Eighth Edition Research Articles

Invasive Lobular Carcinoma: A Multimodality Imaging Primer.

HomeRadioGraphicsVol. 42, No. 4 PreviousNext Breast ImagingRadiographics FundamentalsInvasive Lobular Carcinoma: A Multimodality Imaging PrimerPaul Manning, Soudabeh Fazeli, Vivian Lim, William A. Ladd, Mohammad Eghtedari, Alice Chong, Rebecca Rakow-Penner, Haydee Ojeda-Fournier Paul Manning, Soudabeh Fazeli, Vivian Lim, William A. Ladd, Mohammad Eghtedari, Alice Chong, Rebecca Rakow-Penner, Haydee Ojeda-Fournier Author AffiliationsFrom the Department of Radiology, Breast Imaging Division, UC San Diego Health, Koman Family Outpatient Pavilion, 9400 Campus Point Dr, La Jolla, CA 92037.Address correspondence to H.O.F. (e-mail: [email protected]).Paul ManningSoudabeh FazeliVivian LimWilliam A. LaddMohammad EghtedariAlice ChongRebecca Rakow-PennerHaydee Ojeda-Fournier Published Online:Jun 10 2022https://doi.org/10.1148/rg.210058MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractInvasive lobular carcinomas have an atypical clinical manifestation and imaging appearance, and mammographic, US, and MRI findings can help radiologists accurately assess tumor size and evaluate for multicentric, multifocal, and bilateral disease.Suggested ReadingsHa SM, Chae EY, Cha JH, Kim HH, Shin HJ, Choi WJ. Breast MR imaging before surgery: outcomes in patients with invasive lobular carcinoma by using propensity score matching. Radiology 2018;287(3):771–777. Link, Google ScholarLopez JK, Bassett LW. Invasive lobular carcinoma of the breast: spectrum of mammographic, US, and MR imaging findings. RadioGraphics 2009;29(1):165–176. Link, Google ScholarWeinstein SP, Orel SG, Heller R, et al. MR imaging of the breast in patients with invasive lobular carcinoma. AJR Am J Roentgenol 2001;176(2):399–406. Crossref, Medline, Google ScholarArticle HistoryReceived: May 20 2021Revision requested: July 2 2021Revision received: Aug 1 2021Accepted: Aug 4 2021Published online: June 10 2022Published in print: July 2022 FiguresReferencesRelatedDetailsAccompanying This ArticleInvasive Lobular Carcinoma: A Multimodality Imaging PrimerJun 10 2022Default Digital Object SeriesRecommended Articles Nipple-sparing Mastectomy: What the Radiologist Should KnowRadioGraphics2022Volume: 42Issue: 2pp. 321-339American Joint Committee on Cancer’s Staging System for Breast Cancer, Eighth Edition: What the Radiologist Needs to KnowRadioGraphics2018Volume: 38Issue: 7pp. 1921-1933Digital Breast Tomosynthesis: Update on Technology, Evidence, and Clinical PracticeRadioGraphics2021Volume: 41Issue: 2pp. 321-337Case 242: Radiation-induced AngiosarcomaRadiology2017Volume: 283Issue: 3pp. 909-916Idiopathic Granulomatous Mastitis: Manifestations at Multimodality Imaging and PitfallsRadioGraphics2018Volume: 38Issue: 2pp. 330-356See More RSNA Education Exhibits Invasive Lobular Carcinoma Multimodality Primer: Pictorial Essay for Residents and FellowsDigital Posters2020Invasive Lobular Carcinoma, the Great Imitator of the Breast: A Practical Multimodality Diagnostic Guide for ResidentsDigital Posters2019Keeping Abreast of Disparities in Screening Mammography: A Primer for Understanding the Needs of Underserved PopulationsDigital Posters2020 RSNA Case Collection Male Breast CancerRSNA Case Collection2021Metastatic Melanoma Presenting as Bilateral Breast MassesRSNA Case Collection2020Locally Advanced Invasive Lobular CarcinomaRSNA Case Collection2022 Vol. 42, No. 4 Slide PresentationAbbreviations Abbreviations: IDC invasive ductal carcinoma ILC invasive lobular carcinoma Metrics Altmetric Score PDF download

Nomograms for Predicting Disease-Free Survival in Patients With Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction Receiving Neoadjuvant Therapy and Radical Surgery.

