Clinical Node-positive Disease Research Articles

Benefit of Whole-Pelvis Radiation for Patients With Muscle-Invasive Bladder Cancer: An Inverse Probability Treatment Weighted Analysis.

The value of pelvic lymph node irradiation is debated for patients with muscle-invasive bladder cancer (MIBC) undergoing curative-intent radiation therapy (RT). We sought to compare the oncological outcomes between bladder-only (BO)-RT and whole-pelvis (WP)-RT using a large Canadian multicenter collaborative database. The study cohort consisted of 809 patients with MIBC (cT2-4aN0-2M0) who underwent curative RT at academic centers across Canada. Patients were divided into two groups on the basis of the RT volume: WP-RT versus BO-RT. Inverse probability of treatment weighting (IPTW) and absolute standardized differences (ASDs) were used to balance covariates across treatment groups. Regression models were used to assess the effect of the RT volume on the rates of complete response (CR), cancer-specific survival (CSS), and overall survival (OS). After exclusion criteria, 599 patients were included, of whom 369 (61.6%) underwent WP-RT. Patients receiving WP-RT were younger (ASD, 0.41) and more likely to have an Eastern Cooperative Oncology Group performance status of 0-1 (ASD, 0.21), clinical node-positive disease (ASD, 0.40), and lymphovascular invasion (ASD, 0.25). In addition, WP-RT patients were more commonly treated with neoadjuvant chemotherapy (ASD, 0.29) and concurrent chemotherapy (ASD, 0.44). In the IPTW cohort, BO-RT and WP-RT groups were well balanced (all pretreatment parameters with an ASD <0.10). In multivariable analysis, WP-RT was not associated with CR rates post-RT (odds ratio, 1.14 [95 CI, 0.76 to 1.72]; P = .526) but was associated with both CSS (hazard ratio [HR], 0.66 [95% CI, 0.47 to 0.93]; P = .016) and OS (HR, 0.68 [95% CI, 0.54 to 0.87]; P = .002), independent of other prognostic factors. Our study demonstrated that WP radiation was associated with better survival compared with bladder radiation alone after adjusted analysis. Additional randomized controlled trials are needed to confirm our findings.

Preoperative Albumin-to-Alkaline Phosphatase Ratio as an Independent Predictor of Lymph Node Involvement in Penile Cancer.

Background and Objectives: To investigate the role of preoperative albumin-to-alkaline phosphatase ratio (AAPR) in predicting pathologic node-positive (pN+) disease in penile cancer (PC) patients undergoing inguinal lymph node dissection (ILND). Materials and Methods: Clinical data of patients with squamous cell carcinoma (SCC) PC + ILND at a single high-volume institution between 2016 and 2021 were collected and retrospectively analyzed. An AAPR was obtained from preoperative blood analyses performed within 30 days from their scheduled surgery. A ROC curve analysis was used to assess AAPR cutoff, in addition to the Youden Index. Logistic regression analysis was utilized for an odds ratio (OR), 95% confidence interval (CI) calculations, and an estimate of pN+ disease. A p value < 0.05 was considered to be as statistically significant. Results: Overall, 42 PC patients were included in the study, with a mean age of 63.6 ± 12.9 years. The AAPR cut-off point value was determined to be 0.53. The ROC curve analysis reported an AUC of 0.698. On multivariable logistic regression analysis lymphovascular invasion (OR = 5.38; 95% CI: 1.47-9.93, p = 0.022), clinical node-positive disease (OR = 13.68; 95% CI: 4.37-43.90, p < 0.009), and albumin-to-alkaline phosphatase ratio ≤ 0.53 (OR = 3.61; 95% CI: 1.23-12.71, p = 0.032) were predictors of pN+ involvement. Conclusions: Preoperative AAPR may be a potentially valuable prognostic marker of pN+ disease in patients who underwent surgery for PC.

Circulating Tumor DNA and Risk of Venous Thromboembolism in Locally Advanced Rectal Cancer

