Node Pathological Stage Research Articles

MS06.04 Approaches to Overcoming the Nodal Staging Quality Gap

MS06.04 Approaches to Overcoming the Nodal Staging Quality Gap

P1.14-45 Surgical Outcome of Non-Small Cell Lung Cancer with Clinical Single Zone N2 in Aortopulmonary Zone (LN#5 and LN#6)

Current staging work-up methodology could not exactly reflect clinical nodal status of aortopulmonary zone (AP zone) without invasive diagnostic tools. The aim of the study is to evaluate the surgical outcome of single zone clinical N2 in AP zone (LN #5 or #6). Between 2009 and 2018, a retrospective data of 7488 patients was reviewed. Patients were included when only lymph nodes in AP zone was suspected to be metastasized based on the results of computed tomography (CT), positron emission tomography (PET-CT) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA). Patients were excluded when metastasis was detected by EBUS-TBNA in other mediastinal lymph node zones. Clinicopathologic variables such as pathologic subtype, differentiation and nodal status were evaluated to identify prognostic factors for survival rate and disease-free survival rate (DFS). Ninety-five patients were included, and median duration of follow-up was 35 months (IQR; 20 – 50). Eighty-four patients underwent upfront surgery, and their pathologic nodal staging was pN0 in 20 patients (23.8%), pN1 in 7 (8.3%), pN2a in 40 (47.6%) and pN2b in 17 (20.2%). Overall 5-year survival and 5-year DFS rate was 55.9% 54.5%, respectively. There was no survival difference between patients with pN0-1, pN2a and pN2b (p = 0.345, figure). Neither pathologic N2 nor N2b was not a risk factor for overall survival rate (p = 0.418, 0.159, respectively) and DFS (p = 0.606, 0.650, respectively). In univariate analysis, there was no other significant clinicopathologic factors for survival and DFS. Eleven patients with neoadjuvant treatment showed a similar 5-year survival rate (43.6%) compared with patients with upfront surgery. Current work-up without invasive tools for cN2a in AP zone showed relatively high false-positive rate (32.1%). However, surgical outcome of cN2a in aortopulmonary zone was comparable. Upfront surgery should be considered in highly selected patients.

Quantitative Metastatic Lymph Node Burden and Survival in Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) is an aggressive cutaneous malignancy that is predisposed to local recurrence and regional lymph node (LN) metastases. Current nodal staging for MCC is based on the location of metastatic LNs (regional versus in-transit) and whether a metastasis is detected macroscopically or only microscopically. However, this may underestimate the cumulative effect of increasing metastatic nodal burden, which is a primary driver of survival in multiple malignancies. To this end, we examined the independent, quantitative impact of metastatic LN burden on survival in a large MCC cohort. Patients with non-metastatic MCC undergoing upfront surgical resection with pathologic LN staging between 2004 and 2014 were identified in the National Cancer Database. Univariate and multivariate models were constructed to evaluate the association between survival and number of metastatic LNs, adjusting for patient, tumor, and demographic factors. Restricted cubic spline functions were used to model the non-linear relationship between number of positive LNs and survival. Recursive partitioning analysis (RPA) was used to derive a novel MCC nodal classification system based on nodal covariates, including number of LNs and regional versus in-transit metastasis. Overall, 4218 patients met inclusion criteria, including 1817 (43%) with at least 1 positive LN and 2711 (57%) with no metastatic LNs. In multivariable models, mortality risk increased continuously without plateau with increasing number of metastatic LNs. The risk of death increased most rapidly for the first 2 positive LNs, (hazard ratio [HR] per LN, 1.53; 95% CI, 1.40-1.67; P<0.001), and continued to increase with each positive LN beyond this (HR per LN, 1.04; 95% CI, 1.02-1.06; P<0.001). RPA identified 4 distinct clusters of patients that were used for a new nodal classification system: 0 LNs (N0), 1-2 LNs (N1), 3-8 LNs (N2), and ≥9 LNs (N3). 5-year overall survival for these patients was 67.2%, 46.8%, 30.2%, and 11.2%, respectively. In multivariable Cox regression, the HR for death in comparison to N0 patients was 1.91, 3.41, and 5.94 (all P<0.001) in RPA-derived nodal classifications N1, N2, and N3, respectively. In comparison, the respective HR for American Joint Committee on Cancer (AJCC) nodal classifications N1a, N1b, and N2 were 1.43, 2.69, and 2.86 (all P<0.001) versus N0 patients. Incorporating the RPA-derived system based on LN number into a model with other patient, tumor, and demographic factors exhibited greater concordance with survival than the AJCC system. The number of metastatic LNs is a primary factor influencing survival in MCC. An RPA-derived nodal classification system based solely on this variable improves the accuracy of patient stratification and partitions patients across a wider spectrum of mortality risk in comparison to the current AJCC system. Thus, metastatic LN number may be used to refine MCC staging and help direct adjuvant treatment recommendations.

