Rate Of Upstaging Research Articles

The effect of delay of excisional biopsy on upstage rate for atypical ductal hyperplasia, flat epithelial atypia, intraductal papilloma, and radial scar.

PurposeWhen Core Needle Biopsy (CNB) demonstrates Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Intraductal Papilloma (IDP), or Radial Scar/Complex Sclerosing Lesion (RS), excisional biopsy (EB) is often performed to rule out underlying malignancy with upstage rates (UR) ranging between 1 and 20%. The COVID-19 pandemic led to delayed EB for many patients. We sought to evaluate whether this delay was associated with higher UR.MethodsWe performed a retrospective analysis of women who underwent CNB and then EB for ADH, FEA, IDP, or RS between 2017 and 2021 using an IRB-approved repository. UR was evaluated by days between CNB and EB.Results473 patients met inclusion. 55 were upstaged to cancer (11.6%). 178 patients had pure ADH on CNB and 37 were upstaged (20.8%). 50 patients had pure FEA and 3 were upstaged (6%). 132 had pure IDP and 7 were upstaged (5.3%). 98 had pure RS and 1 was upstaged (1%). 7/15 (46.7%) had a combination of diagnoses or diagnosis with palpable mass and were upstaged.Days between CNB and EB were < 60 for 275 patients (58.1%), 60–90 for 108 (22.8%), 91–120 for 43 (9.1%), and > 120 for 47 (9.9%). There was no significant difference in UR (10.9% for < 60, 14.8% for 60–90, 7% for 90–120, and 12.8% for > 120, p = 0.54). UR for ADH was clinically increased after 60 days (27.8 vs. 17.5%), but this did not reach statistical significance (p = 0.1).ConclusionSurgical delay was not associated with an increased UR.

Systematic endoscopic staging of mediastinum to determine impact on radiotherapy for locally advanced lung cancer (SEISMIC): protocol for a prospective single arm multicentre interventional study

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is established as the preferred method of mediastinal lymph node (LN) staging in non-small cell lung cancer (NSCLC). Selective (targeted) LN sampling is most commonly performed however studies in early stage NSCLC and locally advanced NSCLC confirm systematic EBUS-TBNA evaluation improves accuracy of mediastinal staging. This study aims to establish the rate of detection of positron emission tomography (PET)-occult LN metastases following systematic LN staging by EBUS-TBNA, and to determine the utility of systematic mediastinal staging for accurate delineation of radiation treatment fields in patients with locally advanced NSCLC.MethodsConsecutive patients undergoing EBUS-TBNA for diagnosis/staging of locally advanced NSCLC will be enrolled in this international multi-centre single arm study. Systematic mediastinal LN evaluation will be performed, with all LN exceeding 6 mm to be sampled by TBNA. Where feasible, endoscopic ultrasound staging (EUS-B) may also be performed. Results of minimally invasive staging will be compared to FDG-PET. The primary end-point is proportion of patients in whom systematic LN staging identified PET-occult NSCLC metastases. Secondary outcome measures include (i) rate of nodal upstaging, (ii) false positive rate of PET for mediastinal LN assessment, (iii) analysis of clinicoradiologic risk factors for presence of PET-occult LN metastases, (iv) impact of systematic LN staging in patients with discrepant findings on PET and EBUS-TBNA on target coverage and dose to organs at risk (OAR) in patients undergoing radiotherapy.DiscussionWith specificity of PET of 90%, guidelines recommend tissue confirmation of positive mediastinal LN to ensure potentially early stage patients are not erroneously denied potentially curative resection. However, while confirmation of pathologic LN is routinely sought, the exact extent of mediastinal LN involvement in NSCLC in patient with Stage III NSCLC is rarely established. Studies examining systematic LN staging in early stage NSCLC report a significant discordance between PET and EBUS-TBNA. In patients with locally advanced disease this has significant implications for radiation field planning, with risk of geographic miss in the event of PET-occult mediastinal LN metastases. The SEISMIC study will examine both diagnostic outcomes following systematic LN staging with EBUS-TBNA, and impact on radiation treatment planning.Trial registrationACTRN12617000333314, ANZCTR, Registered on 3 March 2017.

Can a reresection be avoided after initial en bloc resection for high-risk nonmuscle invasive bladder cancer? A systematic review and meta-analysis.

BackgroundThis study aims to evaluate the effectiveness of en bloc resection for patients with nonmuscle invasive bladder cancer (NMIBC) and explore whether a reresection can be avoided after initial en bloc resection.Material and methodsWe conducted research in PubMed, EMBASE, Cochrane Library, and Web of Science up to October 12, 2021, to identify studies on the second resection after initial en bloc resection of bladder tumor (ERBT). R software and the double arcsine method were used for data conversion and combined calculation of the incidence rate.ResultsA total of 8 studies involving 414 participants were included. The rate of detrusor muscle in the ERBT specimens was 100% (95%CI: 100%–100%), the rate of tumor residual in reresection specimens was 3.2% (95%CI: 1.4%–5.5%), and the rate of tumor upstaging was 0.3% (95%CI: 0%–1.5%). Two articles compared the prognostic data of the reresection and non-reresection groups after the initial ERBT. We found no significant difference in the 1-year recurrence-free survival (RFS) rate (OR = 1.44, 95%CI: 0.67–3.09, P = 0.35) between the two groups nor in the rate of tumor recurrence (OR = 0.72, 95%CI: 0.44–1.18, P = 0.2) or progression (OR = 0.98, 95%CI: 0.33–2.89, P = 0.97) at the final follow-up.ConclusionsERBT can almost completely remove the detrusor muscle of the tumor bed with a very low postoperative tumor residue and upstaging rate. For high-risk NMIBC patients, an attempt to appropriately reduce the use of reresection after ERBT seems to be possible.

Treatment patterns and rates of upgrading and upstaging in prostate cancer patients with single GGG1 positive biopsy core.

Not infrequently patients are diagnosed with clinically localized prostate based on a single positive biopsy core exhibiting Gleason grade group 1 (GGG1) with variable prostate-specific antigen (PSA) levels. We investigated treatment patterns and hypothesized that regardless of PSA in cT1- to cT2-stage patients, presence of GGG3/GGG4/GGG5 and/or non-organ confined stage will rarely be identified. Within the Surveillance, Epidemiology, and End Results database (2010-2015), clinically localized prostate cancer (CaP) patients with PSA ≤ 50 ng/ml and a single positive GGG1 biopsy core were identified. Overall treatment rates were examined, estimated annual percentage changes and logistic regression analyses were fitted to test for no-local treatment. Subsequently, rates of upgrading (GGG3/GGG4/GGG5) and/or upstaging (≥pT3 and/or pN1) were investigated in radical prostatectomy patients. 13,342 clinically localized CaP patients harbored single GGG1 positive biopsy core at diagnosis. No local treatment was recorded in 5,235 (53.0%) cT1-stage vs. in 1,039 (49.0%) cT2-stage patients. No local treatment rates increased over time from 35.0% to 67.0% vs. 34.0% to 63.0% in cT1 vs. cT2 patients, observations were confirmed in logistic regression analyses (cT1: multivariable odds ratio [mOR]: 1.39; cT2: mOR: 1.33). In radical prostatectomy treated cT1-patients (n = 2,293) and cT2-patients (n = 659), upgrading vs. upstaging vs. upgrading/upstaging combined was 6.1%, 6.5%, 11.0% and 6.2%, 5.0%, 9.9% respectively. In single GGG1 positive biopsy core CaP patients, the combined proportion of upgrading and upstaging should be expected in one tenth. In consequence, the overwhelming majority harbors favorable grade and stage that is compatible with no local treatment.

A Systematic Review on the Role of Repeat Transurethral Resection after Initial en Bloc Resection for Non-Muscle Invasive Bladder Cancer.

International guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for selected patients with high-risk non-muscle invasive bladder cancer to remove possible residual tumors, restage tumors and improve the therapeutic outcome. However, most evidence supporting the benefits of reTURB is from conventional TURB. The role of reTURB in patients receiving initial En bloc resection of bladder tumor (ERBT) is still unknown. PubMed, Embase, Web of Science, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were systematically searched. Finally, this systematic review and meta-analysis included twelve articles, including 539 patients. The rates of residual tumor and tumor upstaging detected by reTURB after ERBT were 5.9% (95%CI, 2.0%–11.1%) and 0.0% (95%CI, 0.0%–0.5%), respectively. Recurrence-free survival, tumor recurrence and progression were comparable between patients with and without reTURB after initial ERBT. The pooled hazard ratios of 1-year, 2-year, 3-year and 5-year recurrence-free survival were 0.74 (95%CI, 0.36–1.51; p = 0.40), 0.76 (95%CI, 0.45–1.26; p = 0.28), 0.83 (95%CI, 0.53–1.32; p = 0.43) and 0.83 (95%CI, 0.56–1.23; p = 0.36), respectively. The pooled relative risks of recurrence and progression were 0.87 (95%CI, 0.64–1.20; p = 0.40) and 1.11 (95%CI, 0.54–2.32; p = 0.77), respectively. Current evidence demonstrates that reTURB after ERBT for bladder cancer can detect relatively low rates of residual tumor and tumor upstaging and appears not to improve either recurrence or progression.

A Comparative Analysis of Video-Assisted Thoracoscopic Surgery and Thoracotomy in Non-Small-Cell Lung Cancer in Terms of Their Oncological Efficacy in Resection: A Systematic Review.

Video-assisted thoracoscopic surgery (VATS) is considered the standard procedure for surgical resection in non-small-cell lung cancer (NSCLC). However, there is still lingering speculation on its adequacy of lymph node (LN) dissection or sampling and the long-term survival benefits when compared to open thoracotomy. Given the above, we conducted a systematic review comparing VATS and thoracotomy in terms of their oncological effectiveness in resection.We explored major research literature databases and search engines such as MEDLINE, PubMed, PubMed Central, Google Scholar, and ResearchGate to find pertinent articles. After the meticulous screening, quality check, and applying relevant filters according to our eligibility criteria, we identified 16 studies relevant to our research question, out of which one was a randomized controlled trial, one meta-analysis, and 14 were observational studies. The study comprised 44,673 patients with NSCLC, out of whom 15,093 patients were operated by VATS and the remaining 29,580 patients by thoracotomy. The results indicate that VATS is equivalent to thoracotomy in total LNs (N1 + N2) and LN stations dissected. However, a thoracotomy may achieve slightly better mediastinal lymph node dissection (N2) in terms of assessing a greater number of mediastinal lymph nodes and nodal stations. This may be attributed to a better visual field during mediastinal nodal clearance by an open approach. Also, nodal upstaging was consistently more common with an open approach. In terms of long-term outcomes, both overall survival and disease-free survival rates were similar between the two groups, with VATS offering a slightly better survival benefit.Irrespective of the increased rates of nodal upstaging by an open approach, we conclude that VATS should be considered a highly efficient alternative to thoracotomy in both early and locally advanced NSCLC.

Upstage Rate of Complex Sclerosing Lesions/Radial Scars.

Radial scars (RS) and complex sclerosing lesions (CSL) are breast radiologic findings described as small, stellate lesions causing architectural distortion. This can mimic malignancy. Core needle biopsy (CNB) is often performed. Advances in breast imaging have led to increased detection of RS/CSL. The upstage rate of RS/CSL to in situ or invasive disease is 0-40%. We sought to determine the upstaging rate of RS/CSL to in situ, invasive disease, or high-risk lesion at our institution to create excision guidelines. The pathology database of a single center was searched for RS/CSL, from January 2013 to September 2020. We included CNB without malignancy or high-risk lesion (eg, atypical ductal hyperplasia). Patient demographics, indications for biopsy, imaging findings, biopsy procedure, and final pathology were collected. Forty-four patients were included. 52.3% had CNB for architectural distortion on mammography, 18.2% for mass, 11.4% for calcifications, 2.3% for abnormal MRI, and 15.9% for multiple reasons (eg, calcifications and mass). Most had an ultrasound: 43.2% had no abnormality and 34.1% had a mass. All CNB were vacuum assisted, 65.9% with 9-gauge needle, and averaged 10.0 cores. 77.3% were stereotactic biopsies, 13.6% ultrasound, and 6.8% MRI. 59.1% had excision after CNB. 82.1% of patients did not upstage. One patient upstaged to invasive ductal carcinoma (3.6%) and two patients to high-risk lesion (7.1%). There was low upstage rate of RS/CSL on excisional biopsy. Centers could consider close surveillance for RS/CSL on CNB. Longer follow-up in cases of deferred excision is needed to ensure oncologic safety.

