Anatomic Staging Research Articles

Aspirin use and head and neck cancer survival and recurrence.

Head and neck cancer (HNC) has low 5-year survival, and evidence-based recommendations for tertiary prevention are lacking. Aspirin improves outcomes for cancers at other sites, but its role in HNC tertiary prevention remains understudied. HNC patients were recruited in the University of Michigan Head and Neck Cancer Specialized Program of Research Excellence (SPORE) from 2003 to 2014. Aspirin data were collected through medical record review; outcomes (overall mortality, HNC-specific mortality, and recurrence) were collected through medical record review, Social Security Death Index, or LexisNexis. Cox proportional hazards models were used to evaluate the associations between aspirin use at diagnosis (yes/no) and HNC outcomes. We observed no statistically significant associations between aspirin and cancer outcome in our HNC patient cohort (n = 1161) (HNC-specific mortality: HR = 0.91, 95% CI = 0.68-1.21; recurrence: HR = 0.94, 95% CI = 0.73-1.19). In analyses stratified by anatomic site, HPV status, and disease stage, we observed no association in any strata examined with the possible exception of a lower risk of recurrence in oropharynx patients (HR = 0.60, 95% CI 0.35-1.04). Our findings do not support a protective association between aspirin use and cancer-specific death or recurrence in HNC patients, with the possible exception of a lower risk of recurrence in oropharynx patients.

Dichotomous grouping of peripheral arterial calcification grades: A practical predictor of outcome after endovascular therapy in peripheral arterial disease.

There is a general agreement that arterial calcification affects the results of endovascular therapy for peripheral arterial disease (PAD). In addition to lacking evidence for their impact, existing calcification scores are complex, and not practical in everyday decision making. The global limb anatomic staging system (GLASS) adopted dichotomous grouping of calcification grades. In this study we aim to investigate the impact of peripheral arterial calcification scoring after dichotomous grouping on midterm outcomes following endovascular therapy for PAD. This prospective study included all consecutive patients with PAD indicated for endovascular therapy procedure who presented to our tertiary referral center in the period between October 2020 and October 2021. Patients were grouped into Group A (n = 40): with no-to mild calcification (PACSS grade 0,1 and 2), and Group B (n = 53): with severe calcification (PACSS grades 3 and 4). Primary endpoints included technical success rate, primary patency rates, and major adverse limb events rate (MALE) during 2years of follow-up. The mean age of the studied cases (n = 93) was 59.31 ± 6.46years (range 50-75). 70 patients (75.3%) were males, and 23 (24.7%) were females. There was no statistically significant difference between the two groups regarding technical success rate (97.5% in group A versus 94.33% in Group B, p = .457). The Primary patency rate after 1year was lower in group B (74%) compared to group A (89.7%), but this difference was not statistically significant (p = .059). However, the 2-year primary patency rate was significantly lower in group B compared to group A (64% versus 84.6% respectively, p = .034). MALE rate after 2years was significantly higher in group B (28%) as compared to group A (10.4%), P = .048. Studying suspected risk factors revealed that severe calcification was more common in patients with ischemic heart disease (34%) and chronic kidney disease (11%), P= .003 and .002 respectively. Logistic regression analysis showed that patients suffered from IHD and those with length of lesion ≥ 5cm are about five times more likely to have severe calcification compared to their counterparts (OR = 4.875, 95%CI = 1.293-18.383, p = .019, and OR = 4.513, 95% CI = 11.138-17.893, p = .032), respectively. The presence of severe calcification is associated with significantly lower midterm primary patency rates and higher rate of major adverse limb events after endovascular intervention for lower limb denovo arterial lesions.

Evaluating the Impact of Prophylactic Intrathecal Chemotherapy in Diffuse Large B Cell Lymphoma (DLBCL) Patients with High Central Nervous System International Prognostic Index (CNS-IPI) Scores: A Comprehensive Review and Meta-Analysis

Introduction Diffuse large B cell lymphoma (DLBCL) with a high CNS-IPI score poses an increased risk for relapse involving the central nervous system (CNS). Despite various studies seeking to validate the use of CNS prophylaxis, including intrathecal chemotherapy, results have been equivocal. This ambiguity may be partly attributed to the lack of prospective data, patient heterogeneity, limited sample sizes, and outdated methodologies in pre-rituximab studies. Consequently, administering CNS prophylaxis with intrathecal chemotherapy is not a standardized practice, and decisions are often based on individual factors such as anatomical location, disease stage, and specific case characteristics. Methods This systematic review and meta-analysis were conducted and reported using the PRISMA guidelines. A thorough search was conducted across multiple online databases, including Google Scholar, Science Direct, PubMed, Cochrane, CINAHL, EMBASE, ProQuest Dissertation and Theses, ISI web of knowledge, PsycINFO, and Embase for articles on this topic. The date range of the articles included was between 2013-2023 and were limited to English language, peer-reviewed articles, cohort studies, retrospective studies & randomized controlled trials. The inclusion and exclusion criteria for studies helped to determine suitable studies Results Out of 179 studies retrieved from the database search and 2 from other studies' reference lists, 6 met the inclusion criteria for qualitative and quantitative analysis. Data from 2209 patients in these 6 studies was analyzed using a random-effects model to perform a subgroup analysis of the benefits and risks of prophylactic intrathecal chemotherapy for patients with DLBCL and a high CNS-IPI score. The results demonstrated a significant improvement in overall treatment success, with a difference of 0.60 (95% Confidence Interval, 0.45 to 0.93) on a 0-10 Visual Analogue Scale (VAS). The heterogeneity of the studies was determined to be significant (P=0.02), further substantiating the positive impact of prophylactic intrathecal chemotherapy on the therapy success rate for DLBCL patients with high CNS-IPI scores. Conclusion Our review elucidates that intrathecal chemotherapy as a prophylactic measure can reduce the rate of CNS relapse and enhance overall survival for patients with DLBCL possessing a high CNS-IPI score. However, it underscores the necessity to thoroughly assess each patient's unique clinical situation when determining if intrathecal chemotherapy is the appropriate therapeutic approach.

