Primary Site Surgery Research Articles

Impact of Primary Site Surgery on Survival of Patients with de novo Stage IV Breast Cancer.

PurposeThe efficacy of primary site surgery in patients with de novo stage IV breast cancer remains controversial. However, few real-world studies have evaluated the benefits of local surgery on the primary site of stage IV breast cancer in China. The purpose of this study was to investigate the role of local surgery in the de novo stage IV breast cancer.Materials and MethodsWomen with metastatic breast cancer at diagnosis were identified from Guangxi medical university cancer hospital (China) database from 2009 to 2017. The clinical and tumor features, surgical treatment, and survival rates were compared between surgical and non-surgical patients.ResultsTwo hundred forty-three patients were included, of whom 125 underwent primary site surgery. Patients who underwent surgery were more often had small primary tumors, fewer lymph node metastases, and had less visceral involvement. Patients in the surgery group had dramatically longer OS (median 35 vs 22 months, log-rank P=0.006). Stratified survival analysis showed that patients with bone metastasis alone or ≤3 metastasis benefit from surgery, while patients with visceral metastasis did not benefit from surgery. In multivariate analysis, surgical treatment, estrogen receptor status, progesterone receptor status and visceral metastases remained independent factors for survival.ConclusionSurgical resection of the primary site can improve survival in selected de novo stage IV breast cancer patients.

Factors Affecting the Outcomes of Patients with Malignant Rhabdoid Tumors: A Population-Based Study.

Objective: Malignant rhabdoid tumor (MRT) is a rare but aggressive malignancy. It has been a long time since data on this tumor have been updated.Methods: We retrospectively reviewed patients from the SEER database who were pathologically diagnosed with MRT and analyzed incidence rates, clinical features and survival using Stata 12.0.Results: In total, 544 patients were included in the epidemiological analysis. There were two peak periods of MRT incidence: patients younger than 4 years and those older than 70 years. Further survival analysis showed that the survival of children (especially younger than 1 year) was markedly worse than that of adults (P<0.01), and different primary sites were associated with different age groups and survival outcomes. The central nervous system (CNS) was the most common primary site (50.00%), followed by the kidney (15.66%). Patients with MRTs that originated from the digestive system experienced worse survival outcomes than those with MRTs originating from other locations. Primary site surgery conferred survival benefits to patients with renal and digestive system MRTs (HR = 0.06, CI: 0.02-0.23, P<0.01; HR=0.10, CI: 0.02-0.48, P<0.01), whereas radiotherapy conferred benefits to patients with CNS, bone and soft tissue MRTs (HR=0.22, CI: 0.15-0.34, P<0.01; HR=0.44, CI: 0.21-0.90 P=0.03).Conclusions: Our results indicate that age and the primary site of MRT are critical clinical factors that affect patient survival and treatment choices. Primary site tumor resection should be considered for renal and digestive system MRTs, and systematic therapy, including surgery and radiotherapy, should be recommended for the treatment of CNS, bone and soft tissue MRTs.

Primary tumour resection for synchronously metastatic phaeochromocytoma and paraganglioma: A population-based study.

Until recently, there are few effective treatment options for patients with synchronous metastatic phaeochromocytoma (PHEO) and paraganglioma (PGL). Surgical resection may improve the survival outcomes of these patients. To assess the role of surgical resection of the primary tumour in patients with synchronous metastatic PHEO and PGL. Retrospective analysis of patients with synchronous metastatic PHEO/PGL using the Surveillance, Epidemiology, and End Results database (1988-2016). Patients with synchronous metastatic PHEO/PGL who underwent primary tumour resection. Overall survival and Cox regression analyses. A total of 99 patients with metastatic PHEO and 127 metastatic PGL patients were identified from the SEER database. Compared to metastatic PHEO, metastatic PGL patients had a better overall survival (5-year survival rate: 33.3% vs. 49.0%, p=.001). In metastatic PHEO patients, 53 (53.5%) patients underwent surgery for primary site. Surgically treated patients had an improved survival compared to non-surgery patients (5-year survival rate: 50.9% vs. 29.6%, p=.017). Among metastatic PGL patients, primary tumour resection was performed in 74 (58.3%) patients and had no significant effect on the survival of metastatic PGL. In sub-analyses, surgery only conferred a survival benefit in patients with primary tumours originated from aortic/carotid bodies, rather than other sites or abdominal tumours. Our findings suggest that primary tumour resection is associated with improved survival in patients with synchronous metastatic PHEO and those with PGL diseases located in aortic/carotid bodies. In addition, PHEO and PGL should be treated as two distinct clinical entities.

