Revisiting basal cell carcinoma clinical margins: Leveraging natural language processing and multivariate analysis with updated Royal College of Pathologists histological reporting standards

INTRODUCTION

Data supporting the current British Association of Dermatologists guidelines for the management of basal cell carcinoma (BCC) are based on historic studies and do not consider the updated Royal College of Pathologists (RCPath) histological reporting standards. The aim of this study was to use natural language processing (NLP)-derived data and undertake a multivariate analysis with updated RCPath standards, providing a contemporary update on the excision margins required to achieve histological clearance in BCC.

METHODS

A validated NLP information extraction model was used to perform a rapid multi-centre, pan-specialty, consecutive retrospective analysis of BCCs, managed with surgical excision using a pre-determined clinical margin, over a 17-year period (2004-2021) at Swansea Bay University Health Board. Logistic regression assessed the relationship between the peripheral and deep margins and histological clearance.

RESULTS

We ran our NLP algorithm on 34,955 BCCs. Out of the 1447 BCCs that met the inclusion criteria, the peripheral margin clearance was not influenced by the BCC risk level (p = 0.670). A clinical peripheral margin of 6 mm achieved a 95% histological clearance rate (95% confidence interval [CI], 0.93-0.98). Tumour thickness inversely affected deep-margin histological clearance (OR 0.720, 95% CI, 0.525-0.991, p < 0.05). Depth level 2 had a 97% probability of achieving deep-margin histological clearance across all tumour thicknesses.

CONCLUSION

Updated RCPath reporting standards minimally impact the peripheral margin histological clearance in BCC. Larger clinical peripheral margins than those indicated by current guidelines may be necessary to achieve excision rates of ≥95%. These findings emphasise the need for continuous reassessment of clinical standards to enhance patient care.

Improving the effectiveness of multidisciplinary team meetings on skin cancer: Analysis of the National Cancer Research UK survey responses

INTRODUCTION

Skin cancer is the most common form of cancer in the UK, comprising at least 25% of all new cancer diagnoses. Many patients require referral to the local or specialist skin cancer multidisciplinary team (MDT) for ongoing management. However, national data have shown that Specialist Skin Cancer MDTs are costly and do not currently meet NICE standards for composition and quoracy. Innovative solutions to these problems are therefore warranted.

METHODS

We performed a secondary comparative analysis of 3563 quantitative responses to two Cancer Research UK commissioned surveys along with subanalysis of 282 skin cancer MDT respondents.

RESULTS

Good uniformity was observed amongst skin respondents in the belief that risk stratification and prioritization of complex cases were the most important factors compared to other cancer MDT members. The most important priorities for areas requiring change to MDT working deemed by the skin MDT were 1) imaging and pathology results ready for the meeting, 2) time to discuss patients in detail, 3) clear meeting owner in charge, and 4) clear agenda, in advance of the meeting. There was agreement (median Likert score 4) amongst skin MDT respondents that patients should be placed on protocolized treatment pathways.

CONCLUSION

The responses of skin MDT respondents analyzed in the current study support changes to meeting attendance, preparation, and protocolized streaming. In line with other studies, we support tumor-specific guidance for streamlining MDT discussions. We also encourage stakeholders to adopt an evidence-based approach to test, develop, and reassess changes in this herculean task.

The epidemiology, healthcare and societal burden of basal cell carcinoma in Wales 2000-2018: a retrospective nationwide analysis

BACKGROUND

Basal cell carcinoma (BCC) represents the most commonly occurring cancer worldwide within the white population. Reports predict 298 308 cases of BCC in the UK by 2025, at a cost of £265-366 million to the National Health Service (NHS). Despite the morbidity, societal and healthcare pressures brought about by BCC, routinely collected healthcare data and global registration remain limited.

OBJECTIVES

To calculate the incidence of BCC in Wales between 2000 and 2018 and to establish the related healthcare utilization and estimated cost of care.

METHODS

The Secure Anonymised Information Linkage (SAIL) databank is one of the largest and most robust health and social care data repositories in the UK. Cancer registry data were linked to routinely collected healthcare databases between 2000 and 2018. Pathological data from Swansea Bay University Health Board (SBUHB) were used for internal validation.

RESULTS

A total of 61 404 histologically proven BCCs were identified within the SAIL Databank during the study period. The European age-standardized incidence for BCC in 2018 was 224.6 per 100 000 person-years. Based on validated regional data, a 45% greater incidence was noted within SBUHB pathology vs. matched regions within SAIL between 2016 and 2018. A negative association between deprivation and incidence was noted with a higher incidence in the least socially deprived and rural dwellers. Approximately 2% travelled 25-50 miles for dermatological services compared with 37% for plastic surgery. Estimated NHS costs of surgically managed lesions for 2002-2019 equated to £119.2-164.4 million.

CONCLUSIONS

Robust epidemiological data that are internationally comparable and representative are scarce for nonmelanoma skin cancer. The rising global incidence coupled with struggling healthcare systems in the post-COVID-19 recovery period serve to intensify the societal and healthcare impact. This study is the first to demonstrate the incidence of BCC in Wales and is one of a small number in the UK using internally validated large cohort datasets. Furthermore, our findings demonstrate one of the highest published incidences within the UK and Europe.