Improved Staging of Ciliary Body and Choroidal Melanomas Based on Estimation of Tumor Volume and Competing Risk Analyses

The current, 8th edition of the American Joint Committee on Cancer (AJCC) anatomic classification and staging model for uveal melanoma does not fully separate survival estimates for patients with advanced stages of the disease (e.g., IIIB and IIIC). Furthermore, some tumors in higher size categories have a smaller volume than tumors in lower categories. Therefore, we developed a novel model for prognostication of metastatic mortality based on estimations of tumor volume. Retrospective, multicenter case series of patients with uveal melanoma involving the choroid, ciliary body, or both. Six thousand five hundred twenty-eight consecutively registered patients treated at 3 tertiary ocular oncology centers on 2 continents between 1981 and2022. Data on survival, tumor size, and extent were collected for all 6528 patients. Tumor volume was estimated using a simple equation based on largest basal diameter and thickness. Volume-based size categories and stages were developed and validated in independent patient cohorts using competing risk analyses, and correlations with cytogenetic and cytomorphologic features were examined. Cumulative incidence of metastatic death. The 6528 patients were distributed over 7 stages based on estimated tumor volume and anatomic extent (V stages IA, IB, IIA, IIB, IIIA, IIIB, and IIIC), with a 15-year incidence of metastatic death ranging from 7% to 77%. A new category, V1min, and corresponding stage IA, were introduced, indicating an excellent prognosis. Metastatic mortality in V stage IIIC was significantly higher than that in V stage IIIB (P= 0.03), whereas incidence curves crossed for patients in AJCC stages IIIC vs. IIIB (P= 0.53). Univariable and multivariable competing risk regressions demonstrated higher Wald statistics for V stages compared with AJCC stages (1152 vs. 1038 and 71 vs. 17, respectively). The frequency of monosomy 3, gain of chromosome 8q, and epithelioid cytomorphologic features increased with tumor volume (R2= 0.70, R2= 0.50, and R2= 0.71, respectively; P < 0.001) and showed similar correlations with both AJCC and V stages. Anatomic classification and staging of ciliary body and choroidal melanomas based on estimation of tumor volume improves prognostication of metastatic mortality. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Nomogram for predicting survival in patients with mucinous breast cancer undergoing chemotherapy and surgery: a population-based study

BackgroundThe prognosis of patients with mucinous breast cancer (MuBC) is affected by several factors, but the low incidence of MuBC makes it difficult to conduct extensive and in-depth studies. This study was designed to establish a prognostic model and verify its accuracy in patients with MuBC after chemotherapy and surgery to help develop personalized treatment strategies.Materials and methodsPatients with MuBC who underwent chemotherapy and surgery from 2004 to 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. The prognostic factors of patients with MuBC were investigated using a Cox proportional hazards regression analysis. Based on the identified factors, a nomogram was constructed to forecast the overall survival (OS) of patients at 3, 5, and 10 years. Internal (from SEER) and external (from Yunnan Cancer Center, YNCC) verification queues were used to verify the nomogram and demonstrate the predictive capacity of this model.ResultsThe study comprised 1668 MuBC patients from the SEER database and 107 from the YNCC. The nomogram included four characteristics: age, anatomical stage, surgical method, and radiotherapy. The concordance indices in the training, internal verification, and external verification queues were 0.680, 0.768, and 0.864, respectively. The calibration curves for the nomogram showed excellent agreement between the predictions and observations. This nomogram has good clinical application value according to the decision curve analysis.ConclusionsThe prognosis of patients with MuBC who have undergone chemotherapy and surgery can be forecasted using this nomogram, which would be beneficial to help create individualized treatment plans for the affected patients.

Are All Prognostic Stage IB Breast Cancers Equivalent?

