Occult Lymph Node Involvement Research Articles

Predictors of Occult Nodal Involvement in Clinically Node Negative Primary Parotid Carcinoma: An Updated NCDB Analysis

Predictors of Occult Nodal Involvement in Clinically Node Negative Primary Parotid Carcinoma: An Updated NCDB Analysis

Negative Survival Impact of Occult Lymph Node Involvement in Small HER2-Positive Early Breast Cancer Treated by Up-Front Surgery.

(1) Background: The independent negative prognostic value of isolated tumor cells or micro-metastases in axillary lymph nodes has been established in triple-negative breast cancers (BC). However, the prognostic significance of pN0(i+) or pN1mi in HER2-positive BCs treated by primary surgery remains unexplored. Therefore, our objective was to investigate the impact of pN0(i+) or pN1mi in HER2-positive BC patients undergoing up-front surgery on their outcomes. (2) Methods: We retrospectively analyzed 23,650 patients treated in 13 French cancer centers from 1991 to 2013. pN status was categorized as pN0, pN0(i+), pN1mi, and pNmacro. The effect of pN0(i+) or pN1mi on outcomes was investigated both in the entire cohort of patients and in pT1a-b tumors. (3) Results: Of 1771 HER2-positive BC patients included, pN status distributed as follows: 1047 pN0 (59.1%), 60 pN0(i+) (3.4%), 118 pN1mi (6.7%), and 546 pN1 macro-metastases (30.8%). pN status was significantly associated with sentinel lymph node biopsy, axillary lymph node dissection, age, ER status, tumor grade, and size, lymphovascular invasion, adjuvant systemic therapy (ACt), and radiation therapy. With 61 months median follow-up (mean 63.2; CI 95% 61.5-64.9), only pN1 with macro-metastases was independently associated with a negative impact on overall, disease-free, recurrence-free, and metastasis-free survivals in multivariate analysis. In the pT1a-b subgroup including 474 patients, RFS was significantly decreased in multivariate analysis for pT1b BC without ACt (HR 2.365, 1.04-5.36, p = 0.039) and for pN0(i+)/pN1mi patients (HR 2.518, 1.03-6.14, p = 0.042). (4) Conclusions: Survival outcomes were not adversely affected by pN0(i+) and pN1mi in patients with HER2-positive BC. However, in the case of pT1a-b HER2-positive BC, a negative impact on RFS was observed specifically for patients with pN0(i+) and pN1mi diseases, particularly among those with pT1b tumors without ACt. Our findings highlight the importance of considering the pN0(i+) and pN1mi status in the decision-making process when discussing trastuzumab-based ACt for these patients.

Potential Role for Observation in Small Solid Pseudopapillary Neoplasm (SPN).

Solid pseudopapillaryneoplasms(SPN)arerare tumorsof the pancreas, typically affecting young women.Resection is the mainstay of treatment but is associated with significant morbidity and potential mortality. Weexplore the ideathat small, localized SPN could be safely observed. This retrospective review of the Pancreas National Cancer Database from 2004 to 2018 identified SPN via histology code8452. A total of 994 SPNs were identified. Mean age was 36.8 ± 0.5 years, 84.9% (n = 844) were female, and most had a Charlson-Deyo Comorbidity Coefficient (CDCC) of 0-1 (96.6%, n = 960). Patients were most often staged clinically as cT2 (69.5%, n = 457) followed by cT3 (17.6%, n = 116), cT1 (11.2%, n = 74), and cT4 (1.7%, n = 11). Clinical lymph node and distant metastasis rates were 3.0 and 4.0%, respectively. Surgical resection was performed in 96.6% of patients (n = 960), most commonly partial pancreatectomy (44.3%) followed by pancreatoduodenectomy (31.3%) and total pancreatectomy (8.1%). In patients clinically staged as node (N0) and distant metastasis (M0) negative, occult pathologic lymph node involvement was found in 0% (n = 28) of patients with stage cT1 and 0.5% (n = 185) of patients with cT2 disease. The risk of occult nodal metastasis significantly increased to 8.9% (n = 61) for patients with cT3 disease. The risk further increased to 50% (n = 2) in patients with cT4 disease. Herein, the specificity of excluding nodal involvement clinically is 99.5% in tumors ≤ 4 cm and 100% in tumors ≤ 2 cm. Therefore, there may be a role for close observation in patients with cT1N0 lesions to mitigate morbidity from major pancreatic resection.

