The primary surgery improved the survival of FIGO stage IIIC1 cervical cancer with T1b-T2a tumors

The objective of this review article is to discuss the current role of surgery as the primary treatment modality in patients with head and neck squamous cell carcinoma (HNSCC). HNSCC represents one of the cancer locations where the primary treatment modality is the most under discussion. Indeed, the respective roles of primary surgical resection followed, as necessary, by adjuvant radiotherapy or definitive chemoradiotherapy remain controversial. The results of organ preservation trials and the drastic rise in the incidence of human papillomavirus-induced oropharyngeal tumors, which are known to be highly radiosensitive, have led to an increasing use of chemoradiation-based therapies in HNSCC patients. However, no chemoradiation-based protocol has shown better oncologic outcomes than radical primary surgery. Moreover, development of minimally invasive surgical techniques, such as transoral robotic surgery, and advances in head and neck microvascular reconstruction have considerably improved the clinical outcomes of the patients and have led to a reconsideration of the role of primary surgery in HNSCC patients. Surgery should be the primary treatment modality for most resectable oral cavity cancers and for T4a laryngeal/hypopharyngeal cancers. Primary surgery could also be the preferred modality of treatment for most early (T1-T2, N0) laryngeal and hypo/oropharyngeal carcinomas when this strategy offers an opportunity to reserve radiotherapy for a potential recurrence or second primary tumor. Primary surgery should also be considered in patients with locally advanced human papillomavirus-negative oropharyngeal carcinoma.

To compare survival outcomes between primary radical surgery and primary radiation in early cervical cancer. Patient information was extracted from the Surveillance, Epidemiology, and Results database. Patients diagnosed with early cervical cancer of stage T1a, T1b, and T2a (American Joint Committee on Cancer, 7th edition) from 1998 to 2015 were included in this study after propensity score matching. Overall survival (OS) was analyzed using the Kaplan-Meier method. Among the 4964 patients included in the study, 1080 patients were identified as having positive lymph nodes (N1), and 3884 patients were identified as having negative lymph nodes (N0). Patients with primary surgery had significantly longer 5-year OS than those with primary radiotherapy in both the N1 group (P<0.001) and N0 group (P<0.001). In the subgroup analysis, similar results were found in patients with positive lymph nodes of stage T1a (100.0% vs. 61.1%), T1b (84.1% vs. 64.3%), and T2a (74.4% vs. 63.8%). In patients with T1b1 and T2a1, primary surgery resulted in longer OS than primary radiation, but not in patients with T1b2 and T2a2. In multivariate analysis, the primary treatment was identified as an independent prognostic factor in both N1 and N0 patients (HRN1=2.522, 95% CI=1.919-3.054, PN1<0.001; HRN0=1.895, 95% CI=1.689-2.126, PN0<0.001). In early cervical cancer stage T1a, T1b1, and T2a1, primary surgery may result in longer OS than primary radiation for patients with and without lymph node metastasis.

Early glottic cancer: The influence of primary treatment on voice preservation

Background: Although endometrial cancer is not ranked among the ten most common cancer types in Iran, it is the 12th most prevalent in women and the third most common cancer of the female genital tract after breast and ovarian cancer. The mortality rate of endometrial cancer in Iran is 0.6 in 100,000 persons. Several studies have evaluated the correlation of preoperative CA125 in endometrial cancer with several surgicopathologic and prognostic variables, disease recurrence, and the need for lymphadenectomy. Recent data have suggested adjuvant extrafascial hysterectomy after neoadjuvant therapy instead of the initial radical hysterectomy for locally advanced disease. Therefore, it would be helpful to use a preoperative assessment, including serum CA125 measurement to predict the extent of the disease and plan a less complicated therapy. Objectives: To evaluate the cut-off value of CA125 in parametrial and cervical stromal invasion of endometrioid endometrial cancer. Methods: A sample of 128 endometrial cancer cases, surgically staged from 2012 to 2018 in Imam Hossein Hospital were evaluated. According to the exclusion criteria, 82 cases were finally analyzed. A receiver operating characteristic (ROC) curve was used to determine the cut-off value of preoperative CA125 for parametrial and cervical stromal involvement. Results: A high preoperative CA125 level was significantly associated with advanced disease stage, cervical stromal invasion, pelvic lymph node metastases, and higher grade (P < 0.05); the test showed a marginally significant correlation for parametrial invasion, which may be due to sample size limitation (P = 0.058). However, the correlation between CA125 and myometrial/lymphovascular invasions were not statistically significant (P = 0.112 and P = 0.168, respectively). The optimal cut-off value for preoperative CA125 was 45.5 u/mL in parametrial invasion (100% sensitivity, 89% specificity, 33.3% positive predictive value, and 100% negative predictive value), and 41.9 u/mL for cervical stromal invasion (87.5% sensitivity, 87.8% specificity, 43.75% positive predictive value, and 98.48% negative predictive value). Conclusions: Primary radical surgery may not be the first treatment approach in cervical/parametrial involvement. Neoadjuvant (chemo)radiotherapy and adjuvant extrafascial hysterectomy could be an alternative approach with fewer complications. Using preoperative CA125 along with physical examination and imaging modalities would be helpful in this regard. More investigations are needed to assess an agreed cut-off value for preoperative CA125 and endometrial cancer extension.

