Evidence Of Lymph Node Metastasis Research Articles

Abstract P2-08-06: Defining transcriptomic profiles of breast cancer with early lymph node metastases: A FLEX database sub-study

Abstract Introduction: Early lymph node (LN) metastasis often precedes systemic metastasis and corresponds with a 35% decrease in 10-year survival compared to patients without LN metastasis. Understanding biologic pathways involved in early LN metastasis could identify promising drug targets for early-stage breast cancer (EBC) treatment. While tumor size modestly correlates with the probability of clinical or occult axillary metastases, small T1 tumors are often found to have LN metastases, while many large T3 tumors are often LN negative. We compared large tumors without evidence of LN metastasis (pT2-3N0) and small tumors with LN metastasis (pT1N1-3) by whole transcriptome analysis to elucidate molecular biological differences associated with the presence or absence of early LN metastasis at diagnosis. Methods: The FLEX study enrolls patients with EBC who undergo standard of care MammaPrint (MP) and BluePrint (BP) testing, and consent to clinically annotated full transcriptome data collection. MP classifies tumors as having High Risk (HR) or Low Risk (LR) of distant recurrence. MP combined with BP subtype tumors as either Luminal A-type (MP LR; 56.8%), Luminal B-type (MP HR; 36.4%), HER2-type (1.5%), or Basal-type (5.3%). In our primary comparison, 355 patients had small, LN-positive tumors (pT1N1-3), and 235 had large, LN-negative tumors (pT2-3N0). Control groups consisted of small, LN-negative (pT1N0; n=1384) and large, LN-positive tumors (pT2-3N1-3; n=375). R package ‘limma’ was used for quantile normalization and differential gene expression (DGE) analyses. Differentially expressed genes (DEGs) with a false discovery rate < 0.05 and fold change > 1.4 were considered significant for this exploratory analysis. Gene set enrichment analysis (GSEA) was performed using the Hallmark gene sets (MSigDB). Results: Principal component analysis of each sample’s transcriptional profile revealed more gene profile differences between MP risk and BP subtype than by pathological stage. Overall, DGE analysis comparing pT2-3N0 to pT1N1-3 identified 30 DEGs; of which MUCL1 had a > 2-fold decrease. Within MP LR and BP Luminal A-type tumors, no DEGs were identified comparing pT2-3N0 to pT1N1-3. HR tumors had 73 DEGs (33 upregulated and 40 downregulated); two of 40 downregulated genes, including MUCL1, had > 2-fold change. Within Luminal B tumors, 34 DEGs were identified when comparing pT2-3N0 with pT1N1-3, although none had > 2-fold change. Basal and HER2 tumors were not analyzed due to small numbers. GSEA showed upregulated proliferation and oxidative phosphorylation pathways, and downregulated epithelial to mesenchymal transition (EMT) and immune signatures in pT2-3N0 relative to pT1N1-3 tumors overall, within HR, and Luminal B tumors. Conclusion: This study provides a foundation for understanding the mechanisms that promote LN metastasis. Studies have previously correlated LN metastasis with EMT, immune function, and gene overexpression (BCL2L1, AURKA, CDKN2A, MCL1, MYC). While we did not find significant differences in these genes, our results indicated similar differentially regulated pathways. Overall, we found most biological differences within MP HR and Luminal B tumors. Proliferation-related pathways were upregulated and EMT and immune-related pathways were downregulated in pT2-3N0 tumors compared with pT1N1-3 tumors, suggesting these pathways distinguish small, node-positive tumors from large, node-negative tumors and are involved in early LN metastasis. Interestingly, MUCL1 which has been reported to promote migration and invasion in breast cancer, was consistently downregulated in pT2-3N0 relative to pT1N1-3 tumors. Future studies will investigate antineoplastic therapies for EBC that modulate these dysregulated pathways to reduce early LN metastasis and subsequent systemic metastasis. Citation Format: Nibash Budhathoki, Faisal Fa'ak, Nina D'Abreo, Shubhada Dhage, Phyu Phyu Soe, Dennis Holmes, Josien Haan, Shiyu Wang, Patricia Dauer, Andrea Menicucci, William Audeh, Douglas K Marks. Defining transcriptomic profiles of breast cancer with early lymph node metastases: A FLEX database sub-study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-08-06.

