Local Recurrence-free Research Articles

Long-term follow-up of protective effects on salivary and swallowing structures and improvement of late xerostomia and dysphagia by level IIb optimisation in clinical target volume of nasopharyngeal carcinoma.

This study aimed to assess the long-term effect of level IIb clinical target volume (CTV) optimisation on survival, xerostomia, and dysphagia in patients with nasopharyngeal carcinoma (NPC). Clinical data of 415 patients with NPC treated with intensity-modulated radiotherapy between December 2014 and October 2018 were retrospectively analysed. The patients were categorised into modified and comparison groups. Late xerostomia and dysphagia were evaluated using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer scoring. Survival analysis was performed using the Kaplan-Meier method. Differences in late toxicity and dose parameters between both groups were compared. Prognostic factors for survival and late toxicity were assessed using regression analyses. Patients in the modified group developed late xerostomia and dysphagia less frequently than those in the comparison group did (P < 0.001). The mean dose (Dmean) and V26 of parotid glands; Dmean and V39 of submandibular glands; and Dmean of sublingual glands, oral cavity, larynx, and superior, middle, and lower pharyngeal constrictor muscles were lower in the modified group than those in the comparison group (all P < 0.001). Both groups had no significant differences in overall, local recurrence-free, distant metastasis-free, or progression-free survival. The Dmean of the parotid and sublingual glands was a risk factor for xerostomia. The Dmean of the parotid and sublingual glands and middle pharyngeal constrictor muscle was a risk factor for dysphagia. Level IIb optimisation in NPC patients who meet certain criteria specially the exclusion of positive retropharyngeal nodes treated with intensity-modulated radiotherapy has the potential to better protect the salivary and swallowing structures, decreasing the development of late radiation-induced xerostomia and dysphagia while maintaining long-term survival.

Nomogram for prognosis of elderly patients with cervical cancer who receive combined radiotherapy

This retrospective study identified prognostic factors to help guide the clinical treatment of elderly patients (≥ 65 years) with cervical cancer who had undergone radiotherapy. A personalized model to predict 3- and 5-years survival was developed. A review was conducted of 367 elderly women with cervical cancer (staged II–III) who had undergone radiotherapy in our hospital between January 2012 and December 2016. The Cox proportional hazards regression model was used for survival analysis that considered age, hemoglobin, squamous cell carcinoma antigen, pathologic type, stage, pelvic lymph node metastasis status, and others. A nomogram was constructed to predict the survival rates. The median follow-up time was 71 months (4–118 months). The 3- (5-) years overall, progression-free, local recurrence-free, and distant metastasis-free survival rates were, respectively, 91.0% (84.4%), 92.3% (85.9%), 99.18% (99.01%), and 99.18% (97.82%). The following were significant independent prognostic factors for overall survival: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The C-index of the line chart was 0.699 (95% CI 0.652–0.746). The areas under the receiver operating characteristic curves for 3- and 5-years survival were 0.751 and 0.724. The nomogram was in good concordance with the actual survival rates. The independent prognostic factors for overall survival in elderly patients with cervical cancer after radiotherapy were: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The novel prognostic nomogram based on these factors showed good concordance with the actual survival rates and can be used to guide personalized clinical treatment.

Simultaneous integrated or sequential boost to clinically involved lymph nodes in patients with locally advanced cervical cancer treated with definitive chemoradiotherapy

ObjectiveThe optimal treatment of metastatic lymph nodes (LNs) in locally-advanced cervical cancer (LACC) is controversial. With the widespread use of modern radiotherapy (RT) techniques, it is become possible to perform dose escalation in clinically involved LNs. This study aimed to evaluate the oncologic outcomes of dose escalation to the involved LNs with the simultaneous-integrated (SIB) or sequential boost (SEB) techniques as a part of definitive chemoradiotherapy (CRT) for patients with LACC. MethodsThe data of 47 patients treated with definitive CRT with either a SIB or SEB technique to the metastatic LNs between 2015 and 2021 were retrospectively analyzed. All patients received 50.4 Gy/28 fractions of external-beam RT and 28 Gy/4 fractions of brachytherapy. ResultsThe number of boosted LNs was 146. The median size of the LNs was 2 cm (range, 1–5 cm). The median cumulative equivalent dose in 2-Gy fractions for the LNs was 64.2 Gy (range, 57.6–71.2 Gy). During the median 30 months of follow-up (range, 14–91 months), no boosted LNs recurred and the local control (LC) rate was 100%. The 2-year overall, disease-free, local recurrence-free, and distant metastasis-free survival rate was 83.1%, 70.5%, 77.5%, and 74.4%, respectively. In multivariate analysis, the non-squamous cell histology was the only negative independent prognostic factor for DFS and DMFS. Treatment was well tolerated without any serious acute toxicity. Serious late toxicity developed in three (6%) patients as ureteral stenosis, rectal bleeding and pelvic fracture in one patient each. ConclusionsRT dose escalation provides excellent LC for the clinically involved LNs, even for bulky ones, with a low toxicity profile. Routine LN dissection may not be necessary. However, randomized trials are needed to determine the optimal treatment approach.

