Induction Chemoradiotherapy Research Articles

Surgical resection following chemoradiotherapy for thoracic SMARCA4-deficient undifferentiated tumor: a report of two cases

BackgroundThoracic SMARCA4-deficient undifferentiated tumor (SMARCA4-UT) is a high-grade malignant neoplasm with a poor prognosis. Most cases of SMARCA4-UT have extensive chest wall and mediastinum involvement. The efficacy of surgical resection has not been clearly established. Here, we report two surgical cases of SMARCA4-UT with chest wall invasion after chemoradiotherapy.Case presentationThe first patient was a 40-year-old man with back pain. Computed tomography revealed a 6.8 cm mass in contact with the thoracic vertebrae near the intervertebral foramen, which was suspected to involve the third to fifth ribs. The patient was diagnosed with SMARCA4-UT with clinical T3N0M0 stage IIB. The tumor shrank after chemoradiotherapy, and conversion surgery combined with partial vertebrectomy was performed. Histopathological findings revealed 30% residual tumor in the tumor bed. Thirty-six days after surgery, the patient developed multiple liver metastases and peritoneal dissemination. Chemotherapy combined with immune checkpoint inhibitor treatment was performed, resulting in tumor shrinkage. However, peritoneal dissemination recurred within a short interval. The patient died 5 months postoperatively. The second patient was a 74-year-old man with chest pain. Computed tomography revealed a 7.4-cm mass in the left upper lobe with invasion of the third and fourth ribs. The patient was initially diagnosed with non-small cell lung cancer with clinical T4N1M0 stage IIIA. The tumor shrank after induction chemoradiotherapy, and a left upper lobectomy combined with the chest wall resection was performed. Based on histopathological findings, the patient was diagnosed with SMARCA4-UT. The residual tumor percentage was 3%. The patient was followed up for 12 months postoperatively without recurrence.ConclusionsWe performed the complete resection of SMARCA4-UT following chemoradiotherapy. The two surgical cases had different postoperative courses. Radical surgery after chemoradiotherapy is effective for local control. However, its long-term prognostic efficacy remains unclear. Multidisciplinary approaches and further investigations of novel therapeutic options are required.

Induction chemotherapy followed by standard chemoradiotherapy versus standard chemoradiotherapy alone in patients with locally advanced cervical cancer (GCIG INTERLACE): an international, multicentre, randomised phase 3 trial

Locally advanced cervical cancer is treated with chemoradiotherapy (standard of care), but many patients still relapse and die from metastatic disease. We investigated chemoradiotherapy with or without induction chemotherapy to determine whether induction chemotherapy improves both progression-free survival and overall survival. The INTERLACE trial was a multicentre, randomised phase 3 trial done at 32 medical centres in Brazil, India, Italy, Mexico, and the UK. Adults (aged ≥18 years) with locally advanced cervical cancer (FIGO 2008 stage IB1 disease with nodal involvement, or stage IB2, IIA, IIB, IIIB, or IVA disease) were randomly assigned (1:1), by minimisation, using a central electronic system, to standard cisplatin-based chemoradiotherapy (once-a-week intravenous cisplatin 40 mg/m2 for 5 weeks with 45·0-50·4 Gy external beam radiotherapy delivered in 20-28 fractions plus brachytherapy to achieve a minimum total 2 Gy equivalent dose of 78-86 Gy) alone or induction chemotherapy (once-a-week intravenous carboplatin area under the receiver operator curve 2 and paclitaxel 80 mg/m2 for 6 weeks) followed by standard cisplatin-based chemoradiotherapy. Stratification factors were recruiting site, stage, nodal status, three-dimensional conformal radiotherapy or intensity modulated radiotherapy, age, tumour size, and histology (squamous vs non-squamous). Primary endpoints were progression-free survival and overall survival within the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01566240, and EUDRACT, 2011-001300-35. Between Nov 8, 2012, and Nov 17, 2022, 500 eligible patients were enrolled and randomly assigned to the chemoradiotherapy alone group (n=250) or the induction chemotherapy with chemoradiotherapy group. Of 500 patients, 354 (70%) had stage IIB disease and 56 (11%) stage IIIB disease. Pelvic lymph nodes were positive in 215 (43%) patients. 230 (92%) patients who received induction chemotherapy had at least five cycles. Median interval between induction chemotherapy and chemoradiotherapy was 7 days. Four or more cycles of cisplatin were given to 212 (85%) participants in the induction chemotherapy with chemoradiotherapy group and to 224 (90%) of participants in the chemoradiotherapy alone group. 462 (92%) participants received external beam radiotherapy and brachytherapy with a median overall treatment time of 45 days. After a median follow-up of 67 months, 5-year progression-free survival rates were 72% in the induction chemotherapy with chemoradiotherapy group and 64% in the chemoradiotherapy alone group with a hazard ratio (HR) of 0·65 (95% CI 0·46-0·91, p=0·013). 5-year overall survival rates were 80% in the induction chemotherapy with chemoradiotherapy group and 72% in the chemoradiotherapy alone group, with an HR of 0·60 (95% CI 0·40-0·91, p=0·015). Grade 3 or greater adverse events were reported in 147 (59%) of 250 individuals in the induction chemotherapy with chemoradiotherapy group versus 120 (48%) of 250 individuals in the chemoradiotherapy alone group. Short-course induction chemotherapy followed by chemoradiotherapy significantly improves survival of patients with locally advanced cervical cancer. Cancer Research UK and University College London-University College London Hospitals Biomedical Research Centre.