Colectomy for polyps is associated with high risk for complications and low risk for malignancy: Time for endoluminal surgery?

DR. FREDERICK LANE (Indianapolis, Indiana): I'd like to thank the authors for the opportunity to review this paper which seeks to make the case for aggressive endoscopic management of benign colon polyps. Having worked with NSQIP in the past, I realized some items are difficult to extract from the data set, and you addressed this a little bit. You report an upstage rate to cancer of 3.3% in surgeries for colon polyps. How comfortable are you with this number, as I wonder how many of those potentially upstaged patients were listed as cancer patients rather than for coding purposes and, therefore, not really included?

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach.

Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach. A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach. A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028). Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Role of blue-light cystoscopy in detecting invasive bladder tumours: data from a multi-institutional registry.

To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC). Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma insitu and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease. A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.

Upstaging of Fibroepithelial Lesions: A Single-Institution Experience.

Fibroepithelial lesions of the breast (FEL) are heterogeneous lesions ranging from fibroadenomas (FA) to phyllodes tumors (PT). FEL with cellular stroma are diagnostic challenges on core needle biopsy (CNB) as it is difficult to distinguish cellular FA from PT. The purpose of this study was to determine the features of FEL on CNB that may be predictive of PT, the upstage rate to PT after excision, and the outcomes of those who did not undergo excision. Overall, 305 patients with FEL on CNB between 2009 and 2019 were identified from a prospectively maintained institutional database. Presentation, imaging, and pathology were evaluated. Mean age at diagnosis was 43.8years. Pathology on CNB included 97 cases of FEL favoring FA, 19 cases of FEL favoring PT, 3 cases of FEL versus pseudoangiomatous stromal hyperplasia, and 186 cases of FEL not otherwise specified. Following CNB, 96 (31.5%) patients were observed, 158 (51.8%) patients had an excisional biopsy, 48 (15.7%) patients underwent segmental mastectomy, and 3 (1.0%) patients underwent a mastectomy. The upgrade rate from FEL on CNB to PT upon excision was 25.8%. PT on final pathology was more commonly seen when the CNB identified stromal overgrowth, necrosis, and diagnosis of FEL favoring PT. On multivariable analysis, a final diagnosis of PT was associated with age >50years, larger tumor size >2cm, stromal overgrowth, and ≥1 mitoses/10 high power fields (HPF) on CNB. Patients who were observed had smaller tumors compared with those who underwent excision. In this 10-year single-institution experience of FEL, the upstage rate to PT was 25.8%. Excision of FEL is recommended. Furthermore, the observation of lesions appeared to be safe in select cases, specifically in patients with smaller tumor size.

Rates of Upstaging, Between Diagnosis and Surgery, and Clinical Management of Metastatic Cutaneous Squamous Cell Carcinoma: A Case-Control Study.

Cutaneous squamous cell carcinomas (cSCC) have upstage rates of approximately 10.3% to 11.1%. Data are currently limited on the rate of upstaging for metastatic cSCC. The aim of this study was to determine the rates of upstaging, between diagnosis and surgery, and differences in management for metastatic and non-metastatic high-risk cSCC. This was a retrospective, case-control, single institution, multi-center study. Univariate analysis was used. Sixty-eight subjects (34 metastatic & 34 non-metastatic) with 69 tumors were included. The overall rate of upstaging was 46.4%. The most common reasons for upstage were undocumented tumor size and under-diagnosis of poor differentiation. There were no differences in rates of upstaging. Preoperative imaging was performed in 43.6% of wide local excisions (WLE) versus 3.3% of Mohs micrographic surgery (MMS; p < .001). The median days from surgery to sentinel lymph node biopsy (SLNB), or nodal dissection was shorter for WLE versus MMS (0 vs 221 days, p < .001). Improved clinical documentation, including documenting tumor size, and the identification of pathologic risk factors, including poor differentiation and depth of invasion, are needed for proper staging. Preoperative imaging and discussion of SLNB may be beneficial for high-risk T2b and T3 tumors.

Characterizing Occult Nodal Disease Within a Clinically Node-Negative, Neoadjuvant Breast Cancer Population

BackgroundNeoadjuvant therapy aims to preoperatively downstage breast cancer patients. We evaluated nodal upstaging in clinically node-negative (cN0) patients receiving neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy (NET). MethodscN0 patients undergoing neoadjuvant therapy from 2009 to 2018 were reviewed. Univariate and multivariate analyses evaluated rates of nodal upstaging. ResultsA total of 228 cN0 patients with a mean age of 55 years underwent neoadjuvant therapy for Stage I-III invasive carcinoma. Subtypes included ER+/HER2- = 93 (40%), HER2+ = 61 (27%), and triple negative (TNBC) = 74 (33%). Among ER+/HER2- patients, 65 (70%) underwent NET. Overall, 49 patients (21%) were upstaged due to occult nodal disease. Factors associated with higher rates of occult nodal disease included advanced stage on initial presentation (P = .008), larger presenting tumor size (P = .009), low/intermediate tumor grade (P = .025), and ER+/HER2- subtype (P < .001); incidence of occult nodal disease by subtype included: ER+/HER2- = 37%, HER2+ = 15%, TNBC = 8%. Patients experiencing a breast pCR had a significantly lower rate of nodal upstaging compared to those with residual tumor (4% vs. 96%, P < .001). On multivariate analysis, ER+/HER- patients exhibited higher risk of occult nodal disease when compared to patients with HER2+ (odds ratio [OR] = 3.4, 95% CI, 1.2-9.8, P = .003) and TNBC (OR = 5.7, 95% CI, 1.7-19.6, P = .003). Comparing NAC vs. NET in ER+/HER2- patients showed no difference in rates of occult nodal disease (39% vs. 35%, P = .13). ConclusionsER+/HER2- subtype carries higher risk for occult nodal disease after neoadjuvant therapy; NAC versus NET in these patients does not affect nodal upstaging.

Treatment outcomes for stage T1b-2 esophagogastric adenocarcinomas.

e16085 Background: Treatment of localized esophageal, gastroesophageal junction (GEJ), and stomach cancer is neoadjuvant therapy with either chemoradiation or chemotherapy followed by surgery. Treatment for T1b-2 stage disease is not well evaluated and this stage is underrepresented in prospective studies. The aim of this study is to evaluate survival outcomes among the three treatment modalities (neoadjuvant chemotherapy (NACT), neoadjuvant chemoradiation (NACRT), and upfront surgery (US)) in this population using the National Cancer Database (NCDB). Methods: Patients (pts) with clinical stage T1b-2N0 and any pathological stage (excluding metastatic) adenocarcinoma of the esophagus, GEJ, and stomach treated with neoadjuvant therapy or upfront surgery, with or without adjuvant chemotherapy (AC), were identified between 2004 and 2015 in the NCDB. Univariate and multivariable analyses were conducted, and Kaplan-Meier analysis and Cox proportional hazard models were used to identify the association between the three treatment modalities and overall survival (OS). Results: A total of 2260 pts were analyzed. The median follow-up was 66.6 months. The median age was 67 years. Most pts were White (86%) and male (77%). 1018 (45%) had moderately-differentiated grade, while 946 (42%) had poorly-differentiated/undifferentiated grade. The most common site of disease was the lower third of esophagus (34.1%). 161 pts (7%) received NACT, of whom 45 pts received AC; 537 pts (24%) received NACRT, of whom 40 pts received AC. 1562 pts (69%) underwent US, of whom 146 pts received AC. US with AC was associated with the best survival, followed by NACT with AC; median OS was 90.1 and 86.8 months for surgery with AC and NACT with AC, respectively. NACRT was associated with the worst survival (39.5 and 40.2 months with and without AC, respectively). The 5-year OS rates were 59.8%, 58.5%, 52.1%, 44.9%, 37.3%, and 37.8%, for US, NACT, and NACRT, with and without AC, respectively. The rate of tumor upstaging was highest in the NACT group, followed by the NACRT group, and lowest in the US group. Postsurgically, 62 (39%) and 48 (30%) pts in the NACT group and 198 (37%) and 161 (30%) pts in the NACRT group had upstaging in their T and N stages, respectively, compared to 214 (13%) and 326 (21%) pts in the US group. For the 1107 pts who also had pathological T1b-2N0 stage disease following US, no difference in survival was observed with or without AC. Conclusions: Upfront surgery with adjuvant chemotherapy and perioperative chemotherapy are associated with the best survival compared to preoperative radiotherapy. This is the largest study to address the best approach for the treatment of T1b-2 stage disease.

Long-term and pathological outcomes of low- and intermediate-risk prostate cancer after radical prostatectomy: implications for active surveillance

PurposeThe safety of active surveillance (AS) in favorable intermediate-risk (FIR) prostate cancer (PCa) remains uncertain. To provide guidance on clinical decision-making, we examined long-term and pathological outcomes of low-risk and intermediate-risk PCa patients after radical prostatectomy (RP).MethodsThe study involved 5693 patients diagnosed between 1994 and 2019 with low-risk, FIR, and unfavorable intermediate-risk (UIR) PCa (stratification according to the AUA guidelines) who underwent RP. Pathological outcomes were compared, and Kaplan–Meier analysis determined biochemical recurrence-free survival (BRFS) and cancer-specific survival (CSS) at 5, 10, 15, and 20 years. Multiple Cox regression was used to simultaneously control for relevant confounders.ResultsThose at FIR had higher rates of upgrading and upstaging (12.8% vs. 7.2%, p < 0.001; 19.8% vs. 12.0%, p < 0.001) as well as pathological tumor and node stage (≥ pT3a: 18.8% vs. 11.6%, p < 0.001; pN1: 2.7% vs. 0.8%, p > 0.001) compared to patients at low risk. The 20-year BRFS was 69%, 65%, and 44% and the 20-year CSS was 98%, 95%, and 89% in low-risk, FIR, and UIR patients. On multiple Cox regression, FIR was not associated with a worse BRFS (HR 1.07, CI 0.87–1.32), UIR was associated with a worse BRFS (HR 1.49, CI 1.20–1.85).ConclusionPatients at FIR had only slightly worse pathological and long-term outcomes compared to patients at low risk, whereas the difference compared to patients at UIR was large. This emphasizes AS in these patients as a possible treatment strategy in well-counseled patients.

Upstage rate of radial scar/complex sclerosing lesion identified on core needle biopsy

BackgroundWe assessed the cancer upstage rate of Radial Scars (RS), and Complex Sclerosing Lesions (CSL), and risk-stratified lesions based on radiological and pathological features. MethodsCharacteristics of RS/CSL treated from 2013 to 2018 were examined for features associated with cancer. Results78 RS/CSL were found on core needle biopsy (CNB) and surgically excised. 9 (11.5%) lesions were upstaged. Upstaged patients were older (66 vs 51, p = 0.033). More upstaged lesions were accompanied by a mass on both mammography (87.5% vs. 30.0%, p = 0.005) and ultrasound (100.0% vs. 62.8%, p = 0.043). 20.5% of lesions biopsied under ultrasound guidance with small needles (14-18G) were upstaged, but no lesions biopsied under stereotactic guidance with large needles (9–12 G) with vacuum assistance were upstaged (p = 0.009). ConclusionsExcision of RS/CSL seen on CNB is warranted, especially if the patient is older, the CNB is performed under ultrasound guidance with small needles, or if a mass is present on imaging.

Role of CA 125, CA19-9 and CEA in predicting outcome following neoadjuvant chemotherapy in muscle invasive bladder cancer.

496 Background: We have previously shown the prognostic value of three tumor markers (TMs) including Carbohydrate Antigen 125 (CA-125), Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) in muscle invasive bladder cancer (MIBC). Current report presents an update on TM levels before and after neoadjuvant chemotherapy (NAC) and their association with oncological outcomes. Methods: Serum levels of three TMs were prospectively measured in patients with MIBC who underwent NAC between 2011 and 2019. Rate of pathological upstaging (Path-U) and recurrence-free (RFS) was compared between patients with: (1) Elevated versus normal pre-NAC TM (2) Elevated versus normal post-NAC TM, and (3) Elevated pre-NAC TMs with normalized post-NAC TMs (TM responders) versus persistently elevated post-NAC TMs (TM non responders). Results: Of a total of 199 patients, 63 patients had both pre- and post-NAC TMs. 33/63 (52%) patients had elevated pre-NAC TM of whom, 15/33 (45%) were TM responders. Patients with elevated pre-NAC TM had significantly higher rate of Path-U compared to those with normal pre-NAC TM (62% vs. 22.5%, respectively; P &lt; 0.001). There was no significant difference in Path-U in the other two comparison groups. Patients with elevated pre- and post-NAC TM had significantly lower RFS. Compared to TM responders, TM non responders had significantly higher rate of recurrence (70% vs 34%) and shorter median time to recurrence (4.2 months vs 13.5 months) (P = 0.03). In six patients with recurrence who had complete post cystectomy TM, TM recurrence preceded clinical recurrence by median of 1.2 months (IQR 0.8 – 2.4 months). Conclusions: Elevated TM prior to NAC is associated with pathologic upstaging. TM elevation pre- or post-NAC predicts a worse outcome. Post-cystectomy TM might play a role in earlier detection of recurrence.