Patient with gastric cancer who underwent distal gastrectomy after treatment of COVID-19 infection diagnosed by preoperative PCR screening

BackgroundBecause of the coronavirus disease 2019 (COVID-19) pandemic, preoperative screenings for COVID-19 infection are often performed in many institutions. Some patients are diagnosed with COVID-19 infection by antigen tests or polymerase chain reaction (PCR) testing for COVID-19, even if they have no symptoms, such as fever or respiratory symptoms. We herein describe a patient with gastric cancer who underwent distal gastrectomy 6 weeks after recovering from COVID-19 infection diagnosed by preoperative PCR.Case presentationAn 86-year-old man was transferred to our hospital because of hematemesis and melena. A hemorrhagic gastric ulcer was found in the lesser curvature of the antrum by emergency endoscopy. Endoscopic hemostasis was performed, and he was discharged after recovery. A tumor-like lesion in the lesser curvature of the antrum was found on repeat endoscopy and was diagnosed as well-differentiated adenocarcinoma by biopsy. There was no evidence of lymph node metastasis or distant metastasis; therefore, we planned radical surgery. However, he was diagnosed with COVID-19 infection by preoperative PCR screening. Although he had no symptoms, such as fever or respiratory symptoms, he was hospitalized because of his advanced age. He was discharged 10 days after admission, and repeat COVID-19 PCR was negative. We planned radical surgery for the stomach tumor 6 weeks after recovery from the COVID-19 infection. A PCR-negative COVID-19 status was confirmed again before hospitalization. Open distal gastrectomy with Billroth I reconstruction was performed. We avoided ultrasonic scalpels and used a Crystal Vision 450D surgical smoke evacuator (I.C. Medical, Inc., Phoenix, AZ, USA) to reduce intraoperative surgical smoke. The postoperative course was uneventful.ConclusionBecause of the COVID-19 pandemic, some patients are diagnosed with COVID-19 infection by preoperative antigen tests or PCR, even if they have no symptoms. If possible, elective surgery should be performed 4 to 6 weeks after recovery from COVID-19 infection to maximize safety. Moreover, surgeons must consider intraoperative surgical smoke.

Thyroid Lobectomy for T1 Papillary Thyroid Carcinoma in Pediatric Patients

The current recommendation for pediatric patients with papillary thyroid cancer (PTC) is a total thyroidectomy. This recommendation applies to all stages of PTC, including papillary thyroid microcarcinoma (≤1 cm, T1a) tumors. To evaluate the characteristics of American Joint Committee on Cancer T1 PTC tumors in a large pediatric population and to identify a subgroup of patients who may benefit from a thyroid lobectomy instead of a total thyroidectomy. This retrospective cohort study was conducted from January 1, 2009, to May 31, 2020. The study took place at a tertiary care medical center and included 102 patients who were surgically treated for T1 PTC: 52 with stage T1a (≤1 cm) tumors and 50 with stage T1b (>1 cm but ≤2 cm) tumors. Primary outcomes included the presence of bilateral disease and lymph node metastasis. A total of 102 patients (mean age, 15.3 years [range, 9.7-18.9 years]; 84 girls [82.4%]) were included in the analysis. Among 52 patients with T1a tumors, 10 (19.2%) had bilateral disease, and 15 (28.8%) had central neck lymph node (N1a) metastasis. Among 50 patients with T1b tumors, 10 (20%) had bilateral and 13 (26%) had N1a disease. Of those with T1a, unilateral multifocality was associated with bilateral disease (odds ratio [OR], 2.1; 95% CI, 1.3-3.4) and N1a disease (OR, 5.1; 95% CI, 1.5-17.6). Both N1a disease (OR, 20.0; 95% CI, 3.5-115.0) and ≥4 positive lymph nodes (OR, 8.6; 95% CI, 1.2-60.9) were associated with bilateral disease. In patients with no pathologic evidence of lymph node metastasis (N0), there was a 95% rate of unilateral PTC. In patients with T1b tumors, unilateral multifocality was also associated with bilateral disease (OR, 1.8; 95% CI, 1.3-2.7). Patients with T1b tumors had an increased risk of lateral (N1b) neck lymph node metastasis when compared with those with T1a tumors (OR, 3.7; 95% CI, 1.0-14.5). The findings of this cohort study suggest that, in patients with unifocal T1a PTC without clinically evident nodal disease on preoperative ultrasonography, a thyroid lobectomy and central neck dissection may be considered. If there is no evidence of unilateral multifocality or if there are fewer than 4 positive lymph nodes on postoperative pathology, then close observation may be considered. These findings have substantial clinical implications and may result in practice changes regarding the extent of thyroid surgery on low-stage pediatric PTC.