Long-Term Outcomes in Patients With Locally Advanced Rectal Cancer Following R1 Resection After Either Induction Chemotherapy and Chemoradiotherapy or Chemoradiotherapy Alone

IntroductionTotal neoadjuvant treatment (TNT) with induction chemotherapy (ICT) followed by chemoradiotherapy (CRT) has improved long-term outcomes for patients with locally advanced rectal cancer (LARC). However, long-term outcomes have not been investigated for patients with incomplete (R1) resection separately. This study investigates overall survival (OS), disease-free survival (DFS) and local and distant recurrence rates in patients with R1 resection after preoperative treatment with ICT and CRT or CRT. Patients and methodsFrom the NORD database 689 patients with LARC who received treatment between 2006 and 2017 were screened for inclusion. All patients with R1 resection were included. ICT consisted of at least 1 cycle of capecitabine and oxaliplatin (CAPOX) and was followed by radiotherapy concomitant with capecitabine. ResultsAmong 46 patients with R1 resection, 27 (59%) received both ICT and CRT, and 19 (41%) patients received CRT. The 5-year OS was 44% (95% CI, 26%-63%) (ICT + CRT) versus 37% (95% CI, 15%-59%) (CRT) (P = .25) and 5-year DFS was 44% (95% CI, 26%-63%) (ICT + CRT) versus 32% (95% CI, 11%-53%) (CRT) (P = .22). The local recurrence rates showed a small nonstatistical significant difference in local control in the ICT group: 15% compared to 26% in the CRT group (P = .22). Distant recurrence rates were similar: 41% (ICT + CRT) versus 47% (CRT) (P = .48). ConclusionThere was no significant difference in OS, DFS or local and distant recurrence rates between patients who received ICT + CRT versus patients who received CRT only.

Narrative review of indication and management of induction therapy for thymic epithelial tumors.

Thymic epithelial tumors (TETs) are rare and originate from the thymus. Thymomas and thymic carcinomas are the most common types of TETs. Of the two, thymomas tend to have a better prognosis and are typically localized, while thymic carcinomas have a worse prognosis and are more likely to spread. The Masaoka-Koga staging system is commonly used to determine the stage of TETs. Complete resection is the preferred treatment option, but treating locally advanced TETs can be challenging due to the invasion of surrounding structures. In such cases, induction therapy is administered to downstage the tumors and enable complete resection. We conducted this narrative review to evaluate the current progress in induction treatment for locally advanced TETs. The literature search was performed using PubMed and Web of Science in June 2023. Prospective and retrospective published trials, systemic and narrative reviews, and meta-analyses were included. Induction chemotherapy is often used as a preoperative treatment for advanced TETs. Platinum and anthracycline-based chemotherapy regimens are commonly used for treating thymoma (response rate, 37-100%), and complete resection is highly common. Treatment with cisplatin and etoposide, carboplatin and paclitaxel, docetaxel and cisplatin have also demonstrated effectiveness, particularly in patients with thymic carcinoma or thymoma who cannot tolerate anthracycline regimens. The emergence of immunotherapy and targeted therapies may provide additional options for the treatment of TETs. Induction radiotherapy, as the sole treatment for TETs, is not widely practiced due to concerns about potential damage to surrounding tissues. However, combining modern radiation techniques with surgery has shown promising results in selected patients. Induction chemoradiotherapy, which combines chemotherapy and radiation, is an emerging approach for treating TETs. Despite the lack of randomized trials comparing chemotherapy with chemoradiotherapy, concurrent chemoradiation with radiation doses of 40-50 Gy is often considered the optimal induction therapy for thymic carcinoma patients or in more advanced special situations, such as great vessel invasion. Overall, the optimal treatment for locally advanced TETs remains controversial. Induction therapy, including chemotherapy, radiotherapy, or chemoradiotherapy, is administered to downstage tumors and improve resectability. The choice of treatment depends on individual factors such as tumor stage, histology, and overall patient condition. However, further research and well-designed studies are needed to determine the most effective treatment strategies for locally advanced TETs.