The 8th edition of the American Joint Committee on Cancer (AJCC) has recognized the prognostic influence of histologic grade and biomarker status for breast cancer (BC). Contemporary BC staging includes both anatomic tumor extent and prognostic stage. However, prognostic stage IB remains heterogeneous and includes patients with locally advanced anatomic pathologic stage IIIA-B (pT3N1 or pT1-3N2, G1-2) hormone-receptor positive/HER2-negative BC (LA-HR+/HER2-) as well as patients with early-stage anatomic clinical/pathologic stage IA (T1cN0, G2-3) triple-negative BC (ES-TNBC). We hypothesized that although both are classified as prognostic stage IB BC, overall survival (OS) is worse for LA-HR+/HER2- compared to ES-TNBC. We used the National Cancer Database to identify patients with surgically-resected LA-HR+/HER2- BC (pT3N1 or pT1-3N2, grade 1-2) and those with ES-TNBC (T1N0, grade 2-3) from 2004-2017. Patients were excluded if receptor status, tumor grade, and/or TNM staging data were unknown. HR+/HER2- patients treated with neoadjuvant therapy were also excluded. The primary endpoint was OS. Multivariable Cox regression analysis was used to evaluate differences in OS between LA-HR+/HER2- BC and ES-TNBC (adjusting for baseline patient demographic characteristics) in the entire cohort and in the subset of patients that received appropriate treatment based on anatomic stage: radiation (RT), chemotherapy (CT) and hormone therapy for LA-HR+/HER2- BC and CT or CT+RT for ES-TNBC treated with mastectomy or lumpectomy, respectively. We report hazard ratios (HR) with 95% confidence intervals (CI) with p<0.05 considered statistically significant. A total of 45,818 patients met inclusion criteria (N = 17,359 with LA-HR+/HER2- BC and N = 28,459 with ES-TNBC). Over 75% of the LA-HR+/HER2- BC patients have anatomic pathologic stage IIIB disease (pT1-3N2, G1-2). With a median follow-up of 56 months, the 6-year OS rates were 86.1% (LA-HR+/HER2-) vs. 90.4%patients (ES-TNBC) which corresponded to a 63% relative increased risk of death in LA-HR+/HER2- patients compared to ES-TNBC patients (HR = 1.63, 95% CI 1.53-1.73, p<0.0001) after adjusting for all covariates. Approximately 66% (N = 11,533) LA-HR+/HER2- and 69% (N = 19,512) ES-TNBC received appropriate therapy. The 6-year OS was 91.8% (LA-HR+/HER2-) vs. 93.3% (ES-TNBC) which corresponded to a 35% increased risk of death in the LA-HR+/HER2- patients compared to ES-TNBC (adjusted HR = 1.35, 95% 1.24-1.48, p<0.0001). Other covariates associated with OS were age, income, insurance status, facility type, and ethnicity/race. We found that LA-HR+/HER2- BC has significantly worse OS compared to ES-TNBC despite both being classified as prognostic stage IB, even when accounting for treatments delivered. The categorization of pT3N1 or pT1-3N2, G1-2 HR+/HER2- BC as prognostic stage IB needs to be reconsidered in order to provide patients with more accurate information regarding expected OS.

The Effect of Clinical (Anatomical) and Prognostic Stage Groups on Survival in Patients Diagnosed with Breast Cancer: MULTI-Center Study Results, TROD Breast Cancer Study Group

The American Joint Committee on Cancer (AJCC) anatomic stage groups have arguably been the most powerful method in predicting breast cancer outcomes. In the present study, we aimed to determine the differences between anatomical stage and clinical prognostic stage groups, which were obtained by adding biological markers such as histologic tumor grade, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 status to patients diagnosed with breast cancer, the rate of change in stage, and the effect of stage change on survival. The study protocol was sent to all radiation oncology centers in Türkiye. Four centers enrolled their patients to the study. A total of 1470 stage I-III breast cancer patients with complete information on biological markers (histologic tumor grade, hormone receptor, and c-erb B2 receptor status), haven't been treated with neoadjuvant therapy were included to the study and evaluated retrospectively. The 8th edition of AJCC consolidated biological markers in to clinical prognostic stage groups. Kaplan-Meier curves were used to estimate survival. The log-rank test was used to compare the difference between groups. The Cox proportional-hazards regression model was used to determine the association between anatomic-prognostic stage, disease-free survival (DFS), and overall survival (OS). The median follow-up time was 82 (6-237) months. Median age of the patients was 52 years (20-88) and 865 cases (58.8%) were in the postmenopausal period. The axillary lymph node status was negative (N0) in 765 patients (52.1%). Tumor grade was grade I in 200 patients (13.6%), grade II in 812 patients (55.2%) and grade III in 452 patients (30.7%). Estrogen receptor status was positive in 1247 patients (84.8%), PR status was positive in 1178 patients and Her2-neu status was positive in 207 patients (14.1%). A stage change has been identified in a total of 777 patients (52.9%). Compared with the anatomic stage groups, application of the clinical prognostic stage groups assigned 46.4% cases lower and 6.5% cases higher stage. Five- and ten-year OS and DFS rates of the patients are 73.7%, 44.3% and 91.9%, 86.3% respectively. Age (p<0.001), tumor grade (p<0.001), ER status (p<0.001), PR status (p<0.001), cerbB2 receptor status (p = 0.025) were found to be statistically significant variables in multivariable analysis for OS. For DFS, multivariable analysis showed that age (p = 0.027), tumor grade (p = 0.005), anatomical stage (p<0.001) and assigned to higher stage (p = .001) were statistically significant variables. Hormone receptors and c-erb B2 receptor status are independent variables which impact OS and DFS in our patient group which is mostly consisted of early-stage cases according to anatomical stage. In prognostic staging, upstaging stands out as an independent prognostic factor for DFS. The 8th edition of AJCC prognostic stage groups determines the prognosis much better in our patient cohort.