Venous thromboembolism (VTE) is a common complication in cancer patients, which negatively affects treatment delivery and, consequently, prognosis. The pathophysiology of cancer-associated thrombosis (CAT) is extremely complex, relying on cytokine release in response to interactions between tumor cells and macrophages, thus leading to endothelial damage and activation of coagulation. Several risk factors may contribute to VTE risk, including tumor types, advanced stage, and anti-cancer treatments. Anti-angiogenic agents or combination of systemic chemotherapy and concomitant radiotherapy (CT-RT), for instance, are well-established risk factors across different malignancies. Colorectal cancer (CRC) is not listed as a high-risk VTE tumor according to pivotal risk assessment models, although retrospective studies showed a VTE rate of around 20%. Consequently, considering the high prevalence of the disease, VTE in CRC represents a main burden in terms of morbidity, increased healthcare costs, and mortality. Rectal cancer (RC) comprises approximately 30% of all CRC. The treatment of locally advanced disease (LARC) consists of a multimodal approach which includes chemotherapy, radiotherapy, and surgery. In the context of CRC management, circulating tumor DNA (ctDNA) is a fast-growing tool able to detect minimal residual disease, useful for improving patients' stratification and prognosis. Moreover, its determination at the time of diagnosis may represent a surrogate of tumor burden, potentially increasing the risk of VTE compared to ctDNA negative patients. Due to the paucity of prospective data of VTE in LARC, the aim of this analysis is to describe the rate of VTE and the potential association between ctDNA levels at baseline and VTE occurrence. We conducted a prospective observational study enrolling patients with LARC managed with neoadjuvant CT-RT (capecitabine 1650 mg/m2 concomitant with 50,4 Gy pelvic long course radiotherapy), surgery, plus/minus adjuvant chemotherapy at European Institute of Oncology (IEO) between November 2014 and November 2019. Blood samples for ctDNA were obtained at pre-planned timepoints: baseline (T0), end of CT-RT (T1), after surgery (T2), end of adjuvant chemotherapy (T3). ctDNA was extracted from plasma and mutations detected on tumor biopsy (KRAS, NRAS, BRAF, PIK3CA) were evaluated on ctDNA. Among other clinical information, VTE events were collected, including pulmonary embolism (PE), deep vein thrombosis (DVT) and visceral venous thrombosis (VVT). VTE was counted when occurred after or whitin 30 days before LARC diagnosis. The ctDNA value, defined as variant allele frequency (VAF) in a targeted mutation, was analyzed for correlation with clinical outcomes and VTE events. Median baseline ctDNA value was set as threshold to subdivide patients in VAF high and VAF low. We enrolled 111 patients. Sixty-one (55%) patients harboring tumoral tissue mutations underwent liquid biopsy. KRAS mutation was the most frequent one (42%), followed by NRAS (7%) and PIK3CA (5%). Fifty-one patients (83%) had a clinical node positive disease. Baseline Khorana Score (KS) was 0 in 54 patients (88%) and 1 in 7. Median ctDNA value at T0 was 0.11 ng/2ml (range: 0.00 - 17.40). After a median follow up of 82 months, 9 VTE events (15%) were diagnosed, 4 PE, 3 DVT and 2 VVT. The median time from diagnosis to VTE event was 14 months (IQR 6 - 51). VTE occurrence was associated with VAF high at baseline, even though not statistically significant (Hazard Ratio [HR]: 2.85; 95% CI: 0.71-11.4, p value = 0.14). Looking specifically at KRAS mutant patients, 6 VTE events were observed, all experienced by VAF high patients (HR not estimable, p value = 0.001). Considering the overall population, VTE rate was 14% and no statistical differences were observed for VTE development according to mutational profile. In our prospective study on LARC patients, VTE was associated with high levels of ctDNA at diagnosis, although not statistically significant. However, the association was significant in KRAS mutant tumors, which may represent a subset of patients with higher risk of thromboembolic complications. Prospective translational studies using deeper molecular techniques and wider populations are required to define the role of ctDNA as additional predictive tool to stratify VTE risk in cancer patients.

Short-course radiation with consolidation chemotherapy does not increase operative morbidity compared to long-course chemoradiation: A retrospective study of the US rectal cancer consortium.

Neoadjuvant short-course radiation and consolidation chemotherapy (SC TNT) remains less widely used for rectal cancer in the United States than long-course chemoradiation (LCRT). SC TNT may improve compliance and downstaging; however, a longer radiation-to-surgery interval may worsen pelvic fibrosis and morbidity with total mesorectal excision (TME). A single, US-center retrospective analysis has shown comparable risk of morbidity after neoadjuvant short-course radiation with consolidation chemotherapy (SC TNT) and long-course chemoradiation (LCRT). Validation by a multi-institutional study is needed. The US Rectal Cancer Consortium database (2010-2018) was retrospectively reviewed for patients with nonmetastatic, rectal adenocarcinoma treated with neoadjuvant LCRT or SC TNT before TME. The primary endpoint was severe postoperative morbidity. Cohorts were compared by univariate analysis. Multivariable logistic regression modeled the odds of severe complication. Of 788 included patients, 151 (19%) received SC TNT and 637 (81%) LCRT. The SC TNT group had fewer distal tumors (33.8% vs. 50.2%, p < 0.0001) and more clinical node-positive disease (74.2% vs. 47.6%, p < 0.0001). The intraoperative complication rate was similar (SC TNT 5.3% vs. 4.4%, p = 0.65). There was no difference in overall postoperative morbidity (38.4% vs. 46.3%, p = 0.08). Severe morbidity was similar with low anterior resection (9.1% vs. 15.3%, p = 0.10) and abdominoperineal resection (24.4% vs. 29.7%, p = 0.49). SC TNT did not increase the odds of severe morbidity relative to LCRT on multivariable analysis (OR 0.64, 95% CI 0.37-1.10). SC TNT does not increase morbidity after TME for rectal cancer relative to LCRT. Concern for surgical complications should not discourage the use of SC TNT when aiming to increase the likelihood of complete clinical response.