Prophylactic effect of tissue flap in the prevention of bronchopleural fistula after surgery for lung cancer.

Bronchopleural fistula (BPF) is a serious complication of lung resection. To avoid BPF, the bronchial stump/anastomotic site is often covered with a flap of surrounding tissue. One risk factor for BPF is radical lung resection after induction chemoradiotherapy for lung cancer. We retrospectively reviewed our database to elucidate the characteristics of tissue flaps that prevent BPF. This retrospective study included 152 patients treated between 1999 and 2019. We examined the clinicopathological characteristics, including the type and thickness of the tissue flap used to cover the bronchial stump/anastomotic site, and postoperative complications, including BPF. BPF occurred in 5 patients (3.3%). All 5 patients had complications that could have affected delayed wound healing, such as pneumonia. The covering tissue flap thickness was significantly greater in patients without BPF than in those who developed BPF (p = 0.0290). Additionally, the tissue flap thickness was significantly greater than in those with BPF (p = 0.0077), even in high-risk patients who developed pneumonia or radiation pneumonitis on the operative side within 6months postoperatively. Perioperative management is crucial to avoid complications affecting the healing of the bronchial stump/anastomotic site, and the covering tissue flap thickness may be an important factor in avoiding or minimizing BPF.

Induction plus concurrent chemoradiotherapy versus concurrent chemoradiotherapy in elderly patients with locoregionally advanced nasopharyngeal carcinoma

BackgroundThe effectiveness and safety of induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT) in elderly patients with locoregionally advanced nasopharyngeal carcinomas (LANPCs) remain subjects of debate. This study evaluated the efficacy of IC+CCRT compared to CCRT alone in elderly LANPC patients. Materials and methodsThis retrospective, single-center study analyzed 335 elderly patients diagnosed with stage III or IVa NPC who received CCRT with or without IC between 2010 and 2016. Kaplan-Meier analysis and log-rank tests were used to estimate and compare survival rates. Multivariate analysis using Cox proportional hazards regression model was conducted to assess prognostic risk factors. Toxicities were compared using the χ2 test. ResultsThe median follow-up duration was 69.3 months (interquartile range: 42.7–72.6). Baseline clinical characteristics were well-balanced between groups. No significant differences were observed between IC+CCRT and CCRT for any survival-related endpoints, including overall survival (hazard ratio [HR] = 1.26, 95 % confidence interval [CI]: 0.89–1.77, p = 0.188), locoregional relapse-free survival (HR=1.03, 95 % CI: 0.56–1.91, p = 0.913), distant metastasis-free survival (HR=1.39, 95 % CI: 0.90–2.16, p = 0.139), and failure-free survival (HR = 1.25, 95 % CI: 0.85–1.83, p = 0.255). However, the incidence and severity of acute and late toxicities were significantly higher in the IC+CCRT group compared to the CCRT group. ConclusionIn elderly LANPC patients, the addition of IC to CCRT did not improve survival outcomes, but was associated with significant toxicities.

Long-term Outcomes of Salvage Surgery Versus Induction Therapy Followed by Surgical Resection for Advanced NSCLC: A Propensity Score-matched Analysis.

The outcomes of lung cancer treatment have improved over time. However, in contrast to other treatments, the clinical outcomes of salvage surgery are seldom reported because the follow-up periods after salvage surgery are short. We conducted a comprehensive study involving consecutive patients who underwent salvage surgery at two different institutions. Our analysis encompassed the exploration of clinicopathological features, perioperative variables, and surgical outcomes. Additionally, we employed propensity score matching to compare the long-term survival of patients with non-small cell lung cancer (NSCLC) who underwent salvage surgery with those who received induction chemoradiotherapy prior to surgery. Twenty-five patients underwent salvage procedures, while 113 patients received induction chemotherapy followed by surgery during the same study period. When assessing the overall survival (OS) from the registration date to the initial treatment date, the five-year OS rates were 73.8% in the induction group and 70.5% in the salvage surgery group (p=0.674). No significant differences were identified between the two groups in a cohort of 48 patients with NSCLC who were matched using propensity scores. In patients who underwent salvage surgery, reasonable long-term survival was achieved with outcomes comparable to those of induction chemotherapy followed by surgical resection.