Early HER2-positive breast cancer arising from a fibroadenoma: a case report

ABSTRACTBreast cancer arising from fibroadenoma (FA) is rare, in which almost all reported cases are human epidermal growth factor receptor 2 (HER2)-negative. This is the first report to describe a case of HER2-positive breast cancer arising from FA that was treated with chemotherapy plus anti-HER2 therapy. In this early case, upfront surgery outcomes guided the selection of appropriate systemic therapy. A 31-year-old woman previously diagnosed with FA experienced tumor growth. Core needle biopsy and imaging studies confirmed a diagnosis of stage IIA HER2-positive invasive ductal carcinoma (IDC) with no evidence of lymph node metastasis (cT2N0M0). Breast-conserving surgery was performed. Pathological diagnosis revealed stage IA IDC with a predominant intraductal component (pT1aN0M0), arising from FA. In conclusion, we encountered an extremely rare case of HER2-positive breast cancer arising from FA in which pathological infiltration was difficult to predict based on preoperative imaging.

A prospective randomized controlled trial to assess the efficacy and safety of prophylactic central compartment lymph node dissection in papillary thyroid carcinoma

BackgroundThe efficacy of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma remains controversial. We performed a randomized controlled trial to evaluate the efficacy and safety of prophylactic central compartment lymph node dissection in patients with papillary thyroid carcinoma. MethodsIn this parallel-group randomized controlled trial, we assessed 101 patients aged 20 to 70 years with small/noninvasive papillary thyroid carcinoma and no clinical metastases or history of cervical surgery/radiation exposure. Randomization ran from April 2015 to November 2017. Data were collected between April 2015 and October 2020. Of the 101 enrolled patients, 50 underwent total thyroidectomy (TTx group) and 51 underwent total thyroidectomy as well as prophylactic central compartment lymph node dissection (TTx+pCND group). Surgical completeness, local recurrence, successful ablation, postoperative complication, and papillary thyroid carcinoma upstaging were compared between the 2 groups. ResultsNo patient showed structural recurrence after 46.6 ± 9.1 months of follow-up. Both groups had similar rates of surgical completeness and successful ablation. There was no difference in the incidence of complications. More patients were upstaged to pN1a in the TTx+pCND group compared to those in the TTx group (P < .05). ConclusionsProphylactic central compartment lymph node dissection detected more lymph node metastases but did not affect recurrence. The 2 groups showed similar outcomes with regard to surgical completeness, successful ablation, and complications. In conclusion, for small/noninvasive papillary thyroid carcinoma without clinical evidence of lymph node metastases, prophylactic central compartment lymph node dissection may not be required if total thyroidectomy is planned.

Benefits and harms of hemithyroidectomy, total or near-total thyroidectomy in 1-4 cm differentiated thyroid cancer.

For 1-4cm differentiated thyroid cancer (DTC), current ATA guideline recommended hemithyroidectomy (HT) as an acceptable alternative initial procedure to total or near-total thyroidectomy (TT). The aim of this study was to evaluate benefits and harms of HT, TT in 1-4cm DTC. Retrospective cohort study. DTC patients aged 18 years or older who underwent initial thyroidectomyin a tertiary medical centre were included from January 2008 to July 2018. The structural persistent/recurrent disease, reoperation rates and surgicalcomplications were compared using Cox proportional regression and logistic regression. Propensity score matching was performed to adjust for related clinicopathological variables. Among 1824 DTC patients, 795 patients sized 1-4cm were included. A total of 286 patients underwent HT and 509 patients underwent TT. In the matched analysis, no significant difference in disease-free survival (DFS) between HT and TT was observed during the median follow-up period of 56.5 months (hazard ratio [HR] 0.86; 95% CI, 0.37-2.00; p=.733). The difference in DFS between two groups was consistent regardless of age, sex, tumour size, follow-up duration. Meanwhile, HT was associated with a decreased risk of surgicalcomplications (odds ratio [OR] 0.47, 95% CI 0.31-0.71, p<.001), as well as lower proportion of levothyroxine replacement (p=.007). Two cases in HT group received reoperation. Further multivariate analysis showed surgical procedure was not associated with structural persistence/recurrence (HR 0.68; 95%CI, 0.29-1.58, p=.367). For patients with 1-4cm DTC without clinical evidence of lymph node metastasis or extrathyroidal extension, HT was associated with lower risk of surgical complications than TT while provided similar benefits as TT.

