Regional Node Recurrence Research Articles

Adjuvant whole breast radiotherapy with simultaneous integrated boost to tumor bed with intensity modulated radiotherapy technique in elderly breast cancer patients.

BackgroundAdjuvant whole breast radiotherapy is the standard of care for breast cancer patients after partial mastectomy. Intensity-modulated radiation therapy (IMRT) has been reported to reduce acute toxicities compared to conventional radiotherapy. IMRT with simultaneous integrated boost (SIB) technique can deliver higher doses to tumor bed and irradiate whole breast with a lower dose level to shorten overall treatment duration. This study presents the long-term results of adjuvant IMRT with SIB in elderly breast cancer patients who received partial mastectomy.MethodsFrom January 2007 to January 2018, 93 elder breast cancer patients (≥65-year-old) who received IMRT with SIB technique after partial mastectomy were reviewed retrospectively. The axillary areas were managed with either sentinel lymph node biopsies or axillary lymph node dissection. The dose to whole breast was 50.4 Gy in 28 fractions in all patients and the dose to tumor bed was 61.6 to 66.4 Gy in 28 fractions. The primary end point is locoregional control. Secondary end points include: overall survival, breast cancer-specific survival, distant-metastases-free survival, disease-free survival, and acute and chronic toxicities.ResultsThe median follow-up was 56.1 months. One patient had ipsilateral breast tumor recurrence, 3 patients had regional lymph node recurrence, and 9 patients had distant metastases. Death occurred in 5 patients, including 3 patients died of breast cancer progression. Five-year overall survival is 96.3% and 5-year locoregional recurrence-free survival is 96.4%. The 5-year breast cancer specific survival and 5-year distant metastases-free survival is 97.5% and 87.2%, respectively. Seven patients developed second primary cancer after RT. Eighty-one point seven percent patients had acute grade 1 dermatitis while 18.3% suffered from grade 2 dermatitis. The incidence of grade 1 pneumonitis and grade 1 stomatitis was 4.3% and 8.6%, respectively.ConclusionsAdjuvant IMRT with SIB technique is a safe and effective treatment strategy for elderly breast cancer patients after partial mastectomy.

Regional Node Basin Recurrence in Melanoma Patients: More Common After Node Dissection for Macroscopic Rather than Clinically Occult Nodal Disease.

Recommended treatment for patients with sentinel lymph node (SLN)-positive melanoma has recently changed. Randomized trials demonstrated equivalent survival with close observation versus completion lymph node dissection (CLND), but increased regional node recurrence. We evaluated factors related to in-basin nodal recurrence after lymphadenectomy (LND) for SLN-positive or macroscopic nodal metastases. An institutional database and the first Multicenter Selective Lymphadenectomy Trial (MSLT-I) were analyzed independently. Exclusions were multiple primaries, multi-basin involvement, or in-transit metastases. Patient demographics, primary tumor thickness and ulceration, lymph nodes retrieved, and use of adjuvant radiotherapy were analyzed. Multivariate analyses were performed to determine factors predicting in-basin nodal recurrence (significance p ≤ 0.05). The retrospective cohort (577 patients) showed an in-basin failure rate of 6.6% after CLND for a positive SLN and 13.1% after LND for palpable disease (p = 0.001). This recurrence risk persisted after adjustment for patient, tumor, and LND factors [hazard ratio (HR) 2.32; p = 0.004]. In the MSLT-I cohort (326 patients), the failure rate after CLND following SLNB was 6.2%, but 10.1% after LND for palpable recurrence in observation patients. After adjustment for other factors, macroscopic disease was associated with an increased risk of recurrence after LND (HR 2.24; p = 0.05). After LND for melanoma, in-basin recurrence is infrequent, but a clinically significant fraction will fail. Failure is less likely if dissection is performed for clinically occult disease. Further research is warranted to evaluate the long-term regional control and quality of life associated with nodal basin observation, which has now become standard practice.