Abstract P3-05-06: Prognostic impact of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis-related liver fibrosis on postoperative long-term outcomes of breast cancer

Abstract Background: Obesity, the modern ‘epidemic’, has shared correlation with fatty liver disease and breast cancer. However, previous studies on the relation between fatty liver and breast cancer have shown conflicting results on the impact of fatty liver on the survival and recurrence of breast cancer patients. And there was no attempt to find out the effect of liver fibrosis, which is the consequence of fatty liver disease, on female breast cancer patients. So we attempted to investigate the prognostic value of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis(NASH)-related liver fibrosis in patients with breast cancer undergoing surgery, using noninvasive tools like liver-to-spleen attenuation(L/S) ratio and Fibrosis-4(FIB-4) score, respectively. Methods: A total of 933 patients diagnosed with primary invasive breast cancer and receiving surgery at the university-affiliated referral center between April 2006 and December 2019 were included. After excluding patients who had significant alcohol consumption and hepatitis viral infection,838 patients were divided into two groups according to the L/S ratio of 1 measured by the preoperative low-dose computed tomography: 91 patients(10.9%) with a L/S ratio&amp;lt; 1 vs 747 patients(89.1%) with a L/S ratio≥1. They were also divided into two groups based on the FIB-4 score of 2.67: 804 patients (95.9%) with a FIB-4 score&amp;lt; 2.67 vs 34 patients (4.1%) with a FIB-4 score≥2.67. The Cox proportional hazards model was used to calculate the hazard ratio (HR) and the 95% confidence interval (CI). Results: Patients with NAFLD were older, had higher BMI, and had a higher proportion of mastectomy and hyper-transaminasemia. They showed worse overall, disease-free, and regional recurrence-free survivals compared to those without NAFLD (p=0.008, 0.043, and 0.017, respectively), but no significant differences in local recurrence-free, systemic recurrence-free, and contralateral breast cancer-free survivals. The survival outcome of breast cancer did not show any relationship with NASH-related liver fibrosis (overall survival; p=0.061, disease-free survival; p=0.557). NAFLD was a significant risk factor for mortality in multivariable analysis (HR, 2.077; 95% CI, 1.052–4.102; p=0.035). After stratifying for subtypes of breast cancer, the L/S ratio remained a significant predictor of overall, disease-free, local recurrence-free, and regional recurrence-free survivals in only the hormone receptor-positive/HER2−negative subtype (p=0.007, 0.005, 0.009, and &amp;lt; 0.001, respectively). Conclusion: NAFLD is significantly associated with decreased overall survival, disease-free survival and increased regional recurrence in patients with breast cancer especially the hormone receptor-positive/HER2−negative subtype. NASH-related fibrosis was not associated with survival. Therefore, NAFLD should be assessed in the preoperative setting for predicting long-term prognoses of breast cancer patients Citation Format: Hyunsu Yeoh, Siwon Jang, Jong-Ho Cheun, Jin Ah Kwon, Myoung Seok Lee, Bumjo Oh, In Sil Choi, Sohee Oh, Jongjin Kim, Jeong Hwan Park, Won Kim, Ki-Tae Hwang. Prognostic impact of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis-related liver fibrosis on postoperative long-term outcomes of breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-06.

Factors Affecting Local and Regional Recurrence-Free Survival in Triple Negative Breast Cancer Patients: A Single Center Experience

Üçlü negatif meme kanserinde (ÜNMK) hastalık erken evrede tespit edilse de, hastalıksız sağkalım (HSK) ve sağkalım, ÜNMK olmayanlara göre daha düşüktür ve lokal nüks/ uzak metastaz daha erken ortaya çıkma eğilimindedir. Lokal ileri ÜNMK hastalarında neoadjuvan tedavi (NKT) öncelikle tercih edilmektedir. NKT ve tedaviye patolojik tam yanıt (pCR) ise HSK artırmaktadır. Bu çalışma Uludağ Üniversitesi Tıp Fakültesi Meme Cerrahi Kliniğinde ÜNMK tanısı ile ameliyat edilen hastaların lokal ve bölgesel rekürrens (LBR) oranlarına ve rekürrenssiz sağkalımına (LBRSK) etki eden faktörlerini ortaya konulması amaçlanmıştır. 2007-2020 yılları arasında ameliyat edilen hastaların demografik, klinik, patolojik verileri ve sağkalım oranları retrospektif olarak analiz edildi. İstatistiksel analizler SPSS v23 istatistik programı kullanılarak yapıldı. 173 hastanın 83’ü (%47,7) premenopozal ve yaş ortalaması 49,36+12,29 yıldı. Hastaların 106’sı (%63,8) lokal evre, 59’u (%34,1) lokal ileri evre ve 8’i (%4,6) metastatikti. 101 (%58,4) hastaya neoadjuvant, 69 (%40) hastaya adjuvant kemoterapi verildi. 122 (%70,5) hastaya meme koruyucu cerrahi, 99 (%57,2) hastaya sentinel lenf nodu örneklemesi yapıldı. Genel takip süresi ortanca değeri 57,5 ay içerisinde, 34 (%19,7) hasta yaşamını yitirdi. Ortanca rekürrens zamanı 33 ay içerisinde ise 16 (%11,8) hastada lokal nüks, 39 (%26,6) hastada sistemik nüks izlendi. 3-yıllık LBRSK oranı %47,3 izlendi. ÜNMK’de lokal ve sistemik nüks varlığında LBRSK oranları adjuvant ve neoadjuvant tedavide benzer izlenmiştir. NKT sonrası lokal ve rejyonel rekürrensi artıran ve rekürrenssiz sağkalımı azaltan en önemli faktör N3 hastalık ve premenopozal durum olarak izlenmiştir.