Microcystic adnexal carcinoma of the head and neck: Characteristics, treatment, and survival statistics.

Studies on microcystic adnexal carcinoma (MAC) survival rates have been limited. This effort examines the association of patient demographics, treatment modalities, and tumor stage with overall survival (OS) in patients with MAC of the head and neck. All cases of MAC with primary sites of the skin of the head and neck, confirmed histologically, and diagnosed from 2004 to 2016 in the National Cancer Database, were analyzed. We utilized Kaplan-Meier and Cox proportional-hazard models to analyze the characteristics and survival outcomes of the 415 cases that met the criteria. The mean age of diagnosis was 63.8 years (SD ±15.8). Mean OS was 10.8 years with 5- and 10-year OS being 81.0% and 68.0%, respectively. Women were more frequently affected (59.0%; P < .001). Stand-alone primary site surgery was the most common treatment (81.4%): 15.9% of patients were treated with postexcision radiation therapy (RT). 18.3% were treated with RT with or without surgery and/or chemotherapy. RT was independently associated with a decreased hazard of death (HR = 0.23; P = .044). MAC of the head and neck disproportionately affects whites, is more common in women, and has the potential to metastasize. Surgical excision is the commonest treatment; our study shows benefit from judicious RT.

Development and validation of a nomogram to predict synchronous lung metastases in patients with ovarian cancer: a large cohort study.

Purpose: Lung metastasis is an independent risk factor affecting the prognosis of ovarian cancer patients. We developed and validated a nomogram to predict the risk of synchronous lung metastases in newly diagnosed ovarian cancer patients.Methods: Data of ovarian cancer patients from the Surveillance, Epidemiology, and Final Results (SEER) database between 2010 and 2015 were retrospectively collected. The model nomogram was built on the basis of logistic regression. The consistency index (C-index) was used to evaluate the discernment of the synchronous lung metastasis nomogram. Calibration plots were drawn to analyze the consistency between the observed probability and predicted probability of synchronous lung metastases. The Kaplan–Meier method was used to estimate overall survival rate, and influencing factors were included in multivariate Cox regression analysis (P<0.05) to determine the independent prognostic factors of synchronous lung metastases.Results: Overall, 16059 eligible patients were randomly divided into training (n=11242) and validation cohorts (n=4817). AJCC T, N stage, bone metastases, brain metastases, and liver metastases were evaluated as predictors of synchronous lung metastases. Finally, a nomogram was constructed. The nomogram based on independent predictors was calibrated and showed good discriminative ability. Mixed histological types, chemotherapy, and primary site surgery were factors affecting the overall survival of patients with synchronous lung metastases.Conclusion: The clinical prediction model has high accuracy and can be used to predict lung metastasis risk in newly diagnosed ovarian cancer patients, which can guide the treatment of patients with synchronous lung metastases.

Prognostic factors of patients with initially diagnosed T1a glottic cancer: Novel nomograms and a propensity-score matched cohort analysis.

