Significant Difference In Disease-specific Survival Research Articles

Sentinel Node Biopsy in Lieu of Neck Dissection for Staging Oral Cancer

Neck dissection is the standard staging procedure to ascertain the pathologic status of cervical lymph nodes in patients with oral cavity squamous cell carcinoma (OSCC), but it results in multiple morbidities. To examine outcomes of patients with OSCC who underwent sentinel node biopsy (SNB) as the sole neck staging procedure. Retrospective review of patients who underwent SNB during the period 2005 through 2011. National Cancer Institute–designated comprehensive cancer center. Thirty-eight patients with clinically T1 or T2N0 OSCC. Preoperative lymphoscintigraphy with intraoperative gamma probe localization was used. Sentinel lymph nodes were serially sectioned, formalin fixed, and examined at 3 levels. All patients with positive SNB results underwent neck dissection, and the patients with negative SNB results were observed clinically. Sensitivity and predictive value of SNB, recurrence rates, and disease-specific survival rates. There were 18 T1 and 20 T2 tumors. Five patients had positive SNB results, of whom 3 had additional positive nodes on subsequent neck dissection. Two of 33 patients with negative SNB results developed a regional recurrence. The sensitivity and negative predictive value for staging the neck with SNB alone were 71% (5 of 7) and 94% (31 of 33), respectively. Mean follow-up was 31 months. The mean disease-free survival duration for patients with positive and negative SNB results was 30 and 65 months, respectively (P = .08). The disease-specific survival rate for patients with positive and negative SNB results was 80% and 91%, respectively. There was no significant difference in disease-specific survival between patients with true-negative and false-negative SNB results (34 vs 44 months; P = .38). The majority of patients with positive results on SNB had additional positive nodes on neck dissection. A low rate of isolated neck recurrence was found in patients with negative results on SNB. Individuals with negative results on SNB exhibited better overall and disease-specific survival than those with positive results.

Prognostic impact of preoperative hematological disorders and a risk stratification model in bladder cancer patients treated with radical cystectomy

The present study investigated prognostic indicators, including clinicopathological and preoperative hematological factors, and developed a prognostic factor-based risk stratification model in bladder cancer patients treated with radical cystectomy. Data were collected from 249 consecutive bladder cancer patients treated with radical cystectomy without neoadjuvant therapy. Prognostic values of the preoperative hematological parameters, along with the patients' clinicopathological parameters were evaluated. A risk stratification model was developed to predict disease-specific survival after radical cystectomy using the regression coefficients of multivariate analysis. In the multivariate analysis, preoperative hemoglobin and C-reactive protein levels, as well as the pathological factors of T stage, positive surgical margin and lymph node metastasis, were independently predictive of disease-specific survival. Low hemoglobin (<10.5 g/dL), a high C-reactive protein (>0.5 mg/dL), extravesical T stage (≥pT3a) and positive surgical margin were independent predictors of poor disease-specific survival. The risk stratification model showed significant differences in disease-specific survival between the three subgroups. This is the first report to show the significance of combining preoperative hemoglobin with the pathology of radical cystectomy specimens as an independent predictor for disease-specific survival, and it also represents the largest contemporary series to date demonstrating that two types of preoperative hematological disorders, assessed by hemoglobin and C-reactive protein, are independent predictors in bladder cancer patients treated with radical cystectomy. Our risk stratification model could provide physicians with useful prognostic information for identifying patients who might be candidates for multimodal treatments.

Prognostic factors in limited (T1–2, N0–1) oropharyngeal carcinoma treated with surgery ± adjuvant therapy

Surgical therapy for early oropharyngeal carcinoma leads to excellent oncologic results but often requires adjuvant radiotherapy. The purpose of this study was to identify prognostic factors that worsen the outcome of limited oropharyngeal carcinoma treated with surgery ± adjuvant therapy. Two hundred sixty-six patients were retrospectively evaluated between 1980 and 2007. Overall 5-year disease-specific survival (DSS) was 88.7% and local control (LC) was 93.3%. The univariate analysis showed a significant difference in DSS between pT1 and pT2 oropharyngeal carcinoma (DSS, 94.0% vs 81.2%; p = .008) and patients with tumor depth greater than 5 mm (DSS, 94.5% vs 78.9%; p = .031). No difference could be found as to N classification, marginal status, p16 human papillomavirus (HPV) status, type of treatment, and adjuvant radiotherapy. Primary surgical treatment is an effective therapy of limited oropharyngeal carcinoma. Patients with pT2 status and tumor depth of more than 5 mm show a significantly worse survival rate and should be further investigated in future clinical trials.

Radioactive iodine in the treatment of medullary thyroid carcinoma: a controlled multicenter study

Radioactive iodine (RAI) therapy in medullary thyroid carcinoma (MTC) is applied in some centers, based on the assumption that cross-irradiation from thyroid follicular cells may be beneficial. However, no systematic studies on the effect of RAI treatment in MTC have been performed. The aim of this study was to analyze the effect of RAI treatment on survival in MTC patients. Retrospective multicenter study in eight University Medical Centers in The Netherlands. Two hundred and ninety three MTC patients without distant metastases who had undergone a total thyroidectomy were included between 1980 and 2007. Patients were stratified by clinical appearance, hereditary stage, screening status, and localization. All patients underwent regular surgical treatment with additional RAI treatment in 61 patients. Main outcome measures were disease-free survival (DFS) and disease-specific survival (DSS). Cure was defined as biochemical and radiological absence of disease. In multivariate analysis, stratification according to clinical appearance (P=0.72), hereditary stage (P=0.96), localization (P=0.69), and screening status (P=0.31) revealed no significant effects of RAI treatment on DFS. Multivariate analysis showed no significant difference in DSS for the two groups stratified according to clinical appearance (P=0.14). Owing to limited number of events, multivariate analysis was not possible for DSS in the other groups of stratification. Based on the results of the present analysis, we conclude that RAI has no place in the treatment of MTC.

Use of ACE Inhibitors and Angiotensin Receptor Blockers and Primary Breast Cancer Outcomes

BACKGROUND: ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may have anti-tumor properties. We investigated whether the use of ACEI/ARBs affects the clinical outcomes of primary breast cancer patients receiving taxane and anthracycline-based neoadjuvant chemotherapy.METHODS: We included 1449 patients with diagnosis of invasive primary breast cancer diagnosed at the MD Anderson Cancer Center between 1995 and 2007 who underwent neoadjuvant chemotherapy. Of them, 160 (11%) patients were identified by review of their medical record, as ACEI/ARBs users. We compared pathologic complete response (pCR) rates, relapse-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) between ACEI/ARB users and non-users. Descriptive statistics and Cox proportional hazards model were used in the analyses.RESULTS: There was no difference in the pCR rates between ACEI/ARB users and non-users (16% vs 18.1%, p-=0.50). After adjustment for important demographic and clinical characteristics, no significant differences between ACEI/ARB users and nonusers were observed in RFS (HR=0.81; 95% CI=0.54-1.21), DSS (HR=0.83; 95% CI=0.52-1.31), or OS (HR=0.91; 95% CI =0.61-1.37). In a subgroup analysis, the 5-year RFS was 82% in ARB only users versus 71% in ACEI/ARB non-users (P=0.03). In the multivariable analysis, ARB use was also associated with a decreased risk of recurrence (HR=0.35; 95% CI=0.14-0.86). No statistically significant differences in DSS or OS were seen.CONCLUSION: No differences in pCR and survival outcomes were seen between ACEI/ARB users and non-users among breast cancer patients receiving neoadjuvant chemotherapy. ARB use may be associated with improved RFS. Further research is needed to validate this finding.

Is There a Role of Postoperative Radiation Therapy in Completely Resected Stage I/II Thymic Epithelial Tumor?

PurposeRetrospective analyses of patients with stage I-II thymic epithelial tumors (TET) who were treated with either surgery alone (S) or surgery plus postoperative radiation therapy (SRT) were conducted to evaluate the role of adjuvant radiation therapy (RT).Materials and MethodsA total of 110 stage I-II TET patients following complete resection were included in this study. Postoperative radiation therapy was recommended for those with aggressive histologic type and/or invasive features according to the surgeons' judgment during the operation. A median dose of 54.0 Gy (range, 44 to 60 Gy) focused on the primary tumor bed was administered to 57 patients (51.8%).ResultsIn all patients, the rates of overall survival, disease-specific survival, and disease-free survival at 10 years were 91.7%, 97.1%, and 95.8%, respectively. No significant differences in disease-specific survival (100% in the S group and 93.5% in the SRT group at 10 years, p=0.12) and disease-free survival (98.1% in the S group and 94.5% in the SRT group at 10 years, p=0.41) were observed between the treatment groups, although a significantly larger number of World Health Organization (WHO)-type B2-C (p<0.001) and Masaoka stage II (p=0.03) tumors were observed in the SRT group than in the S group. No local recurrence was observed in the SRT group. No grade 2 or greater RT-related toxicities were observed in the SRT group.ConclusionExcellent outcomes were achieved in patients with stage I-II TET who underwent complete resection. Considering excellent local control and low morbidity, adjuvant RT may be considered in high risk patients with WHO-type B2-C histology and Masaoka stage II.

ACE inhibitors and angiotensin receptor blockers use and breast cancer outcomes in patients treated with neoadjuvant systemic chemotherapy.

537 Background: There is a growing body of evidence to suggest that ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) might have anti-tumor properties. We investigated whether the use of ACEI/ARBs during chemotherapy affects the clinical outcomes of breast cancer patients receiving taxane and anthracycline-based neoadjuvant chemotherapy. Methods: We included in this analysis 1449 patients with diagnosis of invasive primary breast cancer diagnosed at the MD Anderson Cancer Center between 1995 and 2007 who underwent neoadjuvant chemotherapy. Of them, 160 (11%) patients were identified by review of their medical record, as ACEI/ARBs users. We compared pathologic complete response (pCR) rates, relapse-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) between ACEI/ARB users and non-users. pCR was defined as no evidence of invasive carcinoma in the breast and axillary lymph nodes at the time of surgery. Descriptive statistics and Cox proportional hazards model were used in the analyses. Results: There was no difference in the pCR rates between ACEI/ARB users (16%) versus non-users (18.1%) (p=0.50). After adjustment for important demographic and clinical characteristics, no significant differences between ACEI/ARB users and nonusers were observed in RFS (HR=0.81; 95% CI=0.54-1.21; P=0.30), DSS (HR=0.83; 95% CI=0.52-1.31; P=0.42), or OS (HR=0.91; 95% CI =0.61-1.37; P=0.66). In a subgroup analysis among ARB users, the 5-year RFS was 82% vs 71% in ACEI/ARB non-users (P=0.03). In the multivariable analysis, ARB use was also associated with a decreased risk of recurrence (HR=0.35; 95% CI=0.14-0.86; P=0.02). However, no statistically significant differences in DSS or OS were seen. Conclusions: No differences in pCR and survival outcomes were seen between ACEI/ARB users and non-users among breast cancer patients receiving neoadjuvant chemotherapy. ARB use may be associated with improved RFS. Further research is needed to validate this finding.

Oral and oropharyngeal squamous cell carcinoma in young patients: The Netherlands Cancer Institute experience

Head and neck squamous cell carcinoma (HNSCC) mainly affects patients between the fifth and seventh decade of life but is increasingly seen in young patients (<40 years old). Controversy exists in the literature regarding outcomes for younger patients with HNSCC. A retrospective cohort analysis was performed comparing survival of 54 early-onset (<40 years) and 1708 older patients with oral and oropharyngeal squamous cell carcinomas (SCC) treated at The Netherlands Cancer Institute between 1977 and 2008. Survival analysis was performed using univariable and multivariable weighted Cox proportional hazards regression. The primary endpoint for the survival analysis was disease-specific survival (DSS). There was no difference in DSS between patients who were 40 years or younger and those older than 40 years (p = .878), although young patients had significantly better overall survival (OS). In this series, patients younger than 40 years with oral and oropharyngeal SCC showed no significant difference in DSS compared with patients older than 40 years, even when adjusted for tobacco and alcohol consumption.

Accuracy of the revised 2010 TNM classification in predicting the prognosis of patients treated for renal cell cancer in the north east of England

BackgroundThe TNM classification for renal cell cancer (RCC) should accurately predict and assign prognostic information for patients. In this study the recent 2010 revision to the TNM classification was compared...

Prognostic Significance of Perirenal Infiltration in Renal Cell Carcinoma (&lt;7 cm)

PurposePathologic stage is the most accurate prognostic factor of renal cell carcinoma. We evaluated whether perirenal fat infiltration is a significant factor in tumors 7 cm or less in size.Materials and MethodsWe retrospectively reviewed the record of 164 cases of tumors 7 cm or less in size. We divided the patients into two groups according to the presence of perirenal fat infiltration (group A, pT1; group B, pT3a). We evaluated relationships, recurrence-free survival and disease-specific survival according to clinicopathologic parameters. Statistical differences were calculated by log-rank test.ResultsA total 131 patients were included in group A, with a mean age of 55.8 years, average tumor size was 4.2 cm, and a mean follow-up period of 43 months. Group B included 33 patients, with a mean age of 55.9 years, an average tumor size of 4.1 cm, and a mean follow-up period of 38 months. There was no significant difference in disease-specific survival; however, recurrence-free survival showed significantly different between two groups (group A: 95.5%, group B: 84.4%).ConclusionIn this study, perirenal fat infiltration proved to be an independent prognostic factor for predicting disease-free survival in patients with tumors of 7 cm or less in size. Therefore, as this study showed, the presence of perirenal fat infiltration requires stricter follow-up planning, even in small renal cell carcinoma.

Prognostic Factors of Limited T1‐2N0‐1 Oropharyngeal Cancers

Objective: Nonsurgical therapies, which utilize combinations of chemotherapy and radiotherapy, have become popular treatments for early oropharyngeal carcinomas (OPC). The aim of this study is to analyze the outcome of primary definitive surgical management of patients with limited OPC and assess the influence of various prognostic factors in survival. Method: A retrospective study was conducted between 1980 and 2007. A total of 266 surgically treated patients were included. The endpoints for the analysis were disease-specific survival (DSS) and local control (LC), with respect to T- and N-classification, status of margins, tumor depth, and type of treatment. Major complications were documented. Results: Overall 5-year DSS was 89.9% and LC 93.3%. The univariate analysis showed a significant difference in DSS between pT1 and pT2 OPC (DSS 94.0% vs 81.2%, P = .008) and patients with tumor depth greater than 5 mm (DSS 94.5% vs 78.9%, P = .031). No difference could be found according to N-stage, marginal status, HPV status, type of treatment, and adjuvant radiotherapy. Multivariate analysis showed that T-stage (HR = 2.49, 95% CI = 1.243-4.974, P = .01) and tumor depth (HR = 2.88, 95% CI = 1.055-7.865, P = .039) were independently associated with DSS. Incidence of major complications was 8% and mortality rate 0.7%. Conclusion: Primary surgical treatment is a very effective therapy against limited OPC independent to the surgical technique used. A low complication and mortality rate was documented. Patients with tumor depth of more than 5 mm have a significant worse survival and should be considered for adjuvant radiotherapy.

A comparison of the outcomes of neoadjuvant and adjuvant chemotherapy for clinical T2‐T4aN0‐N2M0 bladder cancer

Despite evidence supporting perioperative chemotherapy, few randomized studies compare neoadjuvant and adjuvant chemotherapy for bladder cancer. Consequently, the standard of care regarding the timing of chemotherapy for locally advanced bladder cancer remains controversial. We compared patient outcomes following neoadjuvant or adjuvant systemic chemotherapy for cT2-T4aN0-N2M0 bladder cancer. In a retrospective review of a single institutional database from 1988 through 2009, we identified patients receiving neoadjuvant or adjuvant multiagent platinum-based systemic chemotherapy for locally advanced bladder cancer. Survival analysis was performed comparing disease-specific survival (DSS) and overall survival (OS). A total of 146 patients received systemic perioperative chemotherapy (73 neoadjuvant, 73 adjuvant). Of these, 84% (122/146) received cisplatin-based chemotherapy compared with carboplatin-based chemotherapy (24/146, 16.4%). Most patients receiving cisplatin-based chemotherapy were treated with methotrexate/vinblastine/adriamycin/cisplatin (79/122, 64.8%), whereas the remaining patients received gemcitabine/cisplatin (GC) (43/122, 35.2%). In multivariable analysis, there was no significant difference in DSS (P = .46) or OS (P = .76) between neoadjuvant or adjuvant chemotherapy groups. There was statistically significant improvement in DSS when patients received neoadjuvant GC rather than adjuvant GC (P = .049, hazard ratio, 10.6; 95% confidence interval, 1.01-112.2). In this study, there was no statistically significant difference in OS and DSS between patients receiving neoadjuvant versus adjuvant systemic platinum-based chemotherapy for locally advanced bladder cancer. In addition, there was no significant difference between neoadjuvant and adjuvant cisplatin- or carboplatin-based chemotherapy. Chemotherapy sequence relative to surgery appeared less important than whether or not a patient actually received perioperative chemotherapy.

Impact of renal vein invasion and fat invasion in pT3a renal cell carcinoma

• To evaluate the prognostic impact of tumor fat invasion (FI) and renal vein invasion (RVI) in patients with T3a renal cell carcinoma. • In total, 220 consecutive patients treated for renal cell carcinoma between 1992 and 2009 were analyzed. T3a stage cases were selected. • A single pathologist reviewed all cases. • The present study cohort included 46 patients with mean follow-up of 28.6 months, of whom 17 (36.9%) died from disease. Patients were initially divided into three groups including 24 (52.1%) of FI only, 11 (23.9%) of RVI only and 11 (23.9%) of both FI and RVI. • In univariate analysis, no significant differences in disease-specific survival (DSS) were noted between FI only and RVI only groups (P= 0.91). DSS was significantly worse in the FI + RVI group compared to the other groups (P= 0.02). • When grouped into FI or RVI vs FI + RVI, DSS remained significantly lower in the group containing the parameters concurrently (P= 0.009). Progression-free survival also was significantly lower in FI + RVI group (P= 0.01). • Metastasis, positive lymph nodes and the presence of FI + RVI remained as isolated predictors of survival. • Patients with FI + RVI presented a 2.6-fold increase in risk of death from cancer and a 2.5-fold increase in risk of disease progression (P= 0.04) compared to those with either of them alone. • The isolated or concomitant presence of FI and RVI may be used as one of the criteria for staging in the next edition of the Tumour-Node-Metastasis classification because they have significantly different outcomes.

Lymph Node Counts as an Indicator of Quality at the Hospital Level in Colorectal Surgery

Substantial evidence suggests that the number of lymph nodes examined in colorectal cancer (CRC) is a powerful predictor of outcomes. However, the lymph node count as a benchmark of quality in CRC is controversial. We sought to examine the impact of lymph node counts on disease-specific survival (DSS) of CRC patients at the hospital level. This study used data obtained between 1994 and 2003 from Region 5 of the California Cancer Registry. Hospitals in Region 5 of the California Cancer Registry were stratified according to the median number of nodes examined and grouped according to the median number of nodes examined, <7, 7 to 9, and ≥10. These hospital groups were then evaluated for the frequency of meeting the 12-node threshold, frequency of positive lymph nodes, and DSS at the hospital level. Median number of nodes examined in group A was 4 (mean 5.6, SD 5.9), in group B was 8 (mean 9.7, SD 8.5), and in group C was 10 (mean 11.3, SD 9.2). In group A, 13.7%, in group B 32.8%, and in group C, 42.8% met the 12-node threshold. The frequency of N1 and N2 disease for group A was 20.7% and 9.1%, 19. 7% and 11.1% for group B, and 20.1% and 11.3% for group C (p = 0.12). Five-year DSS was 72.7% for group A, 73.7% for group B, and 76.7% for group C (p = 0.002). DSS survival of N0 patients for group A was 78.6%, 81.5% for group B, and 85.1% for group C (p < 0.0001). There was no statistically significant difference in DSS for N1 (p = 0.18) or N2 (p = 0.90) between the 3 groups. Lymph node counts can have value as a benchmark of surgical/pathologic quality in node-negative CRC. These results question the value of lymph node counts as a benchmark of surgical/pathologic quality for node-positive CRC.

Prognosis of early-stage synchronous bilateral invasive breast cancer

Background Contradictory data exists concerning the prognosis of patients with synchronous bilateral breast cancer (SBBC). Most authors report a worse prognosis for SBBC patients compared to unilateral breast cancer (UBC) patients. There are a few studies that did not support these findings. This study gives a comprehensive picture of SBBC and tests the hypothesis that outcome of this entity is based on the tumor with the worse prognosis (reference lesion). Patients & methods The data of two prospective Swiss breast cancer databases covering a 20-year period (1990–2009) was reviewed. Forty-six cases of SBBC were identified. In 34 patients with early-stage SBBC, the reference lesions (defined as the tumor with the more advanced stage or, in cases where both tumors had the same stage, the larger tumor) were compared in a case-control approach with 100 patients having UBC (SBBC/UBC ratio = 1/3). The controls were matched for age, time of diagnosis, tumor size, axillary node status, histological grade and estrogen-receptor status. Differences in terms of survival curves were analyzed using the log rank test; the possible correlation between matched groups was evaluated by a frailty Cox model. Results There were no significant differences in disease-specific survival between SBBC and its unilateral controls (HR, 0.932; 95% CI, 0.322–1.07; p = 0.90). Conclusions The prognosis of SBBC was determined by the reference lesion; the contralateral second tumor had no additional impact on outcome.

Impact of lymph‐node metastasis site in patients with thoracic esophageal cancer

We retrospectively compared surgical outcomes between patients with intra-thoracic and extra-thoracic (cervical and abdominal) lymph-node metastasis. The study population comprised 96 patients with lymph-node metastasis who had undergone curative esophagectomy for thoracic esophageal cancer. The patients were grouped according to whether the site of lymph-node metastasis was intra-thoracic, extra-thoracic, or both intra-thoracic and extra-thoracic. The patient characteristics, survival time, and prognostic factors were compared. The most significant difference in disease-specific survival was detected at a threshold value of four metastatic lymph nodes. Lymph-node metastasis was observed at intra-thoracic sites in 41 patients, at extra-thoracic sites in 20 patients, and at both intra-thoracic and extra-thoracic sites in 35 patients. Intra-thoracic lymph-node metastasis was frequently observed in patients with middle and upper thoracic esophageal cancer. There was no difference in the number of metastatic lymph nodes between patients with intra-thoracic and extra-thoracic lymph-node metastasis. Multivariate analysis revealed that the number of metastatic lymph nodes was an independent prognostic factor, whereas the site of metastatic lymph nodes was not. These findings suggest that the surgical outcomes in patients with thoracic esophageal cancer depend on the number, but not the site, of metastatic lymph nodes after curative esophagectomy.

Survival impact of treatment options for papillary microcarcinoma of the thyroid

Evaluate the impact of medical and surgical interventions on the survival of patients with papillary microcarcinoma (PMC) of the thyroid, a common tumor with an increasing worldwide incidence. Cross-sectional population analysis of a prospectively maintained database. Cases of nonmetastatic PMC treated with cancer-directed surgery with or without postoperative radioactive iodine (RAI) therapy were extracted from the Surveillance, Epidemiology and End Results Database (1988-2005). Kaplan-Meier disease-specific survival (DSS) and overall survivals were compared according to extent of thyroidectomy and use of RAI therapy. Cox regression analysis was performed to determine the influence of these factors on survival. A total of 7,818 cases of PMC were identified. Overall actuarial survival rates at 10 and 15 years were 96.6% and 96.3%, respectively. DSS was 99.9% at both time intervals, with a total of 10 thyroid cancer-related deaths. There were no significant differences in DSS for patients who underwent total thyroidectomy, near-total/subtotal thyroidectomy, or lobectomy (P = .239). DSS for patients receiving RAI therapy was not significantly different than that of patients who did not (P = .504). On multivariate analysis, only increasing age at diagnosis, successfully predicted poor DSS (P = .001), whereas gender (P = .481), use of RAI therapy (P = .633), and extent of thyroidectomy (P = .104) did not. PMC carries an excellent prognosis with respect to both overall and disease-specific survival that is independent of surgical extent and the use of RAI therapy. An isolated, fine-needle-aspiration proven unilateral PMC focus in a patient lacking evidence of metastatic disease may be treated with lobectomy alone.

Long-term Survival in Patients Undergoing Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Single-Center Experience

BackgroundRenal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management. ObjectiveTo evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy. Design, setting, and participantsWe performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed. MeasurementsDisease-free survival (DFS) and disease-specific survival (DSS) were studied. Results and limitationsThe median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups—supradiaphragmatic and infradiaphragmatic—there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non–clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non–clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis. ConclusionsRadical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non–clear-clear cell histology are significant prognostic factors influencing DSS.

Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?

To identify factors that predict delayed (> 5 years) prostate-specific antigen recurrence (PSAR) after radical prostatectomy (RP) and to analyze the associated clinical outcomes. A cohort of 4561 men who underwent RP between 1988 and 2008 was retrieved from the Duke University Prostate Center database. Among them, 1207 (26.5%) had PSAR and were included in this study. The cohort was then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR), and Kaplan Meier analysis was performed. Univariate and logistic regression analysis was carried out to determine significant predictors of delayed PSAR, using factors such as race, age, body mass index, PSA, surgical margin status, pathologic Gleason sum, pathologic tumor stage, and prostate weight. There was a marginal difference between the early and delayed PSAR groups with regard to metastasis-free survival (P = .062). A significant difference in disease-specific survival was found between the 2 groups (P = .025). Patients with pathologic Gleason sums < 7 were more likely to have delayed PSAR as compared to those with pathologic Gleason sums > 7 (OR = 2.38). Patients with a PSA < 10 ng/mL were more likely to have delayed PSAR in comparison to those with PSA > 20 ng/mL (OR = 2.38). Approximately 90% of PSAR occurred within 5 years after RP. Lower pathologic Gleason sums and lower PSA at diagnosis were associated with delayed PSAR. Patients with delayed PSAR have a disease-specific survival advantage as compared to men with early PSAR.

Improved outcomes in patients with lymph node-only stage IV disease in clear cell sarcoma: Results from a large single-institution experience and SEER database analysis

10571 Background: Clear cell sarcoma, or malignant melanoma of soft parts, is a rare soft tissue tumor unusual among mesenchymal malignancies for its propensity to metastasize to regional lymph node basins. Current AJCC staging for soft tissue sarcoma classifies nodal disease (N1) as stage IV disease. We sought to determine whether patients with lymph node-only disease (N1M0) had better outcomes than patients with distant metastases (M1) by looking at outcomes from both a single institution and population-based data. Methods: Clinical and pathologic factors were retrospectively examined utilizing a prospectively maintained database on patients treated at the University of Texas M.D. Anderson Cancer Center (MDACC) between 1980 and 2007. Histology on all patients was independently reviewed by a single MDACC pathologist with molecular confirmation of the characteristic EWSR1-ATF1 fusion transcript or EWSR1 rearrangement when possible. We also performed a SEER database analysis on patients diagnosed with clear cell sarcoma (1988–2007). Overall and stage-specific disease-specific survival (DSS) were estimated using the methods of Kaplan and Meier. Results: Fifty-three patients with clear cell sarcoma were identified from the MDACC database. Median age at diagnosis was 41 years and 60% were female. Our SEER analysis yielded 130 patients with a median age of diagnosis of 40 years and 54% female. Median follow-up for the MDACC cohort was 7.4 years and median follow-up for SEER was 6 years. MDACC 5-year DSS was 67.9% and, in the SEER analysis, 5-year DSS was 61.9%. The 5 year DSS of N1 patients from MDACC was 74%, while M1 was 14% (p=0.0142). The 5-year DSS of N1 patients from SEER was 52%, while M1 was 0% (p=0.0142). Conclusions: Overall DSS in both our single-institution cohort and in SEER is higher than in previously published series. There is a significant difference in DSS between N1M0 and M1 patients for both MDACC and SEER cohorts. These data underscore the importance of lymph node assessment in these patients and suggest that future staging of clear cell sarcoma should differentiate these groups. No significant financial relationships to disclose.