18F-FDG primary tumor uptake to improve N status prediction in cT1 non-metastatic non-small cell lung cancer: development and validation of a positron emission tomography model.

Occult lymph node involvement is a major issue in the management of non-small cell lung carcinoma (NSCLC), with an estimated prevalence of approximately 2.9-21.6% in 18F-FDG PET/CT series. The aim of the study is to construct a PET model to improve lymph node assessment. Patients with a non-metastatic cT1 NSCLC were retrospectively included from two centers, one used to constitute the training set, the other for the validation set. The best multivariate model based on Akaike's information criterion was selected, considering age, sex, visual assessment of lymph node (cN0 status), lymph node SUVmax, primary tumor location, tumor size, and tumoral SUVmax (T_SUVmax). A threshold minimizing false pN0 prediction was chosen. This model was then applied to the validation set. In total, 162 patients were included (training set: 44, validation set: 118). A model combining cN0 status and T_SUVmax was selected (AUC 0.907, specificity at threshold: 88.2%). In the validation cohort, this model resulted in an AUC of 0.832 and a specificity of 92.3% versus 65.4% for visual interpretation alone (p = 0.02). A total of two false N0 predictions were noted (1 pN1 and 1 pN2). Primary tumor SUVmax improves N status prediction and could allow a better selection of patients who are candidates for minimally invasive approaches.

Surgical resection of small, localized mucinous cystic neoplasm is associated with improved survival

Background: Mucinous Cystic Neoplasms (MCN) of the pancreas are defined by the presence of ovarian stroma, harbor significant malignant potential and are often treated with surgical resection. The 2018 European consensus guidelines on pancreatic cystic neoplasms suggested a potential role for observation of MCNs which are less than 4cm and have no “high risk features”. This study set out to explore the role of surgery and/or chemotherapy in clinically node negative MCN ≤4cm (T1-2) and the potential for occult lymph node involvement in these small tumors.

REVIEW OF THE ROLE OF BRACHYTHERAPY IN THE MANAGEMENT OF ORAL CAVITY CANCERS

From the day of invention of Radium, brachytherapy has been practised worldwide. Can any technological advancement in external beam radiotherapy replace brachytherapy? Answer probably no, especially in Gynaecological cancers as categorically stated by GEC-ESTRO experts. External beam radiation therapy using contemporary conformal techniques and brachytherapy play a signicant role in the management of oral cavity cancer. Small sized tumors in most of the oral cavity sites can be managed with brachytherapy alone either with intraoral cone or interstitial brachytherapy in order to minimize exposure of normal tissue. As these techniques do not treat regional lymph node basins, they are only appropriate to use as a single modality in selected stage I and II patients. The risk of occult nodal involvement in stage I and II is very low. External beam radiation therapy to the draining lymph node regions is used as the primary mode of irradiation when regional lymph nodes are at signicant risk for subclinical involvement, and brachytherapy may be added as a boost to the primary tumor. Since head and neck cancers are Surgeons domain, number of patients reporting to Radiation Oncology department is too low to carry out large randomized trial. Most of the patients report to Radiation Oncology department in either in late stage or in an early stage with poor general condition. This paves the way for selection bias and, of course, inferior results when compared with other modality. To evaluate the role of this therapy in treatment of head and neck cancers, we have reviewed its outcomes with oral cavity cancer. In conclusion, brachytherapy with or without EBRT can be an alternative to surgery in early and locally advanced oral cavity cancers although concrete evidence is yet to be produced with a sophisticated study in a reproducible manner

Does the character of the hospital of primary management influence outcomes in patients treated for presumed early stage endometrial cancer and atypical endometrial hyperplasia: a comparison of outcomes from a cancer unit and cancer centre