Diagnostic role of 18F-FDG PET/CT in recurrence detection of surgically treated gastric cancer: a cross-sectional study

BackgroundRadical surgery of gastric cancer is considered as the only curative treatment; however, its poor long-term survival is often occurred due to its recurrence either local and/or distant metastasis. Thus, early detection of recurrence helps in improving the prognosis. Our aim is to assess the diagnostic role of 18F-FDG PET/CT for detecting postoperative recurrence in gastric cancer patients who have a radiological and/or clinical suspicion of recurrence.ResultsThe study was carried over 31 males (62%) and 19 females (38%) pathologically proven with gastric carcinoma and underwent surgical intervention. All patients underwent PET/CT scan where the site and number of positive FDG activity analyzed. The sensitivity, specificity, and accuracy for locoregional recurrence were 75%, 81.58%, and 85% with p value 0.001; for regional lymph node recurrence were 100%, 100%, and 100% with p value < 0.001; for liver metastasis were 100%, 100%, and 100% with p value < 0.001; for peritoneum metastasis were 100%, 97.38%, and 98% with p value < 0.001; and for distant metastasis were 100%, 85.7%, and 94% with p value < 0.001.ConclusionWith agreements to many studies, this study confirms that FDG PET/CT is a highly effective modality for postoperative surveillance detection of recurrent gastric cancer, especially in patients with clinically manifested disease, elevated tumor markers, and an indication of distant metastasis at diagnostic CT.

A Prospective Study of 18F-DCFPyL PSMA PET/CT Restaging in Recurrent Prostate Cancer following Primary External Beam Radiotherapy or Brachytherapy

Radio-recurrent prostate cancer is typically detected by a rising prostate-specific antigen and may reflect local or distant disease. Positron emission tomography (PET) radiotracers targeting prostate-specific membrane antigen, such as 18F-DCFPyL have shown promise in restaging men with recurrent disease postprostatectomy but are less well characterized in the setting of radio-recurrent disease. A prospective, multi-institutional study was conducted to evaluate the effect of 18F-DCFPyL PET/computed tomography (CT) when added to diagnostic imaging (DI; CT abdomen and pelvis, bone scan, multiparametric magnetic resonance imaging pelvis) for men with radio-recurrent prostate cancer. All men were imaged with DI and subsequently underwent 18F-DCFPyL PET/CT with local and central reads. Tie break reads were performed as required. Management questionnaires were completed after DI and again after 18F-DCFPyL PET/CT. Discordance in patterns of disease detected with 18F-DCFPyL PET/CT versus DI and changes in management were characterized. Seventy-nine men completed the study. Most men had T1 disease (62%) and Gleason score <7 (95%). Median prostate-specific antigen at diagnosis was 7.4 ng/mL and at relapse was 4.8 ng/mL. DI detected isolated intraprostatic recurrence in 38 out of 79 men (48%), regional nodal recurrence in 9 out of 79 (11%), distant disease in 12 out of 79 (15%), and no disease in 26 out of 79 (33%). 18F-DCFPyL PET/CT detected isolated intraprostatic recurrence in 38 out of 79 men (48%), regional nodal recurrence in 21 out of 79 (27%), distant disease in 24 out of 79 (30%), and no disease in 10 out of 79 (13%). DI identified 8 out of 79 (10%) patients to have oligometastatic disease, compared with 21 out of 79 (27%) with 18F-DCFPyL PET/CT. 18F-DCFPyL PET/CT changed proposed management in 34 out of 79 (43%) patients. 18F-DCFPyL PET/CT identified extraprostatic disease in twice as many men with radio-recurrent prostate cancer compared with DI and detected a site of recurrence in 87% of men compared with 67% with DI. Furthermore, 18F-DCFPyL PET/CT identified potentially actionable disease (prostate only recurrence or oligometastatic disease) in 75% of men and changed proposed management in 43% of men.

A rare presentation recurrent nasopharyngeal carcinoma with axillary lymph node metastasis

Introduction: Nasopharyngeal carcinoma (NPC) has the highest rate of local and regional cervical lymph node re-currence amongst other head and neck epithelial malignant tumour. Distant recurrence is less common and usually occurs in bone, liver and lung. Recurrent NPC to axillary lymph node is rare.Case report: A 44-year-old male presented with two-month history of painless right axillary swelling. He was di-agnosed with nasopharyngeal carcinoma (NPC) stage IVA (T2N3M0) two years prior to presentation and had underwent neoadjuvant chemotherapy with 5-Fluorouracil and Cisplatin, and concurrent chemo-radiotherapy (CCRT) of total 70 Gy over 35 sessions with Cisplatin. He was on regular monthly surveillance reviews, with no signs of recurrence. Fine Needle Aspiration Cytology (FNAC) of the axillary swelling was reported as metastatic NPC and Positron Emission Tomography/ Com-puted tomography (PET-CT) scan showed foci of high FDG hypermetabolism at right axillary lymph node confirming the diagnosis of recurrent NPC.Conclusion: Recurrence usually occurs in the first two years after completion of treatment. Patients with an overall TNM stage IV or N3, high pre-treatment or persistently detectable post-treatment plasma EBV DNA (pEBV DNA) load are at greatest risk. Management of recurrent NPC depends on local, regional or distant recurrence. Both PET scan and pEBV DNA load can be used for relapse detection. The man-agement for each recurrent NPC case is unique and should be determined by a multidisciplinary team, local expertise and facilities. Knowledge of potential sites of recurrence is essential to both physicians and patients for early detection.