Vagus nerve and phrenic nerve guided systematic nodal dissection for lung cancer.

Systematic nodal dissection (SND), which is defined as “all the mediastinal tissues containing the lymph nodes are dissected and removed systematically within anatomical landmarks”, is vital in surgical treatment for patients with non-small cell lung cancer (NSCLC) with curative intent (1). However, for avoiding surgical complications or other reasons, a variation of SND affects the thoroughness of lymph node dissection and the accuracy of pathologic nodal (pN) staging, which are the most significant prognostic factors in resectable NSCLC (2,3). Also, reduction in the severity and incidence of postoperative complications, such as nerve injury, is of utmost importance and remains challenging (4). Although some studies reported the experience and skills in mediastinal lymph node dissection (4,5), a standard and systematic procedure for nerve protection are still lacking. Therefore, an easy-to-follow standardized approach of SND, which can not only achieve regional en bloc lymph node resection but also effectively protect the nerves, is critically needed. Based on clinical practice experience, we discovered that the hilar and mediastinal lymph nodes are distributed along with the courses of these two nerves and connected in some anatomical regions (Figure 1). Thus, we first divided the lymph nodes into three areas of each side and developed an improved approach named “duo-nerve-guided SND” for resectable lung cancer, aiming to easily achieve complete resection of hilar and mediastinal lymph nodes as well as adipose tissue without increasing the nerve-related complications. Open in a separate window Figure 1 The anatomy of the thoracic vagus nerve and phrenic nerve and the distribution of lymph nodes. (A,C) The hilar and mediastinal lymph nodes were distributed along the vagus and phrenic nerves as well as their anatomical thoracic branches (pulmonary plexus, cardiac plexus, and esophageal plexus); (B,D) the regional lymph nodes distribution. Area A (green), the posterior area of the hilum; area B (blue), the anterior area of the hilum; area C (red), the anterior mediastinal area for the left side, the superior mediastinal area for the right side. (E) The subcarinal lymph nodes in left side (station 7); (F) the station 4L lymph nodes. RVN, right vagus nerve; LVN, left vagus nerve; LRLN, left recurrent laryngeal nerve.

Influence of marginal and segmental bony resection on the local control of oral Squamous cell carcinoma involving the mandible

Background and objective: Marginal or segmental resection of bone are often required for tumor removal in oral squamous cell carcinoma patients to secure adequate margin. The present study aims to evaluate the surgical outcome and post-operative complication of both group of patients and also assesses the local control of the disease in the oral cavity.&#x0D; Methods: In this prospective study, 32 patients who were treated with marginal or segmental jaw resection for oral squamous cell carcinoma of the lower part of oral cavity was undertaken within September 2008 to August 2013.There were 9 males and 23 females with a median age of 40.5 years. Twenty patients underwent marginal and 12 patients had segmental resection of the mandible. Distribution of the subject by age, sex, primary site of lesion, pathologic tumor stage, presence of mandibular invasion, pathologic cervical lymph node stage and feature of post- operative complications were analyzed prospectively.&#x0D; Results: According to this study, the mandible was involved in 83.3% of patient with segmental resection and 15% of patients with marginal resection. Buccal mucosa was mostly involved site in marginal group (60%) and retro molar trigon was highly involved site with segmental group (41.7%). In marginal group 30% cases was involved with stage1 and 70% was stage2; in segmental group 25% cases were stage2 and 67.7% were stage3. Statistically significant difference was exist in pathological cervical node stage(p&lt;0.05). Mandibular invasion was significantly more in segmental group (p&lt;0.05). Soft tissue surgical margins were positive in 4 patients (20%) in the marginal group and in 3 patients (25%) in the segmental group. Negative neck lymph node was found in 20 (63%) cases and positive neck node was found in 12 (37%) cases, of which four patients, including 2(15%) cases in the marginal group and 2(8.3%) cases in the segmental group was died. Trismus and mastication problems were found higher in segmental than marginal resection group.&#x0D; Conclusion: Marginal resection of mandible is effective for patient with oral squamous cell carcinoma in the early stage. Post-operative outcome and local control of disease in segmental group were slightly higher than marginal group. Positive surgical margin status and bone invasion was found as the most important predictor of local control of the diseases in patient with oral squamous cell carcinoma.&#x0D; Bangladesh Journal of Medical Science Vol.18(4) 2019 p.801-807