Robotic Subtotal Gastrectomy with Small Remnant Stomach for Gastric Cancer in the Upper Stomach

BackgroundRobotic subtotal gastrectomy (RsTG) with a small remnant stomach for treatment of gastric cancer (GC) in the upper stomach may have advantages over robotic TG (RTG). These may affect postoperative complications and postoperative nutritional status. MethodsThis is a single-center retrospective study of 46 consecutive patients with GC who underwent RsTG (n = 10) and RTG (n = 36). The indication for RsTG included tumor located in the upper body of the stomach, in which the distance between the upper edge of the tumor and the junction was 2 cm or more and less than 5 cm, and no clinical evidence of lymph node metastasis. ResultsOperation time was significantly longer (384 min) and intraoperative blood loss was significantly larger (38 ml) in the RTG group than in the RsTG group (299.5 min, P = 0.021, and 25 ml P = 0.002). Two patients (5.6%) in the RTG group had complications, while no postoperative complications of higher than grade II were observed in the RsTG group. Serum albumin levels at 3 months after surgery were significantly higher in the RsTG group (3.85 g/dl) than in the RTG group (3.2 g/dl, P = 0.001). Postoperative recovery of bodyweight at 6 months after surgery was significantly better in the RsTG group (91.3%) than in the RTG group (84.25%, P = 0.001). ConclusionRsTG for treatment of patients with GC in the upper body of the stomach is safe and feasible, and may enable improved postoperative nutritional status compared with RTG.

Isolated brachioradialis metastasis of gastric adenocarcinoma after R0 resection

BackgroundGastric cancer is the fifth most common cancer worldwide, with an incidence of 6.72 per 100,000 people. Thirty-two percent of gastric cancer patients will live 5 years after diagnosis. Single-site metastasis is noted in 26% of patients with gastric cancer, most commonly in the liver (48%), peritoneum (32%), lung (15%), and bone (12%). Here, a case is presented in which a single skeletal muscle metastasis appeared after appropriate resection and treatment.Case presentationA 63-year-old man underwent neoadjuvant chemotherapy and a multivisceral en bloc R0 resection. Final pathology showed no evidence of lymph node metastasis with 31 negative lymph nodes. Four months postoperatively, the patient was found to have a rapidly growing biopsy-proven extremity soft tissue gastric metastasis within the brachioradialis muscle. He subsequently underwent metastasectomy and immunotherapy.ConclusionThis case is a rare example of an isolated extremity metastasis of gastric adenocarcinoma in the setting of an R0 resection of the primary tumor and negative nodal disease on final pathology, suggestive of hematogenous spread. We review the biology, workup, and management of gastric cancer and highlight new advancements in the treatment of this aggressive cancer.

Trends and Outcomes of Surgical Management of Primary Papillary Carcinoma in the Pediatric Population

