Synovial sarcoma of anterior abdominal wall

Historically, an adequate surgical procedure has been the most effective means of treating the majority of primary musculoskeletal sarcomas, and amputation has figured prominently in the surgical armamentarium. 4, 7, 9, 19, 21, 29, 41 The recent evidence that certain chemotherapeutic agents may have significant anti-sarcoma activity 2, 15, 17, 38 and coincident technical advances in irradiation therapy, radiographic localization, and reconstructive surgery have fostered enthusiastic interest in extremity-saving treatments. Almost all such treatments emphasize limb salvage as an alternative to amputation and are usually performed under a protective cloak of adjunctive chemotherapy, irradiation or immunoactive agents. 20, 23, 24, 30, 37, 39 Since neither chemotherapy nor irradiation therapy alone has been shown to assure long-term local control of bulk disease, surgical intervention remains an essential step in the overall management of musculoskeletal sarcomas. 3, 9, 17, 18, 29 Questions concerning the magnitude and timing of the surgical procedure are as unanswered as those relating to the most appropriate use of the adjuncts themselves. Increasingly, the surgeon and his patient are confronted with a bewildering array of therapeutic options, the long-term outcomes of which are unknown. These relatively rare sarcomas increasingly are distributed among a variety of treatment protocols in which multiple parameters differ. This trend necessitates interinstitutional cooperation if sufficient numbers of patients are to be available for the timely evaluation of treatments in clinical use. Such cooperation and even effective interinstitutional communication are seriously hampered by the lack of uniform language, so that meaningful comparison of treatments is currently impossible. Prime factors include the lack of a consistent definition of the surgery performed and a serviceable surgical staging system encompassing bone and soft tissue. Standard terminology will assure that like and unlike treatments are appropriately compared. Although an effective staging system should serve all members of the multidisciplinary team, the biologic behavior of musculoskeletal sarcomas suggests that the most useful staging system will articulate with the surgical procedure.

We report our single-institution, multidisciplinary experience of nearly 20 years of working on chest wall soft tissue sarcoma cases. The aim of this study was to evaluate clinical outcomes in patients with chest wall soft tissue sarcoma. A retrospective review of 49 surgically treated patients with chest wall soft tissue sarcoma was conducted from 1997 to 2015. The median age of the patients was 57.0 years. There were 19 full-thickness and 30 partial-thickness resections. Reconstruction was warranted in 37 cases. Sarcomas were high grade in 31 (63.3%) and low grade in 18 (36.7%) cases. Local recurrence developed in 8 and metastasis in 9 patients. No 30-day mortality occurred. By the end of the study period, 35 patients were alive and 14 had died. The 1-, 5-, and 10-year survival rates were 93.8%, 76.0%, and 71.6%, whereas the overall recurrence-free rates were 84.4%, 70.7%, and 70.7% respectively. Favorable prognostic variables for survival included age <50 years and radical treatment (resection with wide margin or resection with marginal margin and adjuvant radiotherapy). Patients who had undergone nonradical treatment had a 3.1-fold lower chance of survival than did those who had undergone radical treatment (95% confidence interval, 0.96-10.12; P = 0.06). Our study suggests that surgical resection with wide margins should continue to be the mainstay for patients with chest wall sarcoma. Even extensive chest wall resections and reconstructions are safe. If wide margins are not achieved, (neo)adjuvant radiotherapy should be considered to improve local control.

Sacrococcygeal chordoma presents a difficult diagnostic and therapeutic problem, with a high rate of local recurrence. The purpose of this report is to define the importance of adequate surgical treatment for optimum outcome and survival. Fifty-two patients underwent surgical treatment for sacrococcygeal chordoma between 1980 and 2001. The series included eighteen female patients and thirty-four male patients, with an average age of fifty-six years (range, thirteen to seventy-six years) at the time of the diagnosis. The surgical approach depended on the level and extent of the lesion, with a posterior approach performed in twenty-two patients and a combined anteroposterior approach used in thirty. A wide surgical margin was achieved in twenty-one patients. At an average of 7.8 years (range, 2.1 to twenty-three years) postoperatively, twenty-three patients were alive with no evidence of disease. Twenty-three patients (44%) had local recurrence. The rate of recurrence-free survival was 59% at five years and 46% at ten years. The overall survival rates were 74%, 52%, and 47% at five years, ten years, and fifteen years, respectively. The most important predictor of survival was a wide margin. All patients with a wide margin survived, and this survival rate was significantly different from that for patients who had had either marginal or intralesional excision (p = 0.0001). Of the twenty-one patients with a wide margin, seventeen (81%) had undergone a combined anteroposterior approach and only four had been treated with a posterior approach. A wide surgical margin is the most important predictor of survival and of local recurrence in patients with sacrococcygeal chordoma. Use of a combined anteroposterior approach increases the likelihood of obtaining a wide margin. Therapeutic Level IV.

