Pretherapeutic Staging Research Articles

Novel computed tomography-based nomograms for the pretherapeutic prediction of response to neoadjuvant chemotherapy with S-1 and oxaliplatin with or without the addition of docetaxel in patients with advanced gastric cancer.

Selecting the appropriate preoperative neoadjuvant chemotherapy (NACT) regimen for patients with advanced gastric cancer (GC) is critical to effective treatment. The aim of this study was to develop nomograms based on pretherapeutic computed tomography (CT) features to predict response to NACT with S-1 and oxaliplatin (SOX) or that with docetaxel and SOX (DOS) in patients with advanced GC. This study enrolled 311 consecutive patients with confirmed advanced GC undergoing contrast-enhanced CT before and after the three cycles of NACT with DOS (n=152) or SOX (n=159), who were randomized into a training cohort (TC) (NACT with DOS: n=111; NACT with SOX: n=120) and validation cohort (VC) (NACT with DOS: n=41; NACT with SOX: n=39). The objective response rate (ORR) was used to evaluate the response to NACT. In the TC, ORR was compared between the DOS and SOX regimens, and independent predictors including CT features and tumor differentiation were determined by univariate and binary logistic regression analyses. Individual nomograms were constructed for the SOX and DOS regimens in the TC, and the predictive accuracy was validated in the VC. After NACT, the percentage of ORR was higher in patients receiving DOS than in those receiving SOX in TC (P value <0.05). The independent predictors after DOS and SOX were pretherapeutic cT stage [odds ratio (OR) =7.364; OR =8.848], cN stage (OR =1.027; OR =1.345), degree of differentiation (OR =7.127; OR =7.835), and gross tumor volume (OR =8.960; OR =8.161) (all P values <0.05). The concordance indexes of the individual nomograms developed using these predictors were 0.940 and 0.932 after DOS or SOX in the TC, respectively, which was validated by calibration plots with a slope close to 45° in the TC and VC. Despite there being a superior response to DOS compared with SOX, nomograms for predicting response to both NACT regimens were similar, with each demonstrating good predictive performance.

Shear-wave elastography as a supplementary tool for axillary staging in patients undergoing breast cancer diagnosis

BackgroundPreoperative evaluation of axillary lymph node status is crucial for the selection of both systemic and surgical treatment in early breast cancer. This study assessed the particular role of additional shear wave elastography (SWE) in axillary staging in patients undergoing initial breast cancer diagnostics.MethodsOne hundred patients undergoing axillary lymph node biopsy due to a sonographically suspicious axillary lymph node were prospectively evaluated with SWE using virtual touch tissue imaging quantification (VTIQ). Mean values of tissue stiffness for axillary tissue and lymph node tissue were measured prior to core-cut biopsy of the lymph node. All lymph nodes were clip-marked during the biopsy. Cut-off values to differentiate between malignant and benign lymph nodes were defined using Youden’s index.ResultsLymph nodes with evidence of malignant tumor cells in the final pathological examination showed a significantly higher velocity as measured by SWE, with a mean velocity of 3.48 ± 1.58 m/s compared to 2.33 ± 0.62 m/s of benign lymph nodes (p < 0.0001). The statistically optimal cutoff to differentiate between malignant and benign lymph nodes was 2.66 m/s with a sensitivity of 69.8% and a specificity of 87.5%.ConclusionsLymph node metastases assessed with SWE showed significantly higher elasticity values compared to benign lymph nodes. Thus, SWE provides an additional useful and quantifiable parameter for the sonographic assessment of suspicious axillary lymph nodes in the context of pre-therapeutic axillary staging in order to differentiate between benign and metastatic processes and support the guidance of definitive biopsy work-up.Critical relevance statementShear-wave elastography provides an additional useful and quantifiable parameter for the assessment of suspicious axillary lymph nodes in the context of pre-therapeutic axillary staging in order to differentiate between benign and metastatic processes and support guiding the definitive biopsy work-up.Key PointsSWE is a quantifiable ultrasound parameter in breast cancer diagnosis.SWE shows a significantly higher velocity in malignant lymph nodes.SWE is useful in improving the sensitivity and specificity of axillary staging.Graphical

Discrepancy between clinical and pathological staging of laryngeal carcinoma: a dilemma to be solved

ObjectivesThe aim of this study was to investigate the degree of discrepancy between the clinical and pathological staging of laryngeal carcinoma, and the potential impact of this discrepancy on the outcomes and prognosis.MethodsThis study was conducted on 127 patients who underwent total laryngectomy over five years (October 2016–October 2021). Data collected from pretherapeutic clinical staging regarding the extent of the tumor affection of different laryngeal subsites was compared to the postsurgical pathological assessment.ResultsOverall, 12 out of 127 patients (9.4%) in the current study, were clinically over-staged from T3 to T4 due to radiological diagnosis of tumor infiltration of laryngeal cartilages that proved pathologically to be free of tumor. Additionally, discordance in the N stage was found in 12.6% (n = 16). However, stage discrepancy did not have a significant impact on the prognosis and survival.ConclusionDiscordance between clinical and pathological TNM staging of laryngeal carcinoma may affect the decision making and the choice of the treatment options. Some improvement can be probably achieved with advancements and higher accuracy of the preoperative diagnostic tools.