Long-Term Results of Bladder Preservation With Twice-Daily Radiation Plus 5-Fluorouracil/Cisplatin or Daily Radiation Plus Gemcitabine for Muscle-Invasive Bladder Cancer—Updated Report of NRG/RTOG 0712: A Randomized Phase 2 Trial

Purpose5-FU/cisplatin and twice-daily radiation (FCT) or gemcitabine and once daily radiation (GD) are effective chemoradiation (CRT) regimens for bladder sparing treatment of muscle-invasive bladder cancer (MIBC). This trial evaluated these regimens and demonstrated efficacy with either regimen at 3 years. With further follow-up, longer term results are reported here. Methods and MaterialsPatients with cT2-4a MIBC were randomized to FCT or GD. Patients had a transurethral resection and induction CRT to 40 Gy. Patients with a complete response (CR) received consolidation CRT to 64 Gy. Others had cystectomy. Adjuvant gemcitabine/cisplatin chemotherapy was administered. The primary endpoint was freedom from distant metastasis (FDM). This updated analysis reports 7-year data. Toxicity and efficacy endpoints, including bladder intact distant metastasis free survival (BI-DMFS) were also assessed. ResultsFrom 12/2008 to 4/2014, 70 patients were enrolled; 66 eligible for analysis, 33 per arm. Median follow-up was 9.1 years for eligible living patients. At 7 years, FDM was 65% and 73% for FCT and GD, respectively. BI-DMFS was 58% (95% CI: 41 – 76) and 68% (95% CI: 51-84), respectively. The post-hoc hazard ratio of 0.75 (95% CI: 0.37-1.55) showed no difference between treatments (p=0.44). Overall survival at 7 years was 48% and 59%. There were 4 and 5 cystectomies performed for FCT and GD, respectively. In the FCT arm, there were 5 (16%), 1 (3%) and 0 grade 3, 4 and 5 late toxicities reported. In the GD arm, there were 7 (23%), 0 and 0. ConclusionsBoth regimens maintained high FDM rates at 7 years. Cystectomy rates were low and overall survival rates high on both arms. Late toxicity rates were low. Either gemcitabine and daily radiation or a cisplatin-based regimen are effective bladder sparing therapies.

Impact of the neutrophil-to-lymphocyte ratio on patients with locally advanced non-small cell lung cancer who suffer radiation pneumonitis during the course of induction chemoradiotherapy followed by surgery.

Radiation pneumonitis (RP) is an obstacle for patients after surgery following induction chemoradiotherapy for locally advanced non-small cell lung cancer (LA-NSCLC). We performed a comparative analysis of the association between clinicopathological factors, including the neutrophil-to-lymphocyte ratio (NLR) and prognosis, in LA-NSCLC patients with or without RP during induction chemoradiotherapy followed by surgery. The subjects of this analysis were 168 patients undergoing trimodality therapy for LA-NSCLC between January, 1999 and May, 2019. Patients were divided into two groups: the RP group (n = 41) and the non-RP group (n = 127). We compared the clinicopathological factors including the NLR between the groups and analyzed the association between the NLR and prognosis. The RP group had more patients with tumors located in the lower lobe, more bilobar resections, shorter operative times, no implementation of postoperative adjuvant chemotherapy, and a higher postoperative NLR than the non-RP group. There were no significant differences in serious postoperative complications and the prognosis. Patients with a low postoperative NLR had a significantly better prognosis in the non-RP group, and a trend toward a better prognosis even in the RP group. Postoperative NLR may be a useful prognostic factor, even for patients who suffer RP after trimodality therapy for LA-NSCLC.

EGFR-mutated lung adenocarcinoma with choroidal oligometastasis during treatment with gefitinib: a case report

The patient was a 74-year-old woman who was diagnosed with lung adenocarcinoma, clinical Stage IIIA. Induction chemoradiation was performed followed by right upper lobectomy and lymph node dissection. Because of positive pleural effusion cytology, which was proven after surgery, the patient was diagnosed with pathological Stage IVA with EGFR L858R mutation. At 17 months after the administration of gefitinib, left choroidal metastasis appeared. Stereotactic irradiation and ruthenium small-beam radiation were effective; however, the metastatic lesion showed regrowth 7 months after these treatments. Because the patient’s choroidal oligometastasis was resistant to conservative therapy, left ophthalmectomy was performed. EGFR mutations (L858R and E709K) were detected in the resected choroidal tumor. The patient continued to take gefitinib. However, a neoplastic lesion developed on the optic nerve adjacent to the resected posterior eye segment. The lesion was treated with stereotactic radiation, gefitinib was switched to afatinib 30 mg, and the patient remains alive and disease free for 11 months.

Chest wall resections for sulcus superior tumors.