Introduction Sarcomas of bone and soft tissue are rare neoplasms with diverse histology and biologic behavior. Approximately 6,600 new cases of soft-tissue sarcoma and 2,500 new cases of bone sarcoma present each year.1 Most of these tumors develop in the extremities. An increased understanding of sarcoma biology, advances in diagnostic imaging modalities, the development of effective adjuvant therapy regimens, and the application of new technologies and techniques for surgical resection and reconstruction have changed the nature and scope of treatment for these tumors. These advances have helped shape current surgical strategies and have prompted an increase in technically demanding limb-sparing surgical procedures. Successful limb conservation preserves, repairs, or reconstructs critical structures necessary for limb function without compromising the oncologic objective of complete tumor extirpation. Because of several factors, the number of patients who are candidates for limb conservation is increasing without a significant increase in the risk of local tumor recurrence or an adverse effect on overall patient survival.2-4 The factors causing this result include refinements in diagnostic and extirpative approaches, improvements in bone and joint reconstruction, and better techniques for coverage of soft-tissue defects. These developments have prompted a critical evaluation of the variables affecting limb preservation, functional outcome, and quality of life for the sarcoma survivor. This report discusses the strategies used at The University of Texas M.D. Anderson Cancer Center to improve the quality of life for patients diagnosed with these complex extremity tumors. Four case examples illustrate the range of clinical challenges confronting the sarcoma oncology team as members try to attain a better patient outcome using multimodality therapy and limb-sparing surgery.

In contemporary practice, there is no debate that appropriately selected patients with early stage invasive breast cancer can be managed with breast-conserving therapy (BCT) to include a segmental mastectomy with a negative margin followed by radiation. This is supported by multiple randomized trials demonstrating equivalent survival after BCT or mastectomy published over two decades ago. Since the publication of these trials showing the efficacy of BCT, the definition of a negative margin has been the subject of frequent debate. One of these trials, the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial, defined a negative margin as ‘‘no ink on tumor.’’ Other trials required complete resection of the tumor but did not specify a required margin width or did not evaluate microscopic margins. Therefore, despite the acceptance of BCT as the preferred approach for management of patients with early stage breast cancer, the optimal margin width required on a segmental resection has been open to interpretation. This has resulted in substantial variability in treatment often leading to recommendations for reexcision for ‘‘wider’’ negative margins. After all, everyone knows that more is better, right? In the current issue of Annals of Surgical Oncology, Moran et al. provide a consensus guideline on margins developed by the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO). This guideline, based on results of a systematic review of 33 studies, suggests that ‘‘no ink on tumor’’ be the standard for an adequate margin in patients with invasive cancer undergoing breast conserving surgery. In order for this ‘‘less is better’’ concept to be implemented into practice on Monday morning, it is helpful to review the goals of BCT and to understand how contemporary practice involves many different multidisciplinary considerations. The goals of BCT are to remove the primary tumor, minimize the risk of local recurrence, and achieve optimal cosmesis. Clearly margin width factors into the equation and surgeons understand the need to remove the tumor with a negative margin. This is drilled into us early in our training, and the first question that we are often asked after surgery is, ‘‘Did you get it all?’’ When excising the primary tumor, one must consider the tumor to breast size ratio and include enough normal breast parenchyma around the tumor such that a negative margin will be achieved without removing more volume of normal breast tissue than necessary. This can present a challenge in that tumors often form unusual shapes and have extensions of invasive or in situ carcinoma that go beyond the obvious palpable or radiographically evident lesion. The reality is that when we remove the tumor, this is done with an estimation of margins grossly and we cannot precisely determine the margin width (1, 2 mm, etc.) until the pathologist performs microscopic assessment. If margin assessment is performed intraoperatively with specimen imaging and immediate pathologic analysis, reexcision of any margins thought to be close or positive can be performed at the time of the initial operation without the need for a return to the operating room at a later date. This approach requires close coordination between surgery, pathology, and diagnostic radiology and may not be possible to implement in all practice settings. More often, margin assessment is determined by the final pathologic evaluation performed in the days after surgery. The surgeon plays a significant role in this evaluation because careful orientation of the specimen will prevent inking of areas that are not true margins or tracking Society of Surgical Oncology 2014