ObjectiveThis study aimed to develop prognostic prediction models for patients with Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) who received neoadjuvant therapy (neoadjuvant chemoradiotherapy or neoadjuvant chemotherapy) and radical surgery. A baseline nomogram and a post-operative nomogram were constructed before neoadjuvant therapy and after surgery. The predictive performance of the constructed nomograms was internally validated and compared to the TNM staging system.Materials and MethodsA total of 245 patients diagnosed with Siewert type II/III AEG and treated with neoadjuvant therapy followed by radical surgery at The Fourth Hospital of Hebei Medical University between January 2011 and December 2017 were enrolled. The variables before neoadjuvant therapy were defined as baseline factors, while the variables of baseline factors along with the variables of treatment and postoperative pathology were defined as post-operative factors. To construct the corresponding nomograms, independent predictors of baseline and post-operative factors were identified. The C-index and a time-dependent receiver operating characteristic curve were used to evaluate the model’s discrimination ability. The calibration ability of the model was determined by comparing the probability of predicted free-recurrence to the actual free-recurrence. Decision curve analysis (DCA) was used to determine the clinical usefulness of the nomogram.ResultsAmong the baseline factors, age, cT stage, cN stage, Borrmann type, and staging laparoscopy were independent prognostic predictors. In contrast, among the post-operative factors, age, cN stage, staging laparoscopy, ypT stage, clinical response, number of positive lymph nodes, number of negative lymph nodes, laurén classification, and lymphatic, or perineural invasion (VELPI) were independent prognostic predictors. The two nomograms were constructed using the independent predictors of prognosis. The C-indexes for the baseline and post-operative nomograms were 0.690 (95% CI, 0.644-0.736) and 0.817 (95% CI, 0.782-0.853), respectively. The AUCs of the baseline nomogram at 3 and 5 years were both greater than cTNM (73.1 vs 58.8, 76.1 vs 55.7). Similarly, the AUCs of the post-operative nomogram were both greater than ypTNM (85.2 vs 69.1, 88.2 vs 71.3) at 3 and 5 years. The calibration curves indicated that both models had a high degree of calibration ability. By comparing the DCA at 3 and 5 years, we determined that the two nomograms constructed had better clinical utility than the TNM staging system.ConclusionsThe constructed nomograms have a more accurate predictive ability than the eighth edition TNM staging system, which can be useful for treatment selection and follow-up monitoring of patients.

Concomitant Hepatic Artery Resection for Advanced Perihilar Cholangiocarcinoma: A Narrative Review.

Simple SummaryIn the eighth edition of their cancer classification system, the Union for International Cancer Control (UICC) defines contralateral hepatic artery invasion as T4, which is considered unresectable as it is a “locally advanced” tumour. However, in the last decade, several reports on hepatic artery resection (HAR) for perihilar cholangiocarcinoma (PHCC) have been published. The reported five-year survival rate after HAR is 16–38.5%. Alternative procedures for the treatment of HAR have also been reported. In this paper, we review HAR for PHCC, focusing on its history, diagnosis, procedures, and alternative procedures.Perihilar cholangiocarcinoma (PHCC) is one of the most intractable gastrointestinal malignancies. These tumours lie in the core section of the biliary tract. Patients who undergo curative surgery have a 40–50-month median survival time, and a five-year overall survival rate of 35–45%. Therefore, curative intent surgery can lead to long-term survival. PHCC sometimes invades the surrounding tissues, such as the portal vein, hepatic artery, perineural tissues around the hepatic artery, and hepatic parenchyma. Contralateral hepatic artery invasion is classed as T4, which is considered unresectable due to its “locally advanced” nature. Recently, several reports have been published on concomitant hepatic artery resection (HAR) for PHCC. The morbidity and mortality rates in these reports were similar to those non-HAR cases. The five-year survival rate after HAR was 16–38.5%. Alternative procedures for arterial portal shunting and non-vascular reconstruction (HAR) have also been reported. In this paper, we review HAR for PHCC, focusing on its history, diagnosis, procedures, and alternatives. HAR, undertaken by established biliary surgeons in selected patients with PHCC, can be feasible.

A multi-institutional study evaluating and describing atypical parathyroid tumors discovered after parathyroidectomy.

ObjectiveTo describe common intraoperative and pathologic findings of atypical parathyroid tumors (APTs) and evaluate clinical outcomes in patients undergoing parathyroidectomy.MethodsIn this multi‐institutional retrospective case series, data were collected from patients who underwent parathyroidectomy from 2000 to 2018 from three tertiary care institutions. APTs were defined according to the AJCC eighth edition guidelines and retrospective chart review was performed to evaluate the incidence of recurrent laryngeal nerve injury, recurrence of disease, and disease‐specific mortality.ResultsTwenty‐eight patients were identified with a histopathologic diagnosis of atypical tumor. Mean age was 56 years (range, 23–83) and 68% (19/28) were female. All patients had an initial diagnosis of primary hyperparathyroidism with 21% (6/28) exhibiting clinical loss of bone density and 32% (9/28) presenting with nephrolithiasis or renal dysfunction. Intraoperatively, 29% (8/28) required thyroid lobectomy, 29% (8/28) had gross adherence to adjacent structures and 46% (13/28) had RLN adherence. The most common pathologic finding was fibrosis 46% (13/28). Postoperative complications include RLN paresis/paralysis in 14% (4/28) and hungry bone syndrome in 7% (2/28). No patients with a diagnosis of atypical tumor developed recurrent disease, however there was one patient that had persistent disease and hypercalcemia that is being observed. There were 96% (27/28) patients alive at last follow‐up, with one death unrelated to disease.ConclusionDespite the new AJCC categorization of atypical tumors staged as Tis, we observed no recurrence of disease after resection and no disease‐specific mortality. However, patients with atypical tumors may be at increased risk for recurrent laryngeal nerve injury and incomplete resection.