The option of T1a glottic cancer treatments remarkably varied in different countries. This study aimed to construct predictive models to predict overall survival (OS) and cancer-specific survival (CSS) of patients with initially diagnosed T1a glottic cancer. And we used propensity score matching (PSM) to reassess the effect of treatments.Data of patients with initially diagnosed T1a glottic cancer were extracted from the Surveillance, Epidemiology, and End Results database. Patients with complete information were randomly divided into the training and the validation cohorts (7:3). Cox regression was conducted to screen significant predictors of the OS and the CSS. PSM was performed to mimic randomized controlled trials. Survival analyses were performed by Kaplan-Meier survival methods, and log-rank tests were utilized.A total of 2342 patients met the inclusion criteria. Survival analyses showed that patients who underwent primary site surgery would have better OS and CSS. Univariate analyses and multivariate analyses proved that stage, N stage, primary site surgery, and chemotherapy significantly affected both the OS and the CSS. Predictive nomograms were established to predict patients' prognosis. Finally, the OS and the CSS for patients who underwent primary site surgery alone were significantly longer than those who underwent radiation alone before and after PSM.We constructed nomograms predicting the OS and the CSS of patients with initially diagnosed T1a glottic cancer. Compared to our previous studies, this study indicated that primary site surgery may be superior to radiation and chemotherapy. At present, chemotherapy should be not recommended for T1a glottic cancer patients.

Marital Status and Prognostic Nomogram for Bladder Cancer With Distant Metastasis: A SEER-Based Study.

BackgroundTo investigate the impact of marital status on overall survival (OS) and create a prognostic nomogram predicting OS in distant-metastatic bladder cancer (DMBC) patients.MethodsThe Surveillance, Epidemiology, and End Results (SEER) database was explored to recruit DMBC patients from 2010 to 2015. Kaplan–Meier survival analysis was used to compare survival differences among different marital status. Univariate and multivariate analyses were used to screen for prognostic factors and then constructed the nomogram based on Cox proportional hazard regression models. Calibration plot diagrams and concordance index (C-index) were used to verify the prognostic nomogram.ResultsKaplan–Meier curves suggested the significant differences of OS among different marital status existed in total (P < 0.001), female (P = 0.011) and male (P = 0.001) DMBC patients, respectively. Multivariate analysis indicated marital status was an independent prognostic factor for OS of DMBC patients. Nomogram showed the contribution of marital status to predicting OS was small. Other independent prognostic factors included age, grade, histology type, surgery of primary site, chemotherapy, and metastasis pattern. By combining seven factors, we constructed a prognostic nomogram for DMBC patients. The C-index of this nomogram for OS prediction was 0.722 (95% CI 0.712–0.732). The calibration curves showed perfect consistency between observed and predictive survival.ConclusionsMarital status was an independent prognostic factor for OS of DMBC patients, but its contribution to predicting OS was small. The prognostic nomogram will provide an individualized evaluation of OS and guidance for suitable treatments in DMBC patients.

Survival and Patterns of Failure in Oligometastatic Esophagogastric Cancer

Metastatic esophagogastric cancer (EGC) has poor outcomes, with median overall survival (OS) of 9-11 months. Studies in other sites such as lung have shown improved survival with local treatment for oligometastasis (OM). However, there is very limited data on oligometastatic EGC. We investigated outcomes, prognostic factors, and patterns of first progression in patients with oligometastatic EGC. From 2008-2018, 1438 patients (pts) presented to our institution with stage IV EGC. Of these, 197 pts had OM (defined as ≤5 metastatic lesions, excluding primary) and were included for analysis. Median age was 67 years and most (77%) were male. 46 pts (23%) had gastric (GC) and 151 (77%) had esophageal/GE junction (GEJ) tumors. First progression was classified as limited to initial sites, new sites, or failure at both initial and new sites. OS was stratified by primary tumor site, number of OM, and sites of OM using Kaplan Meier and log rank tests. Cox proportional hazards model was used to investigate correlation between prognostic factors and outcomes. At a median follow up of 22.5 (1-117) months, median OS for the whole cohort was 25 months (95%CI: 22.6-27.4) with a statistically significant difference between GC and GEJ cancer (37 vs. 25 months, p = 0.03). Location of OM was as follows: non-regional nodes (44%), liver (17%), peritoneal nodules (7%), bone (6%), lungs (4%), brain (2%), liver plus non-regional nodes (5%), and other (15%). Peritoneal nodules were more common in GC whereas bone, lungs, and brain were more common in GEJ cancer. Most pts had a solitary OM (42.6%). The number or sites of OM did not correlate with OS. Of 152 pts who progressed, 91 (60%) had isolated initial site failure, 17% had isolated new site failure, and 23% had both initial and new site failure. 13% and 10% of pts underwent surgery for primary site and OM respectively. Radiation therapy (RT) to primary site (median 37.5 Gy in 15 fractions), was delivered to 37%, usually upon progression (57%). 11% received RT to OM. On univariate analysis, gastric primary, younger age, primary tumor or OM resection, RT to the primary, and isolated initial site failure were significantly associated with better OS. On multivariate analysis, age (HR: 1.031, p = 0.001) surgery to the primary (HR: 0.295, p = 0.002), and initial-site failure (HR: 1.4 p = 0.002) remained significantly correlated with OS. We observed a longer OS for oligometastatic EGC, compared to historical results for general metastatic disease reported in the literature. This suggests that EGC patients with OM are a prognostically distinct group and may benefit from tailored treatment strategies such as ablative local therapy. Most patients first progressed in their initial sites of disease, suggesting a role for local therapy earlier in the treatment course. Younger patients and those undergoing primary tumor resection had superior OS.

