mm margin (P = .12). Local recurrence was identified in 0.26% (5 facial, 1 scalp, and 1 acral), with a mean follow-up time of 5.7 years. LIMITATIONS Margins less than 6 mm were not studied. The use of lentigo maligna diagnosis was not used by all dermatopathologists consistently. The degree of surrounding photodamage was not assessed. CONCLUSION Subclinical extension of lentigo maligna and melanoma in situ are similar. Standard surgical excision of all melanoma in situ subtypes, including lentigo maligna, should include at least 9 mm of normal-appearing skin, which is similar to the amount recommended for early invasive melanoma. Lesions on the head and neck or those with a diameter greater than 1 cm may require even wider margins and are best treated with Mohs micrographic surgery. The perception that lentigo maligna has wider subclinical extension may be related to its frequent location on the head and neck, where photodamage can camouflage the clinical border.
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Affiliation(s)
- Joy H Kunishige
- University of Pittsburgh Medical Center and Zitelli and Brodland PC, Pittsburgh, Pennsylvania.
| | - Linda Doan
- University of Pittsburgh Medical Center and Zitelli and Brodland PC, Pittsburgh, Pennsylvania
| | - David G Brodland
- University of Pittsburgh Medical Center and Zitelli and Brodland PC, Pittsburgh, Pennsylvania
| | - John A Zitelli
- University of Pittsburgh Medical Center and Zitelli and Brodland PC, Pittsburgh, Pennsylvania
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Waddell A, Star P, Guitera P. Advances in the use of reflectance confocal microscopy in melanoma. Melanoma Manag 2018; 5:MMT04. [PMID: 30190930 PMCID: PMC6122529 DOI: 10.2217/mmt-2018-0001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/12/2018] [Indexed: 12/15/2022] Open
Abstract
In vivo reflectance confocal microscopy (RCM) is a noninvasive high-resolution skin imaging tool that has become an important adjunct to clinical exam, dermoscopy and histopathology assessment, in the diagnosis and management of melanoma. RCM generates a horizontal view of the skin, whereby cellular and subcellular (e.g., nuclei, melanophages, collagen) structures, to the level of the upper dermis, are projected onto a screen at near-histological resolution. Morphologic descriptors, standardized terminology, and diagnostic algorithms are well established for the RCM assessment of melanoma, melanocytic, and nonmelanocytic lesions. Clinical applications of RCM in melanoma are broad and include diagnosis, assessment of large lesions on cosmetically sensitive areas, directing areas to biopsy, delineating margins prior to surgery, detecting response to treatment and assessing recurrence. This review will provide an overview of RCM technology, findings by melanoma subtype, clinical applications, as well as explore the accuracy of RCM for melanoma diagnosis, pitfalls and emerging uses of this technology ex vivo.
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Affiliation(s)
- Andréanne Waddell
- Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Department of Medicine/Division of Dermatology, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Department of Medicine/Division of Dermatology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Phoebe Star
- Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia.,Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia
| | - Pascale Guitera
- Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Melanoma Institute Australia, The Poche Centre, North Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Ha R, Friedlander LC, Hibshoosh H, Hendon C, Feldman S, Ahn S, Schmidt H, Akens MK, Fitzmaurice M, Wilson BC, Mango VL. Optical Coherence Tomography: A Novel Imaging Method for Post-lumpectomy Breast Margin Assessment-A Multi-reader Study. Acad Radiol 2018; 25:279-287. [PMID: 29174226 DOI: 10.1016/j.acra.2017.09.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/12/2017] [Accepted: 09/18/2017] [Indexed: 01/08/2023]
Abstract
RATIONALE AND OBJECTIVES This study aimed to assess whether different breast cancer subspecialty physicians can be trained to distinguish non-suspicious from suspicious areas of post-lumpectomy specimen margin in patients with breast cancer using optical coherence tomography (OCT) images (a near-infrared based imaging technique) with final histology as the reference standard. MATERIALS AND METHODS This institutional review board-exempt, Health Insurance Portability and Accountability Act-compliant study was performed on 63 surgically excised breast specimens from 35 female patients, creating a 90-case atlas containing both non-suspicious and suspicious areas for cancer. OCT images of the specimens were performed, providing 6.5-15 µm resolution with tissue visualization 1-2 mm subsurface. From the 90-case atlas, 40 cases were chosen for training and 40 were randomly selected for reader assessment. Three breast imaging radiologists, two pathologists, two breast surgeons, and one non-clinical reader were trained and assessed for ability to distinguish non-suspicious from suspicious findings blinded to clinical data and corresponding histology slides. Duration of training and assessment, sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve for each reader were calculated as well as averages by subspecialty. RESULTS The average training time was 3.4 hours (standard deviation, 1.2). The average assessment time was 1.9 hours (standard deviation, 0.7). The overall average reader sensitivity, specificity, and accuracy for detecting suspicious findings with histologic confirmation of cancer at the surgical margin for all eight readers were 80%, 87%, and 87%, respectively. Radiologists demonstrated the highest average among the disciplines, 85%, 93%, and 94%, followed by pathologists, 79%, 90%, and 84%, and surgeons, 76%, 84%, and 82% respectively. CONCLUSIONS With relatively short training (3.4 hours), readers from different medical specialties were able to distinguish suspicious from non-suspicious OCT imaging findings in ex vivo breast tissue as confirmed by histology. These results support the potential of OCT as a real-time intraoperative tool for post-lumpectomy specimen margin assessment.
