Stage Category Research Articles

Mucinous adenocarcinoma of prostate and prostatic adenocarcinoma with mucinous components: a clinicopathological analysis of 143 cases.

The clinical significance of mucinous prostatic adenocarcinoma (PCa) remains uncertain. From 6440 cases of PCa treated by radical prostatectomy from 2009 to 2014, mucinous components of 5-100% were found in 143 (2.2%) cases. The mean age was 61.4years, mean pre-operative serum prostate-specific antigen (PSA) was 7.8ng/ml and clinical stage category was cT1 in 81% and cT2 in 19% of cases. Cases were graded using the 2014 International Society of Urological Pathology recommendation of grading underlying architecture, and Gleason scores (GS) were 3+4 in 13.3%, 4+3 in 54.5%, 4+4 in 2.1%, 3+4 or 4+3 with tertiary 5 in 11.9% and 9-10 in 18.2%. The mucinous component invariably had a high-grade component. Extraprostatic extension was found in 46.8% of cases. In 21.6%, tumour volume was ≥3cm³ and 9.7% had surgical margin positivity. Seminal vesicle involvement was found in 6.9%. In 73 cases the mucinous component was >25%, and when cases were divided on the basis of the area of mucin present (≤25 versus >25%) there was no significant difference between clinical or pathological features. Similar findings were achieved when cases were compared with grade-matched non-mucinous carcinoma controls. The 5-year biochemical recurrence rates for mucinous versus non-mucinous cancer were 12.5 versus 17% (P=0.15). PCa with mucinous components is often high grade; however, the prognosis appears to be similar to non-mucinous cancers of similar GS.

English

Notwithstanding the nutritional, economic and fisheries importance of Chrysichthys nigrodigitatus, and its relatively high abundance and propagation in Lake Ahozon (South Benin), nothing is known about the well-being of the species in this water body. Thus, this study investigated length and weight frequency distributions, length-weight relationships and condition factors of C. nigrodigitatus. A total of 1020 individuals of C. nigrodigitatus were sampled with seines, cast nets, gill nets and hooks during a 15 month period, from August 2014 to October 2015. Total length (TL) and body weight (W) frequency curves showed a unimodal distribution. The longest TL and highest W recorded were 324 mm and 456.1 g, respectively. In Lake Ahozon, C. nigrodigitatus population exhibited a significant (P≤0.01) isometric growth pattern, indicated by the power function (W = 0.011TL2.99; r=0.96) and the log-transformed linear regression equation (LogW = 2.99 LogTL - 1.94; r=0.96). Growth models varied spatially, sexually, ontogenetically, and seasonally, while corresponding subpopulations showed allometric or isometric growth trends, with slopes b ranging between 2.47 and 3.21. The population showed conditions factors (K) ranging between 0.8 and 3.08 which significantly varied with habitats (F1,1018 = 7.613, P = 0.006), seasons (F2,1017 = 29, P = 0.0001) and life stage categories (F2,1017 =5.583, P = 0.004). The active breeding that provided an important stock of offspring for recruitment, the isometric growth model and the relatively high condition factors indicated the perfect establishment of C. nigrodigitatus in the artificial lake of Ahozon. The sustainable exploitation of fisheries in this non-conventional medium-environment requires an integrated approach of lake management. Key words: Claroteid, condition factor, establishment, fisheries, isometric growth, length-weight model, man-made lake.

Comments on the eighth edition of the TNM classification for lung cancer. Radical changes and limitations: Does size matter?

Cancer is a major public health problem worldwide and the second leading cause of death in the United States of America (USA), following heart disease. Male lung cancer death rates are decreasing in the western world and increasing in China and several other countries in Asia and Africa. Female lung cancer death rates are increasing worldwide, with the exception of the USA, Canada and Australia. Differences in lung cancer incidence patterns between men and women reflect historical differences in tobacco use. Staging of cancer at the time of diagnosis is the most important predictor of survival, and treatment options should be based on the stage. The aim of this overview is to discuss the changes in the 8th Edition of the TNM (Tumor, Nodes, Metastasis) Classification of lung cancer and its impact on predicting patient prognosis. Potential limitations of the classification system and future directions are discussed. A systematic literature search was performed to identify relevant reports. Studies and articles were identified using several online searches of the U.S. National Library of Medicine via www.pubmed.com. The article is based on the International Association for the Study of Lung Cancer (IASLC) Staging and Prognostic Factors Committee report. An international lung cancer database was developed from 35 sources in 16 countries around the globe, with staging and outcome data on 94,708 cases of lung cancer. This new edition of lung cancer TNM staging placed additional emphasis on tumor size, and size cut-off points have been added, which will now be a descriptor in all TNM categories. For the first time a new term was introduced, defined as minimally invasive adenocarcinoma. The additional cut-off point changes will definitely alter treatment recommendations in the future. The node classification remained unchanged in the new edition. Regarding metastasis, M1a refers to cases with intrathoracic metastases, M1b cases with a single metastasis outside the thoracic cavity. The situation involving multiple metastatic deposits, usually in more than one organ, is now classified as M1c. The new staging of lung cancer is based on analysis of survival in large databases, based on tumor size and disease proliferation, and is therefore expected to assess the prognosis of the individual patient more accurately. Based on the current edition of the TNM staging system many patients will be given a different staging category,. It is evident that improved survival may reflect the expected improvements in diagnosis and treatment, the net effect being a stage-for-stage survival increase at all stages. This 8th edition of the TNM classification for lung cancer has placed additional emphasis on tumor size.