Predictive Risk Factors and Online Nomograms for Synchronous Colon Cancer With Liver Metastasis.

ObjectivesTo develop and validate predictive nomograms of cancer specific survival (CSS) and overall survival (OS) for synchronous colon cancer with liver metastasis (SCLM) patients.MethodsPatients with pathologically diagnosed colon cancer with liver metastasis were retrieved from the SEER database between 2010 and 2015. Only SCLM patients were included. Univariate and multivariate cox regression analyses were conducted to identify the potential predictors of patients’ survival outcomes. The selected variables were integrated to create predictive nomograms via R tools. Furthermore, the concordance index Harrell’s C statistic (C-index) was calculated to describe the discrimination of nomograms. Calibration (1000 bootstrap resamples) curves were plotted to compare the predictions of nomograms with the observed outcomes. Decision curve analysis (DCA) and clinical impact curves were performed to evaluate the clinical effects of nomograms.ResultsA total of 22,378 SCLM patients were included. The median time of OS and CSS was 13 and 17 months, respectively. The 1-, 2-, and 3-year rate of OS was 50.6, 28.1, and 14.8%, respectively. While the 1-, 2-, and 3-year rate of CSS was 58.7, 36.8, and 22.5%, respectively. SCLM patients with increased age, left primary tumor location, AJCC IVb stage, and no chemotherapy were associated with an obviously reduced OS and CSS. Variables including age, histological grade, T/N/M stage, tumor size, bone/lung metastasis, CEA, surgery of primary site, and chemotherapy were closely related to the prognoses of SCLM patients. Nomograms of OS and CSS were built and displayed online for convenient utilization. The C-index of OS and CSS monograms were 0.74 and 0.73, respectively, indicating relatively good discrimination of the nomograms. The calibration curves suggested a good agreement between the actual observation and the nomogram prediction. DCAs and clinical impact curves reflected favorable potential clinical effects of predictive nomograms.ConclusionChemotherapy, surgery of primary site, and age were important independent risk factors for the CSS and OS of SCLM patients. We built and validated two reliable nomograms of OS and CSS to predict the prognoses of SCLM patients, which can be accessed online at (https://predictive-tool.shinyapps.io/CSS-DynNomapp/; https://predictive-tool.shinyapps.io/OS-DynNomapp/).

Development and validation of an individualized nomogram for predicting pancreatic adenocarcinoma-specific survival: a SEER population analysis of 5,805 patients.