Tumour Size and T-Stage in Pancreatic Cancer Resection Specimens Depend on the Pathology Examination Approach.

Simple SummaryTumour size is considered a key oncological feature, as it reflects the primary tumour burden. In pancreatic cancer, tumour size also constitutes the defining criterion for staging of the primary tumour (T-stage), which provides essential information for patient treatment, risk stratification in clinical trials and cancer registries. While measurement of tumour size in pancreatic cancer resection specimens is considered accurate and reproducible, this has not been formally proven. This study investigated whether, and in how far, various approaches to tumour size measurement result in different tumour sizes and consequently different T-stages. The study findings show that tumour size and T-stage are different in a significant proportion of cases, depending on whether (i) the tumour was measured in one or two planes and (ii) the macroscopic tumour size was corroborated microscopically. Hence, a divergence in pathology practice may limit the comparability of tumour size and T-stage between institutions.In the eighth edition of the TNM classification for pancreatic ductal adenocarcinoma (PDAC), stages T1 to T3 are defined by tumour size, size measurement being deemed objective and accurate. This study investigated whether various, currently used approaches to tumour measurement result in different tumour sizes and differences in T-stage assignment. In a series of 315 resected PDAC, tumour sizes were measured as follows: macroscopically in a single or in two perpendicular planes and with or without microscopic corroboration. Comparison of the resulting tumour sizes showed that both macroscopic measurement in two planes and microscopic corroboration gave significantly different results (p < 0.001). Compared to the most simple approach (macroscopic measurement in one plane), the comprehensive approach (macroscopic measurement in two planes with microscopic corroboration) resulted in a larger tumour size in 263 (83%) cases (mean absolute size difference: 10 mm; mean relative size change: 36%). T-stage assignment differed in 142 (45%) cases between the simple and comprehensive approach and affected 87%, 38% and 48% of the cases deemed to be stage T1, T2 and T3, respectively. In conclusion, tumour size and T-stage are highly approach-dependent. Consensus on an accurate method is required to ensure comparability of these basic data.

The Science of Making Torque from Wind 2022 (TORQUE 2022)

Wind energy continues to make great strides in its contribution to the net CO2-zero targets of countries around the world. Both wind farms onshore and offshore are being built, but scientific challenges lie ahead if their generation is to be both reliable and economic. These challenges relate to better understanding the characteristics of the wind, how the wind inflow translates to loads and performance, and how best to build and operate the wind farms of the future so that their output can best be integrated into a 21st century energy system. Europe continues to be a hub for scientific research in wind energy and the European Academy of Wind Energy (EAWE) was created to bring together the top research institutes active in wind energy to cooperate, share knowledge and promote scientific excellence. As part of this remit, the conference, The Science of Making Torque from Wind (or TORQUE, for short) was inaugurated in 2004 in the beautiful city of Delft. The conference has gone from strength to strength and is probably the largest scientific conference devoted to wind energy in the world. History came full circle and the eighth edition, TORQUE 2020 was due to be held in Delft. Unfortunately, the global pandemic meant that this conference had to be held online, but the TU Delft Wind Energy Institute was given a further opportunity to host the ninth edition, TORQUE 2022, in person.Following the call for three-page abstracts, 435 submissions were made and, after a two-stage peer review process by over 100 reviewers, 300 full papers were accepted for publication in the proceedings. The conference consisted of three plenary sessions, 28 parallel oral sessions and two poster sessions. Oral presenters had 15 minutes to present their work followed by 5 minutes of questions. All poster presenters were allowed a recorded one-minute pitch which could be accessed in advance of the live 90-minute poster sessions.

Prognostic validity of the American joint committee on cancer eighth edition staging system for well-differentiated pancreatic neuroendocrine tumors

The American Joint Committee on Cancer (AJCC) made improvements for staging pancreatic neuroendocrine tumors (pNETs) in its 8th Edition; however, multicenter studies were not included. We collected multicenter datasets (n=1,086, between 2004 and 2018) to validate the value of AJCC 8 and other coexisting staging systems through univariate and multivariate analysis for well-differentiated (G1/G2) pNETs. Compared to other coexisting staging systems, AJCC 7 only included 12 (1.1%) patients with stage III tumors. Patients with European Neuroendocrine Tumor Society (ENETS) stage IIB disease had a higher risk of death than patients with stage IIIA (hazard ratio [HR]: 4.376 vs. 4.322). For the modified ENETS staging system, patients with stage IIB disease had a higher risk of death than patients with stage III (HR: 6.078 vs. 5.341). According to AJCC 8, the proportions of patients with stage I, II, III, and IV were 25.7%, 40.3%, 23.6%, and 10.4%, respectively. As the stage advanced, the median survival time decreased (NA, 144.7, 100.8, 72.0 months, respectively), and the risk of death increased (HR: II=3.145, III=5.925, and IV=8.762). These findings suggest that AJCC 8 had a more reasonable proportional distribution and the risk of death was better correlated with disease stage.