Limited neck dissection: is it enough in early oral tongue cancer? Retrospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the present study was to analyze the outcome of clinically node-negative early oral tongue cancer after selective neck dissection (SND) versus conventional neck dissection (CND).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 116 patients of early oral tongue cancer underwent neck dissection either SND or CND between 1&lt;sup&gt;st&lt;/sup&gt; January 2013 to 31&lt;sup&gt;st&lt;/sup&gt; December 2016 at Government Royapettah Hospital, Chennai, a tertiary level cancer center. For patients with pN0 after SND had no further procedure while for those with cN1 disease, CND was done as a standard procedure. Comparison between the cN0 nodes to pN1 conversion rates in SND group with cN1 to pN0 rates in CND group was done along with the morbidity rates. The clinicopathological parameters along with intraoperative and postoperative parameter relevant to recurrence were analyzed by univariant and multivariant analysis and both the groups were compared by Chi-square test (SPSS version 26.0). &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In the SND group, pN1 were 2/53 (3.77%) and in the CND group pN1 was 11/63 (17.46%). Mean Nodal retrieval in SND group was 18.96 nodes and in CND group 22.90 nodes per case. Regional nodal recurrences in the SND group were 8/53 (15.81%) and in the CND group was 9/63 (14.28%). Our study shows no significant statistical difference between nodal recurrences in CND and SND group.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Our study data suggests that for cN1 patients, SND may be optimal and early tongue cancer patients with cN0 could be candidates for an SND instead of CND.&lt;/p&gt;

EP1.08-06 Postoperative Oligo-Recurrence of Non-Small Cell Lung Cancer

Postoperative recurrences of non-small cell lung cancer (NSCLC) are usually disseminated and systemic. The concept of oligo-recurrence, defined as a small number of new lesions at a distant site theoretically curable by local therapy, has recently been proposed for several cancers. The aim of this study was to clarify clinical features and outcomes of patients with postoperative oligo-recurrence of NSCLC. From 364 patients who underwent resection for NSCLC between January 2008 and December 2017 at our hospital. A total of 43 patients who developed recurrence were included in this study. Oligo-recurrence was defined as 1-2 loco-regional or distant recurrence lesions restricted to a single organ. Other recurrences were classified as poly-recurrence. Local therapy included surgery, stereotactic radiotherapy and radiotherapy. Oligo-recurrence was identified in 12 (27.9%) patients, mainly as a solitary recurrence (n=11, 91.7%) in regional lymph nodes (n=1), surgical stump (n=2), brain (n=5), lung (n=1), bone (n=2) and liver (n=1). Primary tumor histopathological types included 9 cases of adenocarcinoma, one case of squamous cell carcinoma, one case of pulmonary pleomorphic carcinoma and one case of large cell neuroendocrine carcinoma.The patients with oligo-recurrence had a longer time to recurrence than those with poly-recurrence (median: 23.5 months, 11.0 months). A case of mediastinal lymph node recurrence was performed radiation therapy. A case of surgical stump recurrence underwent lobectomy and other case was performed concurrent chemo-radiotherapy. 4 case of brain metastasis were underwent tumor resection and were performed stereotactic radiotherapy, one case of brain metastasis was performed stereotactic radiotherapy only. A case of lung metastasis underwent wedge resection and was used EGFR-TKI. A case of bone recurrence was performed radiation therapy and was used EGFR-TKI, other case was performed concurrent chemo-radiotherapy. A case of liver metastasis underwent tumor resection. 7 of 12 cases confirmed re-recurrence after local therapy. But 9 patients were alive between 30.4 and 110.0 months after local therapy, whereas three of 5 brain metastatic patients died between 24.9 and 71.8 months. The 5 year overall survival rates after local therapy were 81.5%. The presence of oligo-recurrence can predict a favorable prognosis in patients with NSCLC treated with aggressive local therapy.

