Resection Of Metastatic Sites Research Articles

Enbloc groin node resection reconstructed with external oblique flap for solitary metastatic cholangiocarcinoma: a case report.

Cholangiocarcinoma requires complete surgical resection for cure. Even so, the recurrence and metastasis rates are high, and further treatment is typically through palliative systemic chemotherapy. Curative-intent resection of metastatic site may provide survival benefit in selected cases. However, there were no previous reports of groin node dissection in cholangiocarcinoma. We have reported the first case of intrahepatic mass-forming cholangiocarcinoma with isolated synchronous groin node metastasis, successfully treated with resection of the liver mass followed by groin noderesection, reconstructed with musculofascial flap. A 73-year-old man presented with right upper quadrant abdominal pain radiating to the right groin for two months. Magnetic resonance cholangiopancreatography revealed a 3.1×1.2cm enhancing mass between hepatic segment 4 and the anterior peritoneum, invading the abdominal wall.Computed tomography of the abdomen revealed a 2.4×2.2cm focal enhancing mass at the anterior aspect of the right lower abdominal wall, just anterior to the right inguinal ligament and iliac vessel. He underwent enbloc resection of hepatic segment 4, gallbladder, and anterior abdominal wall, and the histology result is cholangiocarcinoma. After systemic chemotherapy, he underwent enbloc resection of the right groin mass, reconstructed with external oblique musculofascial flap. The patient was able to achieve a 20-month recurrence free survival after the final operation. This case has demonstrated that in a carefully selected case, resection of distant metastasis cholangiocarcinoma can provide survival benefits, even in the rare site of metastasis.

Resection of the Primary Tumor and Survival in Patients with Single-Site Synchronous Oligometastatic Non-Small Cell Lung Cancer: Propensity-Matched Analysis of the National Cancer Database.

Local therapy for the primary tumor is postulated to remove resistant cancer cells as well as immunosuppressive cells from the tumor microenvironment, potentially improving response to systemic therapy (ST). We sought to determine whether resection of the primary tumor was associated with overall survival (OS) in a multicentric cohort of patients with single-site synchronous oligometastatic non-small cell lung cancer. Using the National Cancer Database (2018 to 2020), we evaluated patients with clinical stage IVA disease who received ST and stratified the cohort based on receipt of surgery for the primary tumor (S). We used multivariable and propensity score-matched analysis to study factors associated with S (logistic regression) and OS (Cox regression and Kaplan-Meier), respectively. Among 12,215 patients identified, 2.9% (N = 349) underwent S and 97.1% (N = 11,886) ST (chemotherapy or immunotherapy) without surgery. Patients who underwent S were younger, more often White, had higher income levels, were more likely to have private insurance, and were more often treated at an academic facility. Among those who received S, 22.9% (N = 80) also underwent resection of the distant metastatic site. On multivariable analysis, metastasis to bone, N+ disease, and higher T-stages were independently associated with less S. On Cox regression, S and resection of the metastatic site were associated with improved survival (hazard ratio 0.67, 95% CI 0.56 to 0.80 and hazard ratio 0.80, 95% CI 0.72 to 0.88, respectively). After propensity matching, OS was improved in patients undergoing S (median 36.8 vs 20.8 months, log-rank p < 0.001). Advances in ST for non-small cell lung cancer may change the paradigm of eligibility for surgery. This study demonstrates that surgical resection of the primary tumor is associated with improved OS in selected patients with single-site oligometastatic disease.

Intervention for Hepatic and Pulmonary Metastases in Breast Cancer Patients: Prospective, Multi-institutional Registry Study-IMET, Protocol MF 14-02.