PD44-06 CHEMOTHERAPY VS IMMUNOTHERAPY AS NEOADJUVANT THERAPIES IN CISPLATIN-ELIGIBLE PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023PD44-06 CHEMOTHERAPY VS IMMUNOTHERAPY AS NEOADJUVANT THERAPIES IN CISPLATIN-ELIGIBLE PATIENTS UNDERGOING RADICAL CYSTECTOMY FOR MUSCLE INVASIVE BLADDER CANCER Luigi Nocera, Marco Bandini, Giuseppe Basile, Marco Moschini, Shreyas Naidu, Kyle Rose, Roger Li, Philippe Spiess, and Andrea Necchi Luigi NoceraLuigi Nocera More articles by this author , Marco BandiniMarco Bandini More articles by this author , Giuseppe BasileGiuseppe Basile More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Shreyas NaiduShreyas Naidu More articles by this author , Kyle RoseKyle Rose More articles by this author , Roger LiRoger Li More articles by this author , Philippe SpiessPhilippe Spiess More articles by this author , and Andrea NecchiAndrea Necchi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Chemotherapy has represented one of the cornerstone of the treatment landscape of muscle invasive bladder cancer (MIBC), due to its improvement in survival outcomes. Recently, also immunotherapy also showed to improve both pathological response, as well as survival outcomes. However, no comparison has ever been performed between the two neoadjuvant treatments. We aimed to compare cisplatinum-based chemotherapy and pembrolizumab in MIBC patients undergoing radical cystectomy (RC). METHODS: We retrospectively identified patients with MIBC and treated with RC after neoadjuvant treatment with either cisplatin or pembrolizumab in two tertiary referral centers. Cisplatinum-eligibility represented an inclusion criterion. Conversely, clinical node positive disease and adjuvant chemotherapy administration were exclusion criteria. The endpoint of the analyses was recurrence-free survival (RFS). Statistical analyses consisted of Kaplan-Meier (KM) curves before and after inverse-probability treatment weighting (IPTW), adjusting for age, gender, pathological stage, concomitant CIS and variant histology (VH). RESULTS: Of all 346 patients, median age was 67 years (IQR 60-73) and the majority of patients were male (80.3%). The majority of patients harbored a pT0N0 disease (30.3%) at RC pathology followed by pT2-4N0 (29.5%), pTanyN1-3 (20.5%) and pT1-a-isN0 (19.6%). Moreover, 113 patients (32.6%) exhibited concomitants CIS, while 255 patients (73.7%), 27 patients (7.8%) and 64 patients (18.5%) showed respectively presence of pure/mixed urothelial carcinoma, pure VH and other histology. Overall, 70 patients (20.2%) experienced recurrence (33.9% pelvic vs 66.1% distant) after a median follow-up of 24 months (12-39). KM showed a 24-months RFS of 76.9 vs 86.6% for cisplatinum-based chemotherapy versus pembrolizumab (p<0.01). After IPTW for age, gender, pathological stage, concomitant CIS and VH, KM showed 76.8 vs 93.2% for cisplatinum-based chemotherapy versus pembrolizumab (p=0.01). CONCLUSIONS: We compared RFS after cisplatinum chemotherapy vs pembrolizumab as neoadjuvant treatment in MIBC undergoing RC. Our findings suggest a potentially higher benefit of pembrolizumab, that was confirmed after adjustment for confounders. Source of Funding: NONE © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1126 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luigi Nocera More articles by this author Marco Bandini More articles by this author Giuseppe Basile More articles by this author Marco Moschini More articles by this author Shreyas Naidu More articles by this author Kyle Rose More articles by this author Roger Li More articles by this author Philippe Spiess More articles by this author Andrea Necchi More articles by this author Expand All Advertisement PDF downloadLoading ...

PD44-08 BENEFIT OF WHOLE-PELVIS RADIATION FOR PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER: AN INVERSE PROBABILITY TREATMENT WEIGHTED ANALYSIS

PD44-08 BENEFIT OF WHOLE-PELVIS RADIATION FOR PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER: AN INVERSE PROBABILITY TREATMENT WEIGHTED ANALYSIS

Abstract PD3-03: Preoperative robotic radiosurgery for early breast cancer: results of the phase II ROCK trial (NCT03520894)

Abstract Introduction. Breast-conserving surgery (BCS) followed by postoperative radiotherapy (RT) still represents the standard of care for early breast cancer (BC) patients. Hypofractionated schedules in maximum 15 fractions are currently accepted as the gold standard for external beam whole and partial breast irradiation (PBI). PBI for selected early BC patients allowed a shorter overall treatment duration and an improved patient compliance as compared to old-fashioned RT schedules. Preoperative PBI, due to the advantage of treating a well-defined volume, has been gaining attention in this multidisciplinary scenario. It avoids local treatment delay and might allow tumour downstaging with increased rates of BCS and improved cosmetic outcomes. Since local recurrence might be driven by biological mechanisms of radioresistance rather than geographical miss, higher dose per fraction may overcome repair mechanisms allowing tumoral cells to escape from conventional RT damage. We report the results of the phase II ROCK trial (NCT03520894), enrolling early BC patients treated with preoperative robotic radiosurgery (prRS), in terms of acute and early late toxicity, disease control, and cosmesis. Material and methods. The study recruited between August 2018 and September 2021 at the Radiation Oncology Unit of the University of Florence (Florence, Italy). Eligible patients were women aged 50+ years, with histologically proven invasive early BC, HR+/HER2- disease, without lymph vascular invasion, tumour size up to 25 mm suitable for BCS. Exclusion criteria were clinical node positive disease, multiple foci tumours, and patients with breast lesion limiting within 5 mm from the skin surface. The study aimed to prospectively assess the safety and feasibility of a single Cyberknife® (Accuray Incorporated, Sunnyvale, CA, USA) 21Gy-fraction prRS in preoperative setting, and to identify predictive factors for outcomes based on biologic and clinical features. The primary endpoint was the acute skin toxicity (from the end of prRS to surgery) according to the RTOG and the EORTC scales. Secondary endpoints were the rate of early late skin and non-skin toxicity as measured 90 days from the end of prRS, the rate of pathological complete response (pCR) according to Chevalier score. Cosmetic outcomes were prospectively scored every 6-month using the BCCT.core software. Results. From August 2018 to September 2021, a total of 70 patients were recruited and enrolled. Of those, 41 were excluded due to tumour biology exclusion criteria and 7 due to multiple foci breast disease evidenced at basal MRI. Therefore, 22 patients were successfully treated with pRS. Median age at diagnosis was 68 years (range 50-86), median tumour size was 14 mm (range 7.5-25). Required target dosimetric parameters were met in all patients, as well as normal tissue constraints. Patients received surgery after a median time of 29 days from biopsy, without any delay or postoperative complication. Overall, three G1 adverse events (13.6%) were recorded within 7 days from prRS (1 erythema, 2 breast pain). Three events (13.6%) were recorded between 7 and 30 days from prRS, one G2 breast oedema and two G1 breast pain. No acute toxicity greater than G2 was recorded. Five patients experienced early late G1 toxicity (1 breast pain, 4 breast induration). One patient reported G2 breast induration. No early late toxicity greater than G2 was observed. At a median follow up of 18 months (range 6-29.8), cosmetic results were scored excellent/good and fair in 14 and 5 patients, respectively, while 3 patients experienced a poor cosmetic outcome. Overall, pCR after surgery was reported in 2 patients (9%). Two patients received postoperative whole breast irradiation, according to histopathological results. Conclusions. ROCK trial showed that a single 21 Gy dose prRS represents a feasible technique for selected patients affected by early BC, showing a good safety profile and a promising effectiveness. Citation Format: Icro Meattini, Giulio Francolini, Vanessa Di Cataldo, Luca Visani, Carlotta Becherini, Erika Scoccimarro, Monica Mangoni, Viola Salvestrini, Laura Masi, Chiara Bellini, Raffaela Doro, Federica Di Naro, Marco Bernini, Jacopo Nori, Lorenzo Orzalesi, Simonetta Bianchi, Lorenzo Livi. Preoperative robotic radiosurgery for early breast cancer: results of the phase II ROCK trial (NCT03520894) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD3-03.