A model to predict the overall survival (OS) of pancreatic adenocarcinoma (PAC) is required in consideration of its inferior prognosis. The patients diagnosed with pancreatic cancer between 1975 and 2016 in the Surveillance, Epidemiology, and End Results (SEER) database was used as raw data. A training cohort and a verification cohort were used for internal validation and external validation, respectively. The nomogram model was constructed to predict the OS. A total of 5,805 patients with PAC from 2010-2015 were analyzed. Most patients were over 65 years old (61.8%), white (81.2%), in stage IIA, IIB (49.0%), and IV (32.4%), less than 50 mm in diameter (80.2%). PAC patients with wide involvement range, no metastasis, and infiltration range more than 300 accounted for 58.2%, 67.6%, 78.2%, respectively. The vast majority of the PAC patients (90.9%) did not receive primary site surgery. Most of the PAC patients (68.1%) received chemotherapy and only 25.8% of PAC patients received radiotherapy. The overall mean survival time, overall median survival time and overall survival rate were 15.1 months, 10.0 months, and 16.7%, respectively. Our nomogram that based on age, chemotherapy, grade, Radiation sequence with surgery, Radiation recode, RX Summ-Surg Prim at Site (surgery that removes and/or destroys primary tumor performed as part of the first course of therapy), size, and stage was of well prediction ability.

Calculating the overall survival probability in patients with cervical cancer: a nomogram and decision curve analysis-based study

BackgroundCervical cancer has long been a common malignance troubling women. However, there are few studies developing nomogram with comprehensive factors for the prognosis of cervical cancer. Hence, we aimed to build a nomogram to calculate the overall survival (OS) probability in patients with cervical cancer.MethodsData of 9876 female patients in SEER database and diagnosed as cervical cancer during 2010–2015, was retrospectively analyzed. Univariate and multivariate Cox proportional hazard regression model were applied to select predicted factors and a nomogram was developed to visualize the prediction model. The nomogram was compared with the FIGO stage prediction model. Harrell’s C-index, receiver operating curve, calibration plot and decision curve analysis were used to assess the discrimination, accuracy, calibration and clinical utility of the prediction models.ResultEleven independent prognostic variables, including age at diagnosis, race, marital status at diagnosis, grade, histology, tumor size, FIGO stage, primary site surgery, regional lymph node surgery, radiotherapy and chemotherapy, were used to build the nomogram. The C-index of the nomogram was 0.826 (95% CI: 0.818 to 0.834), which was better than that of the FIGO stage prediction model (C-index: 0.785, 95% CI: 0.776 to 0.793). Calibration plot of the nomogram was well fitted in 3-year overall OS prediction, but overfitting in 5-year OS prediction. The net benefit of the nomogram was higher than the FIGO prediction model.ConclusionA clinical useful nomogram for calculating the overall survival probability in cervical cancer patients was developed. It performed better than the FIGO stage prediction model and could help clinicians to choose optimal treatments and precisely predict prognosis in clinical care and research.

Predictors of Nodal Metastasis in Mucoepidermoid Carcinoma of the Oral Cavity and Oropharynx

Introduction: Mucoepidermoid carcinoma (MEC) of the upper aerodigestive tract (UADT) is an uncommon malignancy, with limited literature available on its clinical and pathologic characteristics. Here, we describe the behavior of MEC of the UADT including pathologic characteristics and predictors of nodal metastasis. Methods: Retrospective cohort study of patients with MEC of the UADT treated at an academic medical center from January 2008 to May 2018. Data was collected about demographics and tumor characteristics including clinical and histological data. The two-tailed Student t test and χ² analysis were performed to assess for predictors of nodal metastasis. Results: We identified 44 patients with minor salivary gland MEC of the oral cavity (OC) and oropharynx (OP). All patients were treated with primary site surgery. The primary site was the OC in 25 patients (57%) and OP in 19 (43%). Low-grade histology was seen in 27 specimens (61.4%), intermediate histology in 9 specimens (20.5%), and high-grade histology in 8 specimens (18.2%). Perineural invasion was noted in 10 specimens (22.7%). Neck dissection was performed in 17 patients (39%), with pathologically positive nodes found in 9 (20.5%). Notably, 5 of the 9 positive nodal specimens were found in clinically node-negative necks. Pathologically positive cervical lymph nodes were significantly associated with the OP as the primary site (p = 0.0005), perineural invasion (p = 0.012), lymphovascular invasion (p < 0.001), and high-grade histology (p = 0.004) in the primary specimen. Discussion: MEC of the UADT is an uncommon malignancy. Our findings suggest elective neck dissection should be considered with perineural and lymphovascular invasion, high-grade tumor, and the OP as the primary site.