Chemoradiotherapy followed by surgical resection (trimodality therapy) is a guideline recommended treatment for sulcus superior tumors (SST). By definition, SSTs invade the chest wall and therefore require en-bloc chest wall resection with the upper lung lobe or segments. The addition of a chest wall resection, potentially results in higher morbidity and mortality rates when compared to standard anatomical pulmonary resection. This, together with their anatomical location in the thoracic outlet, and varying grades of fibrosis and adhesions resulting from induction chemoradiotherapy in the operation field, make surgery challenging. Depending on the exact location of the tumor and extent to which it invades the surrounding structures, the preferred surgical approach may vary, e.g., anterior, posterolateral, hemi-clamshell, or combined approach; all with their own potential advantages and morbidities. Careful patient selection, adequate staging and discussion in a multidisciplinary tumor board in a center experienced in complex thoracic oncology leads to the best long-term survival outcomes with the least morbidity and mortality. Enhanced recovery guidelines are now available for thoracic surgery, promoting faster recovery and helping to minimize complications and morbidity, including infections and thoracotomy pain. Although minimally invasive surgery can enhance recovery and reduce chest wall morbidity, and is in widespread use in thoracic oncology, its use for SST has been limited. However, this is an evolving area and hybrid surgical approaches (including use of the robot) are being reported. Chest wall reconstruction is rarely necessary, but if so, the prosthetic materials are preferably radiolucent/non-scattering, rigid enough while still being somewhat flexible, and inert, providing structural support, allowing chest wall movement, and closing defects, while inciting a limited inflammatory response. New techniques such as 3D image reconstructions/volume rendering, 3D-printing, and virtual reality modules may help pre-operative planning and informed patient consent.

Surgical cervicothoracic-flap repair of neoesophagus–airway fistula after esophagectomy for esophageal cancer: A retrospective cohort study

ObjectiveTo evaluate outcomes of surgical repair of postesophagectomy neoesophagus–airway fistulas (NEAFs). MethodsWe retrospectively included consecutive patients with NEAF managed by various techniques at our center between August 2009 and July 2021. ResultOf the 11 patients (median age, 60 years; interquartile range, 58, 62), 4 had received induction chemoradiotherapy and 4 others induction chemotherapy. NEAF was mainly a complication of anastomotic leakage (n = 6) or attempted stenosis treatment (n = 3). The airway mainly involved was the trachea (n = 8). Airway defects were repaired by resection–anastomosis (n = 5), perforator flaps (n = 4), pedicled pericardium (n = 1), and/or direct suturing (n = 2). Gastric conduit defects were repaired by perforator flaps (n = 6), direct suturing (n = 2), or pedicled pericardium (n = 1). Of the 7 perforator flaps, 4 were internal mammary–artery, two dorsal intercostal–artery, and one supraclavicular–artery flaps. After a median follow-up of 100 months, 2 patients died on early postoperative course from NEAF repair failure and 3 from late NEAF recurrence at 4, 11, and 33 months. Among the remaining 6 patients, 1 died from local tumoral recurrence at 13 months, 1 was last on follow-up at 27 months, alive and eating normally. The other 4 were free from NEAF recurrence and dysphagia or swallowing disorder at 50 months’ follow-up. These 4 results were obtained thanks to perforator flap interposition and airway resection anastomosis. ConclusionsSurgical NEAF repair using perforator flap interposition may provide satisfactory long-term function after strong prehabilitation.

EP08.02-35 Prognostic Impacts of Lymphovascular Invasion of Resected Lung Adenocarcinoma after Induction Chemoradiotherapy

EP08.02-35 Prognostic Impacts of Lymphovascular Invasion of Resected Lung Adenocarcinoma after Induction Chemoradiotherapy

Induction Immunotherapy vs. Consolidation Immunotherapy for Unresectable Stage III NSCLC