Salvage treatment for lymph node recurrence after radical resection of esophageal squamous cell carcinoma

BackgroundPatients with regional lymph node recurrence after radical resection of esophageal cancer have poor therapeutic outcomes. Currently, there is no standard treatment for regional lymph node recurrence, and its prognostic risk factors are not well-understood. This study retrospectively analyzed 83 patients with postoperative regional lymph node recurrence after radical resection of esophageal squamous cell carcinoma. The aim was to evaluate the clinical efficacy and prognostic factors of salvage radiotherapy with or without chemotherapy in these patients.MethodsThe survival and prognostic factors of 83 patients with esophageal squamous cell carcinoma with regional lymph node recurrence after radical surgery were retrospectively analyzed. All patients underwent radiotherapy, of which 74 patients received volumetric modulated arc therapy (VMAT), 9 patients received three-dimensional conformal radiation therapy (3DCRT), administered using a conventional segmentation protocol with a dose distribution range of 50.4–66.2Gy (median dose of 60Gy). In total, 41 patients received radiotherapy alone, 42 received radiotherapy combined with chemotherapy, and the concurrent chemotherapy regimen was mainly composed of either platinum or fluorouracil monotherapy, except for 4 patients who were given 5-fluorouracil plus platinum (FP) or paclitaxel plus platinum (TP).ResultsThe median follow-up time was 24 (range, 9–75) months. The overall survival (OS) rates at 1 year, 2 years, 3 years, and 5 years were 83.0, 57.1, 40.1, and 35.1%, respectively. The median overall survival (OS) time was 18 (range, 5–75) months. The 3-year survival rate was 47.5% in patients with radiation alone and 41.9% in patients receiving concurrent chemoradiotherapy(p = 0.570), while the response rate (CR + PR) in those two groups was 73.2 and 91.4%, respectively. By multivariate analysis of OS, age (worse in younger patients, p = 0.034) was found to be significantly associated with disease prognosis. The commonly toxicities were esophagitis, neutropenia and anemia. 18% patients experienced grade 3 toxicity and no treatment-related death occurred.ConclusionsThese results of this retrospective analysis suggest that radiotherapy with or without chemotherapy is an effective and feasible salvage treatment for lymph node recurrence after radical resection of esophageal squamous cell carcinoma.

A Prospective Phase I trial of Concurrent Cisplatin (CIS) and Radiation Therapy (RT) in Women with Stage II and III Triple-negative Breast Cancer (TNBC)

Patients with TNBC experience a higher rate of both in breast and regional nodal recurrence. CIS is an effective systemic chemotherapy in TNBC, and is also a radiation sensitizer. This prospective, phase Ib trial was designed to assess safety and toxicity and establish the recommended phase 2 dose of concurrent CIS with adjuvant RT for women with stage II and III TNBC. Eligible patients had stage II or III TNBC. Any prior preoperative or adjuvant chemotherapy was permitted except CIS or carboplatin. Patients receiving preoperative therapy could not have a complete pathologic response. CIS was initiated at 10 mg/m2intravenously once weekly, then escalated in a classic 3 + 3 design by 10 mg/m2at each dose level until a dose of 40 mg/m2, or maximum tolerated dose (MTD), was reached. Breast conservation (BCT) and mastectomy (M) patients were accrued in separate parallel cohorts in dose-escalation followed by a 10 patient expansion at the MTD for each group. During the escalation phase, all patients in each dose level were observed throughout the 8-week dose limiting toxicity (DLT) window prior to dose escalation. RT was delivered with conventional once-daily fractionation (1.8-2.0 Gy) to the breast or chest wall to 50-50.4 Gy followed by a 10 Gy lumpectomy site cone down (BCT) or 6-10 Gy incision boost (M) at the discretion of the radiation oncologist. Regional nodal radiation was also at the discretion of the treating physician (46-50.4 Gy). Fifty-five patients were accrued from 2013-2018. Four experienced a DLT. In the BCT cohort, one patient developed tinnitus at the maximum dose level of 40 mg/m2resulting in a cisplatin delay. This was therefore the BCT MTD. In the M cohort, three experienced a DLT. One patient, receiving 30 mg/m2CIS, was hospitalized for a grade 3 urinary infection. Two additional patients had DLTs at 40 mg/m2: one grade 3 neutropenia, and the other tinnitus, both resulting in delays in CIS. As a result, 30 mg/m2was the MTD for the M cohort. Two patients had breaks in radiation, (one day and three days; both hospitalized for infection). The most common adverse events in both cohorts were dermatitis (45% grade 2, 2% grade 3), leukopenia (15% grade 2, 15% grade 3), fatigue (15% grade 2), nausea (11% grade 2), ototoxicity and thrombocytopenia (each 7% grade 2). Only one patient (BCT cohort at 30 mg/m2) experienced grade 3 radiation dermatitis; there were no grade 4 skin reactions. CIS was held (16%) or discontinued early (7%) in 13 patients. Median follow-up was 29.1 months. Three-year disease-free survival was 71% in the BCT cohort, and 70% among M patients. Adjuvant radiation therapy with concurrent CIS is feasible with the MTD of 30 mg/m2and 40 mg/m2IV weekly in M and BCT patients, respectively. Additional study is necessary to determine the long-term benefits of concurrent treatment in this high-risk population.