Computed tomography-based nomogram of Siewert type II/III adenocarcinoma of esophagogastric junction to predict response to docetaxel, oxaliplatin and S-1.

Neoadjuvant chemotherapy (NAC) has become the standard care for advanced adenocarcinoma of esophagogastric junction (AEG), although a part of the patients cannot benefit from NAC. There are no models based on baseline computed tomography (CT) to predict response of Siewert type II or III AEG to NAC with docetaxel, oxaliplatin and S-1 (DOS). To develop a CT-based nomogram to predict response of Siewert type II/III AEG to NAC with DOS. One hundred and twenty-eight consecutive patients with confirmed Siewert type II/III AEG underwent CT before and after three cycles of NAC with DOS, and were randomly and consecutively assigned to the training cohort (TC) (n = 94) and the validation cohort (VC) (n = 34). Therapeutic effect was assessed by disease-control rate and progressive disease according to the Response Evaluation Criteria in Solid Tumors (version 1.1) criteria. Possible prognostic factors associated with responses after DOS treatment including Siewert classification, gross tumor volume (GTV), and cT and cN stages were evaluated using pretherapeutic CT data in addition to sex and age. Univariate and multivariate analyses of CT and clinical features in the TC were performed to determine independent factors associated with response to DOS. A nomogram was established based on independent factors to predict the response. The predictive performance of the nomogram was evaluated by Concordance index (C-index), calibration and receiver operating characteristics curve in the TC and VC. Univariate analysis showed that Siewert type (52/55 vs 29/39, P = 0.005), pretherapeutic cT stage (57/62 vs 24/32, P = 0.028), GTV (47.3 ± 27.4 vs 73.2 ± 54.3, P = 0.040) were significantly associated with response to DOS in the TC. Multivariate analysis of the TC also showed that the pretherapeutic cT stage, GTV and Siewert type were independent predictive factors related to response to DOS (odds ratio = 4.631, 1.027 and 7.639, respectively; all P < 0.05). The nomogram developed with these independent factors showed an excellent performance to predict response to DOS in the TC and VC (C-index: 0.838 and 0.824), with area under the receiver operating characteristic curve of 0.838 and 0.824, respectively. The calibration curves showed that the practical and predicted response to DOS effectively coincided. A novel nomogram developed with pretherapeutic cT stage, GTV and Siewert type predicted the response of Siewert type II/III AEG to NAC with DOS.

The use of axillary ultrasound (AUS) to assess the nodal status after neoadjuvant chemotherapy (NACT) in primary breast cancer patients

IntroductionAxillary Ultrasound (AUS) is standard for pre-therapeutic axillary staging in early breast cancer patients. 35–75 % of the breast cancer (BC) patients with positive axillary lymph nodes receiving neoadjuvant chemotherapy (NACT) convert to pathological node negative. For those patients, axillary surgery after NACT could be de-escalated, if an accurate prediction of the pathologic nodal status following NACT was possible. This study aims to answer the question, whether AUS can be used as a reliable diagnostic tool for restaging of axillary nodal status after NACT. Patients and methodsWe collected data of 96 patients with nodal positive primary breast cancer who received NACT between 2009 and 2015 at the Breast Cancer Center of the University Hospital Ulm. Patients were classified as node negative or positive by AUS after NACT (ycN + or ycN0) and the results were compared to the pathological result obtained after axillary lymph node dissection (ypN + vs ypN0) in all patients. Results58.3 % of the patients had pathological complete remission of axillary lymph nodes after NACT (ypN0). The sensitivity and specificity of AUS were 57.5 % and 78.6 %, respectively. The FNR was 42.5 %. The Positive and Negative Predictive Values (PPV and NPV) were 65.7 % and 72.1 %, respectively. The accuracy of AUS was 69.8 % and not associated with any of the investigated clinico-pathological parameters. ConclusionAUS alone is not accurate enough to replace surgical restaging of the axilla after NACT in initially node positive breast cancer patients.