Incorporating Tumor Characteristics to the American Joint Committee on Cancer Breast Cancer Staging System.

The American Joint Committee on Cancer (AJCC) breast cancer staging system provides important prognostic information. The recently published eighth edition incorporates biological markers and recommends the use of a complex "prognostic stage." In this study, we assessed the relationship between stage, breast cancer subtype, grade, and outcome in a large population-based cohort and evaluated a risk score system incorporating tumor characteristic to the AJCC anatomic staging system. Patients diagnosed with primary breast cancer stage I-IV between 2005-2008 were identified in the California Cancer Registry. For patients with stage I-III disease, pathologic stage was recorded. For patients with stage IV disease, clinical stage was utilized. Five-year breast cancer specific survival (BCSS) and overall survival (OS) rates were determined for each potential tumor size-node involvement-metastases (TNM) combination according to breast cancer subtype. A risk score point-based system using grade, estrogen receptor, and human epidermal growth factor receptor 2 (HER2) status was designed to complement the anatomic AJCC staging system. Survival probabilities between groups were compared using log-rank test. Cox proportional hazards models were used. Among 43,938 patients, we observed differences in 5-year BCSS and OS for each TNM combination according to breast cancer subtype. The most favorable outcomes were seen for hormone receptor-positive tumors followed closely by HER2-positive tumors, with the worst outcomes observed for triple negative breast cancer. Our risk score system separated patients into four risk groups within each stage category (all p < .05). Our simple risk score system incorporates biological factors into the AJCC anatomic staging system, providing accurate prognostic information. This study demonstrates that stage, but also breast cancer subtype and grade, define prognosis in a large population of breast cancer patients. It shows that a point-based risk score system that incorporates these biological factors provides refined stratification and information on prognosis, improving the anatomic American Joint Committee on Cancer (AJCC) staging system. In addition, the overall mortality and breast cancer specific mortality rates detailed here provide much-needed information about prognosis in the current era, refining the current AJCC staging.

Challenges in Pathologic Staging of Bladder Cancer: Proposals for Fresh Approaches of Assessing Pathologic Stage in Light of Recent Studies and Observations Pertaining to Bladder Histoanatomic Variances.

The paradigm of pathologic stage (pT) categorization in bladder cancer remains the depth of invasion into the different histologic layers of the bladder wall. However, the approaches to assigning pT stage category toward an enhanced outcome stratification have been marked by challenges and innovations, due in part to our growing appreciation of the surprisingly perplexing bladder histoanatomy. Upstaging of pT1 tumors after radical cystectomy is substantial and underscores the potential value of pT1 substaging in transurethral resection (TUR) specimens. The 2017 American Joint Committee on Cancer tumor-node-metastasis system recommends pT1 substaging but recognizes the need to optimize the approach. Over the years, the cut-off for microinvasion has been significantly lowered to 0.5 mm and is now a promising scheme for pT1 (micrometric) substaging. Unlike the micrometric approach, histoanatomic substaging using muscularis mucosae (MM) and vascular plexus as landmarks is less feasible in TUR specimens and inconsistent in stratifying the outcome of pT1 tumors. The lamina propria possesses inherent variations in depth, MM, and vascular plexus dispositions that should be factored in future pT1 substaging proposals. Histoanatomic variations among the bladder regions also occur, and studies suggest that trigone and bladder neck cancers may have more adverse outcomes. The muscularis propria (MP), besides being the essential histologic landmark for assigning pT2 stage category, is also considered a surrogate for the adequacy of TUR, furthering the importance of identifying its presence in TUR specimens. MP, however, may be mimicked by hyperplastic or isolated MP-like MM muscle bundles in the lamina propria with overstaging implications, and caution should be exercised in distinguishing these 2 muscle types morphologically and immunohistochemically. Presence of additional superficial MP unique from the detrusor muscle proper may also complicate staging at the trigone and ureter insertion sites. With regard to the depth of MP invasion, large and multicenter studies have reaffirmed the prognostic significance of pT2a/b subcategories. It is revealed that there are at least 3 ways used to demarcate the irregular MP to perivesical soft tissue junction, and use of a common criterion indicates improvement in pT2b/pT3a staging reproducibility. Although studies have shown significantly poorer outcome in pT3b compared with pT3a tumors, this designation has a substantial reliance on the prosector's gross assessment of perivesical soft tissue invasion which if performed incorrectly may lead to staging inaccuracy of pT3 tumors. The 8th edition of the American Joint Committee on Cancer has updated the staging schema for bladder cancers with concomitant prostatic stromal invasion and cancers within bladder diverticula. Because of 2 possible pT designations, prostatic stromal invasion in TUR specimens should not be automatically staged as either pT4a or pT2 (urethral). Recent data support that bladder cancer invading into the seminal vesicle has comparable outcome to pT4b tumors. Interestingly, several studies in pT4a tumors, which are staged based on sex-specific organs, have shown poorer outcome in females than males after radical cystectomy, and while there are possibly several reasons, they may also include anatomic factors. Despite the progress has been made, work remains to be done to inform future bladder cancer pT category definitions and their reproducibility in application and prognostication.