Background: This study aimed to assess the feasibility and efficacy of neoadjuvant chemotherapy (NACT) in treating patients with high-grade neuroendocrine carcinoma of the uterine cervix (HGNEC). Methods: We performed a retrospective case-control study at Asan Medical Center, Seoul, Republic of Korea, from January 1993 to December 2017, involving 60 patients with surgically treated HGNEC. Thirteen patients (21.7%) received NACT before undergoing surgery. Regarding the comparison between the group that underwent NACT and the group that did not, we used a propensity score-matched analysis, matching 22 patients in the primary radical surgery group with 11 patients in the neoadjuvant chemotherapy followed by radical hysterectomy group. Results: In the entire cohort, primary open surgery was more common in the primary surgery group compared to the NACT group (p = 0.004). After propensity score matching (PSM), the median tumor size was 3.5 cm in the primary surgery group and 2.4 cm in the NACT group (p = 0.078). After matching, there was no significant difference in the recurrence rate between the two groups (63.6% in the primary surgery group vs. 63.6% in the neoadjuvant chemotherapy group, p = 0.782). After PSM, the primary surgery group exhibited a lower intraoperative transfusion rate (10%) than the NACT group (45.5%, p = 0.052). Conclusions: While NACT was feasible in patients with HGNEC, it did not significantly improve the survival rate over primary radical surgery.

5597 Background: Primary surgery or radiotherapy are potential treatment options for many patients with head and neck cancer. Both have similar control and survival outcomes, but may have differences in health-related quality of life, including stress and depression. Methods: Between 2004-2009, 133 adults with curatively treated stage I-IVb head and neck cancer (squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx, free of locally recurrent or metastatic disease for 6 months to 3 years following primary treatment) were entered on a prospective randomized double-blind placebo-controlled chemoprevention study. All patients completed the 10-item perceived stress scale (PSS) and the 20-item Centers for Epidemiologic Studies Depression scale (CESD) both at baseline and 12 weeks after being randomized either to a fruit and vegetable concentrate intervention or placebo. Both scales are scored such that higher scores relate to worse quality of life, i.e. more stress or depression, respectively. For a general population, the mean PSS is 13.02. CESD scores >16 signal depression. Results: 89 patients had undergone primary surgery (PS), 44 had received primary radiotherapy (PRT). At baseline and twelve weeks, the mean PSS scores were 9.82 and 8.64 for the PRT group and were 11.09 and 10.31 for the PS group. At baseline and 12 weeks, the mean CESD scores were 7.48 and 9.47 for the PRT group and 9.30 and 8.89 for the PS group. Differences between the PRT and PS groups were not significantly different at baseline or 12 weeks, nor were differences within each group at the two time points. Conclusions: In patients with controlled head and neck cancer, stress, and depression scores as measured by the PSS and CESD did not differ significantly for patients treated with either primary surgery or primary radiotherapy. Mean PSS scores were not higher than those from a normal population and mean CESD scores were not indicative of depression. Twelve weeks of fruit and vegetable concentrate use did not cause any significant changes in mean PSS or CESD scores in either patient group. This study was supported by NSA, Inc. and NIH/NCI grants 3 U10 CA 81851 and R21 CA 106205. No significant financial relationships to disclose.