Dual-tracer PET/CT protocol with [18F]FDG and [68Ga]Ga-FAPI-46 outperforms single-tracer PET/CT with [18F]FDG in different cancer types, resulting in larger functional and gross tumor volume

PurposeFibroblast activation protein (FAP) detected by positron-emission tomography (PET) using fibroblast activation protein inhibitor (FAPI) appears to be a promising target for cancer imaging, staging, and therapy, providing added value and strength as a complement to [18F]fluorodeoxyglucose (FDG) in cancer imaging. We recently introduced a combined single-session/dual-tracer protocol with [18F]FDG and [68Ga]Ga-FAPI for cancer imaging and staging. Malignant tissue visualization and target-to-background uptake ratios (TBRs) as well as functional tumor volume (FTV) and gross tumor volume (GTV) were assessed in the present study with single-tracer [18F]FDG PET/computed tomography (CT) and with dual-tracer [18F]FDG&[68Ga]Ga-FAPI-46 PET/CT.MethodsA total of 19 patients with head and neck and gastrointestinal cancers received initial [18F]FDG-PET/CT followed by dual-tracer PET/CT after additional injection of [68Ga]Ga-FAPI-46 during the same medical appointment (on average 13.9 ± 12.3 min after injection of [18F]FDG). Two readers visually compared detection rate of malignant tissue, TBR, FTV, and GTV for tumor and metastatic tissue in single- and dual-tracer PET/CT.ResultsThe diagnostic performance of dual-tracer compared to single-tracer PET/CT was equal in 13 patients and superior in 6 patients. The mean TBRs of tumors and metastases in dual-tracer PET/CTs were mostly higher compared to single-tracer PET/CT using maximal count rates (CRmax). GTV and FTV were significantly larger when measured on dual-tracer compared to single-tracer PET/CT.ConclusionDual-tracer PET/CT with [18F]FDG and [68Ga]Ga-FAPI-46 showed better visualization due to a generally higher TBR and larger FTV and GTV compared to [18F]FDG-PET/CT in several tumor entities, suggesting that [68Ga]Ga-FAPI-46 provides added value in pretherapeutic staging.

Diagnostic Value of Diffusion-Weighted Imaging with Background Body Signal Suppression (DWIBS) for the Pre-Therapeutic Loco-Regional Staging of Cervical Cancer: A Feasibility and Interobserver Reliability Study.

(1) Background: cervical cancer is one of the leading causes of cancer-related deaths and the fourth most common cancer among women worldwide. Magnetic resonance imaging (MRI) is the modality of choice for loco-regional staging of cervical cancer in the primary diagnostic workup beginning with at least stage IB. (2) Methods: we retrospectively analyzed 16 patients with histopathological proven cervical cancer (FIGO IB1−IVA) for the diagnostic accuracy of standard MRI and standard MRI with diffusion-weighted imaging with background body signal suppression (DWIBS) for the correct pre-therapeutic assessment of the definite FIGO category. (3) Results: In 7 out of 32 readings (22%), DWIBS improved diagnostic accuracy. With DWIBS, four (13%) additional readings were assigned the correct major (I−IV) FIGO stages pre-therapeutically. Interobserver reliability of DWIBS was weakest for parametrial infiltration (k = 0.43; CI-95% 0.00−1.00) and perfect for tumor size <2 cm, infiltration of the vaginal lower third, infiltration of adjacent organs and loco-regional nodal metastases (k = 1.000; CI-95% 1.00−1.00). (4) Conclusions: the pre-therapeutic staging of cervical cancer has a high diagnostic accuracy and interobserver reliability when using standard MRI but can be further optimized with the addition of DWIBS sequences when reporting is performed by an experienced radiologist.