A retrospective study from 2015 to 2020 comparing overall survival (OS) outcomes of a cancer unit and centre for presumed early stage endometrial cancers is presented. Cancer centres manage these presumed early endometrial cancer (EC) in situations of complex co-morbidities, surgical challenges as well as their own local unit patients. Our analysis compares 138 patients at KMH (unit) and 282 patients at RDH (centre) on OS, patient demographics, grading histology and final histology. Patients with presumed early stage EC can be reassured regarding no difference in OS between the cancer unit and centre management (p = .05). However, rates of minimal access surgery were higher at the cancer centre compared to the unit (93.2% versus 68.1%). The rates of upstaged disease were 4% and 8.8% at the cancer unit and centre respectively (p = .096). Sentinel node biopsy and genomic assessment may change future thresholds for centre-level management due to rates of upstaged disease. Impact Statement What is already known on this subject? Presumed lower risk endometrial cancers (endometrioid grades 1 and 2) have a rate of occult nodal involvement of only 1.4%. The BGCS does not recommend lymphadenectomy for low-risk endometrial cancers. These low-risk endometrial cancers should be managed with a hysterectomy and bilateral salpingo-ophrectomy via minimal access surgery. In view of the low rates of occult nodal involvement in low-risk endometrial cancer, surgery can be offered at a cancer unit. What do the results of this study add? Our study demonstrates there is no disadvantage in overall survival in the surgical management of presumed low-risk endometrial cancers at cancer units and centres. However, cancer centres have higher rates of minimal access to surgery despite managing a more elderly population. Our rates of upstaged disease of 4% and 8.8% at the cancer unit and centre indicate a potential benefit of pelvic lymph node assessment. What are the implications of these findings for clinical practice and/or further research? Sentinel lymph node biopsy does not have the surgical morbidity associated with systematic lymph node dissection. Therefore, when applied to presumed early stage endometrial cancer, there are potential changes in the threshold for centre-level management to improve overall survival.

Deep Learning Analysis Using 18F-FDG PET/CT to Predict Occult Lymph Node Metastasis in Patients With Clinical N0 Lung Adenocarcinoma.

IntroductionThe aim of this work was to determine the feasibility of using a deep learning approach to predict occult lymph node metastasis (OLM) based on preoperative FDG-PET/CT images in patients with clinical node-negative (cN0) lung adenocarcinoma.Materials and MethodsDataset 1 (for training and internal validation) included 376 consecutive patients with cN0 lung adenocarcinoma from our hospital between May 2012 and May 2021. Dataset 2 (for prospective test) used 58 consecutive patients with cN0 lung adenocarcinoma from June 2021 to February 2022 at the same center. Three deep learning models: PET alone, CT alone, and combined model, were developed for the prediction of OLM. The performance of the models was evaluated on internal validation and prospective test in terms of accuracy, sensitivity, specificity, and areas under the receiver operating characteristic curve (AUCs).ResultsThe combined model incorporating PET and CT showed the best performance, achieved an AUC of 0.81 [95% confidence interval (CI): 0.61, 1.00] in the prediction of OLM in internal validation set (n = 60) and an AUC of 0.87 (95% CI: 0.75, 0.99) in the prospective test set (n = 58). The model achieved 87.50% sensitivity, 80.00% specificity, and 81.00% accuracy in the internal validation set and achieved 75.00% sensitivity, 88.46% specificity, and 86.60% accuracy in the prospective test set.ConclusionThis study presented a deep learning approach to enable the prediction of occult nodal involvement based on the PET/CT images before surgery in cN0 lung adenocarcinoma, which would help clinicians select patients who would be suitable for sublobar resection.

Mucosal Melanoma of the Oral Cavity: What is the Role of Elective Neck Dissection?