Proposal of organ-specific subdivision of M component and staging system for metastatic pulmonary neuroendocrine tumor

ObjectivesTo evaluate the prognostic significance of patterns of distant metastatic organs in metastatic pulmonary neuroendocrine tumors (PNETs). Methods891 metastatic PNETs patients (G1-typical carcinoid, 200; G2-atypical carcinoid, 68; G3-large-cell neuroendocrine carcinoma, 623) diagnosed between 2010 and 2016 were identified. Multivariate analysis was performed using a Cox regression model to identify prognostic factors associated with cancer-specific survival (CSS). The novel M component was established based on the hazard ratio of different metastatic organs. A disease-specific staging system was then proposed by using k-means cluster analysis. ResultsFor metastatic PNETs, involvement of bone, liver or brain and multiple metastatic organs were identified as independent prognostic factors in multivariate analysis. M categories was subdivided into three subcategories: M1a, lung involvement only or distant lymph node involvement only; M1b, bone involvement only or liver involvement only; M1c, brain involvement regardless of number of metastatic organs or multiple organs involvement except brain. Primary site surgery, chemotherapy and histologic subtypes were independently associated with CSS, but T component and N component were not. After regrouping histologic subtypes and novel M component, we proposed the following modified staging system: stage IVA (G1M1any, G2M1a-b), stage IVB (G2M1c, G3M1a-b) and stage IVC (G3M1c). The 2-year CSS were 77.9 %, 16.4 % and 5.3 %. ConclusionsSubdivision of M component according to patterns of distant metastatic organs facilitates prognostic significance for PNETs. Brain metastases and multiple metastatic organs were associated with significantly inferior prognosis. Incorporating histologic subtypes and novel M categories create a disease-specific staging system showed good discriminatory capacity.

Epidemiology and survival outcomes of primary gastrointestinal melanoma: a SEER-based population study.

Primary melanoma arising in the gastrointestinal (GI) tract is rare and poorly characterized. We sought to describe the epidemiology and survival outcomes of primary GI melanoma. GI melanoma cases were extracted from the Surveillance, Epidemiology, and End Results (SEER) database by tumor site and histology codes. We calculated age-adjusted incidence, and analyzed demographics, clinical characteristics, as well as overall survival (OS) and cancer-specific survival (CSS) of GI melanoma. A total of 1080 histologically confirmed cases of primary GI melanoma were identified, with a median age of 71years (IQR: 59-80). 49.9% of the cases originated from anus, 30.8% had distant disease at diagnosis, and 61.5% received cancer-directed surgery. The distribution of gender and age was varied in GI melanoma subtypes. The incidence of GI melanoma was 0.58 cases per million, and increased remarkably over age, especially in patients aged 60years or older. The median OS and CSS of the whole cohort was 14months (95% CI 12.7-15.3) and 22months (95% CI 18.8-25.2), respectively. Anal melanoma patients had prolonged survival, while those with gastric melanoma had the poorest OS (18 and 4months, respectively). Multivariate analysis showed that decreased survival was associated with age older than 80years, gastric and esophageal origin, advanced-stage disease, lymph node metastasis, and without surgery of primary site. Patients with primary GI melanoma trended topresent with advanced-stage disease. Overall, GI melanoma had a poor prognosis, but the outcome differed according to the primary sites.

A validated survival nomogram for early-onset diffuse gastric cancer.