Management of local recurrences and regional failure in early stage non-small cell lung cancer after stereotactic body radiation therapy.

Stereotactic body radiation therapy (SBRT) is a very effective way to treat early stage non-small cell lung cancer (NSCLC) and small oligometastatic lung lesions with consistently high rates of local control, but both local and regional/distant recurrences still occur. The management of recurrences remains unsettled and may entail repeat SBRT, conventionally fractionated external beam RT (EF-EBRT), chemotherapy or surgery. Most patients with local recurrences [within the initial planning target volume (PTV)] can be salvaged successfully with good cancer specific survival. Nonetheless, proximity of the initial SBRT delivery to organs at risk (ribs, blood vessels, airways) may make retreatment more difficult. With attention to detail and careful patient selection, both surgery and reirradiation can be performed safely and effectively. Strategies for management of regional (nodal) recurrences may require conventional therapies tailored to the patterns of failure. The role of immunotherapy in salvage has not been elucidated as yet. We review here data on the available literature concerning salvage of SBRT lung patients.

OVEREXPRESSION OF TWIST AND REDUCED E-CADHERIN EXPRESSION ARE ASSOCIATED WITH POOR BIOLOGICAL BEHAVIOR IN LOWER LIP SQUAMOUS CELL CARCINOMA: AN IMMUNOHISTOCHEMICAL STUDY

Objectives This study aimed to evaluate the immunoexpression of Twist and E-Cadherin in 59 lower lip squamous cell carcinomas (LLSCC) and to verify their relationship with clinical and histopathological parameters (tumor size, regional lymph node metastasis, clinical stage, outcome, recurrence and tumor histological grade. Possible correlations between these two proteins were also evaluated. Findings Higher expression of E-Cadherin was observed in LLSCCs classified in early clinical stages (stage I) (p Conclusion The results of this study suggest the potential involvement of Twist and E-Cadherin proteins in the modulation of events related to tumor progression and the poor prognosis of LLSCC.

Clinical Outcomes of Isolated Regional Lymph Node Recurrence in Patients With Malignant Cutaneous Melanoma.

Regional lymph node recurrence (RLNR) is the most common pattern of recurrence within 2 years from the diagnosis of patients with non-metastatic malignant cutaneous melanoma. However, isolated RLNR without distant metastasis has been rarely studied. Forty patients with isolated RLNR as a first recurrence were analyzed retrospectively. The clinical outcomes and prognostic impact of clinicopathologic parameters were analyzed. Immunostaining for FOXP3, VEGF, pAKT, and pS6 was also performed. The median disease-free interval from first diagnosis to isolated RLNR and post-recurrence recurrence-free survival (pRFS) were 12 months and 7.2 months, respectively. Distant failure was the most common pattern of failure after isolated RLNR (67.5%). The number of initially harvested lymph nodes (LN) >7 and LN ratio >22.2% at the time of recurrence were prognosticators for pRFS in multivariate analysis. None of the tested biomarkers were significantly related to prognosis. The 5-year post-recurrence overall survival rate was 84.9%. Most patients with isolated RLNR will experience a second failure within months, especially distantly. The number of initially harvested LNs and LN ratio at the time of recurrence could predict pRFS.

Breast cancer hormone receptor negativity, triple-negative type, mastectomy and not receiving adjuvant radiotherapy were associated with axillary recurrence after sentinel lymph node biopsy