Mucosal melanoma (MM) is a rare malignancy that can present in the head and neck (H&N). The Oral cavity is the second most common primary site in the H&N after sinonasal mucosa. This study investigates the impact of demographic and clinical factors on survival in oral cavity MM. Further, it investigates the outcomes and utility of elective neck dissections (END) in the management of oral MM. The National Cancer Database was used to evaluate 432 patients with oral cavity MM from 2004 to 2016. Kaplan-Meir and Cox regression analyses were used to determine variables associated with survival. The mean age was 64.0 ± 16.0 years. Most patients were white (85.1%) and male (60.0%). Gingiva (37.6%) and hard palate (36.1%) were the most common primary subsites in the oral cavity. Five-year overall survival was 31.0%. Age (Hazards Ratio [95% Confidence Interval], 1.03 [1.01-1.06]), N-stage (1.94 [1.10-3.42]), M-stage (10.13 [3.33-30.86]), male sex (1.79 [1.06-3.03]), and African-American race (2.63 [1.14-6.11]) were significantly associated with worse survival. 199 patients (46.9%) underwent neck dissection including 118 with lymph node yield (LNY) ≥ 18. The rate of occult nodal positivity was 45.4% for LNY ≥ 18 and 28.3% for LNY ≥ 1. ENDs were not associated with improved outcomes. However, occult lymph node involvement was associated with worse overall survival (p=0.004). Oral cavity MM has a poor prognosis. Lymph node involvement, distant metastasis, age, race, and male sex are associated with worse outcomes. Performing an END did not improve survival. However, END may have a prognostic role and help select patients for treatment intensification. 4 Laryngoscope, 133:317-326, 2023.

Semaphorin-3F/Neuropilin-2 Transcriptional Expression as a Predictive Biomarker of Occult Lymph Node Metastases in HNSCC

Simple SummaryThe presence of lymph neck node metastasis is the most important clinical prognostic factor in patients with head and neck squamous cell carcinoma. The expression of the semaphorin-3F and neuropilin-2 proteins is involved in the regulation of lymphangiogenesis. We analized the transcriptional expression of semaphorin-3F and neuropilin-2 in head and neck squamous cell carcinoma tumors of patients without clinical or radiology evidence of lymph node involvement treated with elective neck dissection. We found that patients with high semaphorin-3F and low neuropilin-2 had a lower risk of occult lymph node metastasis than the ones who had low semaphorin-3F or high semaphorin-3F and high neuropilin-2. If our results are validated, the expression of the SEMA3F-NRP2 axis could be used as a biomarker predicting the risk of occult lymph node metastasis, with elective neck dissections being indicated exclusively for patients at higher risk. The availability of a biomarker with the capacity to predict the presence of occult lymph node metastases would make it possible to avoid elective neck dissections in low-risk patients, with the consequent decrease in surgical time and morbidity of the treatment without impairing the oncologic outcome.The expression of the semaphorin-3F (SEMA3F) and neuropilin-2 (NRP2) is involved in the regulation of lymphangiogenesis. The present study analyzes the relationship between the transcriptional expression of the SEMA3F-NRP2 genes and the presence of occult lymph node metastases in patients with cN0 head and neck squamous cell carcinomas. We analyzed the transcriptional expression of SEMA3F and NRP2 in a cohort of 53 patients with cN0 squamous cell carcinoma treated with an elective neck dissection. Occult lymph node metastases were found in 37.7% of the patients. Patients with occult lymph node metastases (cN0/pN+) had significantly lower SEMA3F expression values than patients without lymph node involvement (cN0/pN0). Considering the expression of the SEMA3F-NRP2 genes, patients were classified into two groups according to the risk of occult nodal metastasis: Group 1 (n = 34), high SEMA3F/low NRP2 expression, with a low risk of occult nodal involvement (14.7% cN0/pN+); Group 2 (n = 19), low SEMA3F or high SEMA3F/high NRP2 expression, with a high risk of occult nodal involvement (78.9% cN0/pN+). Multivariate analysis showed that patients in Group 2 had a 26.2 higher risk of lymph node involvement than patients in Group 1. There was a significant relationship between the transcriptional expression values of the SEMA3F-NRP2 genes and the risk of occult nodal metastases.