Prognostic impact of tumor-infiltrating lymphocytes and neutrophils in resected non-small cell lung carcinoma

The prognostic impact of tumor-infiltrating lymphocytes (TILs) has been determined in non-small cell lung carcinoma; however, there is no standardized method for counting TILs. In this report, we applied the method proposed by the International Immuno-Oncology Biomarkers Working Group for the assessment of TILs to count the number of tumor-infiltrating neutrophils (TINs). We then analyzed the association between TIL counts, TIN counts, and clinicopathological factors in lung cancer. We retrospectively analyzed a series of 1191 Japanese patients with resected lung adenocarcinoma and squamous cell carcinoma, which were restaged according to the eighth edition of the TNM staging system. Tumors were classified according to the 2015 WHO classification of lung carcinoma. Recurrence-free probability (RFP) and overall survival (OS) were analyzed using the log-rank test and Cox proportional hazard model. Using multivariate analysis for patient outcome in patients with adenocarcinoma, high TIN counts were an independent prognostic factor for worse RFP (hazard ratio [HR]: 1.94, p<0.001) and worse OS (hazard ratio [HR]: 1.75, p=0.006). On the other hand, TIL counts were not related to patient outcome. We have demonstrated that high TINs are unfavorable prognostic markers for resected lung adenocarcinoma. In resected lung squamous cell carcinoma, TIL and TIN counts were not related to patient prognosis. It has been suggested that the immune response to cancer cells may differ depending on the histological type. An understanding of how neutrophils are programmed to perform protumor activities is necessary for the future design of targeted immunotherapies.

High-risk Pathologic Features Based on Presenting Findings in Advanced Intraocular Retinoblastoma: A Multicenter, International Data-Sharing American Joint Committee on Cancer Study

Purpose:To determine the value of clinical features for advanced intraocular retinoblastoma as defined by the eighth edition of the American Joint Committee on Cancer (AJCC) cT3 category and AJCC Ophthalmic Oncology Task Force (OOTF) Size Groups to predict the high-risk pathologic features.Design:International, multicenter, registry-based retrospective case series.Participants:Eighteen ophthalmic oncology centers from 13 countries over 6 continents shared evaluations of 942 eyes enucleated as primary treatment for AJCC cT3 and, for comparison, cT2 retinoblastoma.Methods:International, multicenter, registry-based data were pooled from patients enrolled between 2001 and 2013. High-risk pathologic features were defined as AJCC categories pT3 and pT4. In addition, AJCC OOTF Size Groups were defined as follows: (1) less than half, (2) more than half but less than two thirds, (3) more than two thirds of globe volume involved, and (4) diffuse infiltrating retinoblastoma.Main Outcome Measures:Statistical risk of high-risk pathologic features corresponding to AJCC cT3 subcategories and AJCC OOTF Size Groups.Results:Of 942 retinoblastoma eyes treated by primary enucleation, 282 (30%) showed high-risk pathologic features. Both cT subcategories and AJCC OOTF Size Groups (P < 0.001 for both) were associated with high-risk pathologic features. On logistic regression analysis, cT3c (iris neovascularization with glaucoma), cT3d (intraocular hemorrhage), and cT3e (aseptic orbital cellulitis) were predictive factors for high-risk pathologic features when compared with cT2a with an odds ratio of 2.3 (P = 0.002), 2.5 (P = 0.002), and 3.3 (P = 0.019), respectively. Size Group 3 (more than two-thirds globe volume) and 4 (diffuse infiltrative retinoblastoma) were the best predictive factors with an odds ratio of 3.3 and 4.1 (P < 0.001 for both), respectively, for high-risk pathologic features when compared with Size Groups 1 (i.e., < 50% of globe volume).Conclusions:The AJCC retinoblastoma staging clinical cT3c–e subcategories (glaucoma, intraocular hemorrhage, and aseptic orbital cellulitis, respectively) as well as the AJCC OOTF Size Groups 3 (tumor more than two thirds of globe volume) and 4 (diffuse infiltrative retinoblastoma) both allowed stratification of clinical risk factors that can be used to predict the presence of high-risk pathologic features and thus facilitate treatment decisions.