Abstract P6-01-46: Independent validation of the HER2DX genomic test in HER2-positive breast cancer treated with neoadjuvant docetaxel, carboplatin, trastuzumab +/- pertuzumab (TCH/TCHP): a correlative analysis from a multicenter academic study

Abstract Background: HER2DX (Prat et al. EBiomedicine 2022) is a 27-gene prognostic (risk-score) and predictive (pathological complete response [pCR]-score) assay in early-stage HER2+ breast cancer based on clinical data and the expression of 4 gene signatures (immune, proliferation, luminal differentiation and HER2 amplicon). Here, we aim to evaluate, for the first time, the ability of HER2DX to predict pCR following neoadjuvant TCH or TCHP in HER2+ disease. Methods: Standardized HER2DX was performed in a central lab on baseline pre-treatment FFPE tumor biopsies from the GOM-HGUGM-2018-05 study in Spain, a consecutive retrospective series of patients (pts) with newly diagnosed stage I-III HER2+ breast cancer eligible for neoadjuvant therapy. Pts received standard 6 cycles of docetaxel, carboplatin and trastuzumab (TCH) or TCH with pertuzumab (TCHP) regimens. Primary aim was to test the ability of HER2DX pCR score to predict pCR (ypT0/is ypN0). Secondary objectives were to test the ability of HER2DX pCR score to predict pCR independently of clinical-pathological variables and the PAM50 subtype (HER2-enriched versus not), and to evaluate the association of HER2DX pCR score with the HER2DX risk-score. Logistic regression and receiver-operator curve (ROC) analysis were assessed. Statistical analyses were performed in R code 4.0.5. Results: HER2DX was evaluated in 155 pts (97%) enrolled in the study with available RNA (as of June 2022). Mean age of pts was 50 (range 22-74) and 55.2% of pts (n=85) were pre-menopausal. Clinical T2-4 disease represented 77.4% of cases (n=120), clinical node-positive disease (cN1-3) represented 63.9% of cases (n=99), and 68.0% of tumors (n=105) were hormone receptor-positive. The overall pCR rate was 57.4% (95% confidence interval [CI] 50-65): 52.2% (95% CI 40-64) with TCH (n=67) and 61.4% (95% CI 50-72) with TCHP (n=88). The proportion of HER2DX low-, medium- and high-pCR groups was 34.2%, 34.8% and 31.0%, respectively. HER2DX pCR score (as a continuous variable from 0 to 100) was significantly associated with pCR (odd ratio [OR]=1.03, p=5.91e-07). The pCR rates in HER2DX pCR-high and pCR-low groups were 75.0% and 28.0% (OR=7.6, 95% CI 3.2-19.1, p=7.14e-06), respectively. In pts treated with TCHP, the pCR rates in HER2DX pCR-high and pCR-low groups were 85.7% and 27.3% (OR=16.0, 95% CI 4.3-59.01, p=3.2e-05), respectively. The AUC ROC of HER2DX pCR score (as a continuous variable) and pCR status was 0.746 (in all pts) and 0.812 (in pts treated with TCHP). HER2DX pCR score was significantly associated with pCR independently of hormone receptor status, Ki67, age, menopausal status, pertuzumab use, clinical stage and PAM50 HER2-enriched subtype. The proportion of HER2DX low- and high-risk of relapse disease was 32.0% and 68.0%, respectively. The correlation of HER2DX pCR score and HER2DX risk-score was weak (coefficient=-0.17), as previously described. Proportion of cases according to both HER2DX scores and absolute difference of pCR rates between TCHP and TCH in each combined group is shown in Table. Conclusion: The HER2DX genomic test predicts pCR following neoadjuvant TCH or TCHP regimens independently of clinical-pathological variables and intrinsic subtype. The combination of both HER2DX scores might help better tailor systemic therapy in patients with newly diagnosed stage I-III HER2+ breast cancer. Citation Format: Coralia Bueno-Muiño, Isabel Echavarria, Sara López-Tarruella, Roche-Molina Marta, María del Monte-Millán, Tatiana Massarrah, Yolanda Jerez Gilarranz, Blanca Herrero, Salvador Gámez, Iván Márquez-Rodas, María Cebollero-Presmanes, Nevado Santos Manuel, Pilar de la Morena Barrio, Francisco Ayala de la Peña, José Ángel García-Sáenz, Fernando Moreno Antón, Álvaro Rodríguez Lescure, Teresa Quintanar, Diego Malón-Giménez, Laura Rodriguez-Lajusticia, Ana Isabel Ballesteros García, Dulce Bañón Torres, Lucía Villarejo, Nerea Lobato, Ainhoa Arias, Inmaculada Ocaña, Enrique Álvarez, Laia Paré, Mercedes Marín-Aguilera, Patricia Galván, Fara Brasó-Maristany, Ana Vivancos, Patricia Villagrasa, Joel S Parker, Charles M. Perou, Aleix Prat, Miguel Martín. Independent validation of the HER2DX genomic test in HER2-positive breast cancer treated with neoadjuvant docetaxel, carboplatin, trastuzumab +/- pertuzumab (TCH/TCHP): a correlative analysis from a multicenter academic study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-46.

Benefit of whole-pelvis radiation for patients with muscle-invasive bladder cancer: An inverse probability treatment-weighted analysis.