BackgroundChildhood papillary thyroid cancer is more aggressive than carcinomas in adults. Current American Thyroid Association pediatric guidelines recommend a total or near-total thyroidectomy for all pediatric patients without gross evidence of lymph node metastases. Our objective is to analyze trends in the surgical management of pediatric papillary thyroid cancer and assess how well the guidelines are implemented. MethodsA retrospective cohort study of pediatric patients (ages 19 y and under) who underwent a thyroidectomy was conducted using the Surveillance, Epidemiology, and End Results database 2006-2017. Procedure type was classified as lobectomy or less and subtotal or total thyroidectomy. Descriptive statistics to illustrate patient and tumor characteristics as well as chi-square analysis to evaluate frequency of treatment with total thyroidectomies versus lobectomy or less were performed. Logistic regression analysis controlling for age, sex, size of tumor, rural versus urban institutions, and surgery year was conducted to identify factors predictive of procedure type. ResultsA total of 2271 children underwent surgical management of papillary thyroid cancer between 2006 and 2017. Most patients received a subtotal or total thyroidectomy as surgical management (n = 2,085, 91.8%). One hundred eighty-six patients (8.2%) received a lobectomy or less. The number of lobectomies or less increased with time, with 41 (6.6%) patients between 2006 and 2009, 98 (8.0%) between 2009 and 2015, and 47 (11.1%) between 2016 and 2017 (P = 0.03). Mortality rates were low (n = 15, 0.7%). On logistic regression analysis, later stages, larger sizes, and earlier operative years were predictive of a near-total or total thyroidectomy. ConclusionsDespite the American Thyroid Association Guidelines recommending a total thyroidectomy for pediatric well-differentiated thyroid cancer, the results of this study demonstrate that thyroid lobectomies are being performed in increasing frequency for smaller tumors in earlier stages of disease. Further investigation of whether this trend actually affects the outcomes in this patient cohort is needed.

Applicability and results of liver transplant combined with neoadjuvant chemo-radiotherapy in the treatment of unresectable hilar cholangiocarcinoma

BackgroundIn 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AimTo analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. MethodsObservational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. ResultsBetween 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5–192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. ConclusionThe suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Regional Lymph Node Metastasis on Prostate Specific Membrane Antigen Positron Emission Tomography Correlates with Decreased Biochemical Recurrence-Free and Therapy-Free Survival after Radical Prostatectomy: A Retrospective Single-Center Single-Arm Observational Study.

We sought to address the impact of preoperative prostate specific membrane antigen (PSMA) positron emission tomography (PET) findings prior to radical prostatectomy and pelvic lymph node dissection on biochemical recurrence and time to adjuvant or salvage treatment. Between 2013 and 2017, 64 intermediate and 166 high risk (230) prostate cancer patients received 68Ga-PSMA-11 PET followed by radical prostatectomy and pelvic lymph node dissection. Biochemical recurrence-free and therapy-free survivalwere determined. For all time-to-event analyses, univariable and multivariable Cox proportional hazards models and univariable Kaplan-Meier analyses were applied, with a significance threshold of p <0.05. The overall sensitivity, specificity, positive predictive value and negative predictive value of PSMA PET for pN1 disease was 48.5%, 95.7%, 82.1% and 82.2%, respectively. Median followup was 30.2 months. Biochemical recurrence occurred in 50.4% (116) of patients and adjuvant or salvage treatment was performed in 46.5% (107). Worst biochemical recurrence-free and therapy-free survival was observed in pN1 patients who also exhibited PSMA PET positive lymph node, followed by pN1 patients without PSMA PET positive lymph node and patients without evidence of lymph node metastasis on histology and PSMA PET (median biochemical recurrence-free survival 1.7 vs. 7.5 vs. >36 months, median therapy-free survival 2.6 vs. 8.9 vs. >36 months). Patients with positive lymph node on PSMA PET prior to radical prostatectomy have to expect early biochemical recurrence and adjuvant/salvage therapy, despite thorough pelvic lymph node dissection. Therefore, results from PSMA PET can be used for patients' consultation and more stringent followup as well as for planning of neoadjuvant/adjuvant therapy.

Latissimus dorsi flap: safe, reliable and versatile workhorse flap in the era of minimally invasive breast surgery—a case series