Carotid space involvement is a prognostic factor and marker for induction chemotherapy in patients with nasopharyngeal carcinoma

ObjectivesThe carotid space is an integral part of the parapharyngeal space, with ambiguous prognostic value for patients with nasopharyngeal carcinoma (NPC). This study aimed to investigate the prognostic significance of carotid space involvement (CSI) and propose a treatment strategy. Materials and methodsThis retrospective study enrolled 792 patients with biopsy-confirmed, non-distant metastatic NPC staged by magnetic resonance imaging before treatment. We used multivariable Cox regression models and Kaplan–Meier methods to assess the association between the variables and survival outcomes. A matched-pair method (1:1) was used to compare the survival differences between the patients with CSI treated with induction chemotherapy (ICT)and that of those who were not. ResultsThe incidence rate of CSI was 21.7 % (172/792). Multivariate analysis revealed that CSI was not an independent prognostic factor for survival outcomes in the 792 patients with NPC; however, the Chi-square test showed a different distribution of treatment strategies with ICT for patients with and without CSI. After stratification by ICT, CSI was an independent prognostic factor for overall survival (OS) (p = 0.049) in patients without ICT, but not for distant metastasis-free, local recurrence-free, or progression-free survival (p˃0.05). Additionally, ICT improved OS in patients with CSI (hazard ratio, 0.42; p = 0.019). Matched pair analysis showed that patients with CSI gained prolonged OS from ICT compared with the non-ICT group (88.4 % vs 69.4 %, p = 0.028). ConclusionCSI was an independent negative prognostic factor for OS in patients with NPC without ICT and might be an imaging marker for identifying eligible candidates for ICT.

Ultra-Accelerated Photons, Protons or Brachytherapy for Favorable Early Breast Cancer: Long-Term Results of a 3-Fraction Partial Breast Irradiation Trial

<h3>Purpose/Objective(s)</h3> To report long-term outcomes of a novel partial breast irradiation (PBI) regimen. We hypothesized that condensing treatment to 3 fractions and reducing total dose could improve the therapeutic ratio based on emerging evidence that breast cancer (BC) is more sensitive than surrounding normal tissues to high dose fractions. <h3>Materials/Methods</h3> We conducted a phase 2 trial of photon, proton, or brachytherapy PBI. Technique was selected at physician and patient discretion. Eligible women were age ≥ 50 years and s/p lumpectomy with negative sentinel nodes for estrogen receptor positive (ER+) invasive BC without preoperative chemotherapy or any ductal carcinoma in-situ (DCIS) measuring ≤ 2.5 cm. The regimen was designed to have comparable biologically effective dose as 40 Gy in 15 fractions, assuming an α/β ratio of 3.5. Photon and proton target volumes were post-operative tumor bed plus 1 cm and a 3 mm setup uncertainty margin and prescribed 21.9 Gy (RBE) in 3 fractions. Intracavitary brachytherapy was prescribed 21 Gy in 3 daily fractions. Radiotherapy was administered on 3 consecutive business days. Primary outcome was nurse-assessed adverse (fair/poor) cosmesis by 4-point Harvard scale at 3 years versus pre-PBI. Patients completed quality of life and self-reported cosmesis surveys. Adverse events were assessed using CTCAE, v 4.0. <h3>Results</h3> Between 2015 and 2017, 162 eligible patients were treated: photons in 56, protons in 49, and brachytherapy in 57. Median patient age was 67 years. 79% had invasive BC (all ER+) and 22% had DCIS (83% ER+). Median tumor size was 1.1 cm. Median Ki67 was 10% (IQR 6-17) and grade was 2-3 in 62%. The median of the mean heart/ipsilateral lung doses were photons 0.1/1.6 Gy, protons <0.001/0.1 Gy, and brachytherapy 0.5/0.9 Gy. 55% received endocrine therapy. The proportion of patients with adverse cosmesis (by RN assessment) was 14.4% pre-PBI, 4.0% at 3 years, and 5.6% at last follow-up (at median 4.9 years) with six patients (3.8%, 3 photon, 3 brachytherapy) experiencing cosmetic worsening. 92.7%, 95.9%, and 94.7%, of patients in the photon, proton, and brachytherapy cohorts had good or excellent cosmesis at last follow-up. The proportion with adverse cosmesis by self-report was 0% pre-PBI and 2.0% at 3 years. Four patients developed local recurrence (1 photons, 2 protons, 1 brachytherapy). 5-year local recurrence-free, progression-free, and overall survival were 97.9%, 95.1%, and 96.9%, respectively. There were 2 treatment related grade ≥2 adverse events (grade 2 fibrosis and grade 2 seroma, both brachytherapy associated), and no evidence of deterioration in patient-reported pain, fatigue, breast related or overall quality of life. <h3>Conclusion</h3> Ultra-accelerated 3-fraction PBI exquisitely spared normal tissues, was associated with favorable cosmetic outcomes, disease control, and excellent tolerability. This is an attractive option for small node-negative ER+ BC and DCIS.