Significance of neoadjuvant downstaging in gastric adenocarcinoma

BackgroundNeoadjuvant chemotherapy is established in the treatment of gastric adenocarcinoma. Histopathological regression may have important prognostic implications. There are little data comparing clinical outcomes of patients with gastric adenocarcinoma that received neoadjuvant treatment and those neoadjuvant naive. The aim of this study is to determine the impact of neoadjuvant chemotherapy upon prognosis of patients being treated for gastric adenocarcinoma. MethodsConsecutive patients with gastric cancer from a single center between 2007 and 2017 were evaluated. Patients were treated with either a subtotal or total gastrectomy with D2 lymphadenectomy. Stage-by-stage comparison of the extent of pathological downstaging was conducted for patients who received neoadjuvant treatment (ypTNM) and those who did not (pTNM) using the TNM eighth edition. ResultsOverall, 384 patients underwent gastrectomy, 141 patients received neoadjuvant chemotherapy, and 86 patients (58.1%) were downstaged. Downstaged patients had improved overall survival compared to patients who did not respond to neoadjuvant chemotherapy (not reported vs 66 months, P < .001). Downstaging by >3 stages was the strongest independent predictor of overall survival (hazard ratio: 0.17; 95% confidence interval 0.062–0.44). Overall survival was significantly better among patients in the ypTNM groups when a stage-by-stage comparison was performed with the pTNM group. ConclusionPathological stage is a more accurate predictor of prognosis compared clinical stage with downstaged patients benefiting from lower recurrence rates and improved overall survival. Patients downstaged due to neoadjuvant chemotherapy may potentially have more favorable clinical outcomes compared to stage-matched patients who did not receive this.

Detecting Interval Distant Metastases With 18F-FDG PET/CT After Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer.

PurposePatients with esophageal cancer can develop distant metastases between the start of neoadjuvant chemoradiotherapy (nCRT) and planned surgery (ie, interval distant metastases). 18F-FDG PET/CT restaging after nCRT detects interval distant metastases in ~8% of patients. This study aimed to identify patients for whom 18F-FDG PET/CT restaging after nCRT could be omitted using an existing prediction model predicting for interval distant metastases or by using clinical stage groups.Patients and MethodsPatients with locally advanced esophageal cancer who underwent baseline and restaging 18F-FDG PET/CT, nCRT, and were planned for esophagectomy between 2017 and 2021 were eligible for inclusion in this retrospective study. The primary outcome was the existing model’s external performance (ie, discrimination and calibration) for predicting interval distant metastases. The existing model predictors included tumor length, cN status, squamous cell carcinoma histology, and baseline SUVmax. The secondary outcome determined the clinical stage groups (AJCC/UICC eighth edition) for adenocarcinoma and squamous cell carcinoma for which the incidence of interval distant metastases was <10%.ResultsIn total, 127 patients were included, of whom 17 patients developed interval distant metastases (13%; 95% confidence interval [CI], 8%–21%) and 9 patients were deemed to have false-positive lesions on 18F-FDG PET/CT (7%; 95% CI, 2%–11%). Applying the existing model to this cohort yielded a discriminatory c-statistic of 0.56 (95% CI, 0.40–0.72). The calibration of the existing model was poor (ie, mostly underestimating the actual risk). The incidence of true-positive versus false-positive interval distant metastases for patients with clinical stage II disease was 5% versus 0%; clinical stage III, 14% versus 8%; and clinical stage IVa, 22% versus 9%.ConclusionsThe existing prediction model cannot reliably identify patients at risk for developing interval distant metastases after nCRT for esophageal cancer. Omission of 18F-FDG PET/CT restaging after nCRT could be considered in patients with clinical stage II esophageal cancer.

Distant metastasis in medullary thyroid carcinoma: Clinical outcomes and implications of T stage.

The eighth editionof the American Joint Committee on Cancer tumour, node, and metastasis staging system did not take T stage into consideration when evaluating Stage IV C medullary thyroid carcinoma (MTC) patients. The aim of this study is to investigate the clinical outcomes and implications of T stage in this population. Eligible patients from the Surveillance, Epidemiology, and End Resultsdatabase and the Department of Thyroid Surgery in West China Hospital of Sichuan University and who were diagnosed with Stage IV C MTC were included in this study. The overall survival (OS), the cancer-specific survival (CSS), and the precise cause of MTC-induced death were analysed. The potential risk factors, including the T stage, in the OS and CSS were evaluated by univariate and multivariate Cox regression models. This retrospective study enroled 204 Stage IV C MTC patients. The 5-and 10-year OS rates were 31.8% and 17.1%, respectively, and the 5-and 10-year CSS rates were 40.4% and 22.5%, respectively. More importantly, the rates of MTC-induced death between primary or distant metastatic lesions in Stage IV C MTC patients were comparable in our institution. Additionally, the univariate and multivariate analyses demonstrated that the presence of an advanced T stage was an independent prognostic factor for both the OS (T4 vs. T1-T3, hazard ratio [HR]: 1.714, 95% confidence interval [CI]: 1.175-2.500, p = .005) and the CSS (T4 vs. T1-T3, HR: 1.848, 95% CI: 1.229-2.780, p = .003). To achieve a better risk stratification, further classification of Stage IV C MTC patients by the T stage may be preferable.