Consolidation immunotherapy after chemoradiotherapy (CRT) is the standard of care for unresectable stage III non-small cell lung cancer (NSCLC). However, whether upfront immunotherapy before CRT has similar benefits has not been addressed. This study aimed at exploring the efficacy and safety of induction immunotherapy for unresectable stage III NSCLC through real-world data. Patients diagnosed with stage III NSCLC who received immunotherapy in combination with sequential (sCRT) or concurrent CRT (cCRT) between November 2018 and December 2021 were retrospectively identified. Patients were divided into induction (Ind), consolidation (Con) and induction plus consolidation (Ind+Con) immunotherapy groups. Progression-free survival (PFS) and overall survival (OS) were assessed from the initiation of treatment and estimated by Kaplan‒Meier method. The potential factors affecting PFS and OS were analyzed by univariate and multivariate Cox regression models. One hundred and two patients were included, with 52 (51.0%) patients in the Ind group, 35 (34.3%) in the Con group and 15 (14.7%) in the Ind+Con group. Median PFS was 24.0 months vs. 36.0 months vs. 19.0 months in the three groups, and 2-year PFS were 43.0% vs 51.1% vs 44.4% (p = 0.940). Median OS was not reached (NR) vs. 44.0 months vs. NR, with a 2-year OS rate of 80.5% vs. 84.4% vs. 86.2% (p = 0.861). In the cCRT setting, 2-year PFS rates were 56.7% vs. 71.6% vs. 100.0% (p = 0.439), 2-year OS rates were 92.3% vs. 89.3% vs. 100.0% in the three groups (p = 0.827). In multivariate analysis, elder (HR = 0.487, p = 0.037) and cCRT (HR = 0.282, p = 0.001) were the independent factors favoring PFS, while only elder (HR = 0.088, p = 0.021) was the independent factors favoring OS. Adverse events were similar in the three arms. Further analysis found the objective response rate (ORR) and disease control rate (DCR) in the Ind and Ind+Con group after induction immunotherapy were 59.7% and 98.5%, respectively. Only 1 (1.5%) patient developed progression. Subgroup analysis showed no significant difference in PFS (p = 0.520) and OS (p = 0.116) between patients who responded to induction immunotherapy (PR+CR) and those who did not (SD+PD). Patients with <4 cycles of induction immunotherapy exhibited numerically better PFS than those with ≥4 cycles of induction immunotherapy (p = 0.113) and improved OS (p = 0.021). Induction immunotherapy may achieve similar survival benefits to consolidation immunotherapy, and the combination of induction and consolidation immunotherapy with cCRT appears to achieve better outcomes. It seems feasible and safe to upfront immunotherapy before CRT, and further investigations on the combination of induction immunotherapy and CRT are warranted.

A case of alpha-fetoprotein-positive thymic small cell carcinoma: a case report

BackgroundAn alpha-fetoprotein (AFP)-positive neuroendocrine tumor of the thymus is a rare thoracic malignancy. Few cases of AFP-positive thymic large cell neuroendocrine carcinoma have been reported, with no known previous report of an AFP-positive thymic small cell carcinoma. We encountered a patient with an AFP-positive small cell carcinoma and report here the clinical course.Case presentationA 40-year-old man was transferred to our hospital for a large anterior mediastinal tumor and showed an elevated serum AFP level. Computed tomography-guided biopsy results led to diagnosis of small cell carcinoma. Induction chemoradiotherapy was performed before surgery because of pulmonary artery invasion. The response to Induction chemoradiotherapy varied among sites, with the main tumor showing shrinkage and the metastasis site growth. This discrepancy suggested a histologic type unresponsive to or cancer cells potentially resistant to chemotherapy, thus a surgical re-biopsy was performed and histological findings revealed AFP-positive small cell carcinoma. Additional chemotherapy was performed, though could not control cancer progression, and the patient died 8 months after the first medical examination.ConclusionsOur present clinical experience indicates the importance of histological examination for determining AFP-positive anterior mediastinal tumor treatment. Although AFP-positive neuroendocrine tumor of the thymus is relatively rarer than germ cell carcinoma, differential diagnosis with use of a histological examination should be considered because of the potentially poorer prognosis. The present clinical findings for an AFP-positive neuroendocrine tumor of the thymus case are considered useful for establishing an optimal treatment strategy in the future.

Bilateral video-assisted thoracic surgery for esophageal cancer with left inferior pulmonary vein invasion following chemoradiation therapy

BackgroundThe surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response.Case presentationA 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up.ConclusionsCurative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response.

Induction and concomitant chemoradiotherapy (CCRT) using modified TPF (docetaxel, cisplatin and 5-FU) for the patients with stage IVB advanced head and neck cancer.

e18031 Background: Efficacy of TPF chemotherapy has been reported mainly in the induction chemotherapy (IC) for head and neck squamous cell carcinoma (HNSCC) so far. The aim of this study was to determine the safety and efficacy of CCRT using modified TPF protocol in patients with Stage IVB HNSCC. Methods: Patients with previously untreated, histologically proven Stage IVB disease of the head and neck were eligible for the study. Twenty-six patients of the HNSCC were enrolled between January 2018 and October 2021 including 6 HPV(-) oropharyngeal, 5 hypopharyngeal, 4 ethmoid, 4 maxillary, 2 primary unknown and 5 other cancers. There were 14 T4b and 13 N3b tumors. CCRT consisted of radiotherapy administered once daily to a total dose of 70 Gy, concomitant with 120-hour infusions of 5-FU (600 mg/m2/day), Docetaxel (50 mg/m2, day 2) and Cisplatin (60 mg/m2, day 2) given during first and fifth week of radiotherapy. These drug doses were determined from the results of our former phase I study to assess the dose limiting toxicity of this protocol. Median follow-up period was 21 months. Results: Eight patients with Stage IVB HNSCC underwent IC and CCRT with this modified TPF protocol. Eight patients underwent CCRT using 2 courses of modified TPF. Five patients underwent CCRT with CDDP, three of them underwent arterial infusion of CDDP by super-selective angiography via external carotid artery. Three other patients underwent CCRT using other protocols and two underwent RT without chemotherapy. Bone marrow suppression was the most common adverse event observed through this study. Although all patients showed dermatitis and mucositis at any grade, other grade 3 or 4 adverse events in these patients were not common. Complete response was obtained in all patients except four patients. The progression-free and over-all survival rates at 24 months of all the patients with Stage IVB HNSCC in our series were 53.4% and 59.1%, respectively. Those of the patients who underwent IC and CCRT with modified TPF protocol were 58.3% and 80.0%, respectively and significantly better than those of the patients with other treatment protocols. Conclusions: Our results suggested that IC followed by CCRT using modified TPF was feasible and very effective in patients with Stage IVB HNSCC.