Propensity-matched comparison of laparoscopic and open radical cystectomy for female patients with bladder cancer

To compare the perioperative and oncologic outcomes of female patients receiving laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). Retrospective review of 91 consecutive female patients with urothelial carcinoma of bladder undergoing radical cystectomy at a single academic institution from 2006 to 2017. Those female patients received open radical cystectomy were matched to the patients who underwent laparoscopic radical cystectomy by using propensity score matching in 1 ∶1 ratio. The matching factors included age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, pathologic stage and pathologic nodal stage. The perioperation and oncology characteristics were compared, and Kaplan-Meier method was used to analyze the overall survival (OS), cancer specific survival (CSS) and progression-free survival (PFS) estimates. Finally, we did a sensitive analysis by using multivariable COX regression of all the patients, adjusting for the matching factors. There were 65 ORC and 26 LRC patients identified in this cohort with urothelial carcinoma of bladder, the median follow-up time was 38 months (interquartile range 18-69). The age (P<0.001) and ASA scores (P=0.018) were less for LRC before being matched. There were 22 LRC and 22 ORC patients matching successfully. Before being matched, the estimate blood loss (P=0.005), transfusion rate (P<0.001) and total complications rate (P=0.015) were less for LRC, and the lymph nodes yield was greater for LRC, but there were no differences in OS (P=0.698), CSS (P=0.942) and PFS (P=0.837) between the two groups. After being matched, the estimate blood loss (P=0.009), transfusion rate (P=0.001) and total complications rate (P=0.040) were less for LRC, but there was no difference in the lymph nodes yield. Besides, there were no statistic differences in OS (P=0.432), CSS (P=0.429) and PFS (P=0.284) between the two groups. In addition, in multivariable COX regression analysis, surgical approaches (LRC/ORC) were not found to be a predictor of OS (HR 1.134, 95%CI 0.335-3.835, P=0.839), CSS (HR 1.051, 95%CI 0.234-4.719, P=0.949) and PFS (HR 0.538, 95%CI 0.138-2.095, P=0.371) of the female patients with urothelial carcinoma of bladder. It is advantageous for laparoscopic radical cystectomy in terms of estimating blood loss, transfusion rate and complication rate. But there was no evidence that laparoscopic radical cystectomy for female patients with bladder cancer had a better oncologic prognosis than open radical cystectomy from this study.

Nomogram Identifies Age as the Most Important Predictor of Overall Survival in Oral Cavity Squamous Cell Cancer After Primary Surgery.

Our goal was to determine the most important predictors and construct a nomogram for overall survival (OS) in oral cavity squamous cell cancer (OCSCC) treated with primary surgery followed by observation, adjuvant radiation or chemoradiation. Multivariable analysis was performed using Cox Proportional Hazard model of 9258 OCSCC patients from Surveillance, Epidemiology and End Results Program (SEER) database treated with surgery from 2003 to 2009. Potential predictors of OS were age, gender, race, tobacco use, oral cancer sub-sites, pathologic tumor stage and grade, pathologic nodal stage, extra-capsular invasion, clinical levels IV and V involvement, and adjuvant treatment selection. Weighted propensity scores for treatment were used to balance observed baseline characteristics between three treatment groups in order to reduce bias. Following primary surgery, patients underwent observation (56%), radiation alone (31%) or chemoradiation (13%). All tested predictors were statistically significant and included in our final nomogram. Most important predictor of OS was age, followed by pathologic tumor stage. SEER based-survival nomogram for OCSCC patients differs from published models derived from patients treated in a single or few academic treatment centers. An unexpected finding of patient age being the best OS predictor suggests that this factor may be more critical for the outcome than previously anticipated.