Bronchogenic carcinoma is the cancer that most commonly metastasizes to the brain. The standard treatment schedule for these patients is still unclear, although recommendation level 1 class I advocates for surgical resection together with postoperative whole-brain radiotherapy for patients with good Karnofsky performance status (KPS). We performed a study to identify prognostic factors for the long-term survival of patients with brain metastases from non-small cell lung cancer (NSCLC). This retrospective single-center study included 71 patients with brain metastases from NSCLC having undergone surgical metastasectomy between January 2002 and January 2015. The average age was 58.8 years. A total of 85.9% of the lesions were located in the supratentorial region, 61.9% of the lesions were < 3 cm, and 80.3% of cases were solitary brain metastases. Complete resection was achieved in 90.1% of patients. Clinical debut with motor involvement was associated with higher rates of incomplete surgical resection. Patients with motor deficits had a worse preoperative KPS. The preoperative KPS was > 70 in 74.6% of patients, and the postoperative KPS was > 70 in 85.9% of patients. Overall, 84.5% of the brain surgeries had no complications. Brain metastases were diagnosed as a synchronous presentation in 64.7% of patients.The average survival after brain surgery was 20.38 months. The survival rate was 66.2% at 6 months, 45.1% at 12 months, 22.5% at 24 months, 14.1% at 36 months, and 8.5% at 48 months. Patients < 55 years of age showed a higher survival rate at 12 months and 48 months. Patients > 70 years of age showed a higher mortality rate at 6 months. Complete surgical brain metastasis resection was associated with an increased survival at 6 months, and patients undergoing primary lung surgery had better survival rates at 48 months. A preoperative KPS > 70% improved the prognosis of patients at 6 and 24 months. Surgical complications reduced survival at 6 and 12 months. Surgical resection may be beneficial for a given group of patients: a preoperative KPS > 70; age < 55 years, complete surgical brain metastasis resection, no surgical complications, patients with primary lung surgery, and complete radiotherapy treatment. We did not find any significant difference regarding further factors that probably affect survival rates such as size or number of metastases.

Surgical resection with microscopically negative margins constitutes one of the key elements of a curative therapeutic approach for localized sarcomas. However, the prognostic value of quantitative margin width remains controversial. We sought to determine the prognostic significance of margin status and margin width for local recurrence (LR), distant recurrence (DR), and overall survival. Retrospective analysis of 210 patients undergoing resection of localized sarcoma between 1997 and 2018 at a national sarcoma reference center. Logistic regression did not reveal an effect of metric margin width as a prognostic factor for LR (odds ratio [OR] = 0.98, p = 0.574), DR (OR = 1, p = 0.908), or overall survival (hazard ratio = 0.98, 95% confidence interval = 0.73-1.20, p = 0.609). Subgroup analysis revealed no differences between complete first resections (R0) and re-resections (re-R0) following unplanned R1-resections for LR (p = 0.727) and overall survival (p = 0.125), but a significantly higher DR-rate in re-R0 cases (p = 0.022). Achieving a negative margin is essential in sarcoma surgery, however, metric margin width was not associated with disease-specific outcomes. Re-resection of unplanned R1-resections should be performed to control for LR and overall survival rates. As re-R0 cases were at significantly higher risk of DR, these patients should be followed up closely in standardized surveillance protocols.

Sacral chordoma is a rare low-to-intermediate grade malignant tumour. The mainstay of treatment is still surgery with en bloc and wide resection margins, which can grant the best chances of a long-term control or cure of this disease. The first aim of this paper is to collect data about survival, time to local recurrence and metastasis among patients affected by sacral chordoma and primarily treated with surgery. The second aim is to analyze the influence of level resection, tumor volume and surgical margins on local recurrence. The study population was composed of 14 patients treated with sacral chordoma resection at the National Tumour Institute of Naples-Pascale (Italy) from January 2000 to June 2013. The median follow-up was 84 months (range 24-132 months). The follow-up was characterized by: standard radiographs, MRI, and a CT scan of the chest annually. Time to recurrence or metastasis was calculated from the date of resection to the date of diagnosis of first recurrence or metastasis. Out of all the patients, six died (42.86 %) during the follow-up; 6 (42.86 %) had local recurrence; 4 (28.57 %) had metastasis. At univariate analysis wide surgical margins (R0) were associated with increased survival up to a local recurrence (OR = 0.0286; 95 % CI = 0.0014-0.5739; P = 0.026); the level of resection (OR = 3.33; 95 % CI = 0.3619-30.7025; P = 0.592) and tumour volume (P = 1) did not show a statistically significant correlation. Based on our experience, we hope all patients to be treated by surgery, the only good standard treatment of this disease. The resection should result in margins as wide as possible. For these reasons, it is essential for this disease to be treated in highly specialized centres because only a complete surgery can offer a chance to care for these patients. Solid survival at long-term follow-up can be achieved by a surgical resection performed with wide margins.