Axillary lymph node dissection (ALND) can be avoided in selected patients with positive sentinel lymph nodes (SLNs). However, regional lymph node recurrence may occur after SLN biopsy (SLNB). This study aimed to identify the risk factors for axillary recurrence to ensure safe axillary surgery. Between June 2004 and December 2017, a total of 1056 women underwent SLNB without ALND. Patient data were prospectively entered into the breast cancer database at Kawaguchi Municipal Medical Center. From October 2012, we did not perform ALND in patients with (a) 1 or 2 positive SLNs, (b) positive SLNs that were unmatted or did not show gross extra nodal extension, (c) a clinical tumor size ≤5cm, and in (d) those who received adjuvant endocrine therapy or chemotherapy and radiotherapy. Subsequently, appropriate adjuvant systemic and/or radiation treatment was administered. Of the 1056 patients included, 996 had negative SLNs, 49 had positive SLNs, and 11 had undetectable SLNs. The identification rate for SLNs was 99.0%, and the median number of removed SLNs was 2. During the median 6.9-year follow-up period, 10 patients (1.0%) showed axillary recurrence without SLNs metastasis. Hormone receptor negativity (p<0.01), triple-negative type (0.047), mastectomy (<0.01) and not receiving adjuvant radiotherapy (<0.01) were significantly related to axillary recurrence. ALND can be safely avoided in selected patients with early breast cancer. Patients with hormone receptor-negative tumors, especially triple-negative breast cancer, patients who underwent mastectomy without ALND or those who did not receive adjuvant radiotherapy should be followed up carefully.

Factor analysis of diagnosis and surgical treatment of local regional recurrence in breast cancer patients

Objective: To analyze the association between clinicopathological factors and clinical diagnosis, treatment and surgery of local regional recurrence (LRR) in breast cancer. Methods: A retrospective study was done to evaluate consecutive 7 823 breast cancer LRR cases between January 2009 and August 2018 at Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine. A total of 108 LRR patients were enrolled: 35 cases (32.4%) with ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery, 40 cases (37.0%) of chest wall recurrence (CR), and 33 cases (30.6%) with regional lymph node recurrence (LNR). All patients were female, aged from 26 to 83 years with a mean of 49 years. Clinicopathological factor and its relationship with different sites of LRR and following surgical choice were analyzed by χ(2) test, rank-sum test and Logistic regression. Survival analysis were performed between different LRR patterns and whether undergoing second surgery. Kaplan-Meier survival curves and Log-rank tests demonstrated the distribution of overall survival. Results: Both univariate analysis and multivariate analysis found that axillary lymph nodes (ALN) status (OR=7.27, 95% CI: 1.30 to 40.53, P=0.042) and disease-free interval (OR=0.18, 95% CI: 0.06 to 0.60, P=0.013) were related to different site of LRR. Compared with patients with IBTR, LNR and CR patients had a higher rate of ALN metastasis and a shorter disease-free interval. A total of 36 LRR patients underwent following surgery. In univariate analysis, initial ALN surgery (χ(2)=16.705, P=0.001), pathological type (χ(2)=7.047, P=0.03), ALN status (χ(2)=10.812, P=0.002), disease-free interval (χ(2)=6.118, P=0.023) and LRR site(χ(2)=19.328, P=0.000) were associated with surgical treatment for LRR patients. Multivariate analysis demonstrated that only site of LRR was independently associated with surgery (OR=0.17, 95% CI: 0.05 to 0.65, P=0.024). The 5-year overall survival was 100% and 60.1% (P=0.018) for LRR patients treated with surgery or not. Furthermore, CR patients had significantly worse overall survival than LNR and IBTR patients, with 5-year overall survival 53.1%, 73.5%, and 100% respectively (P=0.021). Conclusions: Initial lymph nodes metastasis and disease-free interval are associated with different site of LRR. LRR site significantly influenced following surgery choice after LRR, which are both related with overall survival after LRR.

Role of P53, E-cadherin and BRAF as predictors of regional nodal recurrence for papillary thyroid cancer

BackgroundRegional nodal recurrence (RNR) in patients diagnosed with papillary thyroid carcinoma (PTC) has increased. Variable immunohistochemical (IHC) markers have been studied for predicting the likelihood of PTC for recurrence. We aimed to clarify the IHC expression of p53, Ecadherin and BRAF as potential markers of RNR in PTC. Method145 (73 study group and 72 control group) patients with PTC were analyzed retrospectively between January 2010 and June 2017. Further classification to a specific histological variant was done, and IHC expression of p53, Ecadherin and BRAF was analyzed both in the primary tumor and in nodal recurrence. ResultsRegarding the risk of RNR, we found certain clinicopathologic features as elder age ≥55 years, tumor size >1 cm, presence of microscopic extrathyroid extension, presence of lymphovascular emboli, and conventional papillary subtype. Furthermore, IHC results for negative E-cadherin, and positive P53 and BRAF are significant risk factors, while radioactive iodine (RAI) adjuvant therapy decrease recurrence risk. ConclusionWe found several risk factors for RNR in PTC diagnosed patients, all of which are easily achievable in clinical settings. In this regard, we suggested that patients with specific clinicopathologic and immunohistochemical features have strict follow up for early detection of RNR as it has a great impact on their survival.