Major depression but not minor to intermediate depression correlates with unfavorable prognosis in surgical colorectal cancer patients underwent adjuvant chemotherapy

ABSTRACTThis study aimed to investigate the correlation of anxiety/depression with clinicopathological features, and the association of anxiety/depression degrees with overall survival (OS) in surgical colorectal cancer (CRC) patients. Three hundred and eighty-one surgical CRC patients were consecutively enrolled and underwent adjuvant chemotherapy accordingly. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Patients with no, minor, intermediate and major anxiety were 249 (65.4%), 79 (20.7%), 37 (9.7%) and 16 (4.2%), respectively, and patients with no, minor, intermediate and major depression were 231 (60.6%), 73 (19.2%), 44 (11.5%) and 33 (8.7%), respectively. Younger age, increased the pathological grade, elevated tumor, node and metastasis (TNM) stage, as well as higher education correlated with raised HADS-A score, while younger age, drinking history, increased pathological grade, elevated TNM stage and higher education associated with raised HADS-D score. There was no difference in OS among CRC patients with no anxiety, minor anxiety, intermediate anxiety and major anxiety. And CRC patients with major depression were of worse OS compared to those with no depression, minor depression or intermediate depression. Younger age, higher pathological grade, TNM stage and education associates with anxiety and depression, and major depression is negatively correlated with OS in surgical CRC patients underwent adjuvant chemotherapy.

Impact of residual nodal involvement after complete tumor response in patients undergoing neoadjuvant (chemo)radiotherapy for rectal cancer

BackgroundThe management of patients with a complete clinical response after neoadjuvant therapy for rectal adenocarcinoma is controversial. Those who advocate for resection point out the inaccuracy of N-staging with current imaging modalities. The objective of this study is to determine the impact of residual nodal involvement after complete tumor regression after neoadjuvant (chemo)radiotherapy. MethodsThe 2004 to 2014 National Cancer Database was queried for patients undergoing proctectomy for nonmetastatic rectal adenocarcinoma who had received neoadjuvant (chemo)radiotherapy and with ypT0 on final pathology. Patients were grouped based on pathologic nodal stage: ypT0N- and ypT0N+. The main outcome was 5-year overall survival. ResultsThere were 5,156 patients with ypT0N- and 527 with ypT0N+. Mean lymph node harvest was similar (ypT0N- 12.2 nodes [standard deviation 9.1] vs ypT0N+ 11.6 nodes [standard deviation 10.3]; P = .086). Patients with ypT0N+ were more likely to have had clinically involved nodes (P < .001) and earlier clinical T-stage (P = .002). Overall survival at 5 years was less for patients with ypT0N+ (80% vs 86%, log-rank P = .014). ypT0N+ was independently associated with worse overall survival (hazard ratio 1.74, 95% confidence interval 1.33–2.28). ConclusionResidual nodal involvement despite complete tumor regression was associated with worse 5-year overall survival compared to complete pathologic response. Additional therapy should be considered in the presence of complete clinical tumor regression after neoadjuvant (chemo)radiotherapy.

Synchronous and metachronous bilateral breast cancer: clinicopathologic characteristics and prognostic outcomes

The incidence of bilateral breast cancer (BBC) reportedly ranges from 1.4 to 11.8%. Women with a first primary breast cancer are at a 2- to 6-fold increased risk of developing contralateral BC. However, there have been limited studies analyzing the clinicopathologic features of BBC and conflicting data exist on the prognostic significance of BBC. In this study, we sought to analyze the incidence of BBC in the era of modern medicine and assess the clinicopathologic characteristics and prognostic outcomes compared to unilateral BC (UBC). Of the 5941 patients with stage I-III BC diagnosed between 1998 and 2013 at our institution, 110 developed BBC, including 58 synchronous BBC (SBBC, interval between the first and the contralateral BC ≤3 months) and 52 metachronous BBC (MBBC, interval >3 months). The median time to the second tumor was 67.9 months among patients with MBBC. BBC was associated with a significantly lower rate of having a ductal type, high grade, HER2-positive or node-positive disease when compared to UBC, while no difference was found for age, race, ER/PR status, or pathologic tumor stage. When compared to MBBC, SBBC was strongly associated with a lobular phenotype, non-high grade, and ER/PR-positive disease; and further demonstrated a significantly higher concordant rate for ER, PR, and HER2 status. Patients with BBC had a significantly worse distant relapse-free survival (RFS) but a similar disease-specific survival (DSS) when compared to those with UBC. Being African American, having a high histologic grade and higher pathologic tumor or node stage was significantly associated with a worse prognosis, while SBBC was associated with a favorable RFS by multivariate analysis. Nodal status was the only independent prognosticator for DSS in patients with BBC. Further investigation into the complex biologic and clinical behavior of BBC may provide novel insights into the therapeutic strategies in the pursuit of precision medicine in this unique subset of patients.