449 Background: Pelvic lymph node irradiation is still under debate for patients with muscle-invasive bladder cancer (MIBC) planned for curative-intent radiation-based therapy (RT). A previous randomized trial suggested bladder-only (BO)-RT was effective in reducing RT-related toxicity, while associated with non-inferior oncological outcomes – bladder preservation rates, disease-free survival, and overall survival (OS) – compared to whole-pelvis (WP)-RT. In this study, we sought to evaluate the impact of the radiation volume (BO-RT vs. WP-RT) on main oncological outcomes in patients with MIBC. Methods: This nationwide study included patients with urothelial MIBC (cT2-4aN0-2M0) who underwent curative RT at 10 academic centers across Canada. Patients clinically staged with pelvic or abdominal wall invasion (cT4b) or enlarged lymph nodes beyond the common iliac bifurcation (cN3) before RT were excluded. Patients were divided into two groups based on the RT volume: WP-RT vs. BO-RT. Inverse probability of treatment weighting (IPTW) and absolute standardized differences (ASDs) were used to balance baseline covariates across treatment groups. Regression models were used to assess the impact of the RT volume on the rates of complete response (CR) to treatment, cancer-specific survival (CSS), and OS while adjusting for potential confounding variables in the weighted cohorts. Results: A total of 599 patients were analyzed, out of whom 369 (61.6%) underwent WP-RT. Patients in the WP-RT group were younger (mean age 73.2 vs. 77.4; ASD 0.41), and more likely to have an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-1 (82.1% vs. 73.5%; ASD 0.21), clinical node-positive disease (12.5% vs. 2.2%; ASD 0.40), and lymphovascular invasion (26.3% vs. 16.1%; ASD 0.25), compared to BO-RT. In addition, WP-RT patients were more commonly treated with neoadjuvant chemotherapy (20.9% vs. 10.4%; ASD 0.29) and concurrent chemotherapy (76.7% vs. 56.5%; ASD 0.44), compared to BO-RT. In the IPTW cohort, age, gender, ECOG PS, clinical staging, the proportion of patients with carcinoma in situ, lymphovascular invasion, variant urothelial histologies, hydronephrosis, and whose tumours were completely resected before RT, treated with NAC, and treated with concurrent chemotherapy were well balanced across groups (all ASDs &lt; 0.10). In multivariable analysis, WP-RT did not impact CR rates post-RT (OR 1.14; p=0.526) but was associated with both CSS (HR 0.66; p=0.016) and OS (HR 0.68; p=0.002), independently of other prognostic factors (Table). Conclusions: Our study demonstrated a significant survival benefit with the use of WP-RT compared to BO-RT in patients with MIBC treated with curative intent. Additional randomized controlled trials are needed to confirm our findings.

Poor response to neoadjuvant chemotherapy in metaplastic breast carcinoma

Metaplastic breast carcinoma (MpBC) is a rare special histologic subtype of breast carcinoma characterized by the presence of squamous and/or mesenchymal differentiation. Most MpBCs are of triple-negative phenotype and neoadjuvant chemotherapy (NAC) is frequently utilized in patients with MpBC. The aim of this study was to evaluate response to NAC in a retrospective cohort of MpBCs. We identified 44 patients with MpBC treated with NAC at our center between 2002 and 2018. Median age was 48 years, 86% were clinical stage II–III, and 36% were clinically node-positive. Most (80%) MpBCs were triple-negative or low (1–10%) hormonal receptor positive and HER2 negative on pre-NAC biopsy. While on NAC, 49% showed no clinical response or clinico-radiological progression. Matrix-producing subtype was associated with clinico-radiological response (p = 0.0036). Post NAC, two patients initially ineligible for breast-conserving surgery (BCS) were downstaged to be eligible for BCS, whereas three patients potentially eligible for BCS before treatment became ineligible due to disease progression. Only one (2%) patient had a pathologic complete response (pCR). Among the 16 patients presenting with biopsy-proven clinical node-positive disease, 3 (19%) had nodal pCR. Axillary lymph node dissection was avoided in 3 (19%) patients who had successful axillary downstaging. Residual cancer burden (RCB) was assessed in 22 patients and was significantly associated with disease-free survival and overall survival. We observed a poor response or even disease progression on NAC among patients with MpBC, suggesting that NAC should be reserved for patients with inoperable MpBC.

Prostate Cancer Radiation Therapy Recommendations in Response to COVID-19

PurposeDuring a global pandemic, the benefit of routine visits and treatment of patients with cancer must be weighed against the risks to patients, staff, and society. Prostate cancer is one of the most common cancers radiation oncology departments treat, and efficient resource utilization is essential in the setting of a pandemic. Herein, we aim to establish recommendations and a framework by which to evaluate prostate radiation therapy management decisions. Methods and MaterialsRadiation oncologists from the United States and the United Kingdom rapidly conducted a systematic review and agreed upon recommendations to safely manage patients with prostate cancer during the COVID-19 pandemic. A RADS framework was created: remote visits, and avoidance, deferment, and shortening of radiation therapy was applied to determine appropriate approaches. ResultsRecommendations were provided by the National Comprehensive Cancer Network risk group regarding clinical node-positive, postprostatectomy, oligometastatic, and low-volume M1 disease. Across all prostate cancer stages, telemedicine consultations and return visits were recommended when resources/staff available. Delays in consultations and return visits of between 1 and 6 months were deemed safe based on stage of disease. Treatment can be avoided or delayed until safe for very low, low, and favorable intermediate-risk disease. Unfavorable intermediate-risk, high-risk, clinical node-positive, recurrence postsurgery, oligometastatic, and low-volume M1 disease can receive neoadjuvant hormone therapy for 4 to 6 months as necessary. Ultrahypofractionation is preferred for localized, oligometastatic, and low-volume M1, and moderate hypofractionation is preferred for postprostatectomy and clinical node positive disease. Salvage is preferred to adjuvant radiation. ConclusionsResources can be reduced for all identified stages of prostate cancer. The RADS (remote visits, and avoidance, deferment, and shortening of radiation therapy) framework can be applied to other disease sites to help with decision making in a global pandemic.