Durable complete response is achieved by balloon-occluded transcatheter arterial chemoembolization for hepatocellular carcinoma.

In 2013 and 2014, the development of microcatheters with balloons for the 4‐Fr system and new embolization materials provided various options for transarterial chemoembolization (TACE), expanding the range of treatment strategies. At our hospital, balloon‐occluded TACE (B‐TACE), conventional TACE (C‐TACE), and drug‐eluting bead TACE (DEB‐TACE) have been actively performed for hepatocellular carcinoma (HCC). This study compared the local recurrence‐free (LRF) periods of nodules with complete necrosis (TE4) obtained using each treatment method by extracting the nodules evaluated as complete response by the modified Response Evaluation Criteria in Solid Tumors. We performed 580 TACE procedures between June 2013 and April 2019. Among them, 58 HCC nodules in 43 patients, 33 nodules in 30 patients, and 45 nodules in 25 patients were evaluated as having complete necrosis after C‐TACE, DEB‐TACE, and B‐TACE, respectively. The time to local recurrence for each nodule was defined as the LRF period, and the quality of TE4 for each TACE was examined. Factors related to overall survival and the LRF period were determined by univariate and multivariate analyses, and overall survival and the LRF period were analyzed using the Kaplan–Meier method. Multivariate analysis of the LRF period showed that B‐TACE was an independent factor. The median LRF periods were 39.3, 13, and 9.1 months for B‐TACE, C‐TACE, and DEB‐TACE, respectively. Moreover, B‐TACE had a significantly longer LRF period than C‐TACE and DEB‐TACE. Conclusion: There was no significant difference between C‐TACE and DEB‐TACE. The LRF period of nodules with TE4 was the longest with B‐TACE, suggesting that B‐TACE should be used to achieve a radical cure in patients with HCC.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for rectosigmoid or upper rectal cancer.

Single-incision laparoscopic surgery (SILS) for rectal cancer is technically challenging, and its clinical impact is unclear. The aim of this study was to evaluate clinical outcomes of SILS for rectal cancer compared with multi-port laparoscopic surgery (MPLS). We retrospectively analyzed 357 consecutive patients with stage I-III rectal cancer located in the rectosigmoid or upper rectum who underwent SILS or MPLS between January 2012 and December 2016, using propensity score-matched analysis. After propensity score-matching, we enrolled 204 patients (n = 102 per group). Before matching, significant group-dependent differences were observed in tumor location (p < 0.001). After matching, preoperative clinical factors were similar between groups. SILS was successful in 73.5% of cases, an additional port was required in 23.5%, and 2.9% were converted to open surgery. Compared to the MPLS group, the SILS group showed shorter operative time (192 vs. 211min, p = 0.015) and shorter postoperative hospital stay (9 vs. 11days, p = 0.038). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the SILS group (24) than in the MPLS group (27, p = 0.008). Postoperative recurrence did not differ between groups, either before or after matching. No significant differences in 3-year disease-free, 3-year local recurrence-free, or 5-year overall survival were found between groups. SILS is safe, is feasible, and offers satisfactory oncological outcomes in selected patients with rectosigmoid or upper rectal cancer.

The clinical outcome of hemicortical resection in extremity malignant bone tumors.

Hemicortical resection is challenging when a huge fungating tumor is covering the osteotomy site. We report the clinical outcome of hemicortical resection and reconstruction for primary bone tumors, especially with high-grade histology and extensive circumferential involvement. We retrospectively reviewed 44 patients (males, n = 18; females, n = 26) who underwent hemicortical resection from 2005 to 2014. The median follow-up period was 46.0 (23-178) months. Disease-specific, local recurrence-free, and metastasis-free survival rates of patients in the malignant group at 5 years were 96.6%, 84.5%, and 93.6%, respectively. Among 42 patients, there were local recurrences (n = 6), metastasis (n = 2), and death (n = 1). Surgical margin was an independent prognostic factor for local recurrence (hazard ratio = 5.7; p = 0.038). The recycled autograft and strut allograft groups did not show statistical difference in bone union. Failure rate was 31.8% and local recurrence was the most frequent, followed by infection. Hemicortical resection can be a feasible option for extremity malignant bone tumors. Regarding reconstruction, there were no difference between autograft and allograft in bone union rate. Surgical margin was an independent prognostic factor for local recurrence.