P-078 - Preoperative neutrophil to lymphocyte ratio as a prognostic factor for patients with colorectal cancer

Introduction: This study aimed to determine the role of the neutrophil to lymphocyte ratio (NLR) as a prognostic marker for patients with colorectal cancer (CRC) undergoing curative resection. Management of CRC and postsurgical treatment is usually arranged using the TNM staging system, but there are still prognostic variations among patients at the same TNM stage. Recent studies showed correlations between the inflammatory response and clinical outcomes in various cancers. The NLR reflected a systematic inflammatory response with some evidence suggesting that an elevated preoperative NLR is associated with poorer survival in patients with CRC. Methods: One hundred seventy eight patients with CRC, undergoing surgical resection in Surgical Departement Generaly Hospital Studenica Kraljevo- Serbia, between 2010. and 2015. were included in our retrospective analysis. Patients separated into two groups according to a cut-off value for NLR. Patient data included age, gender, localisation and differentiation of tumor, TNM stage, survival rate were analyzed for correlation with the NLR. Results: Using ROC curve analysis, we determined a cut-off NLR value of 2.1 in order to best detect differences in patient survival between our groups. The average length of survival in patients that had NLR≤2.1 was 7.3 months (72.7±12) and within these patients, the median of survival had not been reached. Patients with NLR > 2.1 had an average length of survival of 60 months (60.11±3.4) and median of survival was 70.0. The log-rank test showed that there was a statistically significant difference (P = .041) of survival between patients that had NLR ≤ 2.1 compared with those who had NLR > 2.1. Also, the log-rank test showed that advanced pathologic TNM stage (P = .000), pathologic nodal stage (P = .007) were predictive of shorter survival. Conclusion: High pre-treatment levels of NLR is a significant independent predictor of shorter survival in patients with colorectal cancer. This parameter is a simple, cheap, easily accessible laboratory value for identifying patients with poorer prognosis.

Survival After Induction Chemotherapy and Esophagectomy Is Not Improved by Adjuvant Chemotherapy

It remains unclear whether postoperative chemotherapy improves survival among patients with esophageal squamous cell carcinoma who have undergone preoperative chemotherapy and radical resection. Patients treated between January 2000 and December 2016 were reviewed. Eligible patients were divided into two groups: perioperative chemotherapy (preoperative and postoperative chemotherapy) and neoadjuvant chemotherapy only. The primary endpoint was disease-free survival; the secondary endpoints were overall survival and toxicities attributable to postoperative chemotherapy. To minimize the effect of patientheterogeneity between the two groups, we used propensity score matching. The survival analysis was performed using univariate analysis and a multivariable Cox regression model. In total, 252 patients were included in the study. Most were men (208 of 252; 82.5%); median age was 59 years. The follow-up rate was 93.3%. Age, performance status, minimally invasive surgery, and Clavien-Dindo classification were statistically different between the groups (P <.05). After propensity score matching, each group had 59 patients. Five-year disease-free survival (52.4% vs 43.6%, P= .372) and overall survival (68.6% vs 62.4%, P= .359) were not statistically different between the neoadjuvant chemotherapy group and the perioperative chemotherapy group. Cox regression identified both pathologic nodal stage and tumor regression grade are independent prognostic factors for disease-free survival and overall survival (P< .05); adjuvant chemotherapy did not influence disease-free survival (hazard ratio 1.049, 95% confidence interval, 0.587 to 1.876, P= .872) or overall survival (hazard ratio 1.297; 95% confidence interval, 0.606 to 2.775, P= .504). In the perioperative chemotherapy group, 8.5% of patients (5of 59) had grade 3 or greater toxicity. Adjuvant chemotherapy is not indicated for patients with locally advanced esophageal squamous cell carcinoma after neoadjuvant platinum-based chemotherapy and surgery.