Purpose This is a retrospective research comparing the clinical outcomes of single-hole versus multi-hole video-assisted thoracoscopic surgical (VATS) resection for solitary pulmonary nodules (SPN) and examining the factors influencing the diagnosis of benign and malignant pulmonary nodules. Method We collected the clinical data, surgical status, outcomes, and corresponding imaging features of 317 patients with SPN who were surgically resected by VATS and diagnosed as benign or malignant by pathology in our hospital from January 2019 to December 2021. Result Among the 317 patients, 124 (39.12%) underwent single-port VATS and 193 (60.88%) underwent multiple-hole VATS. All patients were grouped according to the different surgical methods, and their postoperative indicators were statistically analyzed. The results showed that neither the single-port VATS group nor the multi-port VATS group had any serious adverse events such as death during the perioperative period. The average operation time, intraoperative blood loss, drainage tube indwelling time, and postoperative hospital stay were significantly lower in the two groups. Statistics of postoperative pathological diagnosis showed that 98 cases (30.91%) of all nodules were benign nodules and 219 cases (69.09%) were malignant nodules, and a further single-multivariate analysis showed that age, nodule maximum diameter, lobular sign, burr sign, vascular cluster sign, and pleural depression sign were independent relevant factors for the diagnosis of benign and malignant nodules. Conclusion VATS is less invasive and has fewer complications and is of great clinical value for both diagnosis and treatment of benign and malignant SPN. Age, maximum nodal diameter, lobar sign, burr sign, vascular set sign, and pleural depression sign were independent correlates affecting the diagnosis of benign and malignant SPN, which reminds that great attention should be paid to patients who are older and have risk factors on imaging, and early and timely active treatment or close follow-up should be carried out.

Interventional pediatric flexible bronchoscopy has many advantages over radiologic investigations in diagnosing uncommon congenital H-type tracheoesophageal fistula (TEF), dual TEF, bronchoesophageal fistula (BEF) and fistula recurrence including higher rates of identification and anatomic localization with guide wire cannulation. We compare the diagnostic utility of flexible bronchoscopy to radiologic techniques for congenital aerodigestive fistula. A single center retrospective review was completed of all cases of pediatric TEF and BEF diagnosed with flexible bronchoscopy between January 2000 and November 2020. Fistulae were diagnosed 21 times in 18 patients at a median age of 1.22 years (interquartile range: 0.50 to 2.99). The median time from diagnosis to repair was 17.5 days (interquartile range: 5.5 to 43). Symptoms commonly related to fistula were found in all patients. Uncommon fistulae included single H-type TEF (n=10, 47.6%), dual H-type TEF (n=2, 9.5%), dual proximal and distal TEF with esophageal atresia (n=5, 23.8%), TEF recurrence (n=2, 14.3%), BEF (n=1, 4.8%), and a BEF recurrence (n=1, 4.8%). Flexible bronchoscopy confirmed the diagnosis in all fistulae using a guide wire cannulation or methylene blue dye injection. A combined procedure with simultaneous bronchoscopy and esophagoscopy was used for 6 fistulae. The positive examination rate was 75% for bronchoscopy compared with 2.6% for contrast swallow studies and 28.6% for tube esophagograms. Flexible bronchoscopy should be considered as a first line investigation in uncommon aerodigestive fistulae. In the absence of a skilled bronchoscopist, the best radiologic investigation is a pull-back tube esophagogram but may still require endoscopic confirmation at the time of fistula repair.