Early Clinical Experience of Utilizing Online Adaptive Radiotherapy for Accelerated Partial Breast Irradiation with Stereotactic Body Radiation Therapy for Early-Stage Breast Cancer Patients

Accelerated partial breast irradiation (APBI) with stereotactic body radiation therapy (SBRT) is becoming popular for early-stage breast cancer (ESBC) due to decreased treatment time and dose to healthy breast tissue. With variability in lumpectomy cavity size post-surgery, CBCT-guided online adaptive RT (oART) may improve target coverage and reduce normal tissue exposure by accounting for inter- and intrafractional cavity variations. In this study, we report our initial clinical experience utilizing APBI oART for patients with ESBC. A total of 15 patients with 17 ESBC cavities (2 with bilateral disease) were treated with SBRT using oART over one year. Patients were immobilized using standard breast simulation setup with free breathing and breath hold (if left sided). The clinical target volume consisted of an isometric 1 cm expansion off the lumpectomy cavity, which was expanded another 3 mm (cropped 3mm from surface) to create the planning target volume (PTV). 95% of the PTV received prescription dose (30 Gy in 5 fractions). The oART delivery process (supervised by physician and physicist) initially coregisters the daily CBCT to the treatment planning CT with alignment to lumpectomy cavity. Target volumes and organs-at-risk were modified at each treatment and the plan re-optimized. Either the re-optimized oART plan or scheduled plan was chosen for each fraction pending which plan best met prespecified clinical goals. Acute toxicity was assessed at one-month follow-up using CTCAE. Patients were age 56 or older, ECOG 0-1, with no known genetic abnormality, and with anatomic stage 0-1A ESBC. Most tumors were located in the upper outer quadrant (n = 12, 70.6%) at middle or posterior depth (n = 15, 88.2%). Final margins were negative. 88% had tantalum clips placed. One patient had an Oncotype DS score of 34 and received systemic therapy. 82.3% met suitable APBI criteria and 3 met cautionary criteria due to high grade, of which 2 had ipsilateral trimodality treatment 10+ years prior and denied mastectomy at recurrence. Mean time to starting RT after lumpectomy was 2.5 months. Mean PTV to breast ratio was 0.12. From simulation to end of treatment, lumpectomy cavity size decreased a median of 27%. oART plans were chosen 89% of the time. VMAT was utilized 52.9% of the time compared to static-field IMRT (47.1%). Three patients were treated with breath hold. 93% of patients were treated on non-consecutive days with average treatment lasting 9.1 ± 2.2 days. CTCAE grade 1 toxicities were hyperpigmentation (n = 6, 40%), breast pain (n = 2, 13.3%), persistent seroma (n = 1, 6.7%), and fatigue (n = 7, 46.7%). No patients experienced fat necrosis, telangiectasias, breast shrinkage, lymphedema, or CTCAE grade 2+ toxicities. oART for APBI using SBRT for patients with ESBC is clinically feasible and allows for variations in lumpectomy cavity size. Nearly half of patients had no complaints or breast changes at one-month follow-up and the remaining had CTCAE grade 1 toxicities alone.

Long Term Evaluation of Cardiac Events and Outcomes Following Breast Cancer Irradiation

Although whole heart dose has been associated with cardiac toxicity in patients receiving radiation therapy for breast cancer, data detailing the clinical significance of cardiac substructures, particularly the left anterior descending artery (LAD), are limited. We investigated whether dose to the LAD correlates with adverse cardiac events and death. We identified 190 female patients treated from 2002 to 2019 who received breast or chest wall irradiation, with or without regional nodal irradiation. Ninety-three patients were treated on their right side, 95 on their left, and two were bilateral. Medical records were queried in healthcare software to identify cardiac events after radiation therapy. Mean and maximum LAD and heart doses, as well as V15LAD, were calculated. Univariate and multivariate Cox regression analyses were performed to determine their association with cardiac toxicity as well as death. Cumulative incidence curves for death and cardiac toxicity were also calculated for the patient population. Median follow-up time was 68 months. Thirty patients experienced a cardiac event (15.7%), with three of these being grade 3 or higher. On univariate analyses, left side (hazard ratio 8, P<0.001), increased Mean LAD Dose per cGy (1.001, P = 0.01), Mean Heart Dose (1.16, P = 0.01), and anatomic stage (3.5, P = 0.003) were statistically significant predictors of death but not of adverse cardiac events. Statistically significant predictors of adverse cardiac events were the receipt of chemotherapy (2.68, p = 0.046) which remained significant even after adjusting for radiation parameters. There was no association with hormonal therapy use. Cumulative incidence curves predicted a 14.11% probability of a cardiac event 5 years after treatment and a 25.7% probability at 10 years after treatment. They also predicted a 9.43% probability of death at both 5- and 10-years post-treatment. On this long-term analysis, doses to the heart seemed to negatively impact survival, but did not have a clear association between cardiac events. In contrast, utilizing cytotoxic systemic therapy seemed have an association, even when adjusted for on multivariable models for cardiac events.

Infrapopliteal 3-Vessel Occlusive Disease Is the Only Predictor of Wound Recurrence After Complete Wound Healing via Endovascular Therapy in Patients With Chronic Limb-threatening Ischemia.