Simple SummaryCurrently, it is unknown whether secondary esophagectomy after endoscopic submucosal dissection (ESD) is comparable to primary esophagectomy. The aim of our retrospective study was to compare short- and long-term clinical outcomes between the two groups. Propensity matching was performed, and 34 patients in each group were compared. Comparing primary and secondary surgery, lymph node metastasis (LNM), overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS), were comparable between the two groups. Comparing the adverse events between the two groups, none of the patients in either group died within 60 days of treatment. There was no significant difference in the overall adverse events, but more early complications were observed in the primary surgery group than in the secondary surgery group. ESD and secondary esophagectomy can be recommended for patients with superficial esophageal cancer, as it does not compromise the outcomes of survival, recurrence, and complications.Even though the conventional treatment for T1 esophageal cancer is surgery, ESD is becoming the primary treatment. Currently, it is unknown whether secondary esophagectomy after endoscopic submucosal dissection (ESD) is comparable to primary esophagectomy when considering outcomes in patients with T1 esophageal cancer. We compared short- and long-term clinical outcomes between the two groups. Primary surgery (esophagectomy) was performed in 191 patients between 2003 and 2014, and 62 patients underwent secondary surgery (esophagectomy) after ESD for T1 esophageal cancer between 2007 and 2019. Propensity matching was performed for age, sex, Charlson Comorbidity Index (CCI), location, pathology, degree of differentiation, tumor size, and invasion depth. Lymph node metastasis (LNM), overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and post-operative complications were compared between groups. Sixty-eight patients were included after propensity score matching; LNM, OS, DSS, and RFS were comparable between the two groups. Comparing primary and secondary surgery, the respective LNM rates were 23.5% and 26.5%, 6-year OS 78.0% and 89.7%, p = 0.15; DSS were 80.4% and 96.8%, p = 0.057; and RFS were 80.8% and 89.7%, p = 0.069. Comparing the adverse events between the two groups, there was no significant difference in the overall adverse events. However, more early complications were observed in the primary surgery group than in the secondary surgery group (50% vs. 20.6%, p = 0.021). Secondary surgery did not increase the risk of LNM. The long-term outcomes were comparable. Therefore, attempts to perform upfront ESD for superficial esophageal squamous cell cancers are justified.

Local treatment improves survival in patients with stage IVB cervical cancer

Breast-conserving therapy has been demonstrated to be just as safe and a less disruptive experience compared with mastectomy for surgically manageable breast cancer. There is, however, no agreement in the literature about the impact of these procedures on several important aspects of quality of life (QOL). The purpose of the present study is to compare the long-term impact of these two surgical approaches on QOL in patients with identical tumor stages and to suggest possible shortcomings of the standard QOL questionnaires. Between August 1999 and May 2000, QOL questionnaires were answered by 152 pair-matched patients at the I. Frauenklinik, Ludwig-Maximilians University Munich, as part of routine follow-up examinations. The pairs of patients, each consisting of one patient after mastectomy and one after breast conservation, were selected according to the highest degree of equivalence in tumor stage. All patients had been initially treated for stage I-III breast cancer without evidence of distant metastases. The QOL was evaluated by using the QLQ-C30 questionnaire version 2.0 of the EORTC Study Group on Quality of Life. We formulated seven additional questions about the patients' satisfaction with the primary surgical treatment modality as viewed from their current perspective. The QOL questionnaires were answered after a median interval of 46 months following primary treatment. Tumor stage, prognostic factors, and adjuvant systemic treatment were well balanced between the two groups. No differences between the two groups were observed in terms of all QOL items measured by the QLQ-C30. Our additional questions, however, revealed that patients in the mastectomy group were less satisfied with the cosmetic result of their primary operation (P < .0001), were more likely to feel basic changes in their appearance (P < .0001), and were more likely to be emotionally stressed by these facts (P < .0001). From their perspective at the time of completing the questionnaires, 11 patients in the mastectomy group (15%) would decide differently about the surgical treatment modality, compared with only 3 patients (4%) in the breast conservation group (P = .025). While the primary surgical treatment modality seems to have no long-term impact on general QOL, certain body-image-related problems may be caused by mastectomy. Standard measuring instruments for QOL may fail to detect differences in satisfaction and adaptation with the primary surgical treatment modality.