Treatments and Outcomes of Paget’s Sarcoma: Literature Review and Cohort Study

Background Sarcomatous transformation of Paget's disease of bone is a very rare, highly fatal complication. Isolated cohort studies have characterized these findings many times. Still, little has been established concerning the effects of patient and tumor characteristics and treatment type on the oncologic prognosis when defined as local recurrence-free, metastatic disease-free, disease-specific, and overall survival. Questions/Purposes (1) What are the oncologic and clinical characteristics of patients who develop and are diagnosed with Paget’s sarcoma? (2) What are the outcomes when examining variables such as sarcoma type, presentation at diagnosis and treatment in Paget’s sarcoma patients? (3) How have treatment and oncologic prognosis changed in recent decades? Methods A literature review of (n=1,001) Paget’s sarcoma cases, retrieved from previous studies and public databases, and a retrospective analysis on a cohort of all adult patients with Paget’s disease of bone (n=1,872) admitted to two large academic centers between 1979 and 2019 was performed. Medical records and the Social Security Index assessed patient survival. Surgical reports were reviewed to determine margin characteristics and intervention type. Incidences of metastasis and recurrence were based on patient notes and biopsy report review. This two-part study describes the effects of patient and tumor characteristics and treatment type on oncologic prognosis. Results Pooled data from our literature review demonstrated a 5-year overall survival rate of 7.9%, in which patient age was significantly associated with worse survival prognosis (p=0.026). Treatment with surgery and adjuvant therapy was significantly associated with improved overall survival (p=0.006) compared to surgery alone or non-surgical treatment. Examining overall trends historically, neither presenting age nor survival appear to have a significant association with the year of diagnosis, demonstrating an R2 of 0.003 (p=0.48) for age at diagnosis and 0.023 (p=0.39) for survival from 1960 and 2016. From our retrospective cohort study, 32 out of 1,872 Paget’s patients were determined to have Paget’s sarcoma, indicating a prevalence of 1.7% for our database. The 5-year local recurrence-free, metastatic disease-free, disease-specific, and overall survival rates were 12.5%, 15.6%, 12.5%, and 18.8%, respectively. Patient age was significantly associated with worse survival outcomes (p=0.005) in our institutions’ patient registry. Conclusion Including over 1,000 Paget's sarcoma patients in our study greatly strengthens the associations between treatment type and survival. While patients undergoing multimodal therapy reported the greatest longevity, concerns remain for mobility and quality of life. Our cohort study indicates that few factors can effectively predict oncologic outcomes for Paget's sarcoma patients. Age is the strongest underlying factor for poor prognosis. Patient outcomes have not changed significantly in the last 80 years; our literature and cohort study highlights the need for increased clinician awareness and improved treatment modalities for Paget's sarcoma. Level of Evidence Level III, retrospective comparative study and review of other level III studies.

Multimodal image-guided ablation on management of renal cancer in Von-Hippel-Lindau syndrome patients from 2004 to 2021 at a specialist centre: A longitudinal observational study

ObjectivesTo analyse the safety, technical feasibility, long-term renal function and oncological outcome of multimodal technologies in image-guided ablation (IGA) for renal cancer in Von-Hippel-Lindau (VHL) patients, and to evaluate factors that may influence the outcome. MethodsRetrospective analysis of a prospective database of VHL patients who underwent IGA at a specialist centre. Patient's demographics, treatment energy, peri-operative outcome and oncological outcomes were recorded. Statistical analysis was performed to determine factors associated with complication and renal function reduction. The overall, 5 and 10-year cancer specific (CS), local recurrence-free (LRF) and metastasis-free (MF) survival rates were presented with Kaplan-Meier Curves. ResultsFrom 2004 to 2021, 17 VHL patients (age 21–68.2) with a mean (±SD) RCC size of 2.06 ± 0.92 cm received IGA. Median (IQR) RCCs per patient was 3 (2–4) over the course of follow up. Fifty-four RCCs were treated using radiofrequency ablation (n = 11), cryoablation (n = 38) and irreversible electroporation (n = 8) in 50 sessions. Primary and overall technical success rate were 94.4% (51/54) and 98% (53/54). One CD-III complication with proximal ureteric injury. Five patients in seven treatment sessions experienced a >25% reduction of eGFR immediately post-IGA. All patients have preservation of renal function at a median follow-up of 79 (51–134) months. The 5 and 10-year CS, LRF and MF survival rates are 100%, 97.8% and 100%. Whilst, the 5 and 10-year overall survival rate are100% and 90%. ConclusionMultimodal IGA of de novo RCC for VHL patients is safe and has provided long term preservation of renal function and robust oncological durability.