Abstract SP094: DCIS - Con

Abstract Ductal carcinoma in situ (DCIS) represents a collection of biologically heterogenous pre-invasive breast lesions some with the potential for progression to invasive cancer. Widespread adoption of screening mammography has increased the diagnosis of DCIS and may contribute to overdiagnosis identifying some conditions that may never impact one’s overall health. Unfortunately, clinicians treating DCIS patients currently lack robust biomarkers stratifying DCIS patients into those at high or low risk for invasive progression. Further, variations in pathologic assessment and grade, intra-lesional DCIS heterogeneity, and discordance in pathologic interpretations between pathologists make it challenging for providers to further identify appropriate low risk DCIS patients for active surveillance. Guideline concordant care including excision and potentially radiation and anti-estrogen therapies should remain as the standard of care and provides a definitive treatment endpoint which patients desire. Existing evidence documents a significant upstage rate of DCIS to invasive disease at surgical excision including a small, but important population benefiting from adjuvant systemic therapy. Finally, patient anxiety and documented poor adherence rates to endocrine therapy preclude active surveillance and after all the morbidity of surgical excision is low. Citation Format: S McLaughlin. DCIS - Con [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SP094.

Comparison of outcomes between laparoscopic and robot-assisted partial nephrectomy for complex renal tumors (RENAL score ≥ 7 or maximum tumor size > 4cm): a systematic review and meta-analysis

Introduction We reviewed current studies and performed a meta-analysis to compare outcomes between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) treating complex renal tumors (RENAL score ≥ 7 or maximum clinical tumor size > 4cm). Evidence acquisition Using the databases of PubMed, Embase, and the Cochrane Library, a comprehensive literature search was performed in April, 2020. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect model. Publication bias was evaluated by funnel plots. Evidence synthesis Ten observational studies including 5193 patients (LPN: 1574; RAPN: 3619) were included. There was no significant difference between the two groups regarding conversion to open (P = 0.07) surgery, all complications (P = 0.12), grade 1-2 complications (P = 0.10), grade 3-5 complications (P = 0.93), operative time (P = 0.94), estimated blood loss (P = 0.17). Patients undergoing LPN had a significant higher rate of conversion to radical (OR: 4.33; 95% CI: 2.01-9.33; p Conclusions For complex renal tumors, RAPN is more favorable than LPN in terms of lower rate of conversion to radical surgery, shorter IT, shorter LOS, less eGFR decline, and lower rate of CKD upstaging. Methodological limitations of observational studies should be taken into account in interpreting these results.

Depth of invasion versus tumour thickness in early oral tongue squamous cell carcinoma: which measurement is the most practical and predictive of outcome?

The 8th edition of the American Joint Committee on Cancer (AJCC) Staging introduced depth of invasion (DOI) into the pT category of oral cavity squamous cell carcinoma. However, we noted multiple practical obstacles in accurately measuring DOI histologically in our daily practice. To compare the prognostic effects of DOI and tumour thickness (TT), a meticulous pathology review was conducted in a retrospective cohort of 293 patients with AJCC 7th edition pT1/T2 oral tongue squamous cell carcinoma. Overall survival (OS) and nodal metastasis rate at initial resection were the primary and secondary outcomes, respectively. We found that TT and DOI were highly correlated with a correlation coefficient of 0.984. The upstage rate was only 6% (18 of 293 patients) when using TT in the pT stage compared with using DOI. More importantly, DOI and TT, as well as pT stage using DOI and pT stage using TT, performed identically in predicting risk of nodal metastasis and OS. We therefore propose to replace DOI, a complicated measurement with many challenges, with TT in the pT staging system.