Clinical outcomes of definitive radiotherapy for patients with cT1aN0M0 esophageal cancer unsuitable for endoscopic resection and surgery.

Studies on the clinical outcomes of radiotherapy for clinical (c)T1aN0M0 (UICC-TNM Classification, Eighth Edition) esophageal cancer (EC) are limited. Therefore, this retrospective study aimed to clarify the clinical outcomes of definitive radiotherapy (RT) or chemoradiotherapy (CRT) for cT1aN0M0 EC unsuitable for endoscopic resection and surgery. Patients with cT1aN0M0 esophageal squamous cell carcinoma who underwent definitive RT or CRT between January 2009 and December 2020 were retrospectively reviewed. The initial response, toxicities, survival rates, recurrence patterns, and salvage treatments of the patients were evaluated. Initial response was measured using the Response Evaluation Criteria in Solid Tumors guideline. Toxicity was assessed and documented following the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Survival rates from the date of initiation of treatment were measured using the Kaplan-Meier method. Twenty patients treated with definitive RT or CRT were included in the study. The median follow-up duration was 55 months (range, 13-131 months). All patients achieved complete response to the initial treatment. Grade 3 acute toxicities observed esophagitis (10%), pneumonitis (5%), and leukopenia (5%). Late toxicities higher than grade 3 were not observed. The 1-, 3-, and 5-year overall and disease-specific survival rates were 100% and 100%, 83% and 100%, and 67% and 100%, respectively. No treatment-related deaths occurred. Among the 20 patients, 6 showed local recurrence and 2 showed metachronous recurrence. Seven patients underwent salvage endoscopic submucosal dissection (ESD), and one underwent argon plasma coagulation treatment. After the endoscopic treatment, no recurrences were observed. Definitive RT or CRT was considered an alternative initial treatment for patients with cT1aN0M0 EC who were unsuitable for endoscopic resection and surgery.

Thiruvasaka Sivapurana - Comparison of Texts

Panniruthirumuraigal of the Tamil Literature Series, which is revered as the chief textbook of the Vedic religion, are among the most easily explained texts on Saiva samayam in the community. The benefactors of the Panniruthirumuraigal are 27 benefactors. The first three of the twelve tirumuras were performed by Thirunana Samandar, the fourth, fifth and sixth tirumuras by Thirunavukkara, the seventh tirumura by Sundaramoorthy swamis, the eighth tirumura by nine arulas, the tenth tirumura by Tirumoolar and the eleventh tirumura by Sivan with twelve arulas. Twelfth tirumura by Sekizhar swami. Thiruvasakam is the eighth edition of the Panniruthirumuraigal. Many people have written texts for this book from time to time. This article examine variations in the the first part of Sivapuranam out of 51 parts in Thiruvasagam. The texts of the Thiruvasagam are numerous. In these discourses only the first part of the Sivapuranam of the three texts titled Thiruvasaka Urai Dharmapura Adinam’s Thiruvasaka Urai, written by Dantapani Desikar and published by Dantapani Desikar, compiled by the Srikali Thandavaraya Swamis and published by Thiruvaduthurai Adinam, is compared.The structure of this article is a comparison of texts of the Shiva Purana 1. General structure of Sivapurana, 2.System of Sivapurana texts, 3.Comparison of texts.

Outcomes of pleurectomy decortication in patients with biphasic mesothelioma

ObjectiveThere are limited small, single-institution observational studies on the role of surgery in patients with biphasic mesothelioma. Herein we report a series of 147 consecutive patients with biphasic mesothelioma treated over 11 years in a high-volume single institution with intended pleurectomy decortication (PDC). MethodsAll patients with biphasic mesothelioma from 2007 to 2017 who underwent PDC in our institution were included and clinical, pathologic, and surgical information was retrieved. Kaplan–Meier estimators and log rank test were used to compare the overall survival, and Cox regression models were used to analyzed prognostic factors. ResultsThere were 117 men (80%), 99 right-sided operations (67%), and median age was 70 (range, 36-86) years. Neoadjuvant therapy was given to 36 (24.5%) and 108 (73.5%) received intraoperative heated chemotherapy. Macroscopic complete resection was achieved in 126 (86%). Tumors were assigned to stages IA (23; 18.8%), IB (60; 47.5%) II (15; 11.5%), IIIA (17; 13.1%), and IIIB (11; 9%) according to the eighth edition of the tumor-node-metastasis classification of malignant tumors. The 30- and 90-day mortality were 1.3% and 6.1%, respectively. The median overall survival in the macroscopic complete resection group was 16.7 months and 24 months in patients younger than 70 years. In a univariate analysis, factors that were associated with patient overall survival included age (P = .001), preoperative percentage forced expiratory volume in 1 second (P = .019), and adjuvant therapy (P < .001). No correlation was found between sex, neoadjuvant therapy, and nodal status to overall survival. ConclusionsIn selected patients with biphasic mesothelioma and good prognostic factors prolonged survival after PDC is expected.

Expert Consensus on the Use of Prognostic Gene Expression Profiling Tests for the Management of Cutaneous Melanoma: Consensus from the Skin Cancer Prevention Working Group.

BackgroundPrognostic assessment of cutaneous melanoma relies on historical, clinicopathological, and phenotypic risk factors according to American Joint Committee on Cancer(AJCC) and National Comprehensive Cancer Network (NCCN) guidelines but may not account for a patient’s individual additional genetic risk factors.ObjectiveTo review the available literature regarding commercially available gene expression profile (GEP) tests and their use in the management of cutaneous melanoma.MethodsA literature search was conducted for original, English-language studies or meta-analyses published between 2010 and 2021 on commercially available GEP tests in cutaneous melanoma prognosis, clinical decision-making regarding sentinel lymph node biopsy, and real-world efficacy. After the literature review, the Skin Cancer Prevention Working Group, an expert panel of dermatologists with specialized training in melanoma and non-melanoma skin cancer diagnosis and management, utilized a modified Delphi technique to develop consensus statements regarding prognostic gene expression profile tests. Statements were only adopted with a supermajority vote of > 80%.ResultsThe initial search identified 1064 studies/meta-analyses that met the search criteria. Of these, we included 21 original articles and meta-analyses that studied the 31-GEP test (DecisionDx-Melanoma; Castle Biosciences, Inc.), five original articles that studied the 11-GEP test (Melagenix; NeraCare GmbH), and four original articles that studied the 8-GEP test with clinicopathological factors (Merlin; 8-GEP + CP; SkylineDx B.V.) in this review. Six statements received supermajority approval and were adopted by the panel.ConclusionGEP tests provide additional, reproducible information for dermatologists to consider within the larger framework of the eighth edition of the AJCC and NCCN cutaneous melanoma guidelines when counseling regarding prognosis and when considering a sentinel lymph node biopsy.

External validation of the eighth edition of the TNM classification for lung cancer in small cell lung cancer

ObjectivesThe newly released eighth edition of the American Joint Committee on Cancer TNM staging system for lung cancer seeks to improve prognostic accuracy but lacks external validation for small cell lung cancer (SCLC). Moreover, previous studies posed a few questions concerning survival differences for patients with specific site N3 node involvement or single-site metastasis (SSM) in different distant organs. The aim of this study was to validate the eighth edition of the TNM classification for SCLC in an independent multi-institutional cohort from China and answer the questions raised by the previous research. MethodsPatients with SCLC from four Chinese cancer centers between 2009 and 2019 were reclassified according to the seventh and eighth edition of the TNM classification. Survival was estimated using the Kaplan-Meier method. Comparisons between adjacent categories and stage groups were performed using Cox proportional hazard regression. R2 statistics were calculated to evaluate the discriminating performance of editions. ResultsOf 3384 enrolled cases, 3358 had clinical stage, 537 had pathological stage, and 511 had both. Progressive deterioration of survival was observed with advancing of TNM categories and stages both in the seventh and the eighth edition. The eighth edition stages had a higher R2 statistic than the seventh edition (0.207 versus 0.197). Newly defined categories M1b and M1c and stages IIIC, IVA and IVB in the eighth edition discriminated groups with significantly different prognosis. Patients with N3 contralateral supraclavicular nodes had a significantly worse prognosis than those without (p = 0.032). For patients with single-site metastasis, liver involvement showed a worse prognosis compared to brain involvement (p = 0.030). ConclusionsOur study provided an external validation of the eighth edition of the TNM classification for lung cancer in Chinese patients with SCLC, and confirmed its improved prognostic accuracy compared with the seventh edition. Patients with N3 and M1b might represent heterogeneous populations that warrant further research.

Prediction of Poor Outcome for Cutaneous Squamous Cell Carcinoma of the Head and Neck Comparing Classification Systems: A Competing Risk Analysis

The most commonly used staging system for cutaneous squamous cell carcinoma (cSCC) of the head and neck is the American Joint Committee on Cancer eighth edition (AJCC8) system (NVDV, 2018; Stratigos et al., 2020). This system is predominantly based on tumor size in lower stages and extradermal or perineural invasion in higher stages. An alternative classification system for cSCC on all locations is the Brigham and Women’s Hospital (BWH) classification system (Jambusaria-Pahlajani et al., 2013). This system is based on high-risk factors derived from tumor characteristics.