ASSESSMENT OF THE RELIABILITY OF THE CRITERIA FOR THE CONSISTENCY OF RADIOIODABLATION

Summary: the article discusses the reasons for the possible ineffectiveness of radioiodablation in patients with differentiated thyroid cancer when using adequate individually calculated activities of 131I. Based on a prospective analysis of post-therapeutic whole-body scintigraphy, laboratory parameters, dosimetric control and clinical manifestations after radionuclide therapy, significant criteria for the possible failure of standard combination therapy are identified and a change in treatment tactics in this group of patients is proposed.Purpose: search for the reasons for unsatisfactory results of radionuclide treatment in patients with differentiated thyroid cancer. Materials and Methods: analysis of 2260 patients with differentiated thyroid cancer who received combined treatment using traditional preparation methods using thyrotropin alpha, from which a group was identified with a high level of 131I. that was unexpected at the pre-therapeutic stage against the background of early radiation diseases and low dosimetry indicators. In patients, laboratory parameters of TSH, thyroglobulin and thyroglobulin antibodies were assessed using radioimmunoassay and clinical manifestations of radiation conditions, taking into account the prescribed therapy; The scintigraphy of the thyroid bed with 99mTc-pertechnetate, post-therapeutic scintigraphy with 131I upon exiting the «closed mode» and dosimetric control under standard conditions every 24 hours after taking the therapeutic activity were performed.Material and methods: prospective single-center analysis of data from 2260 patients with differentiated thyroid cancer who received combined treatment using the traditional preparation method and the use of thyrotropin alfa, from which a group with an unexpected high RP uptake at the pre-therapeutic stage was identified against the background of the absence of early radiation complications and low dosimetry indicators. In patients, laboratory parameters of TSH, TG and AT-TG were assessed using radioimmunoassay and clinical manifestations of radiation reactions, taking into account the prescribed therapy; scintigraphy of the thyroid bed with 99mТс-sodium pertechnetate, post-therapeutic scintigraphy with 131I upon exiting the «closed mode» and dosimetric monitoring with an assessment 48 hours after ingestion of therapeutic activity. Results: analyzed the data of a group of patients in whom there was a marked discrepancy between the usually interdependent results of scintigraphy before and after RIA, which subsequently changed the treatment tactics in their relation. A statistically significant difference was found between the selected groups in terms of the level of stimulated TSH (in patients with predictable (73,9±31,8 mU/L) and unexpected (114,1±30,5 mU/L) uptake of 131I (p=0,0218); by the values of the dose rate 48 hours after the intake of the calculated activity of 131I (p=0,000005). In addition, we additionally analyzed the effect of traditional and drug methods of stimulating thyrotropinemia during preparation for radionuclide ablation. Withdrawal of levothyroxine and with the use of rhTSH, TSH indices were 80,7±27 mU/L and 123,3±75,8 mU/L, respectively (p=0,035), and the levels of stimulated thyroglobulin were 10,2±4,0 ng / ml and 3,2±2,5 ng / ml (p=0,041). Conclusion: the obtained results show that the recommended empirical level of TSH &gt; 30 mU/L is not synonymous with the activation of sodium iodine symporter and the viability of RIA, and also make it possible to distinguish a group of patients with delayed/ partial activation of the symporter. In the continuation of this study, we plan to change the protocol for preparation for radioiodablation and find criteria for pre-therapeutic diagnosis of this group of patients

Additional Diffusion-Weighted Imaging with Background Body Signal Suppression (DWIBS) Improves Pre-Therapeutical Detection of Early-Stage (pT1a) Glottic Cancer: A Feasibility and Interobserver Reliability Study.

(1) Background: Early-stage glottic cancer is easily missed on magnetic resonance imaging (MRI). Diffusion-weighted imaging (DWI) may improve diagnostic accuracy. Therefore, our aim was to assess the value of adding diffusion-weighted imaging with background body signal suppression (DWIBS) to pre-therapeutic MRI staging. (2) Methods: Two radiologists with 8 and 13 years of experience, blinded to each other's findings, initially interpreted only standard MRI, later DWIBS alone, and afterward, standard MRI + DWIBS in 41 patients with histopathologically proven pT1a laryngeal cancer of the glottis. (3) Results: Detectability rates with standard MRI, DWIBS only, and standard MRI + DWIBS were 68-71%, 63-66%, and 73-76%, respectively. Moreover, interobserver reliability was calculated as good (κ = 0.712), very good (κ = 0.84), and good (κ = 0.69) for standard MRI, DWIBS only, and standard MRI + DWIBS, respectively. (4) Conclusions: Standard MRI, DWIBS alone, and standard MRI + DWIBS showed an encouraging detection rate, as well as distinct interobserver reliability in the diagnosis of early-stage laryngeal cancer when compared to the definitive histopathologic report.

Clinical Value of Diffusion-Weighted Whole-Body Imaging with Background Body Signal Suppression (DWIBS) for Staging of Patients with Suspected Head and Neck Cancer.

(1) Background: To determine the importance of diffusion-weighted whole-body MRI with background body signal suppression (DWIBS) in the staging process of patients with suspected head and neck carcinomas. (2) Methods: A total of 30 patients (24 male, 6 female) with a median age of 67 years with clinically suspected head and neck carcinoma with pathologic cervical nodal swelling in ultrasound underwent the staging procedure with computed tomography (CT) and whole-body MRI including DWIBS. (3) Results: In a total of 9 patients, abnormalities in the routine work-up of pretherapeutic staging were found. Five cases of either secondary cancer or distant metastases were only visible in DWIBS, while being missed on CT. One diagnosis was only detectable in CT and not in DWIBS, whereas three diagnoses were recognizable in both modalities. (4) Conclusions: DWIBS in addition to a standard neck MRI in cervical lymphadenopathy suspicious for head and neck cancer yielded additional clinically relevant diagnoses in 17% of cases that would have been missed by current staging routine procedures. DWIBS offered a negative predictive value of 98.78% for ruling out distant metastases or secondary malignancies.