Patterns of locoregional failure in women with early-stage breast cancer treated by whole breast irradiation in the lateral isocentric decubitus position: Large-scale single-centre experience

PurposeThe purpose of this study was to evaluate locoregional control and describe the patterns of failure in patients with breast cancer receiving whole breast radiotherapy in the isocentric lateral decubitus position technique. Patients and methodsIn a series of 832 consecutive female patients with early-stage breast cancer including invasive and in situ tumours treated by breast-conserving surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between 2005 and 2010, all patients who experienced locoregional recurrence were studied. Five-year recurrence-free and overall survival rates were calculated. Regional recurrence mapping patterns were also determined. ResultsThe median age of this series of 832 women was 61.5 years (range: 29–90 years). Various types of fractionation were used: 50Gy in 25 fractions (17.9%), 66Gy in 33 fractions (50Gy in 25 fractions to breast followed by sequential boost to tumour bed to a total dose 66Gy in 33 fractions.) (46.5%), 40Gy in 15 fractions or 41.6Gy in 13 fractions (26.1%) and 30Gy in 5 fractions (9.5%). With a median follow-up of 6.4 years, only 36 patients experienced locoregional recurrence and no association with the fractionation regimen was identified (P=0.2). In this population of 36 patients, 28 (3.3%) had “in-breast” local recurrences (77.8%), two had local recurrences and regional lymph node recurrence (5.6%), and six had regional lymph node recurrence only (in non-irradiated areas; 16.6%). The median time to recurrence was 50 months. Complete mapping of patterns of recurrences was performed and, in most cases, local recurrences were situated adjacent to the primary tumour bed. Cases of local recurrences presented a significantly lower distant metastasis rate (P<0.001) and had a significantly longer overall survival compared to patients with regional lymph node recurrence (P<0.001). However, multivariate Cox regression analysis showed that the site of recurrence had no significant impact on overall survival (P=0.14). ConclusionThe results of this study indicate a low local recurrence rate. Further careful follow-up and recording of recurrences is needed to improve the understanding of patterns of recurrence.

A systematic review of clinical outcomes and radiotherapy-associated toxicity in multicatheter accelerated partial breast irradiation.

To integrate relevant clinical data of multicatheter accelerated partial breast irradiation (mAPBI) for reaching a comprehensive conclusion. We did 3 meta-analyses for clinical outcomes including 1740 women from 4 articles, for acute radiotherapy (RT)-associated toxicity including 1255 patients from 5 articles, and for late RT-related toxicity involving 1565 patients from 9 papers. Clinical outcomes analyses were stratified by molecular subtypes, lymph nodes status, receptor status, and human epidermal growth factor receptor 2 (HER2) status. For the Luminal A/B phenotypes, the disease relapse and failure in survival significantly decreased when compared with triple negative (TN)/HER2-amplified subtypes (P < .00001). The 5-year regional nodal recurrence (RNR), 5-year distant metastasis-free survival (DMFS) and 5-year disease free-survival (DFS) of TN patients were significantly superior to HER2-overexpression patients (P < .00001). The 5-year cause-specific survival (CSS), 5-year DMFS and 5-year overall survival (OS) in women with lymph nodes-negative were significantly improved versus patients with lymph nodes-positive (P = .0001). Conversely, the positive status of HER2 compared with negative one significantly increased the rate of local recurrence (LR) (P = .02). For acute toxicity, the morbidity of dermatitis was significantly higher than hematoma and implant infection (P = .01, P < .0001, respectively). For late toxicity, the occurrences of fibrosis (32%) and telangiectasia (14%) were significantly higher than other complications (P < .0001). HER2-enriched subtype compared with other subtypes has significantly increased disease relapse and failure in survival. HER2-positive status is positively associated with an increased incidence of LR. Dermatitis is the most common acute RT-related toxicity and fibrosis is the first rife late RT-related toxicity.

Thoracoscopic esophagectomy with total meso-esophageal excision reduces regional lymph node recurrence.