To determine the predictors of wound recurrence after complete wound healing in patients with chronic limb-threatening ischemia (CLTI) who underwent endovascular therapy (EVT) for infrapopliteal (IP) lesions with consideration of IP arterial anatomic severity, including classification by the Global Limb Anatomic Staging System (GLASS). This retrospective single-center study assessed patients with de novo CLTI limbs with tissue loss treated via EVT for IP lesions from September 2016 to May 2021. Among these patients, 149 consecutive limbs from 133 patients who achieved complete wound healing were enrolled. The Kaplan-Meier method was used to estimate the wound recurrence rate after complete wound healing. The Cox proportional hazard model was used to assess the association between baseline characteristics and wound recurrence. The cumulative wound recurrence rate 1 year after complete wound healing was 30%. The mean time for wound recurrence was 7±5 months. Only IP arterial anatomic characteristics remained as a predictor of wound recurrence, whereas wound status and management, including the Wound, Ischemia, and foot Infection (WIfI) clinical stage and minor amputation, were not associated with wound recurrence. Multivariate analysis revealed independent associations between wound recurrence and IP 3-vessel occlusive disease (hazard ratio, 2.97; 95% confidence interval, 1.39-6.35), but not poor below-the-ankle runoff, IP Peripheral Arterial Calcium Scoring System (PACSS) grade, and the GLASS IP grade. The only independent predictor of wound recurrence after complete wound healing via EVT in patients with CLTI was IP 3-vessel occlusive disease. In patients with chronic limb-threatening ischemia (CLTI), wound recurrence after complete wound healing remains a challenge, and studies focused exclusively on wound recurrence are still limited. The present study aimed to determine the risk factors for wound recurrence after complete wound healing in patients with CLTI who underwent endovascular therapy (EVT) for infrapopliteal (IP) lesions, with consideration of IP arterial anatomic severity for the first time. The results showed that IP 3-vessel occlusive disease was the only predictor of wound recurrence, whereas wound status/management and other arterial anatomic characteristics including WIfI clinical stages and GLASS grades were not predictors.

A brain metastasis prediction model in women with breast cancer

BackgroundBreast cancer (BC) is a leading cause of mortality and the most frequent malignancy in women, and most deaths are due to metastatic disease, particularly brain metastases (BM). Currently, no biomarker or prediction model is used to predict BM accurately. The objective was to generate a BM prediction model from variables obtained at BC diagnosis. MethodsA retrospective cohort of women with BC diagnosed from 2009 to 2020 at a single center was divided into a training dataset (TD) and a validation dataset (VD). The prediction model was generated in the TD, and its performance was measured in the VD using the area under the curve (AUC) and C-statistic. ResultsThe cohort (n = 5009) was divided into a TD (n = 3339) and a VD (n = 1670). In the TD, the model with the best performance (lowest AIC) was built with the following variables: age, estrogen receptor status, tumor size, axillary adenopathy, anatomic clinical stage, Ki-67 expression, and Scarff–Bloom–Richardson score. This model had an AUC of 0.79 (95%CI, 0.76–0.82; p < 0.0001) in the TD. The 10-fold cross-validation showed the good stability of the model. The model displayed an AUC of 0.81 (95%CI, 0.77–0.85; P < 0.0001) in the VD. Four groups, according to the risk of BM, were generated. In the low-risk group, 1.2% were diagnosed with BM (reference); in the medium-risk group, 5.0% [HR 4.01 (95%CI, 1.8 – 8.8); P < 0.0001); in the high-risk group, 8.5% [HR 8.33 (95%CI, 4.1–17.1); P < 0.0001]; and in the very high-risk group, 23.7% [HR 29.72 (95%CI, 14.9 – 59.1); P < 0.0001]. ConclusionThis prediction model built with clinical and pathological variables at BC diagnosis demonstrated robust performance in determining the individual risk of BM among patients with BC, but external validation in different cohorts is needed.

Effectiveness of post-mastectomy adjuvant chemotherapy for the treatment of patients with prognostic stage IB breast cancer: A SEER-based study.

Adjuvant chemotherapy (AC) is an important, effective treatment for breast cancer. This study evaluates the effectiveness of post-mastectomy AC in treating patients with prognostic stage IB breast cancer. We conducted a retrospective cohort-based study using Surveillance, Epidemiology, and End-Results database. Overall survival (OS) and breast cancer-specific survival (BCSS) were calculated using the Kaplan-Meier method. Multivariate Cox risk models were used to identify the impact of AC. Stratified analysis was performed according to molecular subtypes, anatomic stages, and other risk factors to evaluate the effect of AC on survival. 28,825 women diagnosed with prognostic stage IB breast cancer were included. The 5-year OS was significantly higher in AC group than in non-adjuvant chemotherapy (NAC) group (P<0.0001); however, the 5-year BCSS in AC group was significantly lower than in NAC group (P=0.039). Multivariate analysis revealed that AC was a favorable prognostic factor for OS (P<0.001), but not BCSS (P=0.407). AC was not an independent prognostic factor for BCSS in patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR[+]/HER2[-]) subtype or pT1a-1b/N0-1 stage with HER2 overexpression (HER2[+]) subtype, regardless of whether HR was positive or negative (P>0.05). Meanwhile, AC is not an independent prognostic factor for OS and BCSS in patients with lymph node micrometastases. Our study demonstrates that patients with prognostic stage IB do not fully benefit from AC. Individualized treatment management is required for patients with pT1a-1b/N0-1 tumors, lymph node micrometastases, or HR(+)/HER2(-) subtypes.