Evaluation of different imaging modalities for axillary lymph node staging in breast cancer patients to provide a personalized and optimized therapy algorithm

PurposeThe reliable detection of tumor-infiltrated axillary lymph nodes for breast cancer [BC] patients plays a decisive role in further therapy. We aimed to find out whether cross-sectional imaging techniques could improve sensitivity for pretherapeutic axillary staging in nodal-positive BC patients compared to conventional imaging such as mammography and sonography.MethodsData for breast cancer patients with tumor-infiltrated axillary lymph nodes having received surgery between 2014 and 2020 were included in this study.All examinations (sonography, mammography, computed tomography [CT] and magnetic resonance imaging [MRI]) were interpreted by board-certified specialists in radiology. The sensitivity of different imaging modalities was calculated, and binary logistic regression analyses were performed to detect variables influencing the detection of positive lymph nodes.ResultsAll included 382 breast cancer patients had received conventional imaging, while 52.61% of the patients had received cross-sectional imaging.The sensitivity of the combination of all imaging modalities was 68.89%. The combination of MRI and CT showed 63.83% and the combination of sonography and mammography showed 36.11% sensitivity.ConclusionWe could demonstrate that cross-sectional imaging can improve the sensitivity of the detection of tumor-infiltrated axillary lymph nodes in breast cancer patients. Only the safe detection of these lymph nodes at the time of diagnosis enables the evaluation of the response to neoadjuvant therapy, thereby allowing access to prognosis and improving new post-neoadjuvant therapies.

Comparison of retroperitoneal and transperitoneal surgical routes in laparoscopic nodal staging for locally advanced cervical cancers (FIGO IB3-IVA)

BackgroundThis study compares morbidity and mortality associated with retroperitoneal and transperitoneal para-aortic lymphadenectomy (PAAL) for pretherapeutic nodal staging of locally advanced cervical cancers (FIGO IB3–IVA). MethodsPre-, per- and postoperative data of patients treated for locally advanced stage cervical cancer between 1999 and 2018 in 12 French referral centers (FRANCOGYN Study Group) were retrospectively collected. ResultsThe study was conducted using a sample of 448 patients, of whom 223 (49,8%) underwent retroperitoneal (group 1) and 225 (50,2%) had transperitoneal PAAL (group 2). No differences were noted concerning clinical and histological characteristics between the two groups. Among these 448 patients, 23 (5,1%) had an intraoperative complication (9 (2,0%) in group 1 and 14 (3,1%) in group 2, p = 0.28) and 47 (10,5%) had a postoperative complication (22 (4,9%) in group 1 and 25 (5,6%) in group 2, p = 0.44), only one of which required revision surgery but the patient died. The length of hospital stay was significantly shorter in group 1 than in group 2 (3.97 versus 4.88 days, p < 0.001). There was no significant difference in mortality between the two groups; 34 of 223 patients in group 1 (15.3%) and 40 of 225 patients in group 2 (15.6%) died (HR = 0.968, 95% CI [0.591–1.585]). There was no significant difference in recurrence-free or overall survival between the two groups. ConclusionRetroperitoneal PAAL appears as a valuable and safety surgical route for nodal staging in locally advanced cervical cancer compared with standard transperitoneal PAAL.

Trends in Treatment of Colorectal Cancer and Short-term Outcomes During the First Wave of the COVID-19 Pandemic in Sweden