This study aimed to establish and independently validate a prognostic nomogram for individual risk prediction in patients with early-onset diffuse gastric cancer (EODGC). Data for 794 patients with EODGC from the SEER database were randomly assigned to training (N=558) and internal validation (N=236) sets, and data for 82 patients from the Renmin Hospital of Wuhan University (RMHWHU) were used as an independent validation cohort. Our LASSO regression analyses of the training set yielded five clinicopathological features (race, AJCC stage, surgery for primary site, chemotherapy and tumor size), which were used to create a survival nomogram. Our survival nomogram achieved better predictive performance than the AJCC staging system, the current standard. Additionally, the calibration curves of the prognostic nomogram revealed good agreement between the predicted survival probabilities and the ground truth values. Indeed, our nomogram, which estimates individualized survival probabilities for patients with EODGC, shows good predictive accuracy and calibration ability for both the SEER and RMHWHU cohorts. These results suggest that a survival nomogram may be better at predicting OS for EODGC patients than the AJCC staging system.

The impact of immunotherapy on the survival of pancreatic adenocarcinoma patients who do not receive definitive surgery of the tumor

Background and PurposeImmunotherapy has shown great efficacy in many cancers, but its role in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The objective of this study was to investigate the impact of immunotherapy on the overall survival of PDAC patients who did not receive definitive surgery of the pancreatic primary tumor site using the National Cancer Database (NCDB). Materials and MethodsPatients with pancreatic adenocarcinoma who did not receive surgery were identified from NCDB. Cox proportional hazard models were employed to assess the impact of immunotherapy on survival after adjusting for age at diagnosis, race, sex, place of living, income, education, treatment facility type, insurance status, year of diagnosis, and treatment types such as chemotherapy and radiation therapy. ResultsOf 263,886 patients who were analyzed, 911 (0.35%) received immunotherapy. Among patients who received chemotherapy (101,546), and chemoradiation (30,226) therapy, 555/101,546 (0.55%) received chemotherapy plus immunotherapy, and 299/3,022 (9.9%) received chemoradiation plus immunotherapy. In a multivariable analysis adjusted for the factors mentioned above, immunotherapy was associated with significantly improved OS (HR: 0.866 (0.800–0.937); P < 0.001) compared to no immunotherapy. Chemotherapy plus immunotherapy was significantly associated with improved OS (HR: 0.848 (0.766–0.938); P < 0.001) compared to chemotherapy without immunotherapy. Further, chemoradiation plus immunotherapy was associated with significantly improved OS (HR: 0.813 (0.707–0.936); P < 0.001) compared to chemoradiation alone. ConclusionIn this study, the addition of immunotherapy to chemotherapy and chemoradiation therapy was associated with significantly improved OS in PDAC patients without definitive surgery. The study warrants future clinical trials of immunotherapy in PDAC.

Incidence and prognosis of patients with pulmonary metastases at diagnosis of primary extrapulmonary malignancy: A population-based study.

e19353 Background: As a sign of advanced malignancy, pulmonary metastases often predict poor prognosis and are notoriously difficult to treat, requiring an interdisciplinary combination of chemotherapy, surgery and radiotherapy. Large-scale and generalizable studies examining the incidence and prognosis of patients with pulmonary metastases are still lacking. Methods: We identified 2,649,261 patients with diagnoses of nonhematologic malignancies originating outside of the pulmonary between 2010 and 2016 from the Surveillance, Epidemiology, and End Results (SEER) program. We described the incidence proportion and survival of patients with pulmonary metastases, and determined risk factors and prognostic factors of for pulmonary metastasis. Results: We identified 68,474 patients with pulmonary metastases at diagnosis, accounting for 3.19% of all patients with cancer and 35.94% of those patients with metastatic disease. Tumors with higher lung metastasis rates were pancreas cancer, esophageal cancer, sarcoma, renal cancer, hepatobiliary cancer, all other type of cancer, ovarian cancer and gastric cancer (10.54%, 9.32%, 8.75%, 7.48%, 6.43%, 5.96%, 5.79% and 5.26%, respectively). When considering only patients with distant metastases at diagnosis, The top five types of cancer with pulmonary metastasis were testicular cancer (82.82%), thyroid cancer (72.80%), endometrial cancer (66.87%), renal cancer (66.59%) and cervical cancer (64.89%). Multivariable logistic regression identified several oncology characteristics, such as synchronal bone, brain or liver metastasis (vs without), higher N-stage, and tumor poor pathological differentiation were associated with higher risk of pulmonary metastases. Similar to the risk factors for incidence, more distant metastasis, poor differentiation, higher staging, positive lymph node might also associate with shorter overall survival and cancer-specific survival. Surgery of primary site was a protect factor for survival. Conclusions: For the first time, we provided current generalizable estimates of the incidence and prognosis of patients with pulmonary metastases at diagnosis of an extrapulmonary malignancy. This data may lead to evaluation of early screening of the pulmonary using chest CT scan among patients with newly diagnosed primary extrapulmonary malignancies, and further shape the development of screening and treatment guidelines about pulmonary metastases.