Five-Fraction Prone Accelerated Partial Breast Irradiation: Long-Term Oncologic, Dosimetric, and Cosmetic Outcome

PurposeRandomized data support accelerated partial breast irradiation (APBI) for early-stage breast cancer with variable techniques and cosmesis outcomes. We have treated patients with 5-fraction prone external beam APBI for over a decade and herein report acute and late outcomes. Methods and MaterialsPatients receiving APBI 600 cGy × 5 between 2010 and 2019 were included. APBI was primarily delivered prone, with opposed tangents targeting the tumor bed expanded by 1.5 cm (cropped 6 mm from skin). Ipsilateral breast was constrained to V50% < 60% and V100% < 35%. Survival was estimated with Kaplan-Meier. Late toxicities and clinician- and patient-rated cosmesis were evaluated for patients with >6 months follow-up (FU). ResultsOf 345 patients meeting criteria, 14 were excluded due to APBI given for ipsilateral breast tumor recurrence (IBTR; n = 3), palliation (n = 9), and incomplete radiation therapy course (n = 2). Of the 331 remaining, median age was 70, 7.2% had ductal carcinoma in situ, and 94.3% were treated prone, with 32% treated every other day and 68% on consecutive days. Mean heart dose was 23.8 cGy for left-sided and 12.7 cGy for right-sided cancers. Ipsilateral lung V30% was 0.4%. At 5-year median FU, there were 7 (2.1%) IBTR, 9 (2.7%) contralateral recurrences, and 1 (0.3%) distant metastasis. Five-year local recurrence-free, disease-free, and overall survival was 99.5%, 96.7%, and 98.1%, respectively. When comparing patients with IBTR versus without, a higher proportion did not receive hormone therapy (71.4% vs. 26.2%, P = .018). Rates of acute grade 1 to 2 dermatitis, fatigue, and pain were 35.4%, 21.8%, and 9.4%, respectively, with no grade 3 toxicity. The rate of good-excellent physician- and patient-rated cosmesis (n = 199, median FU 2.8 years) was 92.5% and 89.4%, respectively. Patients experienced low rates of telangiectasia, fibrosis, and retraction/atrophy. ConclusionsWe report excellent dosimetric, oncologic, cosmetic, and late toxicity outcomes for patients treated with 5-fraction APBI. To our knowledge this is the largest series of women treated with prone APBI.

Outcomes of Percutaneous Thermal Ablation for Biopsy-Proven T1a Renal Cell Carcinoma in Patients With Other Primary Malignancies.

OBJECTIVE. The purpose of this article is to investigate the oncologic effectiveness and survival outcomes of percutaneous image-guided thermal ablation for clinical T1a renal cell carcinoma (RCC) in patients with other primary nonrenal malignancies. MATERIALS AND METHODS. We reviewed records of patients with histologically proven T1a RCC (< 4.0 cm) treated with thermal ablation over a period of 10 years between January 2005 and December 2014. We recorded past or current history of primary malignancy other than RCC, status of the primary malignancy, tumor histology (in remission or under therapy), and whether patient was currently alive or not, and if not, the date and reason of death. Three cohorts were studied: patients with RCC only (group A), patients with RCC and other primary malignancy in remission (group B), and patients with RCC and other primary malignancy under treatment (group C). The Kaplan-Meier product-limit estimator was used to estimate the survival rates. RESULTS. One hundred nine patients met the inclusion criteria (109 lesions, 110 ablation procedures). There were 46, 45, and 18 patients in the A, B, and C groups, respectively. The 5-year survival was 87%, 63%, and 40% for groups A, B, and C, respectively. The local recurrence-free survival for the whole sample was 95% at 3, 5, and 10 years. The disease-free survival was 96%, 93%, and 91% at 3, 5, and 10 years. Although a significant difference is noted between the three cohorts in overall survival (p = .02); for RCC, there were no significance differences in the local recurrence-free, disease-free, metastasis-free, and cancer-specific survivals. In addition, there was no difference in outcomes for patients in group B (in remission) when compared with those in group C (under treatment). CONCLUSION. Thermal ablation is an effective and safe modality of treatment of T1a RCC in patients with other primary malignancies that are in remission or under treatment.