The COVID-19 pandemic has had a large impact on health care systems, not least the treatment of malignant diseases, including colorectal cancer. To investigate the treatment of colorectal cancer and short-term outcomes during the first wave of the COVID-19 pandemic, compared with the year before. This register-based cohort study used information from the Swedish Colorectal Cancer Registry during the years 2020 and 2019. Patients were from the Stockholm-Gotland region, 1 of 6 health care regions in Sweden, with approximately one-fifth of the country's population and 8 hospitals. All patients with a diagnosis of colorectal cancer from March 1 to August 31, 2019, and March 1 to August 31, 2020, were eligible. Data were analyzed from May to June 2021. Diagnosis of colorectal cancer during the peak of the COVID-19 pandemic in 2020. The study aimed to compare the number of patients, time to surgery, operation methods, short-term complications, and residents' involvement in surgical practice between 2019 and 2020. Subanalyses were conducted for colon and rectal cancer. A total of 1140 patients (583 men [51%]; median [IQR] age, 74 [26-99] years in 2019 and 73 [24-96] years in 2020) were enrolled. Fewer patients received a diagnosis of colorectal cancer in March through August 2020 compared with the same months in 2019 (550 vs 590 patients). Overall, patient characteristics were similar, but pretherapeutic tumor stage was more advanced in 2020 compared with 2019, with an increased proportion of T4 tumors (30% [172 patients] vs 22% [132 patients]; χ23 = 21.1; P < .001). The proportion of patients undergoing laparoscopic surgery, time to surgery, and 30-day complications were similar, but the proportion of patients treated with ostomy almost doubled between 2019 and 2020, from 17% (53 patients) to 30% (96 patients) (absolute risk, 13.0%; 95% CI, 6.8% to 20.0%). Residents participated in fewer resections in 2020 than in 2019 (35% [108 patients] vs 27% [83 patients]; absolute risk, -7.90%; 95% CI, -15.00% to -0.55%). On the other hand, the treatment and outcomes for rectal cancer were comparable between the years. Significantly more patients were transferred to the nonemergency, COVID-free hospital in the region in 2020. In this Swedish register-based cohort study of patients who received a diagnosis of colorectal cancer during the most intense period of the COVID-19 pandemic, a significant increase in ostomy formation for patients with colon cancer and a lower participation of residents during surgery were observed. These changes most likely were aimed at reducing complications and intensive care unit care.

209: ROLE OF ADJUVANT CHEMOTHERAPY IN LOW BURDEN (YPT0-T1N0) GASTRIC ADENOCARCINOMA AFTER NEOADJUVANT CHEMOTHERAPY

Abstract Background and aim Since 2006, perioperative chemotherapy(periCT) has become an established treatment for patients with resectable gastric adenocarcinoma in Europe after the demonstration of a survival benefit in two randomized clinical trials. However, only half of patients included in the periCT arm started adjuvant chemotherapy(adjCT), suggesting a preponderant effect of neoadjuvant chemotherapy(neoCT) on the survival benefit observed. The aim of this study was to assess the benefit of adjCT on disease-free survival in patients with low tumor burden(LTB) (ypT0N0 or ypT1N0) after neoCT. Methods Data were collected from 30 European centres from 2007 to 2017. Among 2131 included patients, 762 patients received neoCT and 135 had LTB (17.7%), including 40 patients (5.3%) with complete pathological response. Among patients with LTB, 85 (63%) received adjCT(adjCT+) and 50 patients (37%) did not (adjCT-). Propensity score matching analyses were used to compensate for differences in baseline characteristics between ajdCT+ and adjCT- patients. Results NeoCT regimen was mainly based on platinum-fluoropyrimidine doublet or triplet regimen(88.1%). In univariate analysis, predictive factors for LTB after neoCT were antro-pyloric location, pretherapeutic stage≤cT2, well-differentiated tumor, ≥2 cycles of preoperative chemotherapy, intestinal or mixt-type according to Lauren’s classification and non poorly-cohesive cells tumor. Patients in adjCT- group were older and had more frequently severe postoperative complications (≥ grade 3a according to Dindo-Clavien’s classification) than patients in adjCT+ group. Despite this, 5-years overall(OS) and disease-free survival(DFS) rates were comparable between adjCT+ and adjcCT- groups, respectively 92% vs. 82% and 89% vs.83%. After propensity score analysis, OS and DFS remain comparable between adjCT+ and adjCT- groups. In adjCT+ group, patients received mostly the same chemotherapy as that received preoperatively (82%). However, severe toxicity was described in 11 patients (13%). Among patients with ypT0N0 response with a follow-up longer than 3 months, 4 patients experienced tumor recurrence or death (11.4%). All of these patients had received adjuvant chemotherapy. Conclusion Performing adjCT in patients with LTB after neoCT does not seem to provide any benefit on OS or DFS, with non-negligible toxicity rates in counterpart.

Staging for Breast Cancer: A Nationwide Survey about Adherence to Guidelines in German Breast Centers