50 Years Ago in CORR®: Synovial Sarcoma Kirk J. Anderson, MD and Orliss Wildermuth, MD CORR 1961;29:55-70

Disclosure: N. Torres: None. H. Rios: None. G. Rios: None. Y. Medina: None. L. Valerio: None. S. Rosa: None. A. Ortiz: None. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by hyponatremia that results from water retention attributable to persistent arginine vasopressin release. SIADH is considered the most common cause of euvolemic hyponatremia. Head and neck cancers are linked with 1.5% of SIADH cases. Cases reported in the literature about this association with oropharyngeal squamous cell carcinoma (SCC) were few, and no incidence data is currently available. We present a rare case of a patient with SIADH secondary to well-differentiated oropharyngeal squamous cell carcinoma. A case of 63 y/o male with Oropharyngeal SCC, previous gastrostomy, and tracheostomy due to malignancy. The patient initially presented with general malaise and weakness. Maxillofacial and neck CT scans were remarkable for a mass at the left lateral floor of the mouth, measuring approximately 5.7 cm AP x 2.5 cm transverse x 3.7 cm CC. Physical examination was remarkable for cachexia, but normal skin turgor and moist oral mucosa. An incidental finding of severe hyponatremia of 114 mEq was found. Confirmation of hypotonic euvolemic hyponatremia was performed with a urine osmolality of &amp;gt;100 mOsm per kg and high urine sodium (&amp;gt;40 mEq). These findings presented a strong case for our differential diagnosis of SIADH. Other differential diagnoses were hypothyroidism or adrenal insufficiency. The patient’s thyroid stimulating hormone was within normal levels, and adrenal insufficiency workup was negative, making paraneoplastic SIADH the more likely diagnosis due to SCC. Initial treatment was started with a 3% hypertonic solution drip running at 15 ml/hr. The chemistry panel was monitored every six hours to achieve a 6 mEq change, at a slow rate to avoid osmotic demyelination syndrome, a goal of 122 mEq. Sodium was corrected in 24 hours; 3% saline solution drip was discontinued. Once this level was reached, we continued the fluid restriction (&amp;lt;1L daily), and salt packets with meals. After consultation, Nephrology and Endocrinology services agreed with our diagnosis of hypotonic euvolemic hyponatremia due to ectopic production of paraneoplastic SIADH due to the oropharyngeal SCC. The patient’s hypotonic euvolemic hyponatremia was corrected, symptoms improved, and he was discharged with close follow-up with Hematology/Oncology, Nephrology, and Endocrinology services. Paraneoplastic SIADH due to squamous cell carcinoma is rarely observed in the hospital setting. It is important to consider paraneoplastic SIADH from SCC in the differential diagnosis of hypotonic euvolemic hyponatremia since early diagnosis and treatment can decrease long-term complications. We could have also considered pharmacological therapy for SIADH including the use of demeclocycline, vaptans, and furosemide if the patient had not responded to our interventions. We followed guideline therapy with intravenous hypertonic saline at the start, then transitioned to only using oral salt tablets and fluid restrictions. The patient's hyponatremia steadily improved with our interventions and was able to be discharged with close outpatient follow-up. Presentation: Friday, June 16, 2023

Objective Intracranial extraskeletal mesenchymal chondrosarcomas (IEMCs) are malignant aggressive neoplasms. IEMCs originate from the meninges or parenchyma. In the current study, we aimed to figure out the importance of gross total resection (GTR) and adjuvant radiotherapy (RT) by evaluating all reported IEMCs through the literature that included our two patients.Methods and Methods We presented two IEMC patients who were treated at our institutions and followed up for a long duration. To understand the appropriate management for IEMC, we conducted a systematic literature review for previously reported series and cases of IEMCs.Results We surgically treated two young males with IEMC initially diagnosed at their age of 18 and 20 years. The patients were initially treated with GTR and GTR followed by RT, and followed-up for 218 and 73 months, respectively. Through both the patients, we obtained 83 reported IEMC patients from the literature. The mean age of the reported cases was 24.5 ± 16.0 years (2 months–71 years). Female predominance was 54.2%. The mean progression-free and overall survivals were 27.9 and 39.0 months, respectively. The progressiveness rate was 56%. The presence of progressiveness was a poor prognostic factor (p = 0.0008). GTR was achieved in 53.0% of the patients. There was a significant difference between patients who received GTR compared with those who did not receive GTR (p = 0.035).Conclusion Regarding their malignancy and progressiveness, we recommended the maximal surgical resection with wide margins followed by RT as appropriate management for IEMCs with close follow-up. The timely treatment provides high life quality and avoids life-threatening complications.