Predictors of Occult Nodal Involvement in Clinically Node Negative Primary Parotid Carcinoma: An NCDB Analysis

<h3>Purpose/Objective(s)</h3> Primary Parotid Carcinomas (PPC) comprise a wide array of histologies, each with varying propensity for local invasion and cervical nodal involvement. Upfront surgical excision of the primary tumor constitutes the standard of care for PPC, but there exists little consensus regarding management of the clinically negative neck (cN0). We conducted a clinicopathologic correlative analysis of the National Cancer Database (NCDB) to identify predictors of occult nodal involvement in PPC to guide elective neck management. <h3>Materials/Methods</h3> The NCDB was queried for adults with a first malignant diagnosis of cN0M0 cancer of the parotid who underwent adequate surgical resection (defined as subtotal to radical parotidectomy with ³18 nodes examined) without pre-surgical treatment. Pathologic T-classification, tumor size, histology, grade, lymphovascular space invasion (LVSI), gender, and age at diagnosis were specified <i>a priori</i> as variables of interest. The primary outcome, occult nodal positivity (<i>i.e.</i> cN0 but pN+), was assessed by univariable (UVA) and multivariable (MVA) logistic regression analysis, depicted as odds ratios (OR) and corresponding 95% confidence intervals (95% CI) with a prespecified threshold for statistical significance of <i>p</i>£0.05. Recursive partitioning analysis (RPA) was subsequently performed to categorize patients according to their calculated risk of occult nodal disease. <h3>Results</h3> From an initial cohort of 41,445 patients with PPC 978 met inclusion criteria and were included for analysis, of whom 331 (33.8%) had occult nodal involvement. By UVA, the incidence of occult nodal positivity was significantly higher in male patients, those aged 72 and older, patients with high grade disease, pT4 classification, adenocarcinoma histology, a >4cm tumor, and those with positive LVSI. On MVA, tumor size, age, and gender were no longer significantly associated with occult nodal involvement; however, LVSI (OR 6.1, 95% CI 4.3-8.8), carcinoma ex-pleomorphic adenoma (OR 5.6, 95% CI 2.1-14.8), adenocarcinoma (OR 5.1, 95% CI 2.6-9.9), salivary duct (OR 4.0, 95% CI 1.8-8.6), or mucoepidermoid (OR 2.3, 95% CI 1.2-4.3) histology, pT3 (OR 2.0, 95% CI 1.1-3.7) or pT4 (OR 3.9, 95% CI 2.1-7.3) status, and high grade (OR 2.0, 95% CI 1.4-3.0) remained significant. LVSI, histology, pT status, and grade were further evaluated with RPA, which identified LVSI as the strongest predictor of occult nodal involvement (57.1% vs 42.9%, <i>p</i><0.01). <h3>Conclusion</h3> LVSI appears to supersede tumor histology, grade, size, and pT status as the strongest risk factor for occult nodal involvement in PPC. To our knowledge, this is the largest series to evaluate this pathologic feature. Further research into this heretofore underappreciated risk factor and its implications for management of the cN0 neck is warranted.

Quantifying the rate and predictors of occult lymph node involvement in patients with clinically node-negative non-small cell lung cancer

Purpose It is essential to evaluate the risk of occult lymph node (LN) disease in early-stage non-small cell lung cancer (NSCLC), especially because delivering stereotactic ablative radiotherapy (SABR) assumes no occult spread. This study was designed to assist clinicians in roughly quantifying this risk for cN0 NSCLC. Methods The National Cancer Data Base was queried for cN0 cM0 lung squamous cell or adenocarcinoma who underwent surgery and LN dissection without neoadjuvant therapy. Statistics included multivariable logistic regression to evaluate factors associated with pN + disease. Results 109,964 patients were included. For tumors with size ≤1.0, 1.1–2.0, 2.1–3.0, 3.1–4.0, 4.1–5.0, 5.1–6.0, 6.1–7.0, and >7.0 cm, the pN + rate was 4.4, 7.7, 12.9, 18.0, 20.2, 22.5, 24.4, and 26.4%, respectively. When examining patients with more complete LN dissections (defined as removal of at least 10 LNs), the respective values were 6.6, 11.5, 17.6, 25.3, 26.8, 29.7, 30.7, and 31.6%. Moderately-poorly differentiated disease and adenocarcinomas were associated with a higher rate of pN + disease (p < .001 for both). For every cm increase in tumor size, the relative occult nodal risk increased by 10–14% (p < .001). For every elapsed day from initial diagnosis, the relative risk increased by ∼1% (p < .001). Graphs with best-fit lines were created based on tumor size, histology, and differentiation to aid physicians in estimating the pN + risk. Conclusions This nationwide study can allow clinicians to roughly estimate the rate of occult LN disease in cN0 NSCLC. These data can also assist in guiding enrollment on randomized trials of SABR ± immunotherapy, individualizing follow-up imaging surveillance, and patient counseling to avoid post-diagnosis delays.