We investigated the operative outcomes of thoracoscopic esophagectomy (TE) in the prone position, using the concept of total meso-esophageal excision for esophageal cancer. The medical records of 140 consecutive patients with esophageal cancer who underwent radical esophagectomy by TE were reviewed retrospectively, and operative outcomes were compared between patients treated before (non-meso-esophagus; non-ME group) and after (ME group) the introduction of total meso-esophageal excision (ME). There were no significant differences between the groups in postoperative morbidity (non-ME group vs. ME group, 28.3% vs. 41.4%, p = 0.119), 30-day mortality (non-ME group vs. ME group, 0% vs. 1.1%; p = 0.433), and in-hospital mortality (non-ME group vs. ME group, 1.9% vs. 0%, p = 0.199). Although overall survival and relapse-free survival did not differ significantly between the groups, the overall recurrence rate was significantly lower in the ME group than the non-ME group (non-ME group vs. ME group, 43.4% vs. 23%, p = 0.011). In particular, the rate of regional lymph node recurrence in the mediastinum was lower in the ME group (non-ME group vs. ME group, 11.3% vs. 2.3%; p = 0.026). Our results suggest that the ME procedure might be one of the procedures that reduce regional lymph node recurrence in the mediastinum without any deterioration in short-term outcomes.

The impact of adjuvant therapies on patient survival and the recurrence patterns for resected stage IIa\u2013IVa lower thoracic oesophageal squamous cell carcinoma

BackgroundThis study evaluated the impact of adjuvant therapies on patient survival and disease recurrence patterns to identify an effective adjuvant therapy for resected lower thoracic oesophageal squamous cell carcinoma (LTESCC).MethodsClinical data of 127 patients with stage IIa-IVa LTESCC with a minimum 2-year follow-up after oesophagectomy were analysed. The survival and recurrence patterns were compared among patients who received adjuvant radiotherapy, adjuvant chemotherapy, adjuvant chemoradiotherapy, or surgery alone.ResultsEighty-eight patients (69.3%) were identified as having disease recurrence. The regional lymph node recurrence rate was 57.5%, and the recurrence rates were high in the lower neck, upper mediastinum, and upper abdomen. Compared to surgery alone, adjuvant radiotherapy or chemoradiotherapy significantly decreased the recurrence rate (p < 0.05). Adjuvant chemoradiotherapy significantly improved overall survival, disease-free survival, and locoregional recurrence-free survival compared to surgery alone (p = 0.01, 0.01, and 0.00, respectively). Pathologically positive lymph nodes (PPLNs) in the lower mediastinum represented a potential risk factor for cervical recurrence (HR 2.97, 95%CI 1.19–7.39). Multivariable analysis showed that postoperative radiotherapy (HR 0.30, 95%CI 0.13–0.68) and PPLNs in the upper mediastinum (HR 3.72, 95%CI 1.30–10.67) were independent risk factors for upper mediastinal recurrence, while postoperative radiotherapy (HR 0.37, 95%CI 0.16–0.85) and PPLNs in the abdomen (HR 2.57, 95%CI 1.12–5.92) were independent risk factors for abdominal recurrence.ConclusionAdjuvant chemoradiotherapy was the most effective adjuvant therapy for resected stage IIa-IVa LTESCC. The lower neck, upper mediastinum, and upper abdomen were high-risk regions for postoperative radiotherapy. The regions of PPLNs may be important factors for individual targets.

Patterns of regional nodal relapse after D2 lymphadenectomy in gastric cancer: rethinking the target volume.

PurposeThis study mapped the localization of regional nodal recurrence to determine whether the clinical target volume (CTV) should be redefined in adjuvant radiotherapy.Patients and methodsBetween January 2004 and October 2015, a total of 129 patients with gastric cancer following D2 resection who experienced regional recurrence were retrospectively examined. The lymph nodes (LNs) were hand-drawn proportionally on template computed tomography (CT) images of a standard patient by referencing surrounding anatomic landmarks. The association between clinicopathologic factors and LNs at risk was further investigated.ResultsBased on the contour of the recurrent LNs, the authors observed high-risk regions for relapse and drew a density distribution map of 16 LN stations on the CT images. The most commonly involved recurrent LNs were stations 16b (51.2%) and 16a (39.5%). Stations 13, 12, 9, and 14 were involved in 36.4%, 33.3%, 28.7%, and 27.9% of recurrences, respectively. Other regions, including stations 1–6 (perigastric LNs) and station 10 (splenic hilar LN), were of low risk. Notably, 72% (83/116) of recurrent 16b LNs were located in the upper half of 16b1. Analysis within subgroups showed that the pathologic N stage was the only independent risk factor for LN 16 relapse.ConclusionThis mapping suggests a new method for vessel-guided delineation of regional LNs when defining the CTV in patients after standard D2 resection. LNs around the abdominal aorta and its main branches, as well as regions around the hepatic hilar area and pancreatic head, should be the most important radiotherapeutic targets.