Irreversible electroporation (IRE) in renal cell carcinoma (RCC): a mid-term clinical experience

ObjectivesTo evaluate the safety and efficacy of CT-guided IRE of clinical T1a (cT1a) renal tumours close to vital structures and to assess factors that may influence the technical success and early oncological durability.MethodsCT-guided IRE (2015–2020) was prospectively evaluated. Patients’ demographics, technical details/success, Clavien-Dindo (CD) classification of complications (I–V) and oncological outcome were collated. Statistical analysis was performed to determine variables associated with complications. The overall 2- and 3-year cancer-specific (CS), local recurrence-free (LRF) and metastasis-free (MF) survival rates are presented using the Kaplan-Meier curves.ResultsThirty cT1a RCCs (biopsy-proven/known VHL disease) in 26 patients (age 32–81 years) were treated with IRE. The mean tumour size was 2.5 cm and the median follow-up was 37 months. The primary technical success rate was 73.3%, where 22 RCCs were completely IRE ablated. Seven residual diseases were successfully ablated with cryoablation, achieving an overall technical success rate of 97%. One patient did not have repeat treatment as he died from unexpected stroke at 4-month post-IRE. One patient had CD-III complication with a proximal ureteric injury. Five patients developed > 25% reduction of eGFR immediately post-IRE. All patients have preservation of renal function without the requirement for renal dialysis. The overall 2- and 3-year CS, LRF and MF survival rates are 89%, 96%, 91% and 87%.ConclusionCT-guided IRE in cT1a RCC is safe with acceptable complications. The primary technical success rate was suboptimal due to the early operator’s learning curve, and long-term follow-up is required to validate the IRE oncological durability.Key Points• Irreversible electroporation should only be considered when surgery or image-guided thermal ablation is not an option for small renal cancer.• This non-thermal technique is safe in the treatment of small renal cancer and the primary technical success rate was 73.3%.• This can be used when renal cancer is close to important structure.

Rates and Patterns of Recurrences and Survival Outcomes after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium.

There have been concerns about higher incidence of local and retroperitoneal recurrences after robot-assisted radical cystectomy compared to open radical cystectomy. We report and detail relapses following robot-assisted radical cystectomy using a multinational database. A retrospective review of the International Robotic Cystectomy Consortium was performed. Data were reviewed for demographics, and perioperative, pathological and oncologic outcomes. Relapse rates and patterns were analyzed. Kaplan-Meier curves were used to depict relapse-free, local recurrence-free, distant metastasis-free and overall survival. Kaplan-Meier curves were further stratified by disease stage, lymph node status and margins. Multivariate stepwise Cox regression models were used to identify variables associated with relapse-free, local recurrence-free, distant metastasis-free and overall survival. Of 2,107 patients 521 (25%) experienced disease relapse. Mean age (SD) was 68±10 years with a median followup of 26 (IQR 11-55) months for the study cohort. Local recurrences were observed in 11% and distant metastases in 18%. Early oncologic failure (within 3 months) occurred in 4% of patients. The most common sites of local recurrence and distant metastasis were the pelvis (5%) and lungs (6%)/extrapelvic lymph nodes (5%), respectively. Abdominal wall/port site metastasis occurred in 1.2% and peritoneal carcinomatosis in 1.2%. Five-year relapse-free, local recurrence-free, distant metastasis-free and overall survival was 66%, 84%, 74% and 60%, respectively. Patients with higher disease stage, positive lymph nodes and positive soft tissue surgical margins demonstrated worse relapse-free, local recurrence-free, distant metastasis-free and overall survival (log rank p <0.01 for all comparisons). Multivariate regression models identified that node positive status and disease stage (pT3 or greater) were significantly associated with relapse-free, local recurrence-free, distant metastasis-free and overall survival (p <0.01). Disease stage remains the main variable associated with disease relapse and survival following radical cystectomy. Robot-assisted radical cystectomy was not associated with different patterns or higher relapse rates compared to historic open radical cystectomy data.

Reactive Oxygen Species Modulator 1 is Associated with Poor Survival in Patients with Non-Small Cell Lung Cancer After Stereotactic Fractionated Radiosurgery: A Retrospective Pilot Study.

PurposeIt has been reported that the overexpression of reactive oxygen species modulator 1 (Romo1) is significantly associated with poor survival outcomes in patients with lung cancer who received surgical resection, conventional fractionated radiotherapy, and chemotherapy. In this study, we investigated whether Romo1 expression is associated with survival outcomes in patients with early-stage lung cancer who were treated with radiosurgery.MethodsRomo1 protein expression was evaluated and scored in the tumor tissue specimens of 40 patients with non-small cell lung cancer by immunohistochemistry. An optimal cut-off for Romo1 expression was determined and used to allocate patients to low or high Romo1 expression groups. Survival outcomes were compared between the two groups.ResultsRomo1 expression was significantly associated with distant metastasis-free survival. The 1- and 2-year distant metastasis-free survival rates were 96.4% and 92.6% in the low Romo1 expression group and 87.5% and 46.7% in the high Romo1 expression group (P=0.041), respectively. The overall, local recurrence-free, regional recurrence-free, and disease progression-free survival rates were higher in the low Romo1 expression group than the high Romo1 expression group. However, the differences were not statistically significant.ConclusionRomo1 overexpression is associated with poor distant metastasis-free survival in patients with non-small cell lung cancer treated with radiosurgery. Further, large-scale prospective studies are required to identify the clinical efficacy of Romo1 as a potential adverse prognostic factor in lung cancer.