Predictive value of tumor-infiltrating lymphocytes for pathological response to neoadjuvant chemotherapy in breast cancer patients with axillary lymph node metastasis

We investigated the role of tumor-infiltrating lymphocytes (TILs) in pretreatment primary breast cancer to predict pathological response to neoadjuvant chemotherapy (NAC) in patients with clinical node-positive disease (cN +). The subjects of this study were 60 patients with cN + , who received NAC followed by breast surgery with axillary lymph node dissection (ALND). We conducted a semi-quantitative assessment of TILs in pretreatment primary tumors and their association with clinicopathological factors and axillary lymph node metastasis. We observed a higher number of TILs in tumors with negative hormone receptors, positive human epidermal growth factor receptor 2, or high Ki67. TILs were associated with a favorable response to NAC in primary tumors. The rate of axillary pathologic complete response (Ax-pCR) was significantly higher in patients with a high number of TILs than in patients with a low number of TILs (72.0% versus 17.1%, p < 0.001). In multivariable analysis, a high number of TILs was a significant predictor of Ax-pCR as well as of pCR of the primary tumor after NAC. Importantly, all patients with HER2-positive tumors in the high TILs group showed Ax-pCR on ALND. TILs in pretreatment primary breast cancer had the potential to predict therapeutic efficacy of NAC in patients with clinical node-positive disease.

Prostate Cancer Radiation Therapy Recommendations in Response to COVID-19

PurposeDuring a global pandemic, the benefit of routine visits and treatment of patients with cancer must be weighed against the risks to patients, staff, and society. Prostate cancer is one of the most common cancers radiation oncology departments treat, and efficient resource utilization is essential in the setting of a pandemic. Herein, we aim to establish recommendations and a framework by which to evaluate prostate radiation therapy management decisions. Methods and MaterialsRadiation oncologists from the United States and the United Kingdom rapidly conducted a systematic review and agreed upon recommendations to safely manage patients with prostate cancer during the COVID-19 pandemic. A RADS framework was created: remote visits, and avoidance, deferment, and shortening of radiation therapy was applied to determine appropriate approaches. ResultsRecommendations were provided by the National Comprehensive Cancer Network risk group regarding clinical node-positive, postprostatectomy, oligometastatic, and low-volume M1 disease. Across all prostate cancer stages, telemedicine consultations and return visits were recommended when resources/staff available. Delays in consultations and return visits of between 1 and 6 months were deemed safe based on stage of disease. Treatment can be avoided or delayed until safe for very low, low, and favorable intermediate-risk disease. Unfavorable intermediate-risk, high-risk, clinical node-positive, recurrence postsurgery, oligometastatic, and low-volume M1 disease can receive neoadjuvant hormone therapy for 4 to 6 months as necessary. Ultrahypofractionation is preferred for localized, oligometastatic, and low-volume M1, and moderate hypofractionation is preferred for postprostatectomy and clinical node positive disease. Salvage is preferred to adjuvant radiation. ConclusionsResources can be reduced for all identified stages of prostate cancer. The RADS (remote visits, and avoidance, deferment, and shortening of radiation therapy) framework can be applied to other disease sites to help with decision making in a global pandemic.

Impact of Detecting Occult Pathologic Nodal Disease During Resection for Malignant Pleural Mesothelioma

BackgroundLymph node (LN) involvement is a poor prognostic factor for malignant pleural mesothelioma (MPM). However, to our knowledge, postresection outcomes of node-negative (cN0/pN0), occult pathologic nodal disease (cN0/pN+), and clinical node-positive disease (cN+) have not been compared to date. Patients and MethodsThe National Cancer Data Base was queried for newly diagnosed, resected MPM with known clinical/pathologic LN information. Three cohorts were compared: cN0/pN0, cN+, and cN0/pN+. Multivariable logistic regression examined predictors of pathologic nodal upstaging. Kaplan-Meier analysis with propensity matching assessed overall survival (OS); multivariate Cox proportional hazards modeling examined predictors thereof. ResultsOf 1369 patients, 687 (50%) had cN0/pN0, 457 (33%) cN+, and 225 (16%) cN0/pN+ disease. Median follow-up was 29 months. In patients with cN0 disease, factors associated with pathologic nodal upstaging were younger age, greater number of examined LNs, and nonsarcomatoid histology (P < .05 for all). Relative to pN0 cases, occult LN involvement (65% being pN2) was associated with 51% higher hazard of mortality on multivariate analysis (P = .005). Following propensity matching, the OS of cN0/pN+ was similar to cN+ cases (P = .281). On multivariate analysis, the number of involved LNs (continuous variable, P = .013), but not nodal tumor, node, metastasis (TNM) classification or LN ratio (P > .05 for both), was associated with OS. ConclusionDetecting occult nodal disease during resection for cN0 MPM is associated with poorer prognosis, with similar survival as cN+ cases, underscoring the importance of routine preoperative pathologic nodal assessment for potentially resectable MPM. The number of involved LNs (rather than current location-based classification) may provide more robust prognostic stratification for future TNM staging.