Invasive Lobular Breast Cancer: Data to Support Surgical Decision Making

Invasive lobular carcinoma (ILC) is thought be a unique entity with higher rates of multifocal/multicentric and bilateral disease. This study aimed to evaluate the true extent of the disease, risk of bilaterality, lymph node involvement, and impact of preoperative imaging to help guide surgical decisionmaking. A retrospective analysis identified patients treated for ILC between 2004 and 2017. Clinical staging and pathologic results were compared. Follow-up details including local recurrence, contralateral breast cancer (CBC), and survival outcomes were evaluated. The study identified 692 patients with ILC, including 43 patients (6%) with a diagnosis of CBC and 232 patients (33%) with a diagnosis of multifocal/multicentric disease at presentation. Preoperative magnetic resonance imaging (MRI) led to an identification of additional disease in 20% of the patients. Preoperative MRI resulted in a more accurate prediction of tumor size staging but did not improve the discordance between clinical and pathologic nodal staging. Overall, the rate of imaging occult lymph node disease was 24%. At the 6-year follow-up evaluation, a local recurrence had developed in 2.3%, a CBC in 2.3, and a distant metastasis in 9.4% of the patients. The overall survival rate was 96% at 3 years and 91% at 5 years. Invasive lobular carcinoma is a distinct subset of cancer that poses a diagnostic staging challenge. The results of this study favor MRI for accurate tumor staging and for improving detection of multicentricity and bilaterality. However, clinicians should be aware of the higher likelihood of occult lymph node involvement with ILC and subsequent early metastasis.

Outcome after resection of occult and non-occult lymph node metastases at the time of nephrectomy.

There is sparse evidence on outcomes of resected occult LN metastases at the time of nephrectomy (synchronous disease). We sought to analyse a large international cohort of patients and to identify clinico-pathological predictors of long-term survival. We collected data of consecutive patients who underwent nephrectomy and LND for Tany cN0-1pN1 and cM0-1 RCC at 7 referral centres between 1988 and 2019. Patients were stratified into four clinico-pathological groups: (1) cN0cM0-pN1, (2) cN1cM0-pN1(limited, 1-3 positive nodes), (3) cN1cM0-pN1(extensive, > 3 positive nodes), and (4) cM1-pN1. Overall survival (OS) was estimated using the Kaplan-Meier method, and associations with all-cause mortality (ACM) were evaluated using Cox models with multiple imputations. Of the 4370 patients with LND, 292 patients with pN1 disease were analysed. Median follow-up was 62months, during which 171 patients died. Median OS was 21months (95% CI 17-30months) and the 5-year OS rate was 24% (95% CI 18-31%). Patients with cN0cM0-pN1 disease had a median OS of 57months and a 5-year OS rate of 43%. 5-year OS (median OS) decreased to 29% (33months) in cN1cM0-pN1(limited) and to 23% (23months) in cN1cM0-pN1(extensive) patients. Those with cM1-pN1 disease had the worst prognosis, with a 5-year OS rate of 13% (9months). On multivariable analysis, age (p = 0.034), tumour size (p = 0.02), grade (p = 0.02) and clinico-pathological group (p < 0.05) were significant predictors of ACM. Depending on clinico-pathological group, grade and tumour size, 5-year survival of patients with LN metastases varies from 13 to 43%. Patients with resected occult lymph node involvement (cN0/pN1 cM0) have the best prognosis with a considerable chance of long-term survival.

Predictors of occult lymph node metastasis in cutaneous head and neck melanoma.