The psychosocial impact of microtia and ear reconstruction: A national data-linkage study

Introduction

Children with visible facial differences are believed to be at increased risk of negative psychosocial behaviours which may manifest as affective disorders. The aim of this study was to determine whether a diagnosis of microtia, and the associated surgical intervention, is associated with psychosocial implications including impaired educational attainment and a diagnosis of an affective disorder.

Methods

A retrospective case-control study was conducted using data linkage to identify patients in Wales with a diagnosis of microtia. Matched controls were sought on the basis of age, gender and socioeconomic deprivation status to yield a total sample size of 709. incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Educational attainment at 11 years of age, plus a diagnosis of depression or anxiety were used as markers of adverse psychosocial outcomes and the relative risk was attained using logistic regression analyses.

Results

There were no significant associations between a diagnosis of microtia and an increased risk of adverse educational attainment or a risk of an affective disorder diagnosis. Male gender and higher deprivation scores were significantly associated with poorer educational attainment, irrespective of a diagnosis of microtia. Surgical intervention of any nature was also not associated with any increased risk of adverse educational or psychosocial outcomes in microtia patients.

Discussion

Microtia patients in Wales do not appear to be at greater risk of developing affective disorders or impaired academic performance as a result of their diagnosis or associated surgical intervention. Whilst reassuring, the need for appropriate support mechanisms to maintain positive psychosocial wellbeing and academic achievement in this patient cohort is reinforced.

E-cadherin expression in acquired cholesteatoma

OBJECTIVES

The epithelial cell adhesion molecule E-cadherin is important for maintenance normal tissue architecture and for cell-cell communication and immune cell migration. E-cadherin is also present in cholesteatomas. This study determined E-cadherin expression in acquired cholesteatomas and analyzed its expression according to cholesteatoma clinical and histological characteristics.

METHODS

We investigated E-cadherin expression in 30 samples from operated patients with acquired middle ear cholesteatomas that were classified according to their clinical and histological characteristics. E-cadherin expression in cholesteatoma was determined immunohistochemically. A semi quantitative method was used to determine the index of expression of E-cadherin and t-tests, Mann-Whitney U tests and Spearman correlation analysis were used for statistical analysis.

RESULTS

We found significant expression of E-cadherin on CD1, CD3 total, CD4 (p < 0.05), high expression of E-cadherin on CD8 total and CD19/CD38 lymphocytes (p < 0.01) and very high expression of E-cadherin on mast cells and antigen-presenting cells, including Langerhans cells (p < 0.005). We graduated results as no statistically significant (p>0.05), statistically significant (0.05 > p > 0.01), highly statistically significant (0.01 > p > 0.005) and very highly statistically significant (p < 0.005).

CONCLUSION

E-cadherin expression was the same in the cholesteatoma matrix in all samples. There were no differences in expression according to the clinical and histological characteristics of the cholesteatomas.

Perfect angiographic patency of the arterial coronary-coronary conduit five years following surgery

Five years ago, the left internal thoracic artery free segment was used as a coronary-coronary bypass over a single, distal lesion of the large left anterior descending coronary artery in a patient with triple vessel disease. The patient has recently been readmitted, complaining of chest discomfort. Although he was scheduled for percutaneous coronary intervention due to disease progression on the circumflex coronary artery, the perfect angiographic patency of the arterial coronary-coronary conduit has been confirmed.

The radial artery for coronary artery bypass grafting

Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularisation, compared with internal mammary artery grafts. Recently, the use of radial artery for CABG has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent reports of encouraging mid-term and long-term patency rates of the radial artery, supports its continued use as a bypass conduit. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.

Molecular typing of the Legionella pneumophila population isolated from several locations in a contaminated water network

The RAPD (random amplified polymorphic DNA) technique has been developed for the molecular typing of Legionella in order to characterise the populations of hot water systems. During this study, 22 primers were tested and the four most informative ones were selected. The optimisation of the PCR conditions allowed the setting up of a powerful discriminative genotyping method. Moreover, the definition of a quality management method allowed definition of the key steps and the number of replicates to ensure reproducibility of the RAPD pattern. The RAPD was used to study the hot water network of a building. Legionella colonies (91) were isolated from seven locations and genotyped. The diversity of the population in one sample could vary from one to seven different strains. The study of the traceability showed that, in most of the cases, different populations could be present at different locations of the same network.