: Breast reconstruction in Asian women differ from their western counterparts as most Asian ladies have small to moderate sized breast with limited adiposity for abdominal flap reconstruction. Latissimus dorsi (LD) flap is an extremely useful reconstruction option for this particular group of women. Minimally invasive breast surgery is surgery performed via small aesthetically placed incision(s) whilst maintaining oncological principles. As LD flap is conventionally harvested as a myocutaneous flap, it results in a long unsightly donor site scar. Hence, the use of conventional LD flap harvest in combination with minimally invasive oncological resection have raised doubts over its value. To the best of our knowledge, this is the first series to describe our initial experience in using minimally invasive oncological resection techniques in combination with multiple variations of minimally invasive LD flap reconstruction. Consecutive patients who underwent breast reconstruction using LD flap between January to March 2020 were included in this case series and analyzed. Data collection included clinicopathological characteristics of tumor, types of surgery and reconstruction, operative time, blood loss, length of hospital stay, surgical outcomes and complications. Aesthetic outcomes evaluations with clinical and post-operative photography-based assessments were performed, in which patients’ consent was obtained. The mean age of patients was 56 years old (range, 45–69). All had early non-metastatic breast cancer, no evidence of skin or chest wall invasion and no clinical evidence of lymph node metastases. Mean pathological tumor size was 2.8 cm (range, 8 mm to 7 cm). Specimen weight ranged from 34 to 51 g for wide excision cases and 117 to 309 g for mastectomy specimens. The mean blood loss for all was less than 15 mL and mean hospitalization was 1 day. Aesthetic outcome assessed by the performing surgeon and patients graded it to be between good and excellent. All patients were satisfied with their scar appearance, wound length and location. Our initial experience demonstrated the safety and versatility of endoscopically harvested LD flap in combination with minimally invasive breast surgery, which offers an attractive alternative for oncological resection in breast cancer management.

18F-DCFPyL PET/CT for primary staging in 160 high-risk prostate cancer patients; metastasis detection rate, influence on clinical management and preliminary results of treatment efficacy.

Prostate-specific membrane antigen (PSMA) PET/CT shows better diagnostic performance for detection of lymph node and bone metastases as compared to conventional imaging. Studies of PSMA PET/CT in primary staging comprise highly selected patient cohorts. This study evaluates 18F-DCFPyL PET/CT as first-line imaging modality for primary staging of high-risk prostate cancer. From February 2018 until April 2019, all patients with high-risk prostate cancer received 18F-DCFPyL PET/CT for staging of prostate cancer. Baseline characteristics, findings at 18F-DCFPyL PET/CT, number and type of required additional diagnostic procedures, findings at additional diagnostic procedures, and effects of therapy on PSA levels for all patients treated with curative intent were collected and evaluated. One hundred-sixty patients were included in the study of which 90 (56%) had evidence of metastasized disease (N1, M1a, M1b and, M1c in 49%, 28%, 31%, and 3% respectively). Additional diagnostic imaging was needed in 2/160 patients (1%) because of equivocal findings on 18F-DCFPyL PET/CT. Eighty-one patients had evidence of PSMA-positive lymph node metastases, of whom 39 (48%) had no enlarged lymph nodes on CT; 18F-DCFPyL PET detected additional metastatic lymph nodes in 41/42 patients that had evidence of lymph node metastases on CT. 18F-DCFPyL PET altered patients' management in 17% of patients. 18F-DCFPyL PET/CT can be used as first-line imaging modality for therapy selection in patients with primary high-risk prostate cancer, without need for further diagnostic imaging procedures in the majority of patients.

Aplicabilidad y resultados del trasplante hepático combinado con quimiorradioterapia neoadyuvante en el tratamiento del colangiocarcinoma perihiliar irresecable

BackgroundIn 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA). AimTo analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat. MethodsObservational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found. ResultsBetween 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years. ConclusionThe suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment.

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

Tailored radical hysterectomy for locally advanced cervical cancer

ObjectiveThe survival and prognostic factors for locally advanced cervical cancer treated with nerve-sparing Okabayashi–Kobayashi radical hysterectomy have not been elucidated. We aimed to evaluate the oncological outcomes of those patients...

Rare primary lymphoepithelioma-like carcinoma of the renal pelvis.

Lymphoepithelioma-like carcinoma (LELC) is a rare, malignant epithelial tumour which can arise within the upper urinary tract. This letter adds to a previous systematic review and cumulative analysis of 28 published upper urinary tract-LELC cases which provided insight into this disease; however, the current evidence does not provide clinicians with clear guidelines due to its rarity. Therefore, the aim was to report a new case of renal pelvis LELC presented in our hospital. In this instance, we were able to report treatment experience and long-term follow-up results. This patient presented with hypertension and haemturia which initiated further investigation. While ultrasound identified an hypechoic mass, no malignant cells were detected using cytological testing. Abdominal magnetic resonance imaging identified a slightly enhanced mass in the left renal pelvis with no evidence of lymph node metastasis. Ureteroscopic tumor biopsy suggested the existence of urothelial carcinoma, hence, laparoscopic radical left nephroureterectomy with bladder cuff excision was performed. Through patient-practitioner consultations, we decided to adopt a "watch and wait" approach after radical nephroureterectomy rather than administering chemotherapy. Although, we would encourage clinicians to record and publish cases to garner insight into this type of malignant disease.