Primary tumor resection in de novo stage IV breast cancer patients.

Breast and axillary surgery in Stage IV disease is outside current national guidelines but has been a topic of ongoing debate. A single institution retrospective study identified women with de novo stage IV BC from 2011-2016 to evaluate the rate and goals of primary site surgery. Only 10.2% (n=27/265patients) had primary site surgery. The goal of surgery was most often treatment intent (n=23, 85.1%) not palliation (n=4, 14.8%). There was no 30-day mortality and low (n=1, 3.7%) 30-day morbidity. Multi-disciplinary patient care pathways based on modern evidence may help identify patients potentially suitable for primary site surgery.

Evaluating overall survival and competing risks of survival in patients with early-stage breast cancer using a comprehensive nomogram.

BackgroundPatients with early‐stage breast cancer (BC) live long but have competing comorbidities. This study aimed to estimate the effect of cancer and other causes of death in patients with early‐stage BC and further quantify the survival differences.Materials and methodsData of patients diagnosed with BC between 2010 and 2016 were collected from the Surveillance, Epidemiology, and End Results database. The cumulative incidence function for breast cancer–specific mortality (BCSM) and other cause‐specific mortality (OCSM) was estimated, and the differences were tested using the Gray test. The nomogram for estimating 3‐, 4‐, and 5‐year overall survival (OS), breast cancer–specific survival, and other cause‐specific survival was established based on Cox regression analysis and Fine and Gray competing risk analysis. The discriminative ability, calibration, and precision of the nomogram were evaluated and compared using C statistics, calibration plots, and area under the receiver operating characteristic curve.ResultsA total of 196 304 eligible patients with early‐stage BC were identified in this study. Of these, 12 417 (6.3%) patients died: 5628 (45.3%) due to BC and 6789 (54.7%) due to other causes. Five validated variables were incorporated to develop the prognostic nomogram: age, grade, tumor size, subtype, and surgery of primary site (Figure 3). Age was a strong predictive factor, which was more obvious in OCSM. The effect of surgery was more prominent in BCSM. Increased tumor size was correlated with OS and BCSM and slightly correlated with OCSM. Grade and subtype differences were more predominant in BCSM than in OCSM. The established nomogram was well calibrated and displayed good discrimination.ConclusionsWe evaluate OS and competing risks of death in patients with early‐stage BC, establishing the first comprehensive prognostic nomogram.

Risk factors and prognosis of bone metastases in newly diagnosed gastric cancer.

Aim: To predict the occurrence of bone metastases and prognosis among patients with gastric cancer on a population level. Materials & methods: Data were obtained from the SEER database (2010-2016). Multivariable logistic regression and multivariable Cox regression were used to determine factors that predict the occurrence of bone metastasis and prognosis. Results: Cardia cancer, younger age, white race, poor differentiation grade, higher N stage, diffuse-type were positively associated with the presence of bone metastasis. For gastric cancer patients with bone metastasis, the median survival time was longer (9.0 months) among patients with surgery of primary site compared with those without surgery (3.0 months). Conclusion: According to the results of risk assessment, clinical efforts should be targeted to focus on screening high-risk patients.