ObjectiveTo use the Surveillance, Epidemiology, and End Results (SEER) database to verify the findings of a recent National Cancer Database (NCDB) study that identified factors predicting occult nodal involvement in cutaneous head and neck melanoma (CHNM) while identifying additional predictors of occult nodal metastasis and comparing two distinct cancer databases.MethodsCases of CHNM in the SEER database diagnosed between 2004 and 2014 were identified. Demographic information and oncologic data were obtained. Univariate and multivariate analysis were performed to identify factors associated with pathologic nodal positivity.ResultsThere were 34002 patients with CHNM identified. Within this population, 16232 were clinically node-negative, 1090 of which were found to be pathologically node-positive. On multivariate analysis, factors associated with an increased risk of occult nodal metastasis included increasing depth of invasion (stepwise increase in adjusted odds ratio [OR]), nodular histology (aOR: 1.47 [95% CI: 1.21–1.80]), ulceration (aOR: 1.74 [95% CI: 1.48–2.05]), and mitoses (aOR: 1.86 [95% CI: 1.36–2.54]). Factors associated with a decreased risk of occult nodal metastasis included female sex (aOR: 0.80 [0.67–0.94]) and desmoplastic histology (aOR: 0.37 [95% CI: 0.24–0.59]). Between the SEER database and the NCDB, factors associated with occult nodal involvement were similar except for nodular histology and female sex, which did not demonstrate significance in the NCDB.ConclusionRegarding clinically node-negative CHNM, the SEER database and the NCDB have similarities in demographic information but differences in baseline population sizes and tumor characteristics that should be considered when comparing findings between the two databases.Level of evidence4.

Sentinel node mapping and ductal carcinoma in situ.

Pure ductal carcinoma in situ (DCIS) is typically unassociated with a risk of regional lymph node involvement. Retrospective series maintain that larger tumors or high-grade histopathology may harbor a risk of lymph node involvement. Our community hospital retrospectively reviewed a series wherein women with DCIS were subjected to sentinel lymph node biopsy based on large tumor size and/or high-grade histopathology. 232 consecutive women with a diagnosis of pure DCIS were evaluated independently by two breast surgeons, one who typically offers sentinel node mapping to patients with tumors larger than 10mm and the other who offers sentinel node mapping to women with grade3 tumors. 60 women (26%) underwent sentinel node mapping along with appropriate surgery directed to the breast. Women were offered risk-adjusted adjuvant radiotherapy and anti-endocrine therapy. At a median follow-up of 18months (range 6-132months), 9 women (15%) were identified with regional axillary nodal disease. A statistical analysis was conducted between women who did or did not undergo sentinel node mapping because there was overlap in large tumor size and high grade between the two groups. A univariate logistic regression statistic showed a trend toward a significant relationship between grade3 tumors and a risk of occult nodal involvement. This was not confirmed by multivariate analysis. In our moderate-sized surgical experience evaluating women with pure DCIS who underwent a sentinel node mapping due to large tumor size or high grade histology, we were unable to confirm that either is predictive of occult node involvement.

Contact of a tumour with the pleura is not associated with regional recurrence following stereotactic ablative radiotherapy for early stage non-small cell lung cancer

Background and purposeThe aim was to investigate the incidence of isolated regional failure following stereotactic ablative radiotherapy (SABR) and risk factors for recurrence. Materials and methodsEarly stage non-small cell lung cancer (NSCLC) patients treated with SABR were included in this retrospective cohort study, with isolated regional recurrence (IRR) as primary endpoint, distant recurrence (DR) and overall survival (OS) as secondary endpoints. Survival analyses were performed using the cumulative incidence function (IRR and DR) or the Kaplan–Meier method (OS) and Cox proportional hazards modelling for univariate and multivariate analyses. The prognostic effect of contact between the tumour and the pleura was investigated using the CT scans used for SABR planning. ResultsA total of 554 patients were included, of whom 494 could be analysed for IRR. The median follow-up for surviving patients was 48.1 months. Twenty-one patients developed an IRR (4%). The cumulative incidence of IRR and DR after 1-, 2-, and 5 years was 2%, 3%, 7% and 8%, 15% and 21%, respectively. Two year OS was 71%. The presence and type of pleural contact was not associated with any of the studied outcomes. ConclusionThe presence, type and length of pleural contact as surrogate for visceral pleural invasion were not predictive for outcome. Further studies focussing on risk factors for occult nodal involvement, (I)RR, distant metastases and mortality in early stage NSCLC are warranted for the development of risk adapted diagnostic, treatment and follow-up strategies as more younger, operable and fitter patients receive SABR.