Racial Equity among African-American and Non-Hispanic White Men Diagnosed with Prostate Cancer in the Veterans Affairs Healthcare System

African-American (AA) men in the general U.S. population are more than twice as likely to die from prostate cancer than Non-Hispanic White (NHW) men. Racial disparities decrease after the age of 65 when patients become eligible for equal-access Medicare insurance. We hypothesized that receipt of healthcare through the Veterans Affairs Health System, an equal-access medical system, would attenuate disparities between AA and NHW men of all ages. We identified patients diagnosed with prostate cancer between 2000-2015 using the Department of Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI). We used a combination of database/registry coded values and chart review to assemble tumor, treatment, comorbidity, and sociodemographic data and then ascertained date and cause of death using the Social Security death index. Prostate cancer-specific mortality (PCSM) was evaluated using Fine-Gray regression and cumulative incidence function plots. A mediation analysis was performed using sequential variable analysis. The cohort included 60,035 men (18,201 (30.3%) AA, 41,834 (69.7%) NHW) followed for a median of 5.9 years. AA men were more likely to be from regions with lower median income (AA 45,069 vs NHW 51,973, p<0.001) and lower high school graduation rates (AA 0.83% vs NHW 0.87%, p <0.001). They were also younger (AA mean age 63.6 vs NHW 67.2, p<0.001), and had higher median PSA at presentation (AA 6.7 vs NHW 6.2, p<0.001). However, AA men were equally or less likely to present with Gleason 8-10 disease (AA 18.8% vs NHW 19.7%, p<0.001), clinical T-stage 3 or higher (AA 2.2% vs NHW 2.9%, p<0.001), clinical node positive disease (AA 1.4% vs NHW 1.5%, p=0.33) or distant metastatic disease (AA 2.7 vs NHW 3.1, p = 0.01). The unadjusted 10-year incidence of PCSM for AA and NWH men was 4.4% versus 5.1%, respectively. On multivariable analysis, AA men had improved PCSM (subdistribution hazard ratio: 0.85; 95% confidence interval: 0.78-0.93; p < 0.001). Sequential variable analysis did not identify any variables mediating this effect. AA men demonstrated an improved 10-year overall survival (AA 18% vs NHW 23%), with adjusted hazard ratio of 0.84 (0.81-0.88; p<0.001). African-American men diagnosed with prostate cancer in the VA system do not present with more advanced disease or suffer from worse outcomes compared to NHW men despite generally residing in regions with lower socioeconomic status. These findings suggest that access to care is an important determinant of racial equity in prostate cancer diagnosis, receipt of appropriate care, and survival outcomes.

A Single Institution Retrospective Analysis of Adult Head & Neck Rhabdomyosarcoma (HN RMS) from 1984-2017

Head and Neck Rhabdomyosarcoma (HN RMS) in adults is an aggressive and challenging to manage malignancy. Our goal was to describe the presentation, treatment, outcomes, patterns of failure, and prognostic factors of HN RMS patients treated at our institution between 1984 and 2017. A retrospective chart review of adult (>16 years of age) HN RMS patients registered in the multidisciplinary Sarcoma Clinic who received majority of their treatment here was performed. Survival analyses were performed using the Kaplan-Meier Method. Prognostic variables including age, anatomic location, histologic subtype, radiation, and TNM stage were analyzed in univariate (UVA) Cox analyses. Fifty-eight patients were identified, with a median age of 32 years (ranged 16 to 81); 26 were male. Seventy-six percent of tumors (n=45) were parameningeal and 88% (n=51) were >5cm. Fifty percent of patients (n=29) had clinical node positive disease and 15% (n=9) had distant metastases at the time of diagnosis. Local treatment consisted of surgery and radiotherapy (RT) versus RT alone in 9% (n=5), and 91% (n=53) patients respectively; and 76% (n=45) received chemotherapy. Local and regional control at 5 years was 64%, and 73%, respectively. With a median follow-up of 18 months, 5-year Overall Survival (OS) was 34% (95% CI: 20%-48%) for non-metastatic, and 29% (95% CI: 17%-42%) for metastatic patients. Patterns of failure were further analyzed in 49 non-metastatic patients. Sixty-seven percent (n=30) patients relapsed, with median time to progression of 15 months. Median time to distant failure (DF) was 20 months. On UVA, concurrent chemotherapy (HR 2.3, p=0.029) and tumor size (HR 2.6, p=0.01) were associated with worse survival. Distant metastasis was the predominant mode of first failure (n=16, 33%). This population was also enriched for patients with metastases in unusual locations, including testes (n=2), breasts (n=2), leptomeninges (n=12), and bone marrow (n=9). Adult HN RMS of the head and neck is an aggressive malignancy with an unfavorable prognosis, despite intensive treatment, but is potentially curable, particularly with modern radiotherapy techniques and chemotherapy.

Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review.

Background:Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated.Objective:To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa.Methods:Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized.Results:cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions.Conclusions:Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.

Role of lymph node dissection during radical nephroureterectomy for upper urinary tract urothelial cancer: multi-institutional large retrospective study JCOG1110A.

To evaluate the impact of lymph node dissection (LND) on clinical outcome during radical nephroureterectomy (RNU) for patients with upper urinary tract urothelial cancer (UTUC). We, the Urologic Oncology Study Group of the Japan Clinical Oncology Group (JCOG), retrospectively collected data from patients with non-metastatic UTUC who underwent RNU in 30 centers in 1995-2009. Ineligible patients and patients with previous and/or synchronous bladder cancer were excluded, and the remaining 2037 patients were analyzed. We compared overall and cancer-specific mortality between patients who underwent LND (LND group) and those without LND (no-LND group). Among 2037 patients, LND was performed in 1046 (51.4%) patients, and 223 (10.9%) patients had pathological node-positive (pN+) disease. All-cause mortality was observed in 503 patients (24.7%) during follow-up (median 45.8months), including 363 patients (17.8%) who died of UTUC. Patients with pN+ disease showed significantly shorter overall survival (OS) compared with pN0 patients, and the estimated 5-year OS for pN+ patients was 30%. Older age, ≥cT3, and clinical node-positive disease were found as preoperative predictors for pN+ disease by multivariate analysis. In the comparison of OS and cancer-specific mortality between LND and no-LND groups, there was no significant improvement by LND in multivariate analysis. The median number of lymph nodes removed was six (IQR 3-11). There was no significant association between the number of lymph nodes removed and OS. The present study indicates that there is no therapeutic benefit of LND during RNU for UTUC, although pathologically positive LN status can predict poor prognosis.

Adjuvant Chemotherapy Is Associated With Improved Overall Survival in Locally Advanced Rectal Cancer After Achievement of a Pathologic Complete Response to Chemoradiation

BackgroundIn locally advanced rectal adenocarcinoma, 15% to 20% of patients treated with neoadjuvant chemoradiation (nCRT) achieve a pathologic complete response (pCR). The benefit of adjuvant chemotherapy is controversial in rectal cancer. Our objective was to evaluate the effect of clinical risk factors and adjuvant chemotherapy usage on the outcomes of the pCR patient population. Patients and MethodsWe performed a retrospective study using the National Cancer Data Base from 2006 to 2013. The primary outcome was overall survival (OS). The association between OS and patient characteristics (demographics, tumor variables, and treatment) was examined using multivariable Cox regression modelling. ResultsA total of 2891 patients were identified who had achieved a pCR. Of these 2891 patients, 2102 received nCRT and 789 received nCRT followed by adjuvant chemotherapy. The median follow-up duration was 43.2 months. The factors significantly associated with OS included age (P < .001), gender (P = .011), Charlson-Deyo comorbidity score (P < .001), grade (P = .029), clinical T stage (P = .030), carcinoembryonic antigen negativity (P = .002), and receipt of adjuvant chemotherapy (P < .001). Nodal status was not significantly associated with survival. The 5-year OS rate was 94% in the nCRT plus adjuvant group compared with 84% in the nCRT-alone group. Adjuvant chemotherapy was more likely to be given to younger patients (aged < 60 years), higher grade, lower Charlson-Deyo comorbidity score, elevated carcinoembryonic antigen level, higher clinical T stage, and higher clinical N stage. ConclusionOur findings showed a significant improvement in OS for patients who received nCRT plus adjuvant chemotherapy compared with those who received nCRT alone. The nCRT plus adjuvant patients were more likely to be younger, have a lower comorbidity score, have clinical ≥ T3 disease, and have clinical node-positive disease. Thus, a selection bias could have been present. Nonetheless, even in the setting of already excellent outcomes, for patients with locally advanced rectal adenocarcinoma who achieve a pCR, the additional benefit of adjuvant chemotherapy should be weighed against the potential for toxicity.

Abstract P2-01-07: Selective elimination of axillary surgery after primary systemic treatment in clinically node-positive breast cancer patients by combining PET/CT and the MARI procedure (marking the axilla with radioactive iodine seeds)

Abstract Background The increasing use of primary systemic treatment (PST) for patients with breast cancer enables more breast conserving surgery. In addition, PST converts node-positive into node-negative disease in 20-40% of patients. However, the current guidelines still recommend axillary lymph node dissection (ALND) for clinical node-positive disease (cN+), even if it became node-negative after PST, since false-negative rates of sentinel lymph node biopsy after PST range from 5-30%. Recently, an alternative technique has been introduced to stage the axilla after PST: the MARI-procedure (sensitivity 97%; FNR 7%), in which a tumour-positive lymph node is marked with a radioactive iodine seed before the start of PST and selectively removed after PST. In the present study, we propose a new strategy for treatment of the axilla in cN+ patients by combining results of the pre-PST PET/CT with the post-PST MARI-procedure. Material and methods All patients who received a MARI-procedure from July 2014 until May 2016 were included. Before the start of PST a PET/CT was performed for axillary staging and the detection of distant metastasis. A radioactive iodine seed was placed in a proven tumour-positive axillary lymph node (MARI-node), after which PST was given according to Dutch national guidelines. At our institute, we have implemented a protocol in which results of the pre-PST PET/CT and the post-PST MARI-procedure determine the type of axillary treatment. Patients with 1-3 positive axillary lymph nodes (ALNs) on PET/CT and a tumour-negative MARI-node receive no further axillary treatment. Patients with ≤3 positive ALNs on PET/CT and a tumour-positive MARI-node receive axillary radiotherapy, as well as patients with &amp;gt;3 positive ALNs on PET/CT and a tumour-negative MARI-node. An ALND is only performed in patients with &amp;gt;3 positive ALNs on PET/CT and a tumour-positive MARI-node. Results In total 168 patients received a PET/CT and a MARI procedure, of whom 43% were hormone receptor positive, 28% triple negative and 29% Her2-positive. One hundred and eight patients (64%) showed ≤ 3 and 60 patients (36%) &amp;gt;3 suspected ALNs on PET/CT before the start of PST. The axillary pathologic complete response was 39%. In 134 patients (80%) an ALND was omitted; of these patients 94 (56%) were treated with axillary radiotherapy and 40 patients (24%) received no further axillary treatment. In 34 patients (20%) an ALND was performed (Table 1). The median number of positive additional nodes at ALND was 5 (range 0-16). During a median follow-up of 6 months there were no local recurrences. Axillary treatmentSuspective ALNs on PET/CTOutcome MARIAxillary Treatment NoneRadiotherapyALND + Radiotherapy≤3Negative40-- Positive-68-&amp;gt;3Negative-26- Positive--34Total409434ALN: axillary lymph nodes; ALND: axillary lymph node dissection; MARI: Marking the Axilla with Radioactive Iodine Seeds Conclusion Combining pre-PST axillary staging with PET/CT and post-PST staging with use of the MARI-procedure results in a reduction of 80% of axillary lymph node dissections in breast cancer patients with clinical node-positive disease. Citation Format: van der Noordaa MEM, Straver M, van Duijnhoven FH, Groen E, Stokkel M, Vrancken Peeters M-JTFD. Selective elimination of axillary surgery after primary systemic treatment in clinically node-positive breast cancer patients by combining PET/CT and the MARI procedure (marking the axilla with radioactive iodine seeds) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-07.