Topicality of the fundamental and determining importance of chronic critical ischemia of the extremities and its restorative treatment using crural/pedal bypasses in Germany and in Saxony-Anhalt

Currently, there is an increase in severe stages of peripheral arterial occlusive disease (PAOD) with critical ischemia. This seems to correspond to the general demographic change as well as aconsequence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic of the last 3years. The now established and accepted interventional/endovascular approach for severe lower leg PAOD in experienced hands is still considered the first-line treatment but from the authors' perspective crural/pedal venous bypass is experiencing arenaissance. Compact narrative review of the current state of crural/pedal bypass surgery in Germany and Saxony-Anhalt (SA) combined with selective references from the current scientific medical literature and own clinical experiences. The current statistics of case-related diagnosis-related groups (DRG) data show that, especially with the occurrence of the corona pandemic, adecrease in inpatient case numbers of patients with PAOD stage IIB can be observed nationwide and also in SA. The severe PAOD stages have remained approximately the same in case numbers but increased in SA. The risk stratification based on the wound, ischemia and foot infection (WIFI) classification offers the possibility to be able to make statements about the risk of amputation, benefits and type of revascularization measures. The length of the occlusion, occlusion site of the affected vessels and degree of calcification are taken into account in the global limb anatomic staging system (GLASS) to assess the prognosis. The evaluation of the case-based hospital statistics from 2015 to 2020 showed aconstant use of femorocrural/femoropedal bypass surgery in Germany as well as aslight increase in reconstruction using femorocrural bypasses in SA, which seems to correlate with the tendency for an increase in the number of cases of severe PAOD. Parameter-based objectification of the severity of critical limb ischemia should be included in the indications for placement of a crural/pedal bypass. The WIFI classification and GLASS are suitable for this purpose as arelative prognosis of success is also possible. The treatment of critical limb ischemia by crural/pedal bypass surgery continues to find aconstant application in Germany and SA.

Survey of clinicians on the use of adjuvant therapy for premenopausal women with breast cancer.

Considering prognostic and anatomic stages in early-stage premenopausal patients with breast cancer, clinicians decide on performing the multigene assay, adjuvant chemotherapy, or ovarian function suppression (OFS). This decision is also based on genetic information related to hormone receptor-positive and human epidermal growth factor receptor 2 negative results. We aimed to determine the tendency to use adjuvant therapy in clinical practice. From April to May 2022, clinicians of the Korean Breast Cancer Society responded to a web-based survey. The survey included 62 multiple-choice questions mainly on decision-making under different pathologic conditions. Among 92 responding clinicians, 91.3% were breast surgeons. For 35-year-old patients (pT2N0 and Ki-67 50% profile), 96.8% of clinicians selected chemotherapy, whereas 50.7% selected chemotherapy for patients with pT1N0, Ki-67 10%, and without Oncotype Dx (ODX). Only 35.6% selected chemotherapy for 47-year-old patients with the same profiles, while 84.3% and 49.1% chose chemotherapy with ODX recurrence score 21 and 16, respectively. More clinicians selected tamoxifen (TMX) plus OFS than aromatase inhibitor (AI) plus OFS for 5 years of endocrine therapy in patients with adjuvant chemotherapy regardless of genomic and clinical risks. However, for the same patients without adjuvant chemotherapy, more clinicians selected AI plus OFS. A longer duration of additional OFS and TMX was selected in patients with high clinical and genomic risks, and the duration of OFS was relatively shorter in older patients. The decision regarding adjuvant therapy should be made considering clinical and genomic risks and age, and clinicians should consult with patients about adverse effects and compliance.

SDPS-38 A BRAIN METASTASES PREDICTION MODEL IN BREASTCANCER WOMEN

Abstract BACKGROUND Breast cancer (BC) is a leading cause of mortality and the most frequent malignancy in women; most deaths are due to metastatic disease, expressly brain metastases (BM). Currently, there is no biomarker or a prediction model to accurately predict BM. OBJECTIVE To generate a BM prediction model from variables acquired at BC diagnosis. METHODS A retrospective cohort of BC women diagnosed from 2009 to 2020 at a single center was divided into training (TD) and validation datasets (VD). The TD was used to generate a multivariable prediction model. The modeĹs performance was measured applying the area under the curve (AUC), C-statistic, and the Akaike information criteria (AIC). RESULTS 5,009 patients were divided into a TD (n 3339) and a VD (n 1670). In the TD, the model with the best performance (lowest AIC) was built with the following variables: Age, estrogen receptor status, tumor size, axillar adenopathy, AJCC anatomic clinical stage, Ki-67, and the Scarf-Bloom-Richardson score. This model had an AIC of 1241 and an AUC of 0.793 (95%CI 0.761 – 0.825) p &amp;lt;0.0001 in the TD. A 10-fold cross-validation showed good stability of the model. In the VD, the model had an AUC = 0.812 (IC95% 0.774 – 0.850) P &amp;lt; 0.0001 and an AIC = 644. Finally, we present with an online APP and an online calculator for its clinical use. CONCLUSION In a retrospective cohort of women with breast cancer, a prediction model built with clinical and pathological variables at diagnosis displayed a robust performance to measure the individual odds of BM. The model is currently considered for external validation in other institutions and countries.