PET/CT Prediction of Head and Neck Melanoma Nodal Metastases

<h3>Purpose/Objective(s)</h3> Lymph node dissection is an important oncologic treatment for many head and neck melanomas. Over time, surgeons have narrowed the basins covered by neck dissections based on the underlying disease. In melanoma, there is a need for diagnostic modalities that can effectively predict locoregional metastasis to tailor the extent of neck dissection. PET-CT is an imaging modality often employed in oncologic staging, but definitive data are lacking on basin-specific predictive capabilities of PET-CT for head and neck melanoma. The objective of this study is to determine the predictive value of PET-CT for detecting melanoma metastasis to head and neck lymph node basins. <h3>Materials/Methods</h3> This is a retrospective case series of adults who underwent lymphadenectomy for melanoma metastasis to the neck at a single tertiary academic medical center from 2000-2018. Exclusion criteria included: prior head and neck radiation or lymphadenectomy except for sentinel lymph node biopsies, lack of preoperative PET-CT images, incomplete pathology records, or less than one year of follow-up. Demographic data, clinical and pathologic staging, surgical details, and post-operative complications were collected. The eighth edition of the American Joint Committee on Cancer staging system was used. PET-CT was performed according to institutional protocol, and all PET-CT images were re-reviewed by a board-certified nuclear medicine physician blinded to pathology results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for predicting nodal metastasis were calculated by comparing the results of the PET-CT to final pathology, which was considered the gold standard for this study. <h3>Results</h3> 108 subjects were included, 2 of whom had bilateral neck dissections, for a total of 110 neck dissections. Median follow-up was 2.0 years. The average age (SD) was 63 (14), 74% were male, and 93% identified as Caucasian. The most common primary sites were the face (n=30), scalp (n=29), and neck (n=23). The majority of tumors were classified as T2-T4 (77%) and as either cN1 (n=55) or cN0 (n=26) disease. The most frequent surgical complications included seroma (n=7) and hematoma (n=5). There were no reports of gross nerve injury or permanent neuropathies. When compared to final pathology, preoperative PET-CT had a 90% sensitivity (CI 79.5%-95.6%), 92% specificity (CI 80.7 %-97.4%), 93.1% PPV (CI 83.1%-97.8%), and 88.5% NPV (CI 76.7%-95%). In 86.5% of neck dissections, there was concordance on nodal basin metastases between PET-CT and final surgical pathology. <h3>Conclusion</h3> PET-CT demonstrates acceptable predictability of locoregional head and neck melanoma metastases with nodal basin concordance. This information could be incorporated into shared decision making regarding the extent of regional lymph node dissection as treatment paradigms shift.

American Joint Committee on Cancer Tumor Staging System Predicts the Outcome and Metastasis Pattern in Conjunctival Melanoma

To assess the predictive value of the tumor staging system in the AJCC Cancer Staging Manual, Eighth Edition, and histologic features for outcomes and metastasis patterns in conjunctival melanoma (CM). Retrospective, single-center cohort study. Eighty-three patients with CM were treated at Shanghai Ninth People's Hospital between 2000 and2021. We reviewed the clinical and histologic parameters and used Kaplan-Meier survival curves and Cox proportional hazards regression models for risk factor analyses. Time to nodal/distant metastasis, disease-specific survival, metastatic pattern, and metastatic site. At presentation, 5 patients (6%) had clinical tumor (cT)1 disease, 34 patients (41%) had cT2 disease, and 44 patients (53%) had cT3 disease. Four patients (5%) had nodal metastasis (N1), and none had distant metastasis (M1). During follow-up, 12 patients (14%) developed nodal metastasis, 29 patients (35%) developed distant metastasis, and 26 patients (31%) died of disease. The brain, liver, and lung were common distant metastasis sites. Higher cT category was associated with increased risks of distant metastasis (P < 0.001) and disease-specific death (P= 0.002). The separate analysis of primary and recurrent tumors at presentation showed that the patients with cT3 tumors had a higher risk of distant metastasis than those with cT2 tumors. Greater tumor thickness, ulceration, and the presence of regression were correlated with distant metastasis. Previously unreported mutations were detected in the tumor suppressor genes FAT atypical cadherin 4 (FAT4) and spleen associated tyrosine kinase (SYK). Among the 29 patients who developed distant metastasis, we analyzed 2 patterns of metastasis: Eleven patients (38%) developed nodal metastasis before distant metastasis, and 18 patients (62%) developed distant metastasis without previously known nodal metastasis. The patients with cT3 tumors were more likely to follow the latter metastasis pattern (P= 0.02). Conjunctival melanoma presented with mostly advanced stages and high rates of distant metastasis in the current Chinese cohort. This study confirmed the prognostic value of the tumor staging system in the AJCC Cancer Staging Manual, Eighth Edition, for Chinese patients. Histologic features, such as tumor thickness and ulceration, should be emphasized when assessing prognosis and guiding the treatment of CM.