Papillary breast cancer: A retrospective single-centre clinical study.

Papillary carcinoma (PC) of the breast is a rare malignancy that accounts for 0.5%-1% of breast cancers. PC remains an understudied cancer, and we still require further information on its behaviour, staging and management. In particular, a significant proportion of PC cases still undergo sentinel lymph node biopsy without clear empirical justification. In the present study, we provide a valuable cohort of 44 PC patients and examine the clinicopathological features and outcome of loco-regional staging. Our results provide important insights into the behaviour of PC and suggest SLNB may be spared in this condition. Crucially, we show only one histologically confirmed PC case had evidence of nodal metastasis. In addition, up to 5years postsurgery, no patient in our cohort died from their cancer. Together, our results support further work in the utility of SLNB in PC and highlight the favourable prognosis of this tumour. We propose SLNB should not be routinely indicated for patients with PC treated with breast conservation, and future studies should aim to incorporate prospective data to help inform optimal management of PC.

Long-term outcomes of patients with papillary thyroid cancer who did not undergo prophylactic central neck dissection.

The role of prophylactic central neck dissection (CND) in the management of papillary thyroid carcinoma (PTC) is controversial. This study reports outcomes of an observational approach in PTC patients without clinical evidence of lymph node metastasis. Patients with PTC who had surgery (without prophylactic CND) between January 2000 and December 2008 were included in this study. Recurrence-free survival (RFS) and disease-specific survival (DSS) were calculated using the Kaplan-Meier method. Cox regression was used in multivariable models. Out of 625 patients, 486 (77.8%) were female, 144 (23%) were aged 55 years or more, 73 (11.7%) had macroscopic extrathyroidal extension, and 79 (12.7%) had pT3 or pT4 disease. Samples were collected from 12 (1.9%) patients with lymph node metastasis in the perithyroidal tissue and 2 (0.3%) patients with lymph node metastasis in the lateral neck lymph tissue for frozen section examination. After a median follow-up of 104 months, the 10-year DSS and RFS rates were 99.7% and 90.2%, respectively. The 10-year lymph node recurrence rate in the central compartment was 2.7%. pT3/4 stage was an independent predictive factor for RFS (P < 0.001, hazard ratio 1.966, 95% confidence interval 1.446-2.673). The outcomes of patients with clinically negative lymph nodes in the central compartment were favorable without prophylactic CND.

A Multi-institutional Study of Prevalence and Clinicopathologic Features of Non-invasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features (NIFTP) in Korea.

BackgroundIn the present multi-institutional study, the prevalence and clinicopathologic characteristics of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) were evaluated among Korean patients who underwent thyroidectomy for papillary thyroid carcinoma (PTC).MethodsData from 18,819 patients with PTC from eight university hospitals between January 2012 and February 2018 were retrospectively evaluated. Pathology reports of all PTCs and slides of potential NIFTP cases were reviewed. The strict criterion of no papillae was applied for the diagnosis of NIFTP. Due to assumptions regarding misclassification of NIFTP as non-PTC tumors, the lower boundary of NIFTP prevalence among PTCs was estimated. Mutational analysis for BRAF and three RAS isoforms was performed in 27 randomly selected NIFTP cases.ResultsThe prevalence of NIFTP was 1.3% (238/18,819) of all PTCs when the same histologic criteria were applied for NIFTP regardless of the tumor size but decreased to 0.8% (152/18,819) when tumors ≥1 cm in size were included. The mean follow-up was 37.7 months and no patient with NIFTP had evidence of lymph node metastasis, distant metastasis, or disease recurrence during the follow-up period. A difference in prevalence of NIFTP before and after NIFTP introduction was not observed. BRAFV600E mutation was not found in NIFTP. The mutation rate for the three RAS genes was 55.6% (15/27).ConclusionsThe low prevalence and indolent clinical outcome of NIFTP in Korea was confirmed using the largest number of cases to date. The introduction of NIFTP may have a small overall impact in Korean practice.