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Affiliation(s)
- Richard Ha
- Columbia University Medical Center, New York, New York.
| | | | | | | | | | - Soojin Ahn
- Mount Sinai, New Icahn School of Medicine, New York, New York
| | - Hank Schmidt
- Mount Sinai, New Icahn School of Medicine, New York, New York
| | - Margaret K Akens
- Princess Margaret Cancer Centre/University Health Network, Toronto, ON, Canada
| | | | - Brian C Wilson
- Princess Margaret Cancer Centre/University Health Network, Toronto, ON, Canada
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Giudice G, Robusto F, Vestita M, Annoscia P, Elia R, Nacchiero E. Single-stage excision and sentinel lymph node biopsy in cutaneous melanoma in selected patients: a retrospective case-control study. Melanoma Res 2017; 27:573-579. [PMID: 28574976 DOI: 10.1097/cmr.0000000000000370] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Sometimes, diagnostic excision of a primary melanoma would already necessitate skin grafting or transposition skin flaps, especially in areas with an esthetic or functional importance. The utility of sentinel lymph node biopsy (SLNB) after skin reconstruction is controversial. We carried out a single-institution retrospective case-control study. In patients with a wide primary lesion at high clinical-dermatoscopic suspicion for invasive melanoma in anatomical region in which a reconstruction with a skin graft or a flap is required, we proposed the performance of a confocal microscopy examination and an incisional biopsy of the primary lesion. If these diagnostic methodologies confirmed the suspicion of melanoma, lymphatic mapping was performed before the wide excision (WE) of the primary lesion, and WE and SLNB were performed during the same operative procedure. The database evaluation showed 496 patients who had undergone a previous complete local excision and a subsequent SLNB (two-stage group), whereas 61 patients underwent WE and SLNB during the same surgical time (one-stage group). Histological results of the excisional biopsy confirmed the diagnosis of melanoma in all patients of the one-stage group. The false-negative rate was lower in the one-stage group (5.5%) than in the two-stage group (16.7%). Patients of the two groups showed a similar recurrence-free and overall survival period even when corrected for clinic-demographical variables. The concomitant execution of SLNB and WE after confocal microscopy examination and incisional biopsy appears to be a safe and accurate procedure in patients with a wide primary melanoma that requires a skin flaps or a skin graft to cover the residual defect.
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Affiliation(s)
- Giuseppe Giudice
- aDepartment of Plastic and Reconstructive Surgery, Policlinico di Bari, Bari bDepartment of Clinical Pharmacology and Epidemiology, Mario Negri Sud Foundation, Santa Maria Imbaro, Italy
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Rose C. [Diagnostics of malignant melanoma of the skin : Recommendations of the current S3 guidelines on histology and molecular pathology]. Hautarzt 2017; 68:749-761. [PMID: 28875289 DOI: 10.1007/s00105-017-4046-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The updated S3 guidelines on malignant melanoma were established in August 2016. The principles of diagnostics and classification are based on the histopathological results from the primary tumor and if necessary the sentinel lymph nodes. The most important factor for prognosis is the tumor thickness according to Breslow and the detection of sentinel node micrometastases. The surgical safety margin after excision is dependent on the tumor thickness. Furthermore, ulceration of the primary tumor and presence of mitosis in melanomas less than 1 mm in thickness are also considered in the T‑classification. The sentinel lymph nodes should be prepared according to established procedures using HE staining and immunohistochemical methods. The largest tumor diameter of a micrometastasis should be measured in tenths of a millimeter (Rotterdam classification). Molecular pathology testing for mutations in the BRAF and NRAS oncogenes should be carried out in patients with metastatic disease or surgically non-resectable tumors. In addition c-KIT mutations should be tested in acral lentiginous and mucosal melanomas. Treatment with signal transduction inhibitors is possible when mutations have been detected.