[Diffuse and binodular goiter in a patient with tuberous sclerosis]

Tuberous sclerosis complex is hereditary multisystemic, neurocutaneous disorder characterized by hamartomatous lesions mainly involving the brain, skin and viscera. Thyroid gland is rarely affected in these patients. Case history of a patient with tuberous sclerosis complex and diffuse and binodular goiter was presented. No epileptic seizures occurred despite multiple intracranial calcifications, cortical and subependimal tubers, revealed by neuroimaging. Borderline intellectual functioning was determined. Ultrasonographic findings of the heart, abdomen and pelvis were normal. Bone radiographs revealed multiple cystic lesions of the metacarpal, metatarsal and terminal phalanges. Clinical, endocrine and metabolic evaluations were performed because of anxiety, mild weight loss, transient problems of swallowing and breathing complaints, developing when she was 39 years old. Palpable diffuse and asymmetric thyroid enlargement was found. Laboratory tests of thyroid function, ultrasonographic examination and scintiscanning of the thyroid gland and patohistological analysis of fine-needle aspiration biopsy revealed the euthyroid, inactive, diffuse and binodular goiter. Unusual association of goiter and tuberous sclerosis was discussed.

[Detection of B-lymphocyte clonality in samples of salivary gland tissue in patients with primary Sjogren syndrome]

Intensive lymphoplasmocytic infiltration with atrophy of glandular tissue structures is the dominant patohistological feature found in exocrine glands of patients with Sjögren syndrome (SS). The infiltrates consist of T and B lymphocyte clusters that make the structures resembling germinal centers, and numerous plasmocytes that are secreting imunoglobulines locally, including autoantibodies. By applying the polymerase chain reaction (PCR) in our study we have shown the existence of dominant B cell clone in salivary glands samples of 4 out of 6 patients with SS, in the absence of clinical, routine laboratory, and patohistological signs of the lymphoma. B lymphocyte clones were detected upon the amplification of gene segment that encoded variable heavy chain immunoglobulin CDR3 region. Finding of single, dominant B lymphocyte clone could be of predictive significance, because these patients are predisposed to non-Hodgkin lymphoma (NHL) for which there is an assumption that it originates out of salivary glands from one of the clusters of proliferating B lymphocytes.

Tension-free left ITA graft -- the pericardial strip technique

Emphysematous lung occupying the whole dome of the left pleural cavity and expanding well over the midline may occasionally present a significant problem for positioning of the left internal thoracic artery, although the graft has been mobilized up to its origin. To avoid an undue tension on it, we combined a well known technique of the pericardial incision with the pericardial strip technique, enabling the lung to expand freely.

Ventricular performance following valve replacement for chronic mitral regurgitation: importance of chordal preservation

OBJECTIVE

To assess immediate and late changes in left ventricular performance after mitral valve replacement (MVR) for mitral regurgitation with or without preservation of chordae tendineae.

EXPERIMENTAL DESIGN

a prospective, one year follow-up, study.

SETTING

university cardiosurgical hospital.

PATIENTS

Fourteen patients with symptomatic chronic mitral regurgitation were divided into Group A (n = 7), which underwent MVR with chordal preservation, and Group B (n = 7) which underwent MVR with chordal transection.

METHODS

Transesophageal echocardiography, obtained simultaneously with radial artery and pulmonary capillary wedge pressures over a range of loading conditions, was used to estimate left ventricular elastance (Eps), calculated as the slope of peak systolic pressure/end-systolic volume relation, and preload recruitable stroke work (PRSW). Measurements were taken intraoperatively before and after cardiopulmonary bypass, 6 hours later and 10 days later. Transthoracic echocardiography follow-up data were obtained after 3 months and one year.

RESULTS

Eps significantly decreased immediately after MVR (p = 0.018), with no difference among 2 groups. Eps gradually increased to preoperative levels 10 days after surgery. PRSW also significantly decreased after MVR (p = 0.01). The decrease was significantly larger in Group B (p = 0.038). During follow-up, Group A showed a significantly better ejection fraction (p = 0.008), and a smaller end-systolic volume index (p = 0.01) and left ventricular mass index (p = 0.04), than Group B.

CONCLUSIONS

These data support the hypothesis that chordal preservation during MVR has beneficial effects on left ventricular performance.

Chordal preservation improves postoperative ventricular performance following valve replacement for chronic mitral regurgitation

Worsening of left ventricular performance had been recognized after mitral valve replacement for mitral regurgitation. The effects of chordal preservation on ventricular performance after mitral valve replacement have been assessed. Twelve patients with mitral regurgitation were allocated to group A (undergoing mitral valve replacement with chordal preservation), or to group B (undergoing mitral valve replacement with chordal excision). Transoesophageal echocardiography was recorded simultaneously with radial artery and pulmonary capillary wedge pressures. Load was varied by withdrawal of blood from a venous line of cardiopulmonary bypass and/or nitroglycerine bolus. Ventricular performance was assessed by the slope of peak systolic pressure-end-systolic volume relation (Eps), and by the slope of the left ventricular stroke work-end-diastolic volume relationship. Eps significantly decreased immediately after mitral valve replacement (P < 0.02), with no difference among two groups. Eps gradually increased to preoperative levels 10 days after surgery. Pre-load recruitable stroke work also significantly decreased after mitral valve replacement (P = 0.01). The decrease was significantly larger in group B (P < 0.04). These data support the hypothesis that chordal preservation during mitral valve replacement has beneficial effects on left ventricular performance.