Long-term outcomes of patients with conserved breast cancer treated with adjuvant hypofractionated prone breast intensity-modulated radiation therapy.

New techniques for adjuvant radiation therapy after breast conservation include prone positioning, hypofractionation and intensity-modulated radiation therapy (IMRT). Long-term evaluations of this combination are lacking, and we report our own experience. Patients with invasive breast cancer followed for a minimum 36months post-IMRT were eligible. Dose used was 40 Gray in 15 fractions over 3weeks to the whole breast via forward-planned prone, whole breast IMRT. A 10Gy in 5 fraction supine boost was offered. Between January 2012 and January 2020, 2199 patients had breast conservation and adjuvant radiation: 489 received hypofractionated prone breast IMRT, with 155 eligible for our evaluation. Median follow-up was 52months. Median age was 62 (range 36-80), 78.7% were T1, 20.6% were T2, and 12.3% were node-positive. Grade was 1 in 26.5%, 2 in 43.9% and 3 in 29.7%; 87.1% were oestrogen receptor positive, 3.2% were HER2 positive, and 11.0% were triple negative. 58.6% received a boost, 74.8% endocrine therapy and 32.3% chemotherapy. No patient developed local recurrence. One regional recurrence was successfully salvaged. Six patients (3.9%) developed metastases, and 1.9% died. Five-year actuarial local recurrence-free, regional recurrence-free and breast cancer-specific survival rates were 100.0%, 98.2% and 94.8%. Late grade 1 and 2 breast pain occurred in 20.0% and 1.3% of patients. Only 11.0% had new pain compared to pre-radiation. No patient developed radiation-induced pneumonitis, pulmonary fibrosis, rib fracture or cardiac toxicity. All patients scored cosmesis as 'good' or better. Adjuvant hypofractionated prone breast IMRT has excellent locoregional control and minimal toxicity.

Primary urethral cancer: treatment patterns and associated outcomes.

To evaluate treatment patterns and associated outcomes of patients with urethral cancer. After obtaining institutional review board approval we identified 165 patients treated for primary urethral cancer between 1956 and 2017. Treatment included monotherapy (surgery or radiation), dual therapy (surgery+radiation, surgery+chemotherapy, or chemotherapy+radiation) or triple therapy (surgery+radiation+chemotherapy). Rates of different treatments were described by treatment year. The association between treatment type and outcomes was evaluated withmultivariable Cox regression models, adjusting for disease characteristics. The study cohort included 74 men and 91 women, with a median age of 61years. Common histologies were squamous cell (36%), urothelial (27%) and adenocarcinoma (25%). At presentation, 72% of patients had invasive disease, 24% had nodal involvement, and 5% had metastases. Treatment included monotherapy (57%), dual therapy (21%), and triple therapy (10%). The use of monotherapy decreased over time, while rates of dual therapy remained consistent, and rates of triple therapy increased. The median follow-up was 4.7years. Estimated 5-year local recurrence-free, disease-specific and overall survival were 51%, 48% and 41%, respectively. Monotherapy was associated with decreased local recurrence-free survival after adjusting for stage, histology, sex and year of treatment (P = 0.017). There was no evidence that treatment type was associated with distant recurrence, cancer-specific or overall survival. We found preliminary evidence that multimodal therapy, more commonly used in recent years, was of benefit in patients with primary urethral cancer. This finding should be confirmed in further studies involving multiple centres because of the low incidence of the disease.

Influence of complications following total mastectomy and immediate reconstruction on breast cancer recurrence.

Immediate breast reconstruction is safe from an oncological perspective, but the relatively high rate of postoperative complications raises oncological concerns. The present study aimed to evaluate the potential influence of postoperative complications after immediate breast reconstruction on breast cancer recurrence and survival. Patients with breast cancer who had total mastectomy and immediate reconstruction between 2008 and 2013 were followed for at least 5 years. The impact of postoperative complications on oncological outcomes was assessed using multivariable Cox regression analyses. In total, 438 patients with a median follow-up of 82 months were analysed. Five-year local recurrence-free, disease-free and overall survival rates were 95·4, 93·1 and 98·4 per cent respectively. Postoperative complications developed in the operated breast in 120 patients (27·4 per cent) and at other sites (flap donor) in 30 patients (6·8 per cent). Development of breast complications was associated with significantly increased rate of recurrence compared with no complications (16·7 versus 5·9 per cent; P =0·002). In multivariable analysis, patients with breast complications had significantly worse disease-free survival than those with no complications (hazard ratio (HR) 2·25; P=0·015). This remained significant in patients who received adjuvant therapy without delay (8 weeks or less after surgery) (HR 2·45; P=0·034). Development of postoperative complications in the breast can have a negative impact on survival and recurrence after immediate reconstruction.