Incidence of Head and Neck Cancer in East Sudan

This review aims to provide an updated and detailed overview of the incidence of head and neck cancer in the eastern region of Sudan, focusing on studies conducted between 2018 and 2023. It aims to shed light on changes in incidence rates, emerging risk factors, advancements in diagnostic techniques, treatment modalities, and preventive strategies. Accurate knowledge of the latest trends and developments in head and neck cancer incidence is essential for effective public health planning and intervention. One significant aspect that the review highlights is the limited number of head and neck surgeons in East Sudan. It emphasizes the need for specialized training in staging malignancies using head and neck anatomy, as this information is vital for determining appropriate treatment approaches. With a shortage of trained professionals, it becomes even more critical to enhance the anatomic understanding and staging capabilities in order to improve patient outcomes and optimize treatment plans. The review underscores the urgency of addressing this gap in healthcare infrastructure. By increasing the number of head and neck surgeons in East Sudan and providing them with the necessary training, the region can improve its capacity to accurately stage head and neck cancers, leading to more effective treatment decisions and improved patient care. This review provides a comprehensive resource for understanding the current landscape of head and neck cancer incidence in the eastern region of Sudan. It addresses recent trends, emerging risk factors, and the need for improved anatomic understanding and staging capabilities. The findings can guide policymakers, healthcare providers, and researchers in implementing targeted strategies to reduce the burden of head and neck cancer in East Sudan and improve patient outcomes.

Comparing the clinical value of baseline [68Ga]Ga-FAPI-04 PET/CT and [18F]F-FDG PET/CT in pancreatic ductal adenocarcinoma: additional prognostic value of the distal pancreatitis.

Anatomical and molecular staging strategies are needed for the personalized treatment of localized pancreatic ductal adenocarcinoma (PDAC). This study evaluated the performance of [68Ga]Ga-FAPI-04 and [18F]F-FDG PET/CT on the disease staging and prognostic value of patients with localized PDAC on contrast-enhanced (CE)-CT images. Patients with suspected localized PDAC on CE-CT were recruited for static [68Ga]Ga-FAPI-04 and 18[F]F-FDG and PET/CT, and select patients underwent simultaneous 60-min dynamic 68Ga-FAPI-04 PET/CT. The diagnostic and staging performances of the static PET/CT results were evaluated by delineating regions of interest in the primary tumor, whole pancreas, and distal pancreas in both types of scans and then evaluating correlations between the PET/CT findings and clinicopathological characteristics. Furthermore, Kaplan-Meier and hazard ratio (log-rank) methods were used to evaluate the prognostic value of the combined dynamic [68Ga]Ga-FAPI-04 and static [18F]F-FDG PET/CT method. We included 49 patients with histologically confirmed PDAC adenocarcinomas; 32 underwent 60-min dynamic [68Ga]Ga-FAPI-04 PET/CT imaging simultaneously. The static [68Ga]Ga-FAPI-04 method had significantly higher accuracy and uptake values than the static [18F]F-FDG method for primary PDAC lesions, metastatic lymph nodes, and distal metastases. Furthermore, 18.4% and 10.2% of the patients' stages changed after using the [68Ga]Ga-FAPI-04 and [18F]F-FDG PET/CT methodologies, respectively, compared to the CE-CT-designated stage. The Ki values obtained from dynamic [68Ga]Ga-FAPI-04 PET/CT did not differ between PDAC and distal obstructive pancreatitis lesions. Pathologically enlarged tumor size, poor differentiation, and perineural invasion were associated with increased [68Ga]Ga-FAPI-04 uptake but not with [18F]F-FDG uptake. The preoperative prognostic performance of [68Ga]Ga-FAPI-04 was better than that of [18F]F-FDG. Interestingly, combined [68Ga]Ga-FAPI-04 and [18F]F-FDG uptake results in the whole pancreas could further stratify patients based on their postoperative prognosis. 6[68Ga]Ga-FAPI-04 PET/CT was more sensitive and accurate than [18F]F-FDG PET/CT for tumor, node, and metastasis staging of PDAC identified on CE-CT. Additionally, [68Ga]Ga-FAPI-04 uptake was significantly associated with pathologically aggressive tumor features. Combined [68Ga]Ga-FAPI-04 and [18F]F-FDG PET/CT findings improved the prognostic value, potentially providing a non-invasive guide for clinical management. Finally, increased fibroblast activity in PDAC-induced obstructive pancreatitis may be associated with poor patient survival rates.

Effect of Trendelenburg's Operation With Subfascial Ligation of Perforators in Clinical Improvement and Quality of Life Among Patients With Varicose Veins.