A Prospective Clinical Trial to Evaluate Mesothelin as a Biomarker for the Clinical Management of Patients With Esophageal Adenocarcinoma.

To investigate the utility of serum soluble mesothelin-related peptide (SMRP) and tumor mesothelin expression in the management of esophageal adenocarcinoma (ADC). Clinical management of esophageal ADC is limited by a lack of accurate evaluation of tumor burden, treatment response, and disease recurrence. Our retrospective data showed that tumor mesothelin and its serum correlate, SMRP, are overexpressed and associated with poor outcomes in patients with esophageal ADC. Serum SMRP and tumoral mesothelin expression from 101 patients with locally advanced esophageal ADC were analyzed before induction chemoradiation (pretreatment) and at the time of resection (posttreatment), as a biomarker for treatment response, disease recurrence, and overall survival (OS). Pre and posttreatment serum SMRP was ≥1nM in 49% and 53%, and pre and post-treatment tumor mesothelin expression was >25% in 35% and 46% of patients, respectively. Pretreatment serum SMRP was not significantly associated with tumor stage ( P = 0.9), treatment response (radiologic response, P = 0.4; pathologic response, P = 0.7), or recurrence ( P =0.229). Pretreatment tumor mesothelin expression was associated with OS (hazard ratio: 2.08; 95% CI: 1.14-3.79; P = 0.017) but had no statistically significant association with recurrence ( P = 0.9). Three-year OS of patients with pretreatment tumor mesothelin expression of ≤25% was 78% (95% CI: 68%-89%), compared with 49% (95% CI: 35%-70%) among those with >25%. Pretreatment tumor mesothelin expression is prognostic of OS for patients with locally advanced esophageal ADC, whereas serum SMRP is not a reliable biomarker for monitoring treatment response or recurrence.

PD36-07 DEFINING OPTIMAL CANDIDATES FOR BLADDER-SPARING TREATMENT IN MUSCLE-INVASIVE BLADDER CANCER: ANALYSIS USING PATHOLOGICAL REFERENCE STANDARDS AFTER CHEMORADIATION