There is currently no consensus on the prognostic significance of the histological subtype of nasopharyngeal carcinoma (NPC). The aim of the current study was to evaluate the impact of histological subtype on survival in NPC patients based on the Surveillance, Epidemiology, and End Results (SEER) Program. Patients with NPC were identified within the SEER database (2004-2015). The effects of histological subtype on cause-specific survival (CSS) in NPC patients were evaluated using univariate and multivariate Cox regression analyses. Subgroup analysis according to histological subtype in NPC patients was carried out by 1:1 propensity score matching (PSM). A total of 4085 NPC patients were selected from the SEER database, including 1929 with keratinizing squamous cell carcinoma (KSCC), 2203 with nonkeratinizing carcinoma (NKC), and 53 with basaloid squamous cell carcinoma (BSCC). The 3-year and 5-year CSS rates were 61.76% and 55.07% for KSCC patients, 79.57% and 72.09% for NKC patients, and 77.55% and 74.03% for BSCC patients, respectively. Multivariate analysis identified sex, age, marital status, race, T stage, N stage, M stage, radiotherapy, chemotherapy, and histological subtype as significant prognostic factors for CSS in NPC patients. KSCC was found to be associated with worse CSS than NKC on Kaplan-Meier analysis and subgroup analysis after 1:1 PSM. Histological subtype determines the long-term survival outcomes of patients with NPC. Moreover, the NKC subtype has the best prognosis, while the KSCC subtype has the worst prognosis. NA Laryngoscope, 130:E83-E88, 2020.

Evolution of treatment for Hodgkin's disease: a population-based study of radiation therapy use and outcome.

The evidence on the role of retroperitoneal lymphadenectomy is limited to less common histology subtypes of epithelial advanced ovarian cancer. This retrospective cohort study utilized data from the Surveillance, Epidemiology, and End Results Program from January 1, 2010, to December 31, 2019. Patients with stage III-IV epithelial ovarian cancer were included and divided into two groups based on whether they received retroperitoneal lymphadenectomy. The primary outcomes are overall survival (OS) and cause-specific survival (CSS). Among the 10 184 included patients, 5472 patients underwent debulking surgery with retroperitoneal lymphadenectomy, while 4712 patients only underwent debulking surgery. No differences were found in the baseline information between the two groups after propensity score matching. Retroperitoneal lymphadenectomy during debulking surgery was associated with improved 5-year OS (43.41% vs. 37.49%, p < 0.001) and 5-year CSS (46.43% vs. 41.79%, p < 0.001). Subgroup analysis further validate the retroperitoneal lymphadenectomy increased the 5-year OS and CSS in patients with high-grade serous cancer. Although the results were not validated in the less common ovarian cancer (including endometrial cancer, mucinous cancer, low-grade serous cancer, and clear cell cancer), the tendency showed patients with the above four subtypes may benefit from the lymphadenectomy which is restricted for small sample size after propensity score matching. This study revealed that retroperitoneal lymphadenectomy could further improve the survival outcome during debulking surgery in patients with advanced epithelial ovarian cancer. The conclusion was affected by the histology subtypes of ovarian cancer and further studies are needed to validate the conclusion in less common ovarian cancer.

Primary Surgery or Definitive Chemoradiation Therapy for Locally Advanced Hypopharyngeal Squamous Cell Carcinoma

Surgery or chemoradiation for stage IB cervical cancer? How cost effectiveness impacts a complex decision

Radical hysterectomy with parametrectomy remains the standard treatment for early-stage cervical cancer but is associated with significant morbidity. Identifying patients at low risk for parametrial invasion is critical to support less invasive surgical strategies. This retrospective study evaluated 177 patients with Federation of Gynecology and Obstetrics 2018 stage IA-IIB cervical cancer who underwent type III radical hysterectomy with lymphadenectomy between 2001 and 2020. Clinical and pathological data were analyzed to identify predictors of parametrial invasion. Parametrial invasion was observed in 40 patients (22.6%). These patients were significantly older (mean age 56.05±11.16 vs. 49.21±10.80 years, p=0.013), and they were more likely to be postmenopausal. Parametrial invasion was associated with larger tumor size (35.10±13.72 mm vs. 24.15±13.50 mm), greater depth of stromal invasion (>10 mm), lymphovascular space invasion (LVSI), and lymph node metastases, (pelvic and paraaortic), all p<0.01. Bivariate logistic regression identified age ≥55 years [odds ratio (OR): 3.302 95% confidence interval (CI): 1.432-7.614, p=0.005], LVSI positivity [OR: 3.952 (95% CI: 1.641-9.518, p=0.002], and stromal invasion depth >10 mm [OR: 5.326 (95% CI: 2.157-13.153, p<0.001] as independent predictors of parametrial invasion. Age ≥55, LVSI, and deep stromal invasion are significant independent risk factors for parametrial invasion. Careful evaluation of these parameters may guide the selection of patients suitable for less radical surgery, potentially reducing morbidity without compromising oncologic outcomes.