Introduction: The risk for metastasis at primary diagnosis of breast cancer is about 4%. The German guidelines give clear indications on when, who, and how to stage breast cancer patients. Ideally, this should be done via computerized axial tomography (CAT) scan of the thorax and abdomen and an additional bone scan. But daily practice shows that the way health-care providers handle staging recommendations can vary. To objectify adherence to guidelines we started a nation-wide survey. Methods: Between July and September 2020, we sent out a survey via email to all certified and noncertified breast centers and in addition to all Departments of Obstetrics and Gynecology in Germany. We asked for timing of staging, conditions that cause staging, and the applied method. In case we did not get any reply, we sent out a reminder. Results: A total of 220 certified breast centers, 28 noncertified breast centers, and 48 Departments of Obstetrics and Gynecology who care for breast cancer patients took part in our survey. A general pretherapeutic staging was performed in 16.4%, 39.3%, and 66.7% of all institutions and a general postoperative staging was performed in 4.1%, 0%, and 6.3% of each institutional type, respectively. In terms of the applied method, 75% of all certified breast centers used a CAT scan and bone scan, while 23.3% primarily used chest X-ray, ultrasound of the abdomen (27.7%), or MRI. As a potential reason for using X-ray and ultrasound, the presence of a “low-risk” breast cancer was mentioned. Summary: Although certified breast centers show the highest adherence to current guidelines, some still perform a general staging or do not use the recommended staging method. The low probability of primary metastatic breast cancer and the use of a reasonable exposure to radiation warrant a critical discussion.

Feasibility of Laparoscopic Para-Aortic Lymphadenectomy for Locally Advanced Cervical Cancer.

Background:Radiological evaluation of para-aortic lymph node metastasis in patients with locally advanced cervical cancer (LACC) possess the risk of missing microscopic metastasis. We commenced laparoscopic para-aortic lymphadenectomy (Lap-PAN) on patients with LACC for surgical staging in 2016. We assessed the feasibility of Lap-PAN in patients with LACC.Methods:We retrospectively reviewed the records of 31 patients with LACC who were staged at International Federation of Gynecology and Obstetrics (FIGO) 2009 IIB to IVA without enlargement of the para-aortic lymph nodes who underwent radiation therapy in our hospital between January 1, 2011 and December 31, 2018. The postoperative outcomes of Lap-PAN were analyzed, and distinct parameters for each patient, including sites of recurrence and disease-free survival, were compared between the Lap-PAN (n = 12) and no surgery (n = 19) groups.Results:The average operation time for Lap-PAN was 167 min, and the estimated blood loss was less than 50 ml in all patients. There were no perioperative complications. The average number of excised lymph nodes was 25, and no pathological metastases were observed. There was no difference in disease-free survival rates between the Lap-PAN and no surgery groups (p = 0.42). During the follow-up period, there were two cases of recurrence in the cervix in the Lap-PAN group, and three and four cases of lung and para-aortic lymph node recurrence, respectively in the no-surgery group.Conclusions:Lap-PAN was safely performed as a pretherapeutic staging method for LACC without worsening patient prognosis. Although Lap-PAN requires a high level of skill, it may be a method to avoid excessive radiation for LACC.

Tumor downstaging after neoadjuvant chemotherapy determines survival after surgery for gastric adenocarcinoma

BackgroundSince 2006, surgery combined with perioperative chemotherapy is the standard of care for resectable gastric adenocarcinoma in Europe. Specific effects of neoadjuvant chemotherapy remain unknown. The aim was to evaluate the rate of tumor downstaging and its impact on survival in patients undergoing curative resection after neoadjuvant chemotherapy (NeoCT) for gastric adenocarcinoma. Material and MethodsAll patients treated in a curative intent for gastric or esophagogastric junction adenocarcinomas between 1996 and 2016 in our high-volume center were retrospectively included. Tumor downstaging after NeoCT was defined as ypTN inferior to cTN. The accuracy of clinical staging was evaluated in patients treated by upfront surgery before 2006. ResultsDuring the study period, 491 patients were operated for gastric adenocarcinoma, and 449 patients were finally analyzed. Among the 163 (36.3%) patients who received NeoCT, 61 (37.4%) had tumor downstaging. Overall survival and disease-free survival were longer in patients with tumor downstaging compared to patients without it (5-year survival: 84.8% vs 49.7%; P = .002 and 61.7% vs 43.4%; P = .054). In multivariate analysis tumor downstaging was an independent prognosis factor for better overall survival (HR = 5.258; P = .002) and disease-free survival (HR = 2.286; P = .028). Moreover, 45.5% of patients staged cT1-T2N0, in whom upfront surgery was performed, were understaged and ultimately had a more advanced tumor on pathological analysis. ConclusionResponse to neoadjuvant chemotherapy constitutes a major prognostic factor for overall and disease-free survival. In the absence of predictive factors for tumor downstaging, the indication for perioperative chemotherapy should remain broad, in particular because of the low accuracy of pretherapeutic staging and therefore the high risk of understaging tumors.