You have accessJournal of UrologyCME1 Apr 2023PD36-07 DEFINING OPTIMAL CANDIDATES FOR BLADDER-SPARING TREATMENT IN MUSCLE-INVASIVE BLADDER CANCER: ANALYSIS USING PATHOLOGICAL REFERENCE STANDARDS AFTER CHEMORADIATION Hajime Tanaka, Wei Chen, Kasumi Yoshitomi, Takahiko Soma, Masaki Kobayashi, Motohiro Fujiwara, Yuki Nakamura, Bo Fan, Yudai Ishikawa, Shohei Fukuda, Yuma Waseda, Kazuma Toda, Soichiro Yoshida, Minato Yokoyama, Ryoichi Yoshimura, and Yasuhisa Fujii Hajime TanakaHajime Tanaka More articles by this author , Wei ChenWei Chen More articles by this author , Kasumi YoshitomiKasumi Yoshitomi More articles by this author , Takahiko SomaTakahiko Soma More articles by this author , Masaki KobayashiMasaki Kobayashi More articles by this author , Motohiro FujiwaraMotohiro Fujiwara More articles by this author , Yuki NakamuraYuki Nakamura More articles by this author , Bo FanBo Fan More articles by this author , Yudai IshikawaYudai Ishikawa More articles by this author , Shohei FukudaShohei Fukuda More articles by this author , Yuma WasedaYuma Waseda More articles by this author , Kazuma TodaKazuma Toda More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Minato YokoyamaMinato Yokoyama More articles by this author , Ryoichi YoshimuraRyoichi Yoshimura More articles by this author , and Yasuhisa FujiiYasuhisa Fujii More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003334.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder-sparing treatment based on chemoradiotherapy (CRT) has taken a large interest as an alternative to radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). However, major concerns include MIBC recurrence even after achieving clinical complete response (CR) to CRT, which may be derived from microscopic cancer remnant in the preserved bladder. We have conducted a bladder-sparing protocol that incorporates induction CRT and subsequent partial cystectomy (PC). In addition, CRT was administered as an induction therapy before RC for MIBC patients who had no indication for bladder preservation. In this study, we analyzed these patient series and investigated clinical determinants of CRT response using the pathological reference standards to define optimal candidates for bladder preservation. METHODS: We analyzed 285 patients with cT2-4N0M0 bladder cancer who underwent CRT (40 Gy to the true pelvis with concurrent cisplatin) followed by PC/RC (approval # M2019-192). CRT response was assessed using the cystectomy specimens. Risk factors related to the CRT response were identified using multivariable logistic regression model, and the accuracy of the multivariable model was assessed using the area under the curve (AUC) in the receiver operating characteristic curve (ROC) analysis. RESULTS: Clinical T stage was T2/3/4 in 169 (59%)/105 (37%)/11 (3.9%) patients, respectively. The median tumor size was 3.0 cm and 108 patients (38%) had multiple tumors. Hydronephrosis was observed in 69 patients (24%). Overall, 54 (19%), 34 (12%), and 60 (21%) patients had bladder neck involvement (BNI), concomitant carcinoma in situ, and variant histology in the transurethral resection before CRT. The cystectomy specimens revealed ypT0, defined as pathological CR (pCR), in 178 patients (63%). In the multivariable logistic regression analysis, cT3-4 (Odds ratio=0.53 [95% confidence interval: 0.30-0.92]), tumor size>3.0 cm (0.45 [0.26-0.80]), multiplicity (0.34 [0.19-0.59]), and BNI (0.40 [0.20-0.80]) were independently associated with pCR. The final model including the four factors yielded the AUC of 0.75. In the cohort, 85 (30%), 83 (29%), and 117 (41%) patients had 0, 1, and 2 or more risk factors, respectively; pCR rates after CRT in the respective groups were 87%, 65%, and 43% (p<0.001). CONCLUSIONS: Our analysis identified independent risk factors related to CRT response using the pathological reference standards, which may help decide the indication of bladder preservation in MIBC patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e982 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hajime Tanaka More articles by this author Wei Chen More articles by this author Kasumi Yoshitomi More articles by this author Takahiko Soma More articles by this author Masaki Kobayashi More articles by this author Motohiro Fujiwara More articles by this author Yuki Nakamura More articles by this author Bo Fan More articles by this author Yudai Ishikawa More articles by this author Shohei Fukuda More articles by this author Yuma Waseda More articles by this author Kazuma Toda More articles by this author Soichiro Yoshida More articles by this author Minato Yokoyama More articles by this author Ryoichi Yoshimura More articles by this author Yasuhisa Fujii More articles by this author Expand All Advertisement PDF downloadLoading ...

Diet as a Factor Supporting Lung Cancer Treatment—A Systematic Review

The purpose of this study was to summarize the evidence from epidemiological studies concerning associations between diet and the effectiveness of treatment for lung cancer. For this review, a literature search has been conducted in the EMBASE and PubMed databases, including papers published between 1977 and June 2022. The term "lung cancer" was used in conjunction with "diet". Footnotes from the selected papers were also analyzed. The present study is in line with the recommendations included in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review included studies involving adults, including randomized controlled trials (RCTs) and cohort and observational studies. In total, 863 papers were found, with duplicates excluded. Ultimately, 20 papers were reviewed. The present systematic review indicates that vitamin A, ascorbic acid (vitamin C), vitamin E, selenium, and zinc-as antioxidants-can strengthen the body's antioxidant barrier. Furthermore, preoperative immunonutrition may not only improve perioperative nutritional status following induction chemoradiotherapy in lung cancer surgery patients but also reduce the severity of postoperative complications. Similarly, a protein supply may exert a beneficial effect on human health by increasing average body weight and muscle mass. Omega-3 fatty acid content in the diet and the consumption of their main source, fish, may have some regulatory effect on inflammation in patients with lung cancer treated with chemotherapy and radiotherapy. In addition, n-3 fatty acids inhibit tumor cell proliferation and may reduce the toxicity of chemotherapy. Increased energy and protein intake are strongly associated with improved quality of life, functional outcomes, hand grip strength, symptoms, and performance in patients with lung cancer. The use of a supportive diet should be the standard of care, alongside pharmaceutical therapy, in treatment for patients with lung cancer.