Splenic hamartoma is a vanishingly rare condition with an even lower rate of surgical intervention. It is estimated to have an incidence between 0.024% and 0.13%.1 In most cases, splenic hamartomas are detected incidentally or at autopsy.1 Splenic hamartomas are benign vascular neoplasms, consisting of an anomalous mixture of normal splenic contents. They are characterized by CD8 immunosuppression of the vascular endothelial lining.2 We present a case of a 59-year-old male who was seen in a provincial General Surgical outpatient clinic with suspicion of colorectal cancer recurrence. Five years prior he underwent an anterior resection for an obstructing rectosigmoid moderately differentiated adenocarcinoma pT3N2a. Two years post-operatively, Routine surveillance abdominal computed tomography (CT) with intravenous contrast revealed a 22 mm. splenic cystic lesion, which showed no discernible activity on subsequent positron emission tomography-CT. More recently, a raised serum carcinoembryonic antigen (CEA) level of 4.6 μg/L [0–2.5], prompted a repeat CT abdomen scan, which showed that the hypo-attenuated splenic lesion was growing, now measuring 30 mm (Fig. 1). Radiologically this lesion appeared benign, however in light of its growing size, the raised serum CEA and the fact that it was not present at initial diagnosis, the regional gastrointestinal multidisciplinary conference considered the lesion to be a potential intrasplenic solitary metastasis. The recommendation was to proceed with surgical resection. Repeat PET/CT scanning was considered however was deemed unnecessary as it is a costly use of health resource that would not have changed the consensus for operative management and may have caused delays to surgery. Initial dissection was performed laparoscopically. Multiple small bowel adhesions to the anterior and lateral abdominal wall were dissected. The spleen was then mobilized by taking down adhesions on the lower pole as well as its anatomical attachments to the stomach, diaphragm, and transverse colon, with ultrasonic shears. The short gastric vessels were taken and clipped from the upper pole and a dissection plane was developed in front of Gerota's fascia, behind the pancreas, which allowed mobilization of the pancreatic tail and spleen. The spleen was medially mobilized and an approximately 10 cm. upper midline incision was created to deliver the spleen extracorporeally, admitting the surgeons fingers to facilitate its extraction. The splenic blood supply was inspected at this point and the vessels which supplied the area of concern were ligated after confirming demarcation, whilst staying well clear of the pancreas. The lesion was marked with 1 cm margins and excised with ultrasonic shears (Fig. 2). A silk suture was used to underrun the hilar aspect of the excision. Splenorraphy was performed by compressing the spleen around the defect, which was filled with two sheets of vicryl mesh and polysorb suture. Once haemostasis was achieved the spleen was returned to its anatomical location within the abdomen. The laparoscopic partial splenectomy is a challenging procedure with the main difficulty being control and mitigation of intraoperative and/or postoperative bleeding.3 Our approach utilizes the value in laparoscopic mobilization of the spleen and introduces a small midline incision to perform an extracorporeal splenorraphy. Such a technique is seldom described in the literature for treatment of splenic lesions however similar techniques have been described for paediatric patients, demonstrating good feasibility and safety.4 While the risk is relatively low in this age group, our subtotal approach mitigates the well-described risks of total splenectomy including overwhelming post-splenectomy infection and increased susceptibility to encapsulated organisms (OPSI).3, 5 Splenic preservation was also thought to confer a lower risk of post-operative thromboembolism, as patients who receive a total splenectomy for non-haematological disease are known to enter a prothrombotic state.6 This prothrombotic state is thought to be lifelong, with an increased risk of premature coronary artery disease, cerebrovascular events, and venous thromboembolism.6 While our technique is advantageous in certain cases, it is inadvisable in patients with coagulopathy or extensive abdominal adhesions, as these conditions may complicate surgery and increase bleeding risk. Large (>5 cm) or hilar lesions located at the splenic hilum might make partial splenectomy more challenging and increase the risk of injury to the splenic vessels. Additionally, in cases where malignancy is highly suspected, a complete splenectomy might be the more appropriate surgical choice to avoid leaving potential residual disease. Benjamin Reid: Writing – original draft. Divyansh Panesar: Supervision; writing – review and editing. Richard Coutts: Conceptualization; methodology; supervision.

A Phase 1 Trial of OPB-111077 in Combination with Bendamustine (B) and Rituximab (R) in Patients with Relapsed or Refractory (R/R) Diffuse Large B-Cell Lymphoma (DLBCL): Preliminary Results of Dose-Escalation Stage