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Affiliation(s)
- C Rose
- Dermatopathologie Lübeck, Maria-Goeppert-Str. 5, 23562, Lübeck, Deutschland.
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Ponzo MG, Crawford RI, Kossintseva I. Amelanotic Lentigo Maligna Melanoma: Mohs Surgery as the Definitive Treatment of an Invisible Tumour. J Cutan Med Surg 2017; 22:51-57. [DOI: 10.1177/1203475417719046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Amelanotic lentigo maligna melanoma represents <2% of melanomas. Diagnosis is delayed owing to the lack of lesion pigmentation and advanced disease at presentation. Excision with appropriate margins is the treatment standard, but the starting point for such margins is often unclear. We describe 2 patients with amelanotic melanoma treated by Mohs micrographic surgery (MMS) that would not have been cleared by wide local excision alone and provide an extensive review of the literature. Both patients presented with histologic diagnoses of malignant melanoma, one with a barely perceptible biopsy site scar on the left infraorbital cheek/lower eyelid (Breslow 1.8 mm) and the second with an amelanotic tumour on the right helix (Breslow 10 mm). Due to location, aggressive histology, amelanotic appearance, and no apparent surrounding skin surface changes, MMS was elected to maximise margin control. For patient 1, invasive and in situ tumour was found at the American Joint Committee on Cancer–recommended margin of 1.5 cm, and the final defect measured 8.5 × 4.8 cm. Patient 2 had a significant invasive and amelanotic lentigo maligna component, resulting in a 9.0 × 6.5-cm defect. MMS allows for immediate histologic feedback on tumour margins of a clinically invisible tumour and thus offers the most definitive treatment.
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Affiliation(s)
- Marisa Grace Ponzo
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Ian Crawford
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Irèn Kossintseva
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
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Lentigo Maligna, Macules of the Face, and Lesions on Sun-Damaged Skin: Confocal Makes the Difference. Dermatol Clin 2017; 34:421-429. [PMID: 27692448 DOI: 10.1016/j.det.2016.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Distinguishing lentigo maligna (LM) and lentigo maligna melanoma (LMM) from background pigmented non-melanoma lesions is challenging. The field of solar damage can obscure clinical assessment, and diagnostic ambiguities are created due to the overlap of the clinical features of LM with other benign lesions. Moreover, margin assessment on histology is limited by the resemblance between melanocytic hyperplasia of actinically damaged skin and scattered atypical melanocytes of LM/LMM. Dermoscopy has made a significant contribution but is often not sufficient for diagnosis and margin assessment. Confocal microscopy has become an important complementary tool in enhancing the management of these complex lesions.
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Zhao W, Yang S, Yang J, Li J, Zheng J, Qing Z, Yang R. Visual Biopsy by Hydrogen Peroxide-Induced Signal Amplification. Anal Chem 2016; 88:10728-10735. [DOI: 10.1021/acs.analchem.6b03330] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Wenjie Zhao
- State
Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry
and Chemical Engineering, and Collaborative Innovation Center for
Chemistry and Molecular Medicine, Hunan University, Changsha, 410082, People’s Republic of China
| | - Sheng Yang
- School
of Chemistry and Biological Engineering, Changsha University of Science and Technology, Changsha, 410114, People’s Republic of China
| | - Jinfeng Yang
- The
Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410011, People’s Republic of China
| | - Jishan Li
- State
Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry
and Chemical Engineering, and Collaborative Innovation Center for
Chemistry and Molecular Medicine, Hunan University, Changsha, 410082, People’s Republic of China
| | - Jing Zheng
- State
Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry
and Chemical Engineering, and Collaborative Innovation Center for
Chemistry and Molecular Medicine, Hunan University, Changsha, 410082, People’s Republic of China
| | - Zhihe Qing
- School
of Chemistry and Biological Engineering, Changsha University of Science and Technology, Changsha, 410114, People’s Republic of China
| | - Ronghua Yang
- State
Key Laboratory of Chemo/Biosensing and Chemometrics, College of Chemistry
and Chemical Engineering, and Collaborative Innovation Center for
Chemistry and Molecular Medicine, Hunan University, Changsha, 410082, People’s Republic of China
- School
of Chemistry and Biological Engineering, Changsha University of Science and Technology, Changsha, 410114, People’s Republic of China
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