One fourth of early-stage breast cancer cases become metastatic during the follow-up period. Limited metastasis is a metastatic disease condition in which the number of metastatic sites and the extent of the disease both are limited, and the disease is amenable to metastatic intervention. This prospective study aimed to evaluate intervention for limited metastases in the lung, liver, or both. The study enrolled luminal A/B and/or human epidermal growth factor receptor 2 (HER2)-neu+ patients with operable lung and/or liver metastases in the follow-up assessment after completion of primary breast cancer treatment and patients with a diagnosis of metastasis after 2014. Demographic, clinical, tumor-specific, and metastasis detection-free interval (MDFI) data were collected. Bone metastasis in addition to lung and liver metastases also was included in the analysis. The patients were divided into two groups according to the method of treatment for metastases: systemic therapy alone (ST) group or intervention (IT) group. Until June 2020, 200 patients were enrolled in the study. The demographic data were similar between the two groups. The median follow-up time was 77months (range 55-107months) in the IT group (n = 119; 59.5%) and 57months (range 39-84) in the ST-only group (n = 81; 40.5%). The median MDFI was 40months (range 23-70months) in the IT group, and 35months (range 13-61months) in the ST-only group (p = 0.47). The groups had similar surgeries for the primary tumor and axilla. Most of the patients had liver metastases (49.5%, n = 99), and 42% (n = 84) of the patients had lung metastases. Both lung and liver metastases were found in 8.5% (n = 17) of the patients. The primary tumor was estrogen receptor/progesterone receptor-positive in 75% (n = 150) of the patients, and 32% (n = 64) of the patients had HER2-neu+ tumors. Metastatic-site resection was performed for 32% (n = 64) of the patients, and 27.5% (n = 55) of the patients underwent metastatic ablative interventions. In the Kaplan-Meier survival analysis, the hazard of death (HoD) was 56% lower in the IT group than in the ST-only group (hazard ratio [HR], 0.44; 95% confidence interval [CI] 0.26-0.72; p = 0.001). The HoD was lower in the IT group than in the ST-only group for the patients younger than 55years (HR, 0.32; 95% CI 0.17-0.62; p = 0.0007). In the multivariable Cox regression model, HoD was significantly lower for the patients who underwent intervention for metastases and had an MDFI longer than 24months, but their liver metastases doubled the risk of death compared with lung metastases. Metastasis-directed interventions have reduced the risk of death for patients with limited lung/liver metastases who are amenable to interventions after completion of primary cancer treatment. For a select group of patients, such as those with luminal A/B or HER2-neu+ breast cancer who are younger than 55years with limited metastases to the lung and liver or an MDFI longer than 24months, surgical or ablative therapy for metastases should be considered and discussed on tumor boards.

Metastasectomy versus radiation of secondary sites in stage IV breast cancer: Analysis from a national cancer registry

PurposeLocoregional therapy at primary or secondary sites in breast cancer may be associated with improved survival as compared to systemic therapy alone. We explored the sociodemographic and clinicopathologic factors associated with the use of radiation versus surgical resection of metastatic sites (metastasectomy) in patients with de novo stage IV breast cancer, followed by the associated overall survival. MethodsWe sampled the National Cancer Database for patients with de novo stage IV breast cancer, (2010–2017) and described cohort's characteristics using univariate analyses. We identified 5 subgroups based on malignant site involvement: 1. Bone only, 2. Brain only, 3. Liver only, 4. Lung only, and 5. Metastasis involving >1 site. Kaplan-Meier modeling with log-rank testing and multivariate Cox Regression analysis were used to explore differences in overall survival between those that received radiation at secondary sites and those that underwent metastasectomy. ResultsN = 22,749patients were included in this analysis. Radiation (81.2%) was used more commonly than metastasectomy (28.8%). Metastasectomy was associated with better median overall survival across all 5 cohorts (p < .001), with the survival benefit being the most pronounced with lung only (OS: 56.9 months; HR 0.8, 95% CI 0.7–0.9, p = .032), or liver only (OS: 41.6 months; HR: 0.9; 95% CI: 0.7–1.1, p < .001) metastasis. ConclusionMetastasectomy in patients with de novo stage IV breast cancer may be associated with improved overall survival as compared to radiation of secondary lesions, particularly in those with only liver or lung involvement. Prospective randomized controlled trials investigating surgical resection of metastatic sites in patients with breast cancer are warranted.

Metastasectomy versus radiation of secondary sites in stage IV breast cancer.

1094 Background: Prospective trials have yielded mixed results on the utility of surgery in metastatic breast cancer (mBC). Thus far, however, studies have focused primarily on the impact of lumpectomy or mastectomy. We previously showed that a combined approach involving resection of primary and secondary sites (i.e. ‘metastasectomy’) in patients with limited mBC was associated with improved overall survival (OS). We sought to evaluate the effect on OS of two approaches to loco-regional therapy (LRT) at secondary sites: metastasectomy versus radiation therapy. Methods: This is a retrospective analysis of patients diagnosed with mBC from 2010-2017 using the National Cancer Database. We identified 5 cohorts of patients by site of metastasis: mBC involving only 1) bone, 2) brain, 3) liver, or 4) lung; and 5) patients with metastasis involving &gt;1 site. For each cohort, we used Kaplan-Meier (KM) models with log-rank testing to evaluate differences in OS, by the LRT approach at secondary sites (radiation versus metastasectomy). Prior to KM modeling, chi-squared statistics were used in each cohort to assess whether age, race, Charlson/Deyo score (CDS) for comorbidity, and receptor subtype were potential confounders of survival. The KM models were adjusted accordingly, as per the table below. Results: 53.4%) were between 50-70 years old, White (n=53,409, 78.9%), and had hormone receptor (HR)-positive/HER2 receptor-negative breast cancer. N=12,362 patients received radiation therapy at either the bone, brain, liver, or lung; while n=2674 underwent surgical resection of a metastatic site. Of patients with metastasis to 1 site (n=44,451), n=30,341(68.3%) involved the bone, n=1,119 (2.5%) involved the brain, n=5,227 (11.8%) involved the liver, and n=7,764 (17.5%) involved the lung. N=24,017 patients had metastatic disease involving &gt; 1 site. KM modeling revealed superior OS of patients undergoing metastasectomy versus radiation of secondary sites in all 5 cohorts (p&lt;0.05). The difference in median OS (ΔmOS) by LRT approach was more pronounced when metastasis involved only the liver (41.6 months) or lung (48.6 months), versus only the brain (9.7 months) or bone (8.7 months). Conclusions: Metastasectomy appears to confer a superior benefit for OS compared to radiation of secondary sites, particularly in patients with secondary site involvement limited to the liver or lung. More research is needed from prospective trials investigating surgical resection of metastatic sites.[Table: see text]

Perioperative therapy in metastatic colorectal cancer: Pattern of use and survival outcomes.

Multimodality therapy of metastatic colorectal cancer (mCRC) is currently considered the standard of care. The aim of this study was to evaluate the impact of perioperative therapy on surgical resection in mCRC. The National Cancer Database was analyzed for affected patients between 2004 and 2013. Univariate and multivariate analyses were done to identify factors associated with patient outcomes. Kaplan-Meier analysis and Cox proportional hazards models were used for the association between patient characteristics and survival. About 61,940 patients with mCRC were identified. Mean age = 63.4 years (SD ± 14). About 69% had a colon primary and 32% had only one metastatic site. Only 49% of those who underwent surgery for both primary and metastatic sites received postoperative chemotherapy (p < .001). Negative prognostic factors included no chemotherapy received (hazard ratio [HR], 2.32; 2.27-2.37; p < .001), more than three metastatic sites (HR, 2.28; 2.09-2.48; p < .001), year of diagnosis between 2004 and 2008 (HR, 1.71; 1.15-1.20; p < .001) and colon tumor location with right worse than left-sided (HR, 1.21; 1.19-1.24; p < .001). Five-yearoverall survival for resection of the primary and metastatic site (28.2%) was higher than for no surgical treatment (4.7%). Perioperative therapy was associated with improved survival, following resection of metastatic sites or primary tumor.

Trends in Primary Surgical Resection and Chemotherapy for Metastatic Colorectal Cancer, 2000-2016.

When, whether, and in whom primary tumor resection (PTR) for patients with metastatic colorectal cancer (CRC) is indicated remains unknown. With advances in multiagent systemic chemotherapy, PTR may be undertaken less frequently. The aim of this study was to obtain estimates of changes in the utilization of PTR and chemotherapy for metastatic CRC. Patients diagnosed with metastatic CRC between 2000 and 2016 were identified from Surveillance Epidemiology, and End Results (SEER) registry. Multivariable logistic regression defined odds of undergoing PTR. The analysis was also stratified by primary site (colon vs. rectum), age (younger than 50 vs. 50 y and older), and whether patients also underwent resection of metastatic sites (yes vs. no). The secondary endpoint of interest was the receipt of any chemotherapy, also assessed by multivariable logistic regression. Among 99,835 patients with metastatic CRC, 55,527 (55.7%) underwent PTR. The odds of undergoing PTR decreased with a later year of diagnosis, with patients diagnosed in 2016 being 61.1% less likely to undergo surgery than those diagnosed in 2000 (adjusted odds ratio=0.39, 95% confidence interval: 0.36-0.42, P<0.0001; absolute percentage: 62.3% to 43.8%). Similar trends by year for PTR were observed among each of the subgroups, although patients with colon primary, young adults (age younger than 50 y), and patients also undergoing metastasectomy were more likely to undergo PTR (P<0.001 for all). In contrast, the odds of receiving chemotherapy increased dramatically with a later year of diagnosis (adjusted odds ratio=2.21, 95% confidence interval: 2.04-2.40, P<0.0001). From 2000 to 2016, there was a sharp decline in the rate of PTR for patients with metastatic CRC, while the use of chemotherapy increased over the same period. Prospective studies are needed to define the optimal local treatment for patients with metastatic CRC.

Trends in primary surgical resection and chemotherapy for metastatic colorectal cancer, 2000-2016.

e16000 Background: When, whether and in whom resection of the primary tumor for patients with metastatic colorectal cancer (CRC) is indicated remains incompletely elucidated, although a recent randomized trial (JCOG1007, presented at GI ASCO 2020) showed no survival benefit in resection of asymptomatic primary tumors in this population. Given the emergence of multiagent chemotherapy, surgery may be used less, but patterns of care for metastatic CRC have not been reported. As such, we sought to evaluate trends in use of primary surgical resection and chemotherapy among patients with metastatic CRC. Methods: Patients diagnosed with metastatic CRC between 2000-2016 were identified from the Surveillance, Epidemiology and End Results (SEER) registry. Multivariable logistic regression defined odds of undergoing primary surgical resection, with year of diagnosis as the primary independent variable. The cohort analysis was also stratified by primary site (colon versus rectum), age ( &lt; 50 vs. &gt;50 years) and whether patients also underwent resection of metastatic sites (yes versus no). The secondary endpoint of interest was receipt of any chemotherapy, also assessed by multivariable logistic regression. Results: Among 99,835 patients with metastatic CRC, 55,527 (55.7%) underwent resection of their primary tumor. The odds of undergoing primary surgery decreased with later year of diagnosis, with patients diagnosed in 2016 61.1% less likely to undergo surgery than those diagnosed in 2000 (AOR 0.39, 95% CI 0.36-0.42, p &lt; 0.0001; absolute percent 62.3% to 43.8%). Black patients and women were also less likely to have surgery (p &lt; 0.001). Similar trends by year for primary surgery were observed among each of the subgroups, although patients with colon primary, young adults (age &lt; 50), and patients also undergoing metastatectomy were more likely to undergo primary surgery (p &lt; 0.001 for all). In contrast, the odds of receiving chemotherapy increased dramatically with later year of diagnosis, with patients diagnosed in 2016 221% more likely to receive chemotherapy than those diagnosed in 2000 (AOR 2.21, 95% CI 2.04 to 2.40, p &lt; 0.0001; 45.5% to 64.0%). Conclusions: From 2000-2016, we observed a sharp decline in the rate of primary surgical resection for patients with metastatic CRC, while use of chemotherapy increased over the same period. Prospective studies are needed to define the optimal local treatment for patients with metastatic CRC, perhaps with stratification by molecular and clinical characteristics, in order to optimize both cancer-specific and symptomatic outcomes.

Retrospective Study of the Clinicopathological Characteristics of Adult Granulosa Cell Tumour of the Ovary at a Tertiary Care Centre

This retrospective analysis aimed to evaluate the clinicopathological characteristics of adult granulosa cell tumours (AGCT) treated at a tertiary care centre. Demographic, clinicopathological, treatment and follow-up details of all patients with AGCT treated from January, 2003 till July, 2014 were extracted from institutional cancer registry and Electronic Medical Records, after obtaining necessary clearance from institutional ethical committee, and institutional review board. The details obtained were tabulated and analyzed. Thirty-three patients were identified to have AGCT; 24 at initial diagnosis and nine at recurrence. Mean age at diagnosis among patients seen at initial diagnosis and those at recurrence was 50.42 years versus 40.78 years, while mean tumour size was 11.9 cm and 14.8 cm respectively. Abdominal pain was most common symptom at presentation. All patients had upfront surgery. Of the 24 cases seen initially, 16 had staging surgery; among whom six were second surgery, one in the fertility sparing group, and five in the non-sparing group. None were upstaged. Complete resection was feasible in all 16. Three cases had fertility preserving surgery. Among the patients who had staging surgery, 81.25% were stage I and the rest stage IIb. Six patients received postoperative chemotherapy. The mean follow-up period was 42.08 months. Mean time to relapse among the nine recurrent cases was 92.79 months. All patients had intra-abdominal recurrence, pelvis and omentum being the most common sites. Resection of metastatic sites was done in all nine cases. Three patients received preoperative chemotherapy and one received postoperative radiotherapy. The mean overall survival was 170.18 months. Complete resection of tumour is feasible both in primary and recurrent cases. Fertility preserving surgery may be offered to women with early-stage disease who opt to retain fertility. Long term follow-up with pelvic and whole abdominal surveillance is necessary.

A population-based propensity-matched study of regional dissections in patients with metastatic osteosarcoma

BackgroundThe survival rates of patients with metastatic osteosarcoma are poor, and the prognosis is closely related to the choice of treatment, especially surgery. This study aimed to evaluate the survival outcomes of patients with metastatic osteosarcoma undergoing regional dissections.MethodsWe collected data on patients with metastatic osteosarcoma between 2004 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier curves were used to compare overall survival (OS) and cancer-specific survival (CSS), while univariate and multivariate Cox regression analyses were used to evaluate outcomes. Propensity score matching (PSM) was used to minimize the effects of confounding factors.ResultsThe SEER database had records of 2768 patients diagnosed with osteosarcoma, of whom 398 were included in our study. Of the included patients, 116 (29.15%) underwent regional dissections, while 282 (70.85%) underwent non-regional dissections. The univariate and multivariate Cox regression analyses, prior to PSM, showed that OS (hazard ratio (HR): 0.34, 95% confidence interval (CI): 0.26–0.44, P<0.001 and HR: 0.47, 95% CI: 0.35–0.64, P<0.001, respectively) and CSS (HR: 0.33, 95% CI: 0.25–0.43, P<0.001 and HR: 0.46, 95% CI: 0.34–0.63, P<0.001, respectively) were better in patients who underwent regional dissections than those who underwent non-regional dissections. Compared with non-regional dissections, regional dissections, which included both primary tumour resection (PTR) and primary tumour and metastatic site resection (PTMR), were associated with better OS (P<0.001) and CSS (P<0.001) . However, the survival outcomes following PTR and PTMR showed no significant difference. After PSM, patients in the regional dissection group still had a higher OS (P<0.001) and CSS (P<0.001) than those in the non-regional dissection group.ConclusionsCompared with non-regional dissection, regional dissection resulted in better survival in patients with metastatic osteosarcoma.

3:09 PM Abstract No. 33 Comparison of radiofrequency ablation and stereotactic radiotherapy for primary treatment of intrahepatic cholangiocellular carcinoma: results from the National Cancer Database

The incidence of intrahepatic cholangiocellular carcinoma (ICC) is increasing in the US. There is currently no data on the effectiveness of local treatment options for ICC patients. The most recent version of the National Cancer Database (NCDB) was queried for adult patients diagnosed with ICC between 2004-2016. Patients receiving surgical resection of metastatic sites were excluded. HCC treatment was stratified as radiofrequency ablation (RFA) and stereotactic radiotherapy (SRT; defined as beam-based radiotherapy). Kaplan-Meier plots, log rank tests and Cox proportional hazards models were used to evaluate overall survival. Propensity score matching was utilized to account for potential confounders. A total of 999 patients met inclusion criteria, of which n = 267 (26.7%) received RFA and n = 732 (73.7%) SRT. Median SRT radiation dose was 45Gy (IQR: 30-50Gy) over a median of 5 fractions (IQR: 4-15 fractions). Patients treated with SRT were more male with private insurance and low comorbidities compared to RFA. SRT was less common for low-stage ICC compared to RFA and for larger tumors (median size, 52 vs. 34 mm, P <0.001). ICC treatment via SRT was more common in East North Central States. Annual case numbers for both treatment modalities increased from 2004-2016. After propensity score matching RFA to, a matched cohort with n = 178 patients was obtained with balanced confounders between both treatment modalities. Overall survival was evident for RFA vs. SRT in the matched cohort (HR = 0.71, 95% CI: 0.54-0.93, p = 0.01). For local ICC treatment, RFA shows longer overall survival than SRT, even after adjustment for confounders.

Abstract No. 497 Comparison of radiofrequency ablation and stereotactic radiotherapy for primary treatment of low- and intermediate-stage hepatocellular carcinoma: results from the National Cancer Database

Stereotactic radiotherapy (SRT) is an emerging treatment modality for HCC; however, there is scarce data to compare it to established radiofrequency ablation (RFA). The most recent version of the National Cancer Database (NCDB) was queried for adult patients diagnosed with AJCC stage 1-3 hepatocellular carcinoma (HCC) between 2004-2016. Patients receiving surgical resection of metastatic sites were excluded. HCC treatment was stratified as radiofrequency ablation (RFA) and stereotactic radiotherapy (SRT; defined as beam-based radiotherapy). Kaplan-Meier plots, log rank tests and Cox proportional hazards models were used to evaluate overall survival. Propensity score matching was utilized to account for potential confounders, separately for stage 1 and stage 2/3 disease. A total of 13,030 patients met inclusion criteria, of whom n = 10,517 (80.6%) received RFA and n = 2531 (19.4%) SRT. Median SRT radiation dose was 44 Gy (IQR: 30-50 Gy) over a median of 5 fractions (IQR: 3-11 fractions). Patients treated with SRT were more commonly older whites with Medicare insurance and low comorbidities compared to RFA. SRT was less common for stage 1 HCC compared to RFA (48.3% vs. 67.7%, P <0.001) and for larger HCC (median size, 40 vs. 26 mm, P <0.001). HCC treatment via SRT was more common in East North Central and Middle Atlantic States. Annual case numbers for both treatment modalities increased from 2004-2016. After propensity score matching RFA to SRT for stage 1 HCC, a matched cohort with n = 1,868 patients was obtained with balanced confounders between both treatment modalities. Overall survival was evident for RFA vs. SRT in the matched cohort (HR = 0.67, 95% CI: 0.59-0.75, P <0.001). Comparable results were obtained for stage 2/3 HCC after propensity score matching (n = 1,694 patients, RFA vs. SRT HR = 0.62, 95% CI: 0.55-0.69, P <0.001). A majority of patients with non-surgically treated HCC receive RFA that shows superior overall survival versus stereotactic radiotherapy.

Perioperative therapy in patients with metastatic colorectal cancer.

e18231 Background: Knowledge about perioperative systemic therapy in metastatic colorectal cancer (mCRC) is limited. We aim to describe the nationwide pattern of use and survival outcomes of patients with mCRC treated with surgical resection. Methods: Data were obtained from all US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2013. Univariate and multivariate analyses was done to identify factors associated with patient outcome. Results: A total of 61,940 patients with stage IV CRC older than 18 years were identified. Mean age was 63.4 years (SD±14), with a male preponderance (54.8%). About 80% were Caucasian and 69.9% had colon cancer. Compared to medical treatment only, resection of both primary and metastatic sites (13.5%; HR 0.40; 0.37-0.44; p &lt; 0.001), or primary site resection alone (49.2%; HR 0.52; 0.48-0.56; p &lt; 0.001) were associated with improved overall survival (OS). Other co-variates associated with improved survival included younger age group, year of diagnosis (2009-2013), colon tumor location, and &lt; 3 metastatic sites (Table). Five-year OS for resection of primary and metastatic site (28.2%) was higher than for primary site resection alone (14.9%) or no surgical treatment (4.7%). Conclusions: Resection of metastatic sites or primary tumor was associated with improved survival in patients with stage IV CRC.[Table: see text]

Stereotactic Body Radiation Therapy for Renal Cell Carcinoma with Inferior Vena Cava Thrombus – Initial Experience Report and Literature Review

Background: Renal cell carcinoma (RCC) with inferior vena cava thrombus (IVC-TT) represents a relatively infrequent presentation. Curative treatment includes extirpative surgery; however, this is associated with high rates of recurrence and complications. Stereotactic body radiation therapy (SBRT) has been used to treat metastatic RCC with good results. SBRT may be used as part of multimodal therapy to provide local control of IVC-TT. Objective: We report our initial experience with SBRT to IVC-TT, including extended follow-up, and review the literature. Results: We report on two patients with level IV IVC-TT. Both had progressive disease while receiving systemic therapy and were eventually treated with SBRT to the IVC-TT, which showed good local control. Overall survival from the time of SBRT was 18 and 34 months, with no additional systemic therapy; one patient underwent additional SBRT and resection of metastatic sites. Conclusions: SBRT to RCC IVC-TT may be considered in selected patients for local tumor control.

Pattern and risk factors for distant metastases in gastrointestinal neuroendocrine neoplasms: a population‐based study

An increased incidence of gastrointestinal neuroendocrine neoplasms (GI‐NENs) has been reported worldwide, and metastasis is the leading cause of GI‐NEN‐related death. Studies of different metastatic patterns in patients with different primary sites are limited. A population‐based retrospective cohort study was conducted with the Surveillance, Epidemiology, and End Results (SEER) database. Patients with a GI‐NEN diagnosis between 2010 and 2014 were included. All statistical analyses were performed using Intercooled Stata 12.0 software. There were 12,501 patients eligible for analysis. The metastatic status, primary sites, and histology types affected the patients’ overall survival. The liver was the most common metastasis site (65.21% of patients with metastases). Esophageal NENs had the highest risk of metastasis (49.35%), whereas appendiceal NENs had the lowest risk of metastasis (2.79%). Neuroendocrine carcinomas (NECs) were more likely to develop metastatic disease than were neuroendocrine tumors (NETs); 7.12% of patients with NET and 30.20% of patients with NEC developed metastatic disease. The metastatic patterns varied according to the different primary sites and histology types. NECs had a higher potential to develop extrahepatic metastasis at all primary sites than did NETs. Regarding the choice of treatment, surgical resection of primary lesions lowered the risk of tumor‐specific death (HR = 0.37, CI: 0.30–0.46, P < 0.01), but surgical resection of metastatic sites did not confer an extra survival benefit (HR = 0.82, CI: 0.63–1.06, P = 0.14). Different primary sites and histology types of GI‐NENs have different metastatic patterns and survival. This knowledge could help clinicians to identify patients who require extra surveillance, provide insight for future studies on the mechanisms of metastasis, and establish a prognostic prediction model.

Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers.

Despite substantially improved survival with metastatic site resection in colorectal cancers, uptake of aggressive surgical approaches remains low among certain patients. It is unknown whether financial determinants of care, such as insurance status, play a role in this treatment gap. We sought to evaluate the effect of insurance status on metastasectomy in patients with advanced colorectal cancers. This was a retrospective cohort study. Using the National Cancer Data Base Participant User File, incident cases of colorectal cancer metastatic to the lung and/or liver with diagnosis from 2010 to 2013 were identified. We identified 42,300 patients in our cohort with a mean age 64 years. Controlling for patient, tumor, and hospital characteristics, hierarchical regression was used to examine associations between hospital payer mix and metastatic site resection. Metastatic site resection occurred in 12.3% of all patients. Adjusting for patient and hospital fixed effects, we found that patients who were uninsured or on Medicaid were 38% less likely to undergo metastasectomy (OR = 0.62 (95% CI, 0.56-0.66)). Patients in hospitals with staff treating a high percentage of uninsured patients or patients with Medicaid were less likely to undergo metastasectomy, even after controlling for individual patient insurance status. The study was limited by its retrospective design and the granularity and accuracy of the National Cancer Data Base. Differences in insurance status and hospital payer mix are associated with differences in rates of metastatic site resection in patients with colorectal cancer that is metastatic to the lung and/or liver. There is a need for improved access to metastatic site resection for individual patients who are uninsured or who have Medicaid insurance, as well as for all patients who seek care at hospitals treating a large proportion of patients who are uninsured or on Medicaid. Remedies for individual patients could include improved access to private insurance through employment or individual plans or improved reimbursement from Medicaid for this procedure. Strategies for patients at low-performing hospitals include selective referral to centers that perform mestastectomy more frequently when appropriate.

Variation in hospital treatment patterns for metastatic colorectal cancer.

There are many treatment options for metastatic colorectal cancer (CRC). However, to the authors' knowledge, national treatment patterns for metastatic CRC, and the stability of hospital treatment patterns over time, have not been well described. Data from the 2006 through 2011 National Cancer Data Base were used to study adults with newly diagnosed metastatic CRC (84,161 patients from 1051 hospitals). Using hierarchical models, the authors characterized hospital volume in the use of different treatment modalities (primary site resection, metastatic site resection, chemotherapy, and palliative care). The authors then assessed variation in the receipt of treatment according to the hospitals' relative volume of services used. Finally, the extent to which hospital treatment patterns changed over the past decade was examined. Overall use of volume of services varied widely (5.0% in the hospitals with low volumes of service to 22.3% in the hospitals with high volumes of service). As hospitals' volumes of services increased, adjusted rates of metastatic site surgery (6.6% to 30.8%; P<.001) and multiagent chemotherapy (37.8% to 57.4%; P<.001) use increased, but primary site resection demonstrated little variation (56.8% vs 59.5%; P = .024). It is interesting to note that use of palliative care also increased (8.1% to 11.3%; P = .002). Hospital treatment patterns did not change over time, with hospitals with high volumes of service consistently using more metastatic site resection and multiagent chemotherapy than hospitals with low volumes of service. There is wide variation in hospital treatment patterns for patients with metastatic CRC, and these patterns have been stable over time. It appears that much of the approach for metastatic CRC treatment depends on the hospital in which the patient presents.

Clinical outcomes of Chinese patients with metastatic colorectal cancer receiving first-line bevacizumab-containing treatment.

After the approval of bevacizumab for the first-line treatment of metastatic colorectal cancer (mCRC) in China, published information was still limited. This observational cohort study enrolled 175 mCRC patients who initiated bevacizumab-containing first-line chemotherapies at Sun Yet-sen University Cancer Center. Backbone chemotherapies included FOLFIRI (45.6%), FOLFOX (34.9%), and XELOX (19.5%). Effectiveness data, safety profiles, and treatment patterns were collected and compared between oxaliplatin- and irinotecan-based groups. The median treatment durations of bevacizumab in first-line and total were equivalent between oxaliplatin- and irinotecan-based group (5.0 vs. 4.8 and 6.0 vs. 5.9months, respectively). Median progression-free survival (PFS) was 10.6months, and median overall survival (OS) was 24.2months in entire population. No significant difference was found between irinotecan- and oxaliplatin-based groups in PFS (10.8 vs. 10.1months, p=0.21) or in OS (27.5 vs. 23.7months, p=0.68). Overall response rate in entire population was 38.3%, and the disease control rate was 86.3%. Bevacizumab-associated serious adverse events included hypertension (4.2%), bleeding (3.6%), proteinuria (3.0%), venous thromboembolism (0.6%), and wound-healing complications (0.6%). Curative-intent surgery after conversion chemotherapy was carried out in 23 patients (13.7%). Multivariate analyses showed that maintenance therapy (p=0.001), resection of metastatic sites (p=0.002), and disease-free interval (p=0.003) were independent prognostic factors for OS survival. In spite of small discrepancies in treatment patterns, irinotecan- and oxaliplatin-based chemotherapeutic regimens are equally compatible partners for bevacizumab in first-line Chinese mCRC treatment.

The Significance of Metastasectomy in Patients with Metastatic Renal Cell Carcinoma in the Era of Targeted Therapy.

Objective. To investigate the efficacy of surgery in the treatment of metastatic renal cell carcinoma (mRCC) and to identify prognostic factors. Methods. A single center retrospective study of 96 patients with mRCC from December 2004 to August 2013. Results. The median follow-up time was 45 months. Thirty-one (32.3%) of the patients received complete resection of metastatic sites, 11 (11.5%) of the patients underwent incomplete resection of metastatic sites, and 54 (56.3%) of the patients received no surgery. In the univariate Kaplan-Meier analysis, the median overall survival times of the three groups were 52 months, 16 months, and 22 months, respectively (p < 0.001). The difference in the overall survival time was statistically significant between complete resection and no surgery groups (HR = 0.43, p = 0.009), while there was no significant difference between the incomplete metastasectomy and no surgery groups (HR = 1.80, p = 0.102). According to the multivariate Cox regression analysis, complete metastasectomy (HR = 0.49, p = 0.033), T stage > 3 (HR = 1.88, p = 0.015), disease free interval <12 months (HR = 2.34, p = 0.003), and multiorgan involvement (HR = 2.00, p = 0.011) were significant prognostic factors. Conclusion. In the era of targeted therapy, complete metastasectomy can improve overall survival. Complete metastasectomy, T stage > 3, disease free interval <12 months, and multiorgan involvement are independent prognostic factors.

Clinicopathologic characteristics and prognostic factors of 63 gastric cancer patients with metachronous ovarian metastasis.

ObjectiveThis study aims to explore the clinicopathologic characteristics and prognostic factors of gastric cancer patients with metachronous ovarian metastasis.MethodsClinicopathologic data were collected from 63 post-operative gastric cancer patients with metachronous ovarian metastasis. The patients were admitted to the Cancer Institute and Hospital, Chinese Academy of Medical Science and Peking Union Medical College between January 1999 and December 2011. A log-rank test was conducted for survival analysis. Possible prognostic factors that affect survival were examined by univariate analysis. A Cox regression model was used for multivariate analysis.ResultsThe incidence of ovarian metastasis was 3.4% with a mean age of 45 years. Up to 65.1% of the patients were pre-menopausal. The mean interval between ovarian metastasis and primary cancer was 16 months. Lowly differentiated carcinoma ranked first in the primary gastric cancers. The majority of lesions occurred in the serous membrane (87.3%). The metastatic sites included N2-3 lymph nodes (68.3%), bilateral ovaries (85.7%), and peritoneal membrane (73%). Total resection of metastatic sites was performed (31.7%). The overall median survival was 13.6 months, whereas the overall 1-, 2-, and 3-year survival rates were 52.5%, 22.0%, and 9.8%, respectively. The 5-year survival rate was zero. Univariate analysis showed that the patient prognosis was correlated with metastatic peritoneal seeding, vascular tumor embolus, range of lesion excision, and mode of comprehensive treatment with adjuvant chemotherapy (P<0.05). Multivariate analysis indicated that metastatic peritoneal seeding was an independent prognostic factor for gastric cancer patients with ovarian metastasis (P<0.01).ConclusionEffective control of peritoneal seeding—induced metastasis is important for improving the prognosis of gastric cancer patients with ovarian metastasis.