Background Assessing patients' quality of life has received increasing attention, mainly because questions have been raised regarding the direct benefits of the treatment provided. Hence, clinical outcomes and quality of life must be measured after chronic venous disease treatment. The primary objective of the study was to assess the improvement in clinical outcome and improvement in quality of life using the revised venous clinical severity score and chronic venous insufficiency questionnaire-14, respectively, in patients with varicose veins undergoing Trendelenburg's surgery and subfascial ligation of perforators. The secondary objective was to identify the relationship between the revised venous clinical severity scoreand the chronic venous insufficiency questionnaire-14 score. Method The present study is a single-center, prospective cohort study to assess the clinical improvement and quality of life in patients with varicose veins undergoing Trendelenburg surgery and subfascial ligation of perforators. All the study participants were evaluated preoperatively with the clinical, etiological, anatomical, and pathophysiological stage of the disease, revised venous clinical severity score for the clinical severity, and the chronic venous insufficiency questionnaire-14 questionnaire for the quality of life. The study participants were reviewed 90 days after surgery and reassessed for clinical severity and quality of life, both scores. Results Of the 87 screened varicose vein patients, 52 were included in the study. However, one patient was lost to follow-up. There were 38 (74.5%) males and 13 (25.5%) females. There was a significant difference in the preoperative and postoperative mean revised venous clinical severity score of the C3, C4, and C6 stages of the disease (p-value =<0.01). There was a significant difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 scorein C3, C4, and C6 (p-value = <0.01). There was a significant difference in the median preoperative and postoperative revised venous clinical severity score (p-value = <0.01). There was a considerable difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score(p-value = <0.01). The correlation coefficient between the preoperative chronic venous insufficiency questionnaire-14 scoreand the revised venous clinical severity score was 0.26 (p-value = 0.58), and the correlation coefficient between the postoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.42 (p-value = <0.01). Conclusion Patients undergoing Trendelenburg's surgery and subfascial ligation of perforators for varicose veins significantly improved the clinical severity and quality of life. There was significant improvement among the overall revised venous clinical severity scoreand chronic venous insufficiency questionnaire-14 scoreafter surgery among the different clinical classes. There was no preoperative correlation between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. However, there was a significant correlation between the postoperative revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score.

Adaptive Radiation Therapy: A Review of CT-based Techniques.

Adaptive radiation therapy is a feedback process by which imaging information acquired over the course of treatment, such as changes in patient anatomy, can be used to reoptimize the treatment plan, with the end goal of improving target coverage and reducing treatment toxicity. This review describes different types of adaptive radiation therapy and their clinical implementation with a focus on CT-guided online adaptive radiation therapy. Depending on local anatomic changes and clinical context, different anatomic sites and/or disease stages and presentations benefit from different adaptation strategies. Online adaptive radiation therapy, where images acquired in-room before each fraction are used to adjust the treatment plan while the patient remains on the treatment table, has emerged to address unpredictable anatomic changes between treatment fractions. Online treatment adaptation places unique pressures on the radiation therapy workflow, requiring high-quality daily imaging and rapid recontouring, replanning, plan review, and quality assurance. Generating a new plan with every fraction is resource intensive and time sensitive, emphasizing the need for workflow efficiency and clinical resource allocation. Cone-beam CT is widely used for image-guided radiation therapy, so implementing cone-beam CT-guided online adaptive radiation therapy can be easily integrated into the radiation therapy workflow and potentially allow for rapid imaging and replanning. The major challenge of this approach is the reduced image quality due to poor resolution, scatter, and artifacts. Keywords: Adaptive Radiation Therapy, Cone-Beam CT, Organs at Risk, Oncology © RSNA, 2023.

The Added Prognostic Value of Oncotype Recurrence Score to AJCC Prognostic Staging System in Stage III ER+/HER2- Breast Cancer.

Prognostic prediction based on prognostic stage (PS) with the Oncotype DX recurrence score (RS) has not been validated in stage III ER+/HER2- breast cancer. This study aimed to evaluate the added prognostic significance of RS incorporated with the PS system and to compare the prognostic prediction improvement with anatomic TNM stage (AS) using nomogram construction. The SEER database was indexed to identify ER+/HER2- invasive ductal or lobular breast cancer in AS IIIA-IIIC with RS results diagnosed from 2004 to 2013. Patients with RS < 18, 18-30 and > 30 were categorized into low-, intermediate- and high-risk RS groups. Comparisons of the distribution of clinical-pathologic characteristics among RS risk groups were performed using Pearson's chi-square test. Breast cancer-specific survival (BCSS) was estimated using the Kaplan-Meier method and compared across RS or PS by log-rank test. Cox regression was used to evaluate the factors independently related to BCSS. A nomogram comprised of PS and RS was constructed with discrimination, calibration and clinical benefit evaluated. Altogether 629 patients who received RS were enrolled. There were 326 cases (51.8%) with low-risk RS, 237 (37.7%) with intermediate-risk RS and 66 (10.5%) with high-risk RS; 344 patients (54.7%) had PS IB, 84 (13.4%) had IIB, 150 (23.8%) had IIIA, 46 (7.3%) had IIIB, and only 5 had (0.8%) IIIC. Both PS and RS were independent prognostic factors for BCSS. There were significant or trends of differences in survival among RS within subtypes stratified by PS. There were significant differences in survival among PS only within intermediate-risk RS. A nomogram prediction 5-year BCSS was constructed with a c-index of 0.811. Lower histologic grade, positive PR and fewer positive lymph nodes were independently correlated with low-risk RS. PS incorporated with RS had improved prognostic significance for stage III ER+/HER 2- breast cancer.