Invasive nodal evaluation prior to stereotactic ablative radiation for non-small cell lung cancer

IntroductionInvasive nodal evaluation (INE) is used to improve staging for early stage non-small cell lung cancer (NSCLC), including when stereotactic ablative radiation (SABR) is used. Consensus guidelines from the NCCN recommend performing INE for patients with T2N0 tumors and considering INE for those with T1N0 tumors. We reasoned that if INE results in significant stage migration in the form of substantially fewer patients with occult nodal involvement, then patients treated with SABR who do not undergo INE should have worse overall survival (OS). MethodsPatients diagnosed 2004–2014 with stage T1–2N0M0 NSCLC and treated with SABR were identified from the National Cancer Database. Factors associated with INE were determined using mixed effects logistic regression. We tested for an association between INE and OS for patients diagnosed 2004–2013 using mixed effects proportional hazards regression methods. Results24,603 SABR patients were identified. 6% of the 19,322 patients with T1 tumors and 9% of the 5281 patients with T2 tumors had INE. Median OS was 2.8 years for the no-INE group and 2.7 years for the INE group (log-rank P = 0.69). No significant association was observed between the use of INE and OS in the univariate analysis (HR 1.02, 95% CI 0.94–1.11) or the multivariate analysis (HR 0.94, 95% CI 0.86–1.02). These findings were confirmed using propensity score matched and instrumental variable analysis. On subgroup analysis, INE was associated with a non-significant trend for improved OS in patients with T2 tumors (HR 0.87, 95% CI 0.76–1.00) but not T1 tumors (HR 0.98, 95% CI 0.88–1.09). ConclusionsDespite current NCCN recommendations, the rate of INE was low for patients with stage T1 or T2 tumors. While omitting INE represents a compromise in the completeness of nodal evaluation, we found that it was not associated with a detriment in overall survival.

Clinicopathologic Factors Predictive of Occult Lymph Node Involvement in Cutaneous Head and Neck Melanoma.

Objectives Evaluate clinicopathologic factors contributing to regional lymph node (LN) metastases in cutaneous head and neck melanoma (HNM). Study Design Retrospective review of a national cancer database. Setting National Cancer Database (2004-2012). Methods National Cancer Database (NCDB) cases diagnosed between 2004 and 2012 were reviewed. Inclusion criteria were head and neck cutaneous site codes, melanoma histology codes, and clinically node-negative status. Independent, clinicopathologic factors associated with pathologic positive LN status were identified by multivariable logistic regression. Subset analysis was performed on thin melanoma cases of 0.75 to 1 mm tumor depth to determine factors predictive of LN involvement and survival. Results Of 66,495 cases meeting inclusion criteria, 18,882 had nodes examined pathologically with 9.7% presenting with occult positive LN involvement. Mean (SD) age was 62.9 (16.13) years, and primary sites were scalp and neck (42.2%), face (40.2%), and external ear, lip, or eyelid (7.6%). Multivariable analysis found younger age; primary site of cutaneous scalp, neck, or face; increasing thickness; mitoses; ulceration; and vertical growth phase presence were independently associated with LN positivity ( P < .001). Only 2% of 0.75- to 1.0-mm Breslow thickness cases had regional LN involvement, and age >70 was negatively associated with LN involvement ( P = .002) in this subset. Conclusion This is the largest study examining factors predictive of occult LN involvement in patients with clinical node-negative cutaneous HNM who may benefit from sentinel LN biopsy. Primary sites of external ear, lip, or eyelid are less likely to present with occult nodal involvement, and older patients with T1a melanoma ≥0.76 mm are unlikely to present with regional node metastasis and may not require sentinel node guided management.

MS 06.05 The Use of Adjuvant IMRT after Pleurectomy/Decortication

MS 06.05 The Use of Adjuvant IMRT after Pleurectomy/Decortication