Factors Influencing Locoregional Recurrence and Disease-Free Survival in Buccal Mucosal Squamous Cell Carcinoma

Oral cancers are the most common malignancy affecting Indian population with buccal mucosa being the frequent subsite. This study is to evaluate the histopathological factors influencing locoregional recurrence (LRR) and disease-free survival (DFS) in buccal mucosal squamous cell carcinoma (BSCC). One hundred and twenty patients treated surgically for BSCC with a curative intend between January 2014 and December 2015 were retrospectively analyzed. Histopathological factors like tumor stage, grade of differentiation, tumor front, skin involvement, bone involvement, depth of invasion, perineural invasion, lymphovascular emboli, primary resection margin in frozen section, nodal stage, extracapsular extension, and lymph node ratio were analyzed and compared for LRR and DFS. With a median follow-up of 41 months, LRR occurred in 34 patients (28.3%) and a 2-year DFS was 75.8%. Multivariate analysis identified that the factors that independently influenced the LRR were pathological nodal stage (p < 0.0001) and primary resection margin in frozen section (p < 0.0001). A single neck node involvement increases risk by 6.8 times for LRR compared to no nodal involvement (95% CI 2.897–15.888, p < 0.0001). Frozen section studies on primary tumor excision margin showed that close margin had 2.3 times chance of LRR (95% CI 1.020–5.035, p < .045) and involved margin showed 20.9 times risk of LRR compared to clear margin(95% CI 6.529–67.021, p < 0.0001). Primary resection margin on frozen section and pathological nodal status are the most important factors influencing LRR and DFS. This study highlights importance of aggressive treatment and close follow-up even with a single node involvement and when frozen section margin clearance is less than 5 mm.

Proposal of a new nodal classification for operable non-small cell lung cancer based on the number of negative lymph nodes and the anatomical location of metastatic lymph nodes.

Lymph node metastasis is one of the most important prognostic indicators in patients with radically resected non-small cell lung cancer (NSCLC). This retrospective study aimed to compare the predictive value of metastatic lymph nodes (MNs), lymph node ratio (LNR), resected lymph nodes (RNs), and negative lymph nodes (NNs) with the currently used pathologic nodal (pN) staging category.We conducted a retrospective analysis of 1019 consecutive NSCLC patients treated with complete resection in a single institution. Prognostic values of various lymph node factors were evaluated by analysis of univariate and multivariate Cox proportional hazards model, and the results were compared with those using the location-based pN stage classification.The median follow-up duration was 47 months. During this period, 353 cases of cancer recurrence and 337 deaths were reported. Multivariate cox analysis indicated that both pN and NN categories were independent predictors of patient survival. The patients were divided into six groups on the basis of pN and NN categories. The survival rates of the groups were as follows: pN0, NN≥8, 81.4%; pN0, NN<8, 73.8%; pN1, NN≥8, 61.4%; pN1, NN<8, 54.2%; pN2, NN≥8, 48.4%; and pN2>1, NN<8, 35.0%. Comparison of the predictive values of the lymph node factors showed that the new N category was a more valuable prognostic factor in operable NSCLC.The combination of anatomically based pN stage classification and the number of MNs is an accurate prognostic determinant in patients with operable NSCLC which can be equal to 8th N category.

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Renal cell carcinoma (RCC) accounts for 2%–3% of all adultmalignancies, representing the seventh most common cancer inmen and the ninth most common cancer in women [1].Worldwide, there are ∼209000 new cases and 102000 deathsper year. The incidence of all stages of RCC has increased overthe past several years, contributing to a steadily increasing mor-tality rate per unit population. Active and passive cigarettesmoking is an established risk factor for RCC as well as hyper-tension. However, anti-hypertensive medications such as diure-tics are not independently associated with RCC development.RCC also appears to be more common in patients with obesity,end-stage renal failure, acquired renal cystic disease and tuber-ous sclerosis.Approximately 2%–3% of RCC are hereditary and severalautosomal dominant syndromes are described, each with a dis-tinct genetic basis and phenotype, the most common one beingVon Hippel Lindau disease.In recent years, many new genes associated with RCC havebeen reported (such as PBRM1, SETD2, BAP1). Their roles inpathogenesis and as prognostic biomarkers are currently underinvestigation.