The IASLC Lung Cancer Staging Project: External Validation of the Revision of the TNM Stage Groupings in the Eighth Edition of the TNM Classification of Lung Cancer

IntroductionRevisions to the TNM stage classifications for lung cancer, informed by the international database (N = 94,708) of the International Association for the Study of Lung Cancer (IASLC) Staging and Prognostic Factors Committee, need external validation. The objective was to externally validate the revisions by using the National Cancer Data Base (NCDB) of the American College of Surgeons. MethodsCases presenting from 2000 through 2012 were drawn from the NCDB and reclassified according to the eighth edition stage classification. Clinically and pathologically staged subsets of NSCLC were analyzed separately. The T, N, and overall TNM classifications were evaluated according to clinical, pathologic, and “best” stage (N = 780,294). Multivariate analyses were carried out to adjust for various confounding factors. A combined analysis of the NSCLC cases from both databases was performed to explore differences in overall survival prognosis between the two databases. ResultsThe databases differed in terms of key factors related to data source. Survival was greater in the IASLC database for all stage categories. However, the eighth edition TNM stage classification system demonstrated consistent ability to discriminate TNM categories and stage groups for clinical and pathologic stage. ConclusionsThe IASLC revisions made for the eighth edition of lung cancer staging are validated by this analysis of the NCDB database by the ordering, statistical differences, and homogeneity within stage groups and by the consistency within analyses of specific cohorts.

Outcome of Head and Neck Cancer Patients Who Did Not Receive Curative-Intent Treatment

There exists a subgroup of patients with head and neck cancer (HNC) who neither warrant nor request curative-intent treatment and who progress to a terminal-care paradigm. The purpose of this study was to determine the frequency of and reasons for an HNC terminal-care referral and the time to and place of death for such patients. The authors undertook a retrospective cohort study of all attendees with HNC who had undergone multidisciplinary team (MDT) assessment at the Calvary Mater Hospital (Newcastle, Australia) from January 2013 through December 2014. The primary predictor variables were a heterogeneous set of factors grouped together into logical demographic (age and gender) and clinicopathologic (tumorhistology, site, and stage) categories and the reason for referral to terminal care. The secondary outcome variables were survival and place of death. A descriptive statistical analysis was undertaken and survival data were graphically displayed as Kaplan-Meier estimates. Of the 412 attendees with HNC who underwent MDT assessment, 74 (18%) were identified as having been immediately referred for terminal care. Their median survival was 6months (95% confidence interval, 4.75-7.50). The most common reason for referral for terminal care was tumor extent. The most common place of death recorded for the group was a hospice facility. This study serves as a timely reminder that when curative-intent HNC treatment optionshave been exhausted, dialog and action need to be directed to transitioning the patient to a terminal-care management paradigm.

MP43-16 VARIATION IN ACTIVE SURVEILLANCE UTILIZATION FOR THE MANAGEMENT OF PROSTATE CANCER IN A REGIONAL COLLABORATIVE

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance II1 Apr 2017MP43-16 VARIATION IN ACTIVE SURVEILLANCE UTILIZATION FOR THE MANAGEMENT OF PROSTATE CANCER IN A REGIONAL COLLABORATIVE Adam Reese, Claudette Fonshell, Serge Ginzburg, Thomas Guzzo, Thomas Lanchoney, Bret Marlowe, Marc Smaldone, Edouard Trabulsi, Robert Uzzo, and Pennsylvania Urologic Regional Collaborative Adam ReeseAdam Reese More articles by this author , Claudette FonshellClaudette Fonshell More articles by this author , Serge GinzburgSerge Ginzburg More articles by this author , Thomas GuzzoThomas Guzzo More articles by this author , Thomas LanchoneyThomas Lanchoney More articles by this author , Bret MarloweBret Marlowe More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Edouard TrabulsiEdouard Trabulsi More articles by this author , Robert UzzoRobert Uzzo More articles by this author , and Pennsylvania Urologic Regional Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1326AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Active surveillance (AS) is gaining increasing acceptance as an effective management strategy for men with low risk prostate cancer. We analyzed a regional prostate cancer collaborative in order to characterize variation in the utilization of AS among practitioners and identify factors influencing AS rates. METHODS The Pennsylvania Urologic Regional Collaborative (PURC), established in 2014, is a voluntary collaborative of urology practices in Southeastern Pennsylvania focused on the evaluation and improvement of prostate cancer care. We prospectively identified men with newly diagnosed prostate cancer across 6 academic and private practice sites from PURC, and determined the percentage of men initially managed with AS. Variations in AS rates by individual practitioner were determined for men with NCCN very low or low risk disease. Demographic and clinicopathologic parameters were assessed to determine how these factors influenced AS rates. RESULTS Between May 2015 and October 2016, 282 of 1154 (19.6%) men with newly diagnosed prostate cancer underwent AS as initial management strategy, including 82/104 (78.9%) men with NCCN very low and 133/322 (41.3%) with NCCN low risk disease. AS rates stratified by practitioner for men with very low or low risk disease ranged from 11.1% to 100% (Figure 1). Associations of demographic and clinicopathologic parameters with AS rates are shown in the Table. High PSA, Gleason score, clinical stage, and NCCN risk category were all strongly associated with decreased utilization of AS (all p-values < 0.01). CONCLUSIONS Recent data report AS rates as high as 91% and 74% for NCCN very low and low risk prostate cancer, respectively. In the PURC collaborative, we observed lower rates of AS utilization for men with low risk prostate cancer, and significant variation in AS utilization among practitioners. These findings demonstrate the potential importance of quality collaboratives such as PURC in helping to identify variations in care and targets for quality improvement within local markets. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e560 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Adam Reese More articles by this author Claudette Fonshell More articles by this author Serge Ginzburg More articles by this author Thomas Guzzo More articles by this author Thomas Lanchoney More articles by this author Bret Marlowe More articles by this author Marc Smaldone More articles by this author Edouard Trabulsi More articles by this author Robert Uzzo More articles by this author Pennsylvania Urologic Regional Collaborative More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD52-08 CAN LOOKS DECEIVE? NOT ALL CLINICALLY “CYSTIC” RENAL MASSES HARBOR INDOLENT BIOLOGY

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging III1 Apr 2017PD52-08 CAN LOOKS DECEIVE? NOT ALL CLINICALLY “CYSTIC” RENAL MASSES HARBOR INDOLENT BIOLOGY Benjamin Ristau, Lyudmila DeMora, Eric Ross, Randall Lee, Michael Haifler, Shreyas Joshi, Andres Correa, David Chen, Richard Greenberg, Rosalia Viterbo, Marc Smaldone, Robert Uzzo, and Alexander Kutikov Benjamin RistauBenjamin Ristau More articles by this author , Lyudmila DeMoraLyudmila DeMora More articles by this author , Eric RossEric Ross More articles by this author , Randall LeeRandall Lee More articles by this author , Michael HaiflerMichael Haifler More articles by this author , Shreyas JoshiShreyas Joshi More articles by this author , Andres CorreaAndres Correa More articles by this author , David ChenDavid Chen More articles by this author , Richard GreenbergRichard Greenberg More articles by this author , Rosalia ViterboRosalia Viterbo More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Robert UzzoRobert Uzzo More articles by this author , and Alexander KutikovAlexander Kutikov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2196AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cystic renal cell carcinomas (RCC) are suggested to be clinically indolent. As such, a distinct pathologic staging category for these lesions was recently proposed. While not without merit, these recommendations fail to account for limitations in the ability of modern imaging to differentiate cystic RCC from more biologically aggressive mimics. We evaluated the frequency of high grade kidney cancer in the highly selected cohort of surgically resected renal masses having cystic appearance on pre-operative radiographic imaging. METHODS A prospectively maintained institutional database was queried for clinically cystic renal masses that underwent surgery from January 2000 - June 2016 (n=2,729 kidney surgeries). Patient and tumor characteristics including age at surgery, smoking history, Charlson comorbidity index (CCI), gender, race, BMI, surgery date, laterality, Bosniak classification, histology, grade, size, and nearness to the collecting system were tabulated. Associations between tumor grade and patient/tumor characteristics were evaluated using generalized estimating equations. RESULTS Eighty-nine patients (n=101 cystic lesions) met strict inclusion criteria; the majority (77%) were older than 50 years of age and the mean Charlson comorbidity index was 1.15 (SD1.48) (Table 1). Of the 101 clinically cystic renal masses, 23% were confirmed pathologically as high grade RCC while 77% were low grade RCC (n=56) or benign (n=22). CCI was associated with high grade surgical pathology (OR 1.37, 95% CI 1.05-1.79, p = 0.02). There was no association between tumor grade and the remainder of the patient/tumor characteristics analyzed. CONCLUSIONS Recently proposed changes to the kidney cancer staging system define a tumor's cystic nature based on pathologic examination. Proceeding with surgery for a radiographically “cystic” renal mass was a rare event in our cohort; however, among those that went onto surgery, nearly a quarter harbored high grade pathology. Before making changes to the clinical RCC staging system, a better understanding of the limitations inherent to radiographic determination of low malignant potential, cystic renal masses is necessary. © 2017FiguresReferencesRelatedDetailsCited byRistau B and Kutikov A (2017) Editorial CommentJournal of Urology, VOL. 199, NO. 3, (639-640), Online publication date: 1-Mar-2018. Volume 197Issue 4SApril 2017Page: e992 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Benjamin Ristau More articles by this author Lyudmila DeMora More articles by this author Eric Ross More articles by this author Randall Lee More articles by this author Michael Haifler More articles by this author Shreyas Joshi More articles by this author Andres Correa More articles by this author David Chen More articles by this author Richard Greenberg More articles by this author Rosalia Viterbo More articles by this author Marc Smaldone More articles by this author Robert Uzzo More articles by this author Alexander Kutikov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Staging cutaneous squamous cell carcinoma metastases to the parotid gland.

The staging of cutaneous squamous cell cancers (cSCC) was revised by the American Joint Committee on Cancer in 2010 to incorporate known prognostic factors and expand the N (node) category. The purpose of this study was to validate this staging system using a North American cohort, and to compare it to the O'Brien P (Parotid) and N staging system. An exhaustive collaborative database search was performed for all patients with cSCC metastasis to the parotid gland treated at three major Canadian tertiary referral centers from December 1999 to March 2015. The data collected for each patient included overall survival; disease-free survival; tumor, node, and metastasis) staging; and postoperative radiation status. Post-hoc analysis was completed to discern the strongest prognostic factors of survival as they relate to the abovementioned staging systems. Of 136 patients identified, 80% had a documented history of previously treated head and neck cSCC an average of 27 months prior to presentation. Average size of the parotid lesion at recurrence was 4.5 cm. Ninety-six percent of patients underwent surgical resection of the parotid metastasis. Five-year overall and disease-free survival is 79% and 55%, respectively. Only cSCC staging and cSCC-N category had statistically significant differences between groups. cSCC staging had the largest percentage of variation in overall survival explained. Patients with cSCC metastasis to the parotid gland proved to have a moderate survival rate, despite presenting with advanced disease. cSCC staging in the setting of parotid metastasis, despite its limitations, currently offers the most predictive staging system available. 4. Laryngoscope, 127:2063-2069, 2017.

Abstract P5-08-02: Improving the AJCC breast cancer staging system by incorporating tumor biomarkers

Abstract BACKGROUND: The current American Joint Committee on Cancer (AJCC) breast cancer staging system provides important prognostic information, however its use is limited by the lack of data incorporating prognostic and predictive biological markers. In this study we sought to determine the relationship between stage, breast cancer subtype, grade and outcome in a large population-based cohort, and to develop a risk score point-based system incorporating biological factors to the current AJCC staging system. METHODS: Patients diagnosed with primary breast cancer stage I-IV, between 2005-2008 were identified in the California Cancer Registry. For patients with stage I-III disease, pathological stage was recorded. For those with stage IV, clinical stage was used. 5 year-breast cancer specific survival (BCSS) and overall survival (OS) rates were determined for each potential TNM combination according to breast cancer subtype. Cox proportional hazard models were used to identify independent predictors of outcome. A risk score point-based system (range 0-3 points) was created to complement the current anatomic AJCC staging system. One point was assigned for each one of the following tumor characteristics: hormone receptor (HR)-negative status, HER2-negative status and grade 3. Survival probabilities between groups were compared using log-rank test. Multivariable analysis models according to stage and risk score were performed for BCSS and OS. RESULTS: A total of 43,938 patients were included. The 5-year BCSS and OS for each TNM combination differed according to breast cancer subtype. The best outcomes were seen among HR-positive patients followed closely by those with HER2-positive and HR-positive tumors with the worst outcomes observed among patients with triple negative tumors. In a multivariable model, after adjusting for stage, treatment variables and other important confounders, ER negative status (OR 2.14; 95%CI 1.98-2.30), HER2-negative status (OR= 1.24; 95%CI1.14-1.34) and grade 3 (OR=2.03; 95% CI 1.88-2.20) were independent predictors of BCSS. Our risk score system separated patients into 4 risk groups within each stage category (all P&amp;lt;0.05). Similar results were seen for OS. The results in the table show that combining stage and risk score provides improved prognostic information. Hazard ratios for BCSS according to stage and risk score.Stage/Risk ScoreHazard Ratio95%CII-0Reference I-10.630.42-0.97I-22.811.87-4.23I-34.902.79-8.61IIA-03.652.26-5.91IIA-12.241.50-3.33IIA-25.873.94-8.73IIA-39.356.24-13.99IIB-04.763.13-7.24IIB-15.043.37-7.53IIB-29.465.63-15.92IIB-314.599.78-21.79IIIA-09.136.12-13.62IIIA-17.384.92-11.06IIIA-212.017.14-20.19IIIA-332.5421.59-49.04IIIB-018.9712.62-28.52IIIB-119.0512.68-28.61IIIB-228.3418.91-42.47IIIB-335.6121.33-59.43IIIC-011.525.84-22.74IIIC-115.766.07-40.94IIIC-226.7716.74-42.83IIIC-356.6336.60-87.60IV-049.9330.64-81.36IV-167.4545.36-100.23IV-2107.6272.36-60.07IV-3164.04107.18-251.04 CONCLUSIONS: Incorporating biological factors to the current AJCC staging system provides more accurate prognostic information and reflects current treatment practice. The proposed risk score improves the AJCC breast cancer staging system and should be incorporated in the upcoming revision. Citation Format: Chavez-MacGregor M, Mittendorf EA, Clarke CA, Lichensztajn DY, Hunt KK, Giordano SH. Improving the AJCC breast cancer staging system by incorporating tumor biomarkers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-02.

Lymph node metastasis in gastric cancer: Location of positive station to predict survival after preoperative therapy.

166 Background: We sought to determine the association between the identification of positive lymph nodes on D2 lymph node dissection (LND) with stage and outcomes, in the era of preoperative treatment for gastric cancer. Methods: We reviewed data from a prospectively maintained database of gastric cancer patients who underwent resection of gastric or gastroesophageal cancer at our institution from 2005-2016. Central lymph nodes (CnLN) were defined as common hepatic, celiac, and proximal splenic artery lymph nodes (stations #8, 9, and 11p). Risk factors for CnLN metastases, and overall survival (OS) were examined. Results: We identified 356 patients, median age was 64 years (IQR 54-71) and 59% were male. Preoperative therapy was given in 66% of patients. D2 LND was performed in 80% of patients, and the median number of LN examined was 25 (IQR 18-34). Most patients (N = 244, 68%) had separately-examined CnLN in pathology and the median number of examined LNs was higher in this group (27 vs 19; p &lt; 0.001). The CnLN positivity rate was 9.1% (22/244; #8: 4.8%, #9: 6.1%, and #11p: 4.8%), which was higher in advanced pT stage patients (pT0 - 3%, pT1 - 0%, pT2 - 6%, pT3 - 18%, pT4 - 13%; p = 0.001). If we assume that D2 LND was not performed on these patients, a total of 7 (3%, 7/244) patients would have had pN stage down-migration (6 with N1 to N0, 1 with N2 to N1). Of the 22 CnLN-positive patients, 10 (45%) had pN1, 2 (9%) had pN2, and 10 (45%) had pN3 stages. On multivariate analysis, EUS N stage (positive) was associated with positive CnLNs (OR 2.86 [95%CI 1.08-7.58]). Among 342 patients who had R0 resection, the median follow-up was 3.6 years, and the median OS was 11.6 years. Among patients who received preoperative therapy, pT3/4 stage (HR 2.44 [1.27-4.69]; p = 0.01) and positive CnLN (HR 5.44 [2.36-12.52]; p &lt; 0.001) were negatively associated with OS by multivariate analysis. Conclusions: CnLN metastases are uncommon in gastric cancer, and are associated with an adverse impact on OS. However, long-term survival is still possible in patients with positive CnLN whom underwent a D2 lymph node dissection. Larger multi-institutional studies are needed to determine if CnLN positivity requires a separate staging category.

Prognostic Performance of a New Staging Category to Improve Discrimination of Disease-Specific Survival in Nonmetastatic Oral Cancer

Inflammatory status is associated with outcome in oral squamous cell carcinoma (OSCC). Combining the preoperative neutrophil to lymphocyte ratio (NLR) and histopathologic features may provide clinicians with more exact information regarding the prognosis of OSCC. To compare the prognostic performance of the routinely used pathologic TNM staging with a new staging category that incorporates the NLR and histopathologic features. This retrospective cohort study included 396 patients with newly diagnosed OSCC who underwent major surgery at a medical center from January 1, 2006, through December 31, 2013. Follow-up was completed on October 31, 2015, and data analysis was performed from January 1, 2016, through April 30, 2016. The multivariate Cox proportional hazards regression model was used to determine the clinical or pathologic factors associated with 5-year disease-specific survival (DSS), and these factors were assigned integer points to create a new staging category. The monotonicity and discriminatory ability of the pathologic TNM staging and new staging category were evaluated with the linear trend χ2 test, Akaike information criterion, and Harrell C statistic. In total, 396 patients who underwent major surgery with curative intent for OSCC with or without adjuvant therapy were included in this study (mean [SD] age, 53 [11] years; 367 men [92.7%] and 29 women [7.3%]). Perineural invasion (adjusted hazard ratio [aHR], 1.74; 95% CI, 1.23-2.46), high NLR (aHR, 1.60; 95% CI, 1.11-2.30), advanced pT (T3 + T4) classification (aHR, 1.59; 95% CI, 1.13-2.25), and advanced pN (N2) classification (aHR, 3.96; 95% CI, 2.78-5.63) were independent prognostic survival factors. The β coefficients from the Cox proportional hazards regression model were used to develop an integer-based weighted point system (perineural invasion, score of 1; NLR, score of 1; advanced pT, score of 1; and advanced pN, score of 3). The summations of these risk scores were stratified for the new staging category as follows: new stage I, score of 0; new stage II, score of 1; new stage III, score of 2 or 3; and new stage IV, score of 4 to 6. Compared with the American Joint Committee on Cancer staging category, this new staging category provided better monotonicity with a higher linear trend χ2 value (106 vs 49), better discriminatory ability with smaller Akaike information criterion (1497 vs 1533), and greater Harrell C statistic (0.73 vs 0.69) for 5-year DSS. The results remained robust after adjusting other risk factors. In this study, new staging category had better DSS discriminatory ability and could help to identify high-risk patients for intense adjuvant therapy.

P1.06-041 Overall Survival and Intermediate Outcomes among Scandinavian Non-Small Cell Lung Cancer Patients: The SCAN-LEAF Study

The past decade has seen several advances in the field of non-small cell lung cancer (NSCLC), with improved tools for tumor characterization as well as novel targeted and immune therapies. It is important to understand the current treatment landscape including treatment outcomes, in order to maximize patient benefits from these advances. SCAN-LEAF is a Scandinavian retrospective cohort study with prospective annual data cuts, providing a unique opportunity for insights into real-world clinical NSCLC practice over more than a decade. It includes clinical practice patterns of tissue biopsy, pathological diagnosis and tumor biomarker status testing, and their relationship to treatment choices and outcomes. Here, we present intermediate and survival outcomes by disease stage and histology subtype, and factors associated with survival. SCAN-LEAF consists of a registry-based cohort including all diagnosed NSCLC patients in Denmark, Norway and Sweden (Cohort 1), and a Swedish sub-cohort (Cohort 2) supplemented with data from electronic medical records (EMRs). Based on the first data collection including data from NSCLC patients diagnosed 2005-2013, overall survival (OS; Cohort 1 & 2) and progression-free survival (PFS; Cohort 2) will be estimated using Kaplan-Meier analysis and reported as cumulative incidences (with 95% CI) by disease stage at diagnosis, histological subtype, biomarker status, presence of metastases, age and gender. Response rates (Cohort 2) will be described by treatment line in addition to stage and histology subtype. Association of stage with survival (Cohort 1 and 2) and treatment response (Cohort 2) will be analyzed by Cox regression with time to event (death or response) as outcome variable and disease stage category at diagnosis, follow-up time, and therapy line as stratification variables. In addition, the relationship between OS and intermediate outcomes, as well as predictors of OS (e.g. smoking and biomarker status, lesion location, metastasis at diagnosis), will be explored by Cox regression (Cohort 2). Intermediate and survival outcomes for Scandinavian NSCLC patients diagnosed between 2005 and 2013, as well as any association between overall survival and factors such as patient characteristics and treatment patterns, will be presented. The SCAN-LEAF study, expected to include >115,000 Scandinavian NSCLC patients and >2,000 sub-cohort patients diagnosed between 2005 and 2018 during the full duration of the study, will give valuable insights into current care, changing treatment patterns and patient outcomes in a real-world setting. A better understanding of factors associated with survival and intermediate outcomes among NSCLC patients will inform clinical decision-making.

Chronic lymphocytic thyroiditis does not influence the risk of recurrence in patients with papillary thyroid carcinoma and excellent response to initial therapy.

This study evaluated the recurrence in patients with papillary thyroid cancer and an excellent response to initial therapy, comparing those with and without chronic lymphocytic thyroiditis. This was a prospective study. Patients who met the following criteria were selected: diagnosis of papillary thyroid cancer; submitted to total thyroidectomy followed or not by ablation with 131I; and neck ultrasonography without abnormalities, nonstimulated thyroglobulina (Tg) ≤0.2 ng/ml, and undetectable antithyroglobulin antibodies (TgAb) 12-18 months after initial therapy. The patients were divided into two groups: group A, with chronic lymphocytic thyroiditis on histology; group B, without chronic lymphocytic thyroiditis on histology. Groups A and B were similar in terms of sex and age of the patients, characteristics of the tumor, tumor-node-metastase stage and risk category. The time of follow-up ranged from 24 to 120 months (median 66 months). During follow-up, 5 patients of group A (2.6 %) and 9 patients of group B (2 %) developed recurrence (p = 0.77). Patients with chronic lymphocytic thyroiditis were more likely to progress to persistently borderline TgAb. No patient had positive TgAb (above the reference value) during follow-up. Recurrences occurred in 12/588 patients (2 %) with undetectable TgAb in all measurements, in 1/32 (3.1 %) with detectable TgAb on some occasion but that returned to undetectable spontaneously, and in 1/13 (7.7 %) with persistently borderline TgAb. These rates did not differ significantly (p = 0.25). The results of the present study showed the absence of an association between chronic lymphocytic thyroiditis and recurrence risk at least in patients with an excellent response to initial therapy.

Life cycle assessment (LCA) of digested sewage sludge incineration for heat and power production

This paper presents a comparative life cycle assessment (LCA) of an existing digested sewage sludge incineration for heat and power production. Operations of an existing sewage sludge incineration plant based on a fluidized bed combustor (FBC) and a hypothetical cement kiln (CK) facility using sludge as a secondary fuel are described in detail as two different scenarios. The comparison of these two scenarios is performed based on 15 impact categories in the characterization stage. The results show that the sewage sludge incineration scenario based on FBC has a better environmental performance in the most of the impact categories including global warming, respiratory organic and inorganic, aquatic and terrestrial ecotoxicity, terrestrial acidification/nutrition, aquatic acidification, land occupation, and mineral extraction. In the human health category, the scores of the CK scenario precedes the scores of FBC scenario because the residual materials of the incineration in the cement kiln are immobilized with the produced clinkers whereas in the FBC system, they are landfilled. This study aims to show the environmental burdens of each option based on different impact categories in order to give a clear perspective to decision makers for drawing an environmentally friendly and sustainable sludge disposal policy.

Childhood Sexual Abuse and Early Timing of Puberty

PurposeThe purpose was to examine whether the timing of puberty, indexed by breast development and pubic hair development, was earlier for sexually abused females compared with a matched comparison group of nonabused females, controlling for key alternative confounds. MethodsA cohort of sexually abused females and matched comparisons was followed longitudinally at mean ages 11 through 20 years. Sexually abused participants (N = 84) were referred by protective services. Comparison participants (N = 89) were recruited to be comparable in terms of age, ethnicity, income level, family constellation, zip codes, and nonsexual trauma histories. Stage of puberty was indexed at each assessment by nurse and participant ratings of breast and pubic hair development using Tanner staging—the gold standard for assessing pubertal onset and development. Cumulative logit mixed models were used to estimate the association between sexual abuse status and the likelihood of transitioning from earlier to later Tanner stage categories controlling for covariates and potential confounds. ResultsSexual abuse was associated with earlier pubertal onset: 8 months earlier for breasts (odds ratio: 3.06, 95% CI: 1.11–8.49) and 12 months earlier for pubic hair (odds ratio: 3.49, 95% CI: 1.34–9.12). Alternative explanations including ethnicity, obesity, and biological father absence did not eradicate these findings. ConclusionsThis study confirms an association between exposure to childhood sexual abuse and earlier pubertal onset. Results highlight the possibility that, due to this early onset, sexual abuse survivors may be at increased risk for psychosocial difficulties, menstrual and fertility problems, and even reproductive cancers due to prolonged exposure to sex hormones.

Lymphadenectomy and risk of reoperation or mortality shortly after surgery for oesophageal cancer.

The prognostic role of lymphadenectomy during surgery for oesophageal cancer is questioned. We aimed to test whether higher lymph node harvest increases the risk of early postoperative reoperation or mortality. A population-based cohort study including almost all patients who underwent resection for oesophageal cancer in Sweden in 1987–2010. Data were collected from medical records and well-established nationwide Swedish registries. The exposures were number of removed lymph nodes (primary) and number of node metastases (secondary). The main study outcome was reoperation/mortality within 30 days of primary surgery. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using Poisson regression, adjusted for age, sex, co-morbidity, neoadjuvant therapy, tumour stage, tumour histology, surgeon volume, and calendar period. Among 1,820 participants, the risk of reoperation/mortality did not increase with greater lymph node harvest (RR = 0.98, 95%CI 0.96–1.00, discrete variable) or with greater number of removed metastatic nodes (RR = 1.00, 95% CI 0.95–1.05, discrete variable). Similarly, in stratified analyses within pre-defined categories of tumor stage, surgeon volume and calendar period, increased number of removed nodes or node metastases did not increase the risk of reoperation/mortality. Lymphadenectomy during oesophageal cancer surgery is a safe procedure in the short term perspective.

Can multiparametric MRI replace Roach equations in staging prostate cancer before external beam radiation therapy?

PurposeTo investigate the agreement between Roach equations (RE) and multiparametric magnetic resonance imaging (mpMRI) in assessing the T-stage of prostate cancer (PCa). Materials and methodsSeventy-three patients with biopsy-proven PCa and previous RE assessment prospectively underwent mpMRI on a 3.0T magnet before external beam radiation therapy (EBRT). Using Cohen’s kappa statistic, we assessed the agreement between RE and mpMRI in defining the T-stage (≥T3 vs.T≤2) and risk category according to the National comprehensive cancer network criteria (≤intermediate vs. ≥high). We also calculated sensitivity and specificity for ≥T3 stage in an additional group of thirty-seven patients with post-prostatectomy histological examination (mpMRI validation group). ResultsThe agreement between RE and mpMRI in assessing the T stage and risk category was moderate (k=0.53 and 0.56, respectively). mpMRI changed the T stage and risk category in 21.9% (95%C.I. 13.4–33-4) and 20.5% (95%C.I. 12.3–31.9), respectively, prevalently downstaging PCa compared to RE. Sensitivity and specificity for ≥T3 stage in the mpMRI validation group were 81.8% (95%C.I. 65.1–91.9) and 88.5% (72.8–96.1). ConclusionRE and mpMRI show moderate agreement only in assessing the T-stage of PCa, translating into an mpMRI-induced change in risk assessment in about one fifth of patients. As supported by high sensitivity/specificity for ≥T3 stage in the validation group, the discrepancy we found is in favour of mpMRI as a tool to stage PCa before ERBT.

Magnetic Resonance Imaging-Detected Intracranial Extension in the T4 Classification Nasopharyