Blog

• Surgical margin status:
  • Remains one of the most powerful and actionable prognostic factors in oral tongue / oral cavity SCC
• Classically, Scholl and colleagues:
  • Reviewed 268 patients with squamous carcinoma of the oral tongue:
    • They found that 54 (20.1%) had microscopic “cut-through” at the intraoperative frozen section margin:
      • An initially positive margin
  • Even when additional resection converted these to final negative margins:
    • Local control remained significantly worse:
      • Than in patients whose margins were clear on the first pass
  • They also reported that margin involvement patterns differed by T stage:
    • T1 to T2 tumors:
      • More often had positive mucosal margins
    • T3 to T4 tumors:
      • Commonly failed at the deep / soft-tissue margins
• Similar observations were made in classic series evaluating “positive” epidermoid carcinoma margins in the head and neck:
  • Looser, Shah, and Strong:
    • Demonstrated that patients with involved margins:
      • Had substantially higher local recurrence than those with negative margins:
        • With early reports quoting local recurrence in roughly two-thirds to three-quarters of patients with positive margins versus about one-third with negative margins
  • Loree and Strong:
    • Subsequently examined 398 oral cavity SCCs:
      • Showing that positive or “close” margins (tumor at or within 0.5 mm of the inked edge, or significant premalignant change / in situ carcinoma at the margin):
        • Were associated with a doubling of local recurrence (36% vs 18%) and inferior 5-year survival compared with negative margins (52% vs 60%)
• The reliability and utility of intraoperative frozen section (FS) margin assessment have also been extensively studied:
  • Spiro et al:
    • Reported an overall intraoperative FS diagnostic accuracy of approximately 89% for oral tongue cancer:
      • Importantly found that accuracy was similar whether sections were taken directly from the patient’s tumor bed or from the oriented surgical specimen
    • Positive or “close” margins:
      • Defined in their series as tumor present at the ink or within roughly one high-power field of the resection edge:
        • Were associated with a significantly increased risk of local recurrence (p < 0.003)
  • Subsequent work by Byers and others:
    • Confirmed the prognostic and therapeutic value of frozen section (FS):
      • Guided re-resection in HNSCC:
        • But also highlighted that FS cannot fully compensate for suboptimal initial resection planes
• Definitions of margin status and distance:
  • There is now better consensus on margin nomenclature
  • Most contemporary series and guidelines define:
    • Positive margin:
      • Invasive carcinoma or severe / high-grade dysplasia:
        • At the inked edge, or < 1 mm from the inked edge
    • Close margin:
      • Invasive carcinoma typically 1 to 4 or 1 to 5 mm from the inked edge:
        • Cut-off values vary:
        • But a 5 mm microscopic threshold is most commonly used in oral cavity SCC
    • Clear margin:
      • ≥ 5 mm from invasive tumor to the inked edge after formalin fixation
• Tasche et al., in a large JAMA Otolaryngology analysis:
  • Proposed that a distance < 1 mm behaves biologically like an involved margin:
    • With similarly high local recurrence risk
  • Whereas 1 to 5 mm margins had intermediate risk and ≥ 5 mm margins were associated with the lowest recurrence
• More recent multicenter work emphasizes the importance of deep margin distance in particular:
  • With data suggesting that deep margins ≤ 3 mm carry a significantly higher risk of local failure compared with > 3 mm:
    • Even when the mucosal margin is wide
• Impact of positive and close margins on outcomes:
  • Multiple retrospective series and meta-analyses now support and refine the early observations of Scholl, Looser, Loree, and Strong:
    • Positive final margins are consistently associated with:
      • ~ 2-fold higher risk of local recurrence,
        increased regional / distant failure in some series, and significantly worse disease-specific and overall survival
  • Binahmed et al. and McMahon et al:
    • Both showed that patients with involved margins:
      • Had roughly double the local recurrence and significantly poorer survival compared with those with clear margins, and that close margins behaved intermediately between clearly negative and frankly positive margins
  • Liao et al:
    • Identified margin status, together with T stage, DOI, and perineural invasion:
      • As major predictors of local tumor control in oral cavity SCC
  • A 2019 systematic review and meta-analysis by Gorphe:
    • Concluded that positive margins carry an approximately two-fold increased risk of death and local failure across head and neck sites, independent of other factors
  • More granular contemporary analyses, including Buchakjian et al. and Szewczyk et al., have shown that:
    • Positive margins (< 1 mm) remain the strongest margin-related predictor of:
      • Local, regional, and distant recurrence
    • Close margins (1 to 4.9 mm) often do not independently worsen outcomes if other adverse factors (lymphovascular invasion, perineural invasion, ENE, nodal disease, advanced T stage):
      • Are absent and if appropriate adjuvant therapy is given when indicated
  • The prognostic effect of close margins is modulated by:
    • Depth of invasion, pattern of invasion, and composite histologic risk models (e.g., Brandwein-Gensler)
  • Subsite-specific studies have further refined this:
    • Tongue and floor-of-mouth tumors are particularly prone to failure at the deep margin:
      • In several series, deep margin positivity or ≤ 2 to 3 mm clearance:
        • Has been more predictive of local recurrence than mucosal margin distance
• Microscopic cut-through and “revised” margins:
  • Building on Scholl’s original work, the concept of microscopic tumor cut-through (MTCT):
    • A positive FS margin that is revised to negative on final pathology, has been extensively studied
    • Patel et al. (Head & Neck 2010) showed that MTCT:
      • Was associated with significantly worse local control and disease-specific survival compared with margins that were negative from the outset:
        • Particularly in patients with nodal disease
    • Guillemaud et al. similarly reported that intraoperative cut-through, even if revised to R0:
      • Predicted higher local recurrence and worse outcomes in oral cavity SCC
    • A meta-analysis by Bulbul et al. concluded that clearance of a positive margin improves outcomes relative to leaving it unrevised:
      • But patients with MTCT still fare worse than those whose margins were always negative:
        • Suggesting MTCT is a marker of more aggressive biology and / or challenging local anatomy
    • More recently, Agne et al. evaluated T3 to T4 OCSCC and confirmed that MTCT:
    • remained an independent predictor of local recurrence on multivariable analysis (HR ~1.8–2.2 for local failure):
      • Although its effect on disease-specific survival attenuated when controlling for nodal stage and other high-risk features
• These data support considering MTCT as a high-risk feature warranting discussion of treatment intensification:
  • For example (e.g., adjuvant chemoradiotherapy) in a multidisciplinary tumor board, even when final margins are technically negative
• Kwok et al. addressed the related question of “clear versus revised margins” in 417 patients with oral and pharyngeal carcinoma:
  • Patients who required immediate re-resection for a positive FS margin but ended with R0 status:
    • Had survival similar to those with primary R0 resection, and both groups did substantially better than patients left with residual microscopic or macroscopic disease
  • This suggests that while MTCT carries biologic risk:
    • An aggressive intraoperative strategy to convert to R0 is still beneficial and should remain standard practice
• Intraoperative margin assessment:
  • Specimen vs tumor bed:
    • There is growing recognition that how margins are sampled:
      • Is almost as important as the final measurement
    • Meier et al.’s AHNS survey and several subsequent series have documented wide variation in intraoperative margin practices (tumor bed vs specimen mapping, number of samples, definition of “adequate” clearance), and a substantial rate of FS–permanent section discrepancy
  • Key contemporary points include:
    • Specimen-based mapping (oriented and inked, with communication between surgeon and pathologist):
      • Tends to provide more reliable correlation between FS and final margins than random tumor-bed biopsies
    • FS accuracy remains high (often ~ 85% to 95%):
      • But false-negatives and false-positives still occur:
        • Particularly at the deep margin, in previously irradiated fields, and in specimens with significant shrinkage
    • In some series, “complete FS margins” with a measurable 1 to 5 mm histologic buffer were associated with improved local control compared with conventional limited sampling
  • Recent reviews and consensus statements (e.g., Kubik et al., Kain et al., Chen et al. 2024) now recommend:
    • A planned 1 to 1.5 cm gross resection margin in vivo for oral tongue SCC, anticipating ~30% to 50% shrinkage with formalin fixation and tissue relaxation
    • Routine use of oriented, inked specimens with targeted FS from high-risk areas (deep margin, close relationship to muscle bundles or neurovascular structures)
    • Consideration of advanced adjuncts—near-infrared fluorescence mapping, specimen 3D-mapping, and emerging augmented-reality registration—for difficult tongue and floor-of-mouth resections
• Integration with histologic risk models:
  • Finally, margin status must be interpreted in the context of overall histologic risk
  • The Brandwein-Gensler model:
    • Worst pattern of invasion, perineural invasion, lymphocytic host response and later refinements:
      • Have shown that high-risk tumors have markedly increased recurrence and disease-specific mortality even when margins are clear
  • Conversely, some low-risk early-stage tumors with close (but not involved) margins may do well without aggressive adjuvant therapy
  • This supports a nuanced, risk-adapted approach in which:
    • Positive margins or MTCT → strong indication for adjuvant chemoradiotherapy in most patients
    • Close margins (1 to 4 mm) → individualized decision based on DOI, nodal status, PNI/LVI, pattern of invasion, and patient-specific factors
    • Clear margins (≥ 5 mm) → lowest risk group, managed according to other adverse features.
• Reviewed:
  • Scholl P, Byers RM, Batsakis JG, Wolf P, Santini H. Microscopic cut-through of cancer in the surgical treatment of squamous carcinoma of the tongue: prognostic and therapeutic implications. Am J Surg. 1986;152:354-360. 
  • Looser KG, Shah JP, Strong EW. The significance of “positive” margins in surgically resected epidermoid carcinomas. Head Neck Surg. 1978;1:107-111. 
  • Loree TR, Strong EW. Significance of positive margins in oral cavity squamous carcinoma. Am J Surg. 1990;160:410-414. 
  • Spiro RH, Guillamondegui O, Paulino AF, et al. Pattern of invasion and margin assessment in patients with oral tongue cancer. Head Neck. 1999;21:408-413. 
  • Chen TY, Emrich LJ, Driscoll DL. The clinical significance of pathological findings in surgically resected margins of the primary tumor in head and neck carcinoma. Int J Radiat Oncol Biol Phys. 1987;13:833-837. 
  • McMahon J, O’Brien CJ, Pathak I, et al. Influence of condition of surgical margins on local recurrence and disease-specific survival in oral and oropharyngeal cancer. Br J Oral Maxillofac Surg. 2003;41:224-231. 
  • Binahmed A, Nason RW, Abdoh AA. The clinical significance of the positive surgical margin in oral cancer. Oral Oncol. 2007;43:780-784. 
  • Liao CT, Chang JTC, Wang HM, et al. Analysis of risk factors of predictive local tumor control in oral cavity cancer. Ann Surg Oncol. 2008;15:915-922. 
  • Patel RS, Goldstein DP, Guillemaud J, et al. Impact of positive frozen section microscopic tumor cut-through revised to negative on oral carcinoma control and survival rates. Head Neck. 2010;32:1444-1451. 
  • Guillemaud J, Patel RS, Goldstein DP, et al. Prognostic impact of intraoperative microscopic cut-through on frozen section in oral cavity squamous cell carcinoma. J Otolaryngol Head Neck Surg. 2010;39:370-377. 
  • Kwok P, Gleich O, Hübner G, Strutz J. Prognostic importance of “clear versus revised margins” in oral and pharyngeal cancer. Head Neck. 2010;32:1479-1484. 
  • Gorphe P. A systematic review and meta-analysis of margins in head and neck cancer. Oral Oncol. 2019;95:93-101. 
  • Tasche KK, Buchakjian MR, Pagedar NA, Sperry SM. Definition of “close margin” in oral cancer surgery and association of margin distance with local recurrence rate. JAMA Otolaryngol Head Neck Surg. 2017;143:1166-1172. 
  • Buchakjian MR, Tasche KK, Robinson RA, et al. Association of main specimen and tumor bed margin status with local recurrence and survival in oral cancer surgery. JAMA Otolaryngol Head Neck Surg. 2016;142:1191-1198. 
  • Kain JJ, Birkeland AC, Udayakumar N, et al. Surgical margins in oral cavity squamous cell carcinoma: current practices and future directions. Laryngoscope. 2020;130:128-138. 
    Szewczyk M, et al. A matter of margins in oral cancer—how close is enough? Cancers (Basel). 2024;16(8):1488. 
  • Agne GR, et al. Oncologic outcomes of microscopic tumor cut-through in locally advanced oral squamous cell carcinoma. Arch Head Neck Surg. 2022;51:e20220013. 
    Chen Y, et al. Surgical margins in head and neck squamous cell carcinoma. Int J Surg. 2024;109:54-66. 
  • Brandwein-Gensler M, et al. Oral squamous cell carcinoma: histologic risk assessment, but not margin status, is strongly predictive of local disease-free and overall survival. Am J Surg Pathol. 2005;29:167-178.  

The treatment landscape for HER2-positive early breast cancer (EBC) is evolving rapidly — and trastuzumab deruxtecan (T-DXd) is emerging as a potential new standard in both the neoadjuvant and adjuvant settings.

🔹 Neoadjuvant Setting

DESTINY-Breast11

T-DXd followed by THP (docetaxel + trastuzumab + pertuzumab) demonstrated:

Significantly higher pathologic complete response (pCR) rates compared with standard anthracycline-based regimens A chemotherapy-sparing strategy with reduced anthracycline exposure Favorable tolerability profile consistent with prior T-DXd data

📊 Early reports show pCR rates approaching ~65–70%, exceeding historical benchmarks for standard neoadjuvant regimens (typically ~55–60%).

Clinical Implication:

We may be entering an era of antibody–drug conjugate (ADC)-based neoadjuvant intensification, potentially redefining the backbone of HER2-directed therapy.

Reference:

Hurvitz SA et al. DESTINY-Breast11. Presented at ESMO 2024 / SABCS 2024 (late-breaking data).

🔹 Adjuvant Setting

DESTINY-Breast05

For patients with residual invasive disease after neoadjuvant therapy, T-DXd demonstrated:

53% reduction in risk of invasive disease–free survival (iDFS) events compared with T-DM1 Superior invasive disease–free survival Manageable toxicity, with ILD rates consistent with prior experience

This builds upon the paradigm established by KATHERINE, where T-DM1 replaced trastuzumab in patients with residual disease.

Now, T-DXd appears poised to replace T-DM1 in this high-risk population.

Reference:

DESTINY-Breast05. Presented at ASCO 2025.

von Minckwitz G et al. KATHERINE trial. NEJM. 2019;380:617–628.

🔬 Why This Matters

We are witnessing:

A shift from monoclonal antibodies → ADC-based escalation Earlier deployment of highly potent HER2-directed agents Refinement of risk-adapted therapy based on response

If adopted into guidelines (NCCN, ASCO, ESMO), this could:

Redefine the management of residual disease Potentially reduce recurrence risk further in high-risk HER2+ EBC Change neoadjuvant sequencing strategies

⚠️ Considerations

ILD/pneumonitis risk requires vigilance Cost-effectiveness and long-term survival data pending Optimal sequencing with pertuzumab still being clarified

📌 Bottom Line

T-DXd is no longer just a metastatic drug.

It is rapidly reshaping the curative-intent HER2+ early breast cancer algorithm.

Choledochal Cysts – Types and Management

Choledochal cysts are congenital cystic dilatations of the biliary tree. They are associated with an abnormal pancreaticobiliary junction and carry a significant lifetime risk of malignancy (especially cholangiocarcinoma).

Classification (Todani Classification)

The most widely used system is the Todani classification, which divides choledochal cysts into five main types:

Type I – Extrahepatic bile duct dilatation (most common, 50–80%)
• Ia – Diffuse cystic dilatation of CBD
• Ib – Focal segmental dilatation
• Ic – Fusiform dilatation of CBD

Management:
→ Complete excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy

Type II – True diverticulum of CBD
• Saccular outpouching from extrahepatic bile duct

Management:
→ Diverticulectomy ± primary closure of CBD

Type III – Choledochocele
• Intraduodenal dilatation of distal CBD (within ampulla)

Management:
→ Endoscopic sphincterotomy (often sufficient)
→ Surgical excision if large/symptomatic

Type IV – Multiple cysts
• IVa – Both intrahepatic and extrahepatic involvement
• IVb – Multiple extrahepatic cysts only

Management:
→ Excision of extrahepatic bile duct + Roux-en-Y hepaticojejunostomy
→ Liver resection if localized intrahepatic disease
→ Liver transplant if diffuse severe intrahepatic disease

Type V – Caroli Disease
• Multiple intrahepatic cystic dilatations only

Associated with congenital hepatic fibrosis.

Management:
→ Segmental liver resection (localized)
→ Liver transplantation (diffuse disease)

Clinical Presentation
• Children: classic triad (rarely complete)
• Abdominal pain
• Jaundice
• Palpable mass
• Adults:
• Recurrent cholangitis
• Pancreatitis
• Biliary colic
• Incidental finding

Investigations
• Ultrasound – initial test
• MRCP – investigation of choice
• CT if malignancy suspected
• LFTs

ERCP mainly therapeutic (type III).

Complications
• Cholangitis
• Pancreatitis
• Stones
• Strictures
• Rupture (rare)
• Cholangiocarcinoma (10–30% lifetime risk if untreated)

Principles of Management (Important for Practice)

1. Complete cyst excision whenever possible
2. Avoid drainage procedures (obsolete due to cancer risk)
3. Long-term follow-up due to residual malignancy risk
4. Early surgery in children once diagnosed

Surgical Standard Operation

Cyst excision + Roux-en-Y hepaticojejunostomy
→ Gold standard for Type I and IV

Mirizzi Syndrome: The rare but challenging complication where an impacted gallstone in the cystic duct or Hartmann’s pouch causes external compression or fistulization into the common bile duct. The modified Csendes classification grades severity from Type 1 (external compression only) through Type 5 (cholecystobiliary fistula with gallstone ileus). Type 1 shows simple compression without fistula formation. Type 2 involves erosion affecting less than one-third of the bile duct circumference. Type 3 extends to involve one-third to two-thirds of the duct. Type 4 shows complete destruction of the bile duct wall. Type 5 adds the complication of cholecystoenteric fistula with gallstone ileus. Recognition is critical during cholecystectomy as misidentification can lead to bile duct injury. Higher types require bile duct reconstruction

New 5-Year Evidence Supporting Radiofrequency Ablation (RFA) in Early-Stage Breast Cancer

I’m pleased to share results from the RAFAELO Phase 3 multicenter trial — published online in Annals of Surgical Oncology (Feb 18, 2026) — assessing radiofrequency ablation (RFA) as a minimally invasive alternative to partial mastectomy in early-stage breast cancer. 

🔍 Study Overview

• Design: Multicenter, single-arm, Phase 3 clinical study.

• Population: 370 women with solitary Tis–T1 (≤1.5 cm), N0M0 breast carcinomas.

• Intervention: Percutaneous RFA followed by whole-breast radiation (45–60 Gy).

• Primary Endpoint: 5-year ipsilateral breast tumor recurrence-free survival (IBTRFS). 

📈 Key Findings

✔ At 5 years, IBTRFS was 98.6% (90% CI 97.1–99.3%), exceeding the pre-specified noninferiority margin of 90%.

✔ Only 2 ipsilateral recurrences were observed at 5 years.

✔ Grade ≥3 skin ulceration was rare (1/370 patients), underscoring a favorable safety profile.

✔ These results suggest that RFA with adjuvant radiation may be comparable to partial mastectomy in appropriately selected early-stage patients. 

🏷 Clinical Significance

This large prospective trial provides the most robust long-term evidence to date that RFA — a less invasive approach — may be a viable local-control strategy in small, node-negative breast cancers. These findings reinforce ongoing interest in expanding treatment options that balance oncologic safety with patient-centred care (e.g., cosmesis, procedural morbidity). 

Optional Add-Ons for Engagement

🔹 Thanks to the RAFAELO Study Group and contributing centers for advancing patient-centred oncology. 

🔹 Looking forward to longer follow-up, quality-of-life data, and comparative trials against standard surgery

https://idp.springer.com/authorize?response_type=cookie&client_id=springerlink&redirect_uri=https%3A%2F%2Flink.springer.com%2Farticle%2F10.1245%2Fs10434-026-19220-0

• Conference Overview
  Held March 12–15, 2025 in Vienna with >3,100 global participants.
  Focused on early breast cancer (BC): evidence, controversies, consensus, and breakthroughs.
  Included lectures, debates, poster sessions, and the renowned St. Gallen Consensus Session.
  Hansjoerg Senn Memorial Lecture was introduced to honor a major contributor to BC care. 
  
  🔬 Systemic Therapy & Novel Agents
  Goal of early BC therapy is to improve overall survival (OS) through better systemic and local treatment.
  Surrogate endpoints (e.g., pathological complete response) are crucial for accelerating drug development.
  New endocrine therapies (SERDs) are being evaluated, with emphasis on QoL and resistance mechanisms.
  Anti-HER2 advances from metastatic setting are being translated to early BC, including adaptive trial designs.
  Antibody-drug conjugates (ADCs) hold potential in early BC; ongoing trials are evaluating various indications. 
  
  🧬 Liquid Biopsy & Biomarkers
  ctDNA and liquid biopsy show promise for minimal residual disease (MRD) detection and relapse risk stratification.
  Tumor-informed assays have higher sensitivity than tumor-agnostic panels.
  Circulating tumor cells (CTCs) are prognostic but less sensitive; CHIP mutations may confound results.
  Multiple trials are exploring ctDNA as a tool for guiding post-treatment strategies. 
  
  HER2+ Breast Cancer
  Trastuzumab remains a foundational therapy after 20 years.
  Duration of trastuzumab (6 vs. 12 months) continues to be debated; 12 months remains standard.
  Improved HER2 testing and classification helps tailor therapies, especially in HER2-low disease.
  De-escalation strategies (e.g., PET-adapted) are under study for selected patients.
  Residual disease post-neoadjuvant therapy moves toward T-DM1 or other combinations; new trials are ongoing. 
  
  Tailoring Treatment & De-Escalation
  Omitting radiotherapy (RT) or endocrine therapy (ET) in very low-risk patients is under investigation.
  Minimally invasive alternatives (e.g., cryoablation) are being evaluated to reduce surgical burden.
  Older patients need individualized decision making rather than age-based exclusion from therapy.
  Tools like ESMO Magnitude of Clinical Benefit Scale can help weigh benefits vs toxicity. 
  
  Surgery & Local Management
  Breast-conserving surgery (BCS) remains preferred when feasible; mastectomy does not guarantee survival benefit.
  Radiotherapy tailoring (partial, hypofractionation) reduces toxicity while maintaining control.
  Post-neoadjuvant surgery focuses on resection of residual disease; MRI radiomics and biopsies aid prediction.
  Reconstruction decisions must be individualized, involving patient preferences and RT considerations. 
  
  ER+ Disease Nuances
  Optimizing adjuvant therapy (ET, CDK4/6 inhibitors, genomic assays) depends on recurrence risk and biomarkers.
  Chemotherapy benefit varies by genomic risk scores and age—particularly in premenopausal women.
  Extended ET decisions benefit from clinical, genomic, and novel biomarkers like ctDNA.
  Invasive lobular carcinoma (ILC) and ER-low tumors need refined imaging and therapeutic stratification. 
  
  Artificial Intelligence (AI) Integration
  AI has potential to enhance:
  Biomarker discovery and response prediction
  Treatment planning and radiation delivery
  Target identification and clinical decision support
  Collaboration between AI developers and clinicians is essential for clinical implementation. 
  
  Imaging & Staging Updates
  PET-CT may be useful in higher-stage early BC; routine use in stage I remains limited.
  Breast MRI improves staging but increases interventions without clear outcome benefit; selective use recommended.
  Follow-up imaging remains guided by existing evidence; future strategies might integrate new technologies and ctDNA. 
  
  Hereditary BC & Prevention
  Germline mutations (BRCA1/2, PALB2, ATM, CHEK2) justify altered management and intensive screening.
  Risk-reducing surgeries lower incidence, though survival benefits require longer follow-up.
  Non-surgical options (e.g., intensified screening, risk-reducing medications) are important for many carriers. 
  
  Axillary Management
  Sentinel lymph node biopsy (SLNB) remains standard for clinically node-negative patients.
  Omission of upfront axillary surgery is considered in select scenarios with multidisciplinary input.
  Trials are evaluating safe approaches to avoid full axillary dissection post-neoadjuvant therapy. 
  
  Clinical Trials & Patient-Centered Design
  High-quality trials require real-world applicability, patient involvement, meaningful endpoints, and QoL measures.
  Trial design frameworks (e.g., SPIRIT, PRECIS-2) help balance explanatory vs pragmatic objectives. 
  
  Special Populations
  BC during pregnancy requires tailored imaging and therapy planning to optimize maternal and fetal safety.
  Young patients and those with reproductive concerns need individualized counseling and treatment adaptation. 

https://ecancer.org/en/journal/article/2075-the-19th-st-gallen-international-breast-cancer-conference-primary-therapy-of-patients-with-early-breast-cancer-evidence-controversies-consensus-key-moments-and-breakthroughs?utm_campaign=automated-emails&utm_source=siteupdates-en-html-20260213&utm_medium=email&utm_target=d8628274966ebe70f6f44ff9393f2797c2d952c553cc7fa3f43de5e1c17fd7171edb509c851169c954d77de3b71e4aa86c3e034376f2253f-f23386

Paper summary (Eur Arch Otorhinolaryngol, 2026) — “The impact of drains on surgical outcomes in thyroid surgery”

This is a meta-analysis of randomized controlled trials comparing drain vs no drain after adult thyroid surgery (search Jan 1995–Aug 2025). It included 10 RCTs (n=1,078) and assessed haematoma/seroma (primary) plus SSI, return-to-theatre, pain, and length of stay. 

Key findings

No significant difference with drains for: Haematoma (p=0.15) Seroma (p=0.64) Return-to-theatre (p=0.22)  Drains were associated with worse outcomes: Higher SSI (4.2% vs 0.5%, p=0.01) Longer LOS (≈ +1.2 days, p<0.0001) More pain (MD ≈ +2.2, p=0.001) 

Conclusion of the authors: routine drains don’t reduce clinically important collections/bleeding outcomes and should be selective/patient-specific. 

Additional high-yield evidence on the same question

Systematic reviews

2017 meta-analysis (14 studies, n=1,927): drains increased infection and length of stay, with no significant differences in haematoma/seroma or RLN palsy/hypoparathyroidism.  Cochrane review: highlights the key limitation of drains—they can block with clot and do not replace meticulous haemostasis / re-exploration when bleeding occurs; overall evidence did not support routine use. 

Randomized trials (examples)

2013 RCT (Uganda, n=68): no-drain group had shorter LOS and less pain, with no signal that drains prevented important complications.  2023 RCT (lobectomy + central neck dissection, n=104): no routine drain needed; no-drain group had shorter LOS and better comfort metrics. 

Evidence-based recommendation (practical)

1) Default position

For uncomplicated thyroidectomy/hemithyroidectomy, the best available RCT/meta-analysis evidence supports NO routine drain because it does not reduce haematoma/seroma and does increase SSI, pain, and LOS. 

2) When a drain may be reasonable (selective use)

Consider a drain selectively when you believe a drain will meaningfully manage expected ongoing output or permit monitoring in a high-risk scenario, e.g.:

Extensive dissection / large dead space (e.g., combined procedures, broad flap elevation) Significant intraoperative oozing despite optimization (coagulopathy, difficult hemostasis) Reoperative thyroid surgery Very large goiter/substernal component (case-dependent) Neck dissection / lateral compartment work (many surgeons drain these by default; note: classic drain trials often exclude lateral neck dissections) 

(Even in these settings, it’s worth emphasizing: drains don’t “prevent” a dangerous post-thyroidectomy hematoma—rapid recognition and evacuation remain key, and drains may clot off.) 

3) What to do instead of routine drains (high-impact steps)

Meticulous hemostasis + Valsalva before closure Layered closure / dead-space minimization Standardized post-op neck checks and early warning protocol (swelling, tightness, voice change, stridor) Clear hematoma pathway (immediate bedside opening vs OR depending on severity/resources)

• Atypical ductal hyperplasia (ADH):
  • Is a benign proliferative breast lesion:
    • Characterized by filling and distention of ducts by dysplastic monotonous epithelial cells:
      • Forming architecturally complex patterns, including:
        • Cribriform-like secondary lumens or micropapillary formations
  • It is found in approximately 10% of benign breast biopsies
  • It confers a four-fold increased risk of subsequent breast cancer:
    • With a cumulative incidence approaching 30% at 25 years
• Definition and Histopathology:
  • ADH is defined by cytologic and architectural features:
    • Established by Page and colleagues in 1985
  • The lesion shows:
    • Proliferation of dysplastic, monotonous epithelial cells:
      • With architectural complexity and nuclear hyperchromasia
  • The key distinction from ductal carcinoma in situ (DCIS) is quantitative rather than qualitative:
    • ADH shares histologic features with low-grade DCIS but is less extensive
    • If the lesion meets criteria for DCIS in terms of quality but involves fewer than two ducts or measures less than 2 mm:
      • It is classified as ADH
  • This places ADH in a transitional zone between benign and malignant disease:
    • Making it a premalignant lesion
• Epidemiology:
  • ADH:
    • Is found in approximately 10% of core needle biopsy specimens with benign findings
  • Both atypical ductal and atypical lobular hyperplasia:
    • Occur with equal frequency and confer similar breast cancer risks
  • The lesion is typically discovered incidentally on screening mammography:
    • In asymptomatic women
• Risk Factors and Modifiers:
  • Younger age at diagnosis:
    • Is associated with higher subsequent breast cancer risk
  • Family history of breast cancer:
    • May increase risk, though data are conflicting
  • Number of atypical foci significantly impacts risk:
    • Women with ≥ 3 foci have a standardized incidence ratio (SIR) of 5.29 compared to 3.11 for a single focus
  • Dense breasts:
    • Increase risk compared to fatty breasts
• Imaging Characteristics:
  • ADH:
    • Has no pathognomonic imaging appearance and typically mimics findings seen in small cancers
  • Mammographic Features:
    • Clustered microcalcifications:
      • Are the most common finding directly correlated with ADH:
        • Present in 64% to 82% of cases
      • Calcifications of intermediate concern or higher probability of malignancy:
        • Are more frequent when ADH is associated with malignancy
    • May also present as masses, asymmetric densities, or architectural distortion
    • Direct mammographic-histologic correlation:
      • Occurs in approximately 41% of cases
  • Ultrasound Features:
    • Most lesions appear as hypoechoic masses (64%)
    • Irregular shape (51%) and microlobulated margins (49%)
    • No specific posterior acoustic features (53%)
    • Parallel orientation (57%)
    • Presence of calcifications on ultrasound is significantly associated with upgrade to malignancy
  • ADH lesions are typically assigned BI-RADS category 4 (suspicious abnormality):
    • Warranting tissue sampling by core needle biopsy
• Management:
  • Surgical Excision:
    • Surgical excision remains the standard of care for ADH diagnosed on core needle biopsy:
      • Due to upgrade rates of 15% to 30% to DCIS or invasive cancer
    • A 2020 meta-analysis of 6,458 lesions:
      • Found a 29% upgrade rate for surgically excised ADH
    • The Society of Surgical Oncology recommends routine excision:
      • Noting an upgrade rate of at least 20%
  • Emerging Evidence for Selective Observation:
    • Recent literature suggests that select low-risk ADH lesions may be candidates for observation rather than routine excision:
      • Lesions that appear completely removed at biopsy
      • Limited foci:
        • Fewer than 2 to 3 foci
      • No necrosis or significant atypia on pathology
      • Small groups of mammographic calcifications
      • No enhancement on MRI
      • No underlying risk factors:
        • No history of breast cancer
        • No genetic mutation
        • No concurrent high-risk lesions
  • A 2022 study found that selected women with ADH who met predetermined low-risk criteria and were managed nonoperatively:
    • Had a 1.2% index site cancer rate at median 5.2-year follow-up:
      • Comparable to the 1.5% rate in those who underwent surgery
  • A 2025 study applying COMET trial criteria:
    • Found only a 3.43% upgrade to invasive disease in low-risk patients
• Post-Diagnosis Management:
  • For women with confirmed ADH on excisional biopsy:
    • Enhanced surveillance:
      • Annual mammography plus breast MRI screening
    • Risk-reducing medications:
      • Endocrine therapy (tamoxifen or aromatase inhibitors) is strongly recommended by NCCN guidelines:
      • With an 86% risk reduction for women with atypical hyperplasia
    • Lifestyle modifications:
      • Counseling on healthy lifestyle factors
  • Prognosis:
    • ADH confers a relative risk of approximately 4 for future breast cancer compared to women without the diagnosis
    • The absolute risk is substantial and sustained over time:
      • Cumulative Breast Cancer Incidence:
        • 5 years: 6.6% (95% CI 4.4-9.7%)
        • 10 years: 13.9% (95% CI 7.8-23.6%)
        • 25 years: 30% (either DCIS or invasive cancer)
      • The 10-year cumulative incidence is approximately 14.6%:
        • Representing about 1% per year
      • Risk increases with the number of atypical foci present:
        • Women with ≥ 3 foci have nearly double the risk of those with a single focus
    • Important Prognostic Considerations:
      • Risk affects both the ipsilateral and contralateral breast:
        • Though ipsilateral risk may be slightly higher
      • The risk does not plateau but continues to increase linearly over decades
      • Approximately half of subsequent breast cancers:
        • Occur within the first 5 years after ADH diagnosis
      • Both DCIS and invasive cancer contribute to subsequent events
      • The NCCN Breast Cancer Risk Reduction guidelines:
        • Classify women with atypical hyperplasia as high-risk and recommend risk-reducing endocrine therapy for those with life expectancy ≥ 10 years, given the substantial and sustained elevation in breast cancer risk
• References:
  • Atypical Hyperplasia of the Breast — Risk Assessment and Management Options. Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. The New England Journal of Medicine. 2015;372(1):78-89. doi:10.1056/NEJMsr1407164.
  • Updates on Management of Atypical Hyperplasia of the Breast. Klassen CL, Fraker JL, Pruthi S. Mayo Clinic Proceedings. 2025;100(6):1051-1057. doi:10.1016/j.mayocp.2025.01.029.
  • Subsequent Breast Cancer Risk Following Diagnosis of Atypical Ductal Hyperplasia on Needle Biopsy. Menes TS, Kerlikowske K, Lange J, et al. JAMA Oncology. 2017;3(1):36-41. doi:10.1001/jamaoncol.2016.3022.
  • Benign Breast Disease and Breast Cancer Risk in the Percutaneous Biopsy Era. Sherman ME, Vierkant RA, Winham SJ, et al. JAMA Surgery. 2024;159(2):193-201. doi:10.1001/jamasurg.2023.6382.
  • Atypical Hyperplasia of the Breast: Mammographic Appearance and Histologic Correlation. Helvie MA, Hessler C, Frank TS, Ikeda DM. Radiology. 1991;179(3):759-64. doi:10.1148/radiology.179.3.2027988.
  • Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature. Harper LK, Carnahan MB, Bhatt AA, et al. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2023;43(10):e230016. doi:10.1148/rg.230016.
  • Atypical Ductal Hyperplasia Diagnosed at Sonographically Guided Core Needle Biopsy: Frequency, Final Surgical Outcome, and Factors Associated With Underestimation. Mesurolle B, Perez JC, Azzumea F, et al. AJR. American Journal of Roentgenology. 2014;202(6):1389-94. doi:10.2214/AJR.13.10864.
  • Mucocele-Like Tumors of the Breast as Cystic Lesions: Sonographic-Pathologic Correlation. Kim SM, Kim HH, Kang DK, et al. AJR. American Journal of Roentgenology. 2011;196(6):1424-30. doi:10.2214/AJR.10.5028.
  • Diagnosis of Columnar Cell Lesions and Atypical Ductal Hyperplasia by Ultrasound-Guided Core Biopsy: Findings Associated With Underestimation of Breast Carcinoma. Ahn HS, Jang M, Kim SM, et al. Ultrasound in Medicine & Biology. 2016;42(7):1457-63. doi:10.1016/j.ultrasmedbio.2016.02.009.
  • Society of surgical oncology medical student & trainee primer for breast surgical oncology. Marissa K. Boyle, Julia M. Selfridge, Rachel E. Sargent, et al.
    Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions. Schiaffino S, Calabrese M, Melani EF, et al. Radiology. 2020;294(1):76-86. doi:10.1148/radiol.2019190748.
  • Risk of Breast Cancer in Selected Women With Atypical Ductal Hyperplasia Who Do Not Undergo Surgical Excision. Kilgore LJ, Yi M, Bevers T, et al. Annals of Surgery. 2022;276(6):e932-e936. doi:10.1097/SLA.0000000000004849.
  • Implications of the COMET Trial for the Management of Atypical Ductal Hyperplasia. Zaveri S, Sun SX, Bevers TB, Albarracin CT, Bedrosian I. Annals of Surgical Oncology. 2025;:10.1245/s10434-025-18236-2. doi:10.1245/s10434-025-18236-2.
  • Atypical Hyperplasia of the Breast: Clinical Cases and Management Strategies. Vegunta S, Mussallem DM, Kaur AS, Pruthi S, Klassen CL. Cleveland Clinic Journal of Medicine. 2023;90(7):423-431. doi:10.3949/ccjm.90a.22098.
    Breast Cancer Risk Reduction. National Comprehensive Cancer Network. Updated 2025-08-29.
  • Use of Endocrine Therapy for Breast Cancer Risk Reduction: ASCO Clinical Practice Guideline Update. Visvanathan K, Fabian CJ, Bantug E, et al. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2019;37(33):3152-3165. doi:10.1200/JCO.19.01472.
    Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. Obstetrics and Gynecology. 2017;130(1):e1-e16. doi:10.1097/AOG.0000000000002158.
  • Atypical Ductal or Lobular Hyperplasia, Lobular Carcinoma in-Situ, Flat Epithelial Atypia, and Future Risk of Developing Breast Cancer: Systematic Review and Meta-Analysis. Baker J, Noguchi N, Marinovich ML, et al. Breast (Edinburgh, Scotland). 2024;78:103807. doi:10.1016/j.breast.2024.103807.
  • Trajectory of Subsequent Breast Cancer Diagnoses in a Diverse Patient Cohort With Breast Atypia. Limberg JN, Thomas SM, Dalton JC, et al. Annals of Surgical Oncology. 2024;31(11):7550-7558. doi:10.1245/s10434-024-15788-7.

A cutting-edge study published in npj Breast Cancer today reports validation of the HER2DX genomic test as a robust prognostic tool in first-line advanced HER2-positive breast cancer treated with trastuzumab, pertuzumab, and a taxane (THP). 

🔬 What was done: Researchers combined real-world data from 215 patients across Spanish and Polish cohorts. They assessed baseline tumor tissue using the HER2DX assay to derive genomic scores linked to outcomes in patients receiving standard first-line HER2-targeted therapy (THP). 

📊 Key findings:

• A high ERBB2 mRNA score was associated with significantly longer progression-free and overall survival, as well as higher objective response rates — independent of traditional clinical variables. 

• The team developed a HER2DX metastatic prognostic score that outperformed ERBB2 mRNA levels alone in predicting outcomes, suggesting genomic profiling can further refine risk stratification in advanced disease. 

📈 Implications: This study supports the clinical utility of HER2DX in identifying patients with HER2-positive advanced breast cancer who might derive the greatest benefit from existing first-line therapies — and highlights the growing role of genomic tools in precision oncology. 

Rodrigo Arrangoiz, MD

Surgical Oncologist, Mount Sinai Medical Center (MSMC)

Head & Neck and Breast Cancer Specialist

https://www.nature.com/articles/s41523-026-00909-0

Primary thyroid lymphoma is rare (<2% of thyroid malignancies), but it is crucial to recognize because management is very different from other thyroid cancers.

🧠 Key features

Arises from lymphoid tissue within the thyroid Strongly associated with Hashimoto’s thyroiditis Often presents with rapid thyroid enlargement over weeks Symptoms may include neck pressure, difficulty swallowing, or breathing changes

🔍 How is thyroid lymphoma diagnosed?

Ultrasound may show a diffusely enlarged, hypoechoic thyroid CT/MRI helps assess airway compression and extent Core needle biopsy (or surgical biopsy) is usually required FNA alone may be insufficient for definitive diagnosis

⚖️ How is it treated?

Unlike most thyroid cancers, surgery is NOT the main treatment.

Management typically includes:

Chemotherapy Radiation therapy Multidisciplinary care with medical oncology and radiation oncology

➡️ Surgery is reserved for airway compromise or diagnostic uncertainty.

📈 Prognosis

Depends on histologic subtype (e.g., MALT vs diffuse large B-cell) Many patients, especially with indolent subtypes, have excellent outcomes with appropriate therapy

🦋 Early recognition prevents unnecessary thyroid surgery and enables prompt, effective treatment.

👨‍⚕️ Dr. Rodrigo Arrangoiz, MD

Surgical Oncologist – Thyroid, Head & Neck, Breast

Mount Sinai Medical Center

📌 Take-home message:

A rapidly enlarging thyroid—especially in patients with Hashimoto’s—should raise suspicion for thyroid lymphoma and prompt specialist evaluation.

📚 References

Derringer GA et al. Primary thyroid lymphoma. Am J Surg Pathol Stein SA et al. Thyroid lymphoma. Endocrinol Metab Clin North Am NCCN Guidelines: B-Cell Lymphomas