Is hysterectomy beneficial in radical cystectomy for female patient with urothelial carcinoma of bladder? A retrospective analysis of consecutive 112 cases from a single institution

BackgroundThere is no criterion for determining whether female patients operated with cystectomy would benefit from hysterectomy. This study compares the oncological outcomes between female patients receiving uterus preserving cystectomy (UPC) and uterus excision cystectomy (UEC).MethodsRetrospective review of 121 female patients with urothelial carcinoma of bladder undergoing UPC (n = 63) or UEC (n = 49) at a single institute between January 2006 and April 2017. Individual postoperative follow-up plans were performed for patients through outpatient visits. Overall survival (OS) and progression-free survival (PFS) estimates were analyzed using Kaplan-Meier method and multivariable Cox regression.ResultsThe median follow-up time was 36 months (interquartile range 16–69). Among patients, 5 (4.1%) had uterus invasion. OS probability (p = 0.939) and PFS probability (p = 0.565) were similar in two groups. In multivariable Cox regression analysis, hysterectomy was not found to be a predictor of OS (hazard ratio 0.908, 95%CI 0.428–1.924, p = 0.801) and PFS (hazard ratio 1.109, 95%CI 0.439–2.805, p = 0.826) after adjusting for age, preoperative clinical stage, pathological stage, pathological nodal stage, neoadjuvant/adjuvant chemotherapy, location of the tumor, and surgical margin. No significant difference of overall survival probability was observed in the patients with organ-confined bladder cancer (p = 0.675) and in patients with no organ-confined bladder cancer (p = 0.695).ConclusionsThe results showed that the rate of uterus invasion was low in patients analyzed in this cohort. It was also found that hysterectomy was not an independent predictor of OS and PFS after radical cystectomy in patients with bladder cancer.

Radiomics Signature on Computed Tomography Imaging: Association With Lymph Node Metastasis in Patients With Gastric Cancer.

Background: To evaluate whether radiomic feature-based computed tomography (CT) imaging signatures allow prediction of lymph node (LN) metastasis in gastric cancer (GC) and to develop a preoperative nomogram for predicting LN status.Methods: We retrospectively analyzed radiomics features of CT images in 1,689 consecutive patients from three cancer centers. The prediction model was developed in the training cohort and validated in internal and external validation cohorts. Lasso regression model was utilized to select features and build radiomics signature. Multivariable logistic regression analysis was utilized to develop the model. We integrated the radiomics signature, clinical T and N stage, and other independent clinicopathologic variables, and this was presented as a radiomics nomogram. The performance of the nomogram was assessed with calibration, discrimination, and clinical usefulness.Results: The radiomics signature was significantly associated with pathological LN stage in training and validation cohorts. Multivariable logistic analysis found the radiomics signature was an independent predictor of LN metastasis. The nomogram showed good discrimination and calibration.Conclusions: The newly developed radiomic signature was a powerful predictor of LN metastasis and the radiomics nomogram could facilitate the preoperative individualized prediction of LN status.

Quantitative FDG PET/CT may help risk-stratify early-stage non-small cell lung cancer patients at risk for recurrence following anatomic resection.

Preoperative identification of non-small cell lung cancer (NSCLC) patients at risk for disease recurrence has proven unreliable. The extraction of quantitative metrics from imaging based on tumor intensity and texture may enhanced disease characterization. This study evaluated tumor-specific 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computerized tomography (PET/CT) uptake patterns and their association with disease recurrence in early-stage NSCLC. Sixty-four stage I/II NSCLC patients who underwent anatomic resection between 2001 and 2014 were examined. Pathologically or radiographic confirmed disease recurrence within 5 years of resection comprised the study group. Quantitative imaging metrics were extracted within the primary tumor volume. Squamous cell carcinoma (SCC) (N=27) and adenocarcinoma (AC) (N=41) patients were compared using a Wilcoxon signed-rank test. Associations between imaging and clinical variables with 5-year disease-free survival (DFS) and overall survival (OS) were evaluated by Cox proportional-hazards regression. Clinical and pathologic characteristics were similar between recurrence (N=34) and patients achieving 5-year DFS (N=30). Standardized uptake value (SUV)max and SUVmean varied significantly by histology, with SCC demonstrating higher uptake intensity and heterogeneity patterns. Entropy-grey-level co-occurrence matrix (GLCM) was a significant univariate predictor of DFS (HR =0.72, P=0.04) and OS (HR =0.65, P=0.007) independent of histology. Texture features showed higher predictive ability for DFS in SCC than AC. Pathologic node status and staging classification were the strongest clinical predictors of DFS, independent of histology. Several imaging metrics correlate with increased risk for disease recurrence in early-stage NSCLC. The predictive ability of imaging was strongest when patients are stratified by histology. The incorporation of 18F-FDG PET/CT texture features with preoperative risk factors and tumor characteristics may improve identification of high-risk patients.

Prognosis of upstaged N1 and N2 disease after curative resection in patients with clinical N0 non-small cell lung cancer.

Nodal upstaging occasionally occurs after curative resection in clinical N0 non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the prognosis of clinical N0 NSCLC (T1-2, tumor size 5 cm or smaller) after upstaging to pathologic N1 or N2. From 2005 to 2015, 676 consecutive patients were diagnosed with clinical T1-2N0 NSCLC and underwent curative resection. Among these, tumors were upstaged to N1 in 46 patients and to N2 in 24 patients. We analyzed the prognosis of upstaged tumors. For comparison of prognosis between nodal upstaging groups and others in the same stage, patients with preoperative pathologically proven N1 (n=31) and N2 (n=55) NSCLC were included in the study. A total of 70 patients (10.4%) had nodal upstaging after curative resection of clinical N0 NSCLC. Upstaging to N1 occurred in 46 patients and upstaging to N2 occurred in 24 patients. The 5-year disease-specific survival rate was not statistically different between the upstaged and non-upstaged N1/N2 groups in N1 disease (73.3% vs. 70.5%, P=0.247) or in N2 disease (58.9% vs. 50.7%, P=0.283). Multivariate analysis showed that nodal upstaging was not a significant prognostic factor in N1 or N2 NSCLC (hazard ratio =0.385, P=0.235; hazard ratio =0.677, P=0.458). Postoperative nodal upstaging from clinical T1-2N0 NSCLC was not a significant prognostic factor in the same stage. Therefore, surgical treatment of clinical T1-2N0 lung cancer diagnosed by imaging without preoperative pathologic lymph node staging can be a treatment option.

Clinicopathological features and impact of adjuvant chemotherapy on the long-term survival of patients with multiple gastric cancers: a propensity score matching analysis

BackgroundLittle is known about the correlation between the clinicopathological features, postoperative treatment, and prognosis of multiple gastric cancers (MGCs). In this study, we aimed to investigate the correlation between these features and the impact of postoperative adjuvant chemotherapy on the long-term survival of patients with MGC.MethodsThe clinical and pathological data of patients diagnosed with gastric adenocarcinoma who had radical gastrectomy from January 2007 to December 2016 were analyzed. Using propensity score matching, the prognostic differences, and the impact of postoperative adjuvant chemotherapy between those with MGC and solitary gastric cancers (SGC) were compared.ResultsAmong the 4107 patients investigated, the incidence of MGC was 3.2% (133/4107). Before matching, patients with MGC and SGC had disparities in the type of gastrectomy, pathological tumor stage (pT), pathological node stage (pN), and pathological tumor-node-metastasis stage (pTNM). After a 1:4 ratio matching, the clinical data of 133 cases of MGC and 532 cases of SGC were found to be comparable. The 5-year overall survival (OS) rate was 56.6% in the entire matched cohort, 48.1% in the MGC group, and 58.7% in the SGC group (P = 0.013). Multivariate analysis revealed that MGC, age, pT stage, pN stage, and adjuvant chemotherapy were independent predictors of OS (all P < 0.05). Stratified analyses demonstrated that for the cohort of advanced gastric cancer (AGC) patients who did not had adjuvant chemotherapy, the 5-year OS rate of advanced cases of MGC was inferior than that of SGC patients (34.0% vs. 46.1%, respectively; P = 0.025) but there were no significant difference in the 5-year OS rate between advanced MGC and SGC patients who had adjuvant chemotherapy (48.0% vs. 53.3%, respectively; P = 0.292). Further, we found that the 5-year OS rate of advanced MGC who had adjuvant chemotherapy was significantly higher than those who did not had adjuvant chemotherapy (48.0% vs. 34.0%, P = 0.026).ConclusionsPatients with advanced MGC was identified as having a poorer survival as to SGC patients, but the implementation of postoperative adjuvant chemotherapy showed that it had the potential to significantly improve the long-term prognoses of MGC patients.