FDG-PET/CT for pretherapeutic lymph node staging in non-small cell lung cancer: A tailored approach to the ESTS/ESMO guideline workflow

ObjectivesIn patients with NSCLC, current ESTS and ESMO guidelines recommend invasive lymph node (LN) staging with EBUS-TBNA even if FDG-PET/CT is negative for mediastinal LNs if at least one of three risk factors is present (cN1, non-peripheral primary or primary >3 cm). Modified workflows to avoid unnecessary invasive procedures were evaluated. Materials and methodsMonocentric retrospective analysis of pretherapeutic FDG-PET/CT in 247 patients with NSCLC (62 % male; age, 68 [43–88] years) using an analog or digital PET/CT scanner. PET windowing was standardized. LNs were positive if ‘LN uptake > mediastinal blood pool’ or short axis >10 mm. Surgery or EBUS-TBNA served as reference for diagnostic accuracy per LN station. In all patients with negative mediastinal LNs by PET/CT, LN histology from surgery was available. ResultsAmong 700 L N stations analyzed, 180 were malignant. Sensitivity and specificity of PET/CT per LN station were 93 % and 71 %. Following current guidelines, 76 patients with mediastinal negative PET/CT required confirmatory invasive staging. Only 5/76 patients had unexpected pN2 (all had adenocarcinoma). In a modified approach, confirmatory invasive staging was confined to patients with mediastinal negative PET/CT who showed all three risk factors. Using this modification, EBUS-TBNA could have been omitted in 62 (82 %) of the 76 patients who required EBUS-TBNA based on current recommendation. Among these 62 patients, only one patient had unsuspected pN2 (single-level) while the remaining 61 of 62 omitted EBUS-TBNA were deemed unnecessary because mediastinal LNs were confirmed to be negative. No multi-level pN2 would have been missed. ConclusionIn the current analysis, 82 % of EBUS-TBNA procedures in patients with mediastinal negative PET/CT could have been omitted by modifying the current guideline workflow as proposed (i.e., restricting EBUS-TBNA in patients with cN0/1 to those with all three risk factors). This was consistent with different PET/CT scanners. Prospective confirmation is required.

Patterns of cervical lymph node metastasis in supraglottic laryngeal cancer and therapeutic implications of surgical staging of the neck

PurposeAccurate therapeutic management of the neck is a challenge in patients with supraglottic laryngeal cancer. Nodal metastasis is common at all disease stages, and treatment planning relies on clinical staging of the neck, for both surgical and non-surgical treatment. Here, we compared clinical and surgical staging results in supraglottic carcinoma patients treated with primary surgery to assess the accuracy of pre-therapeutic clinical staging and guide future treatment decisions.MethodsRetrospective analysis of clinical, pathological, and oncologic outcome data of 70 patients treated with primary surgery and bilateral neck dissection for supraglottic laryngeal cancer. Patients where clinical and pathological neck staging results differed, were identified and analyzed in detail.ResultsOn pathologic assessment, patients with early stage (pT1/2) primaries showed cervical lymph node metastases in 55% (n = 17/31) of cases, compared to 67% (n = 26/39) of patients with pT3/4 tumors. In 24% (n = 17/70) of all patients, cN status differed from pN status, resulting in an upstaging in 16% of cases (n = 11/70) and a downstaging in 9% (n = 6/70) of cases. 14% of patients with cN0 status had occult metastases (n = 5/30). As assessed by a retrospective tumor board, in case of a non-surgical treatment approach, the inaccurate clinical staging of the neck would have led to an over- or undertreatment of the neck in 20% (n = 14/70) of all patients.ConclusionOur data re-emphasize the high cervical metastasis rates of supraglottic laryngeal cancer across all stages. Inaccurate clinical staging of the neck is common and should be taken into consideration when planning treatment.

FDG-PET-CT/MRI in head and neck squamous cell carcinoma: Impact on pretherapeutic N classification, detection of distant metastases, and second primary tumors.

To assess the effect of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the pretherapeutic staging of N classification, detection rate of distant metastases, and second primaries. Retrospective study on patients with head and neck carcinoma. We compared pretherapeutic N classification by ultrasound, computed tomography (CT)/magnetic resonance imaging (MRI), and FDG-PET-CT/MRI. A change in the N classification due to FDG-PET-CT/MRI was observed in 116 patients (39.5%) compared to N classification by ultrasound and fine-needle aspiration cytology. Patients with advanced nodal classification (>N2a) were more likely to be reclassified. Distant metastases were detected in 19 patients and a total of 36 second primaries were diagnosed by FDG-PET-CT/MRI. Detection of distant metastases was more likely in regional advanced disease (>N2a). Smokers (>10 py) had a significantly higher risk of second primary. FDG-PET-CT/MRI leads to a significant change in pretherapeutic N classification. The cumulative incidence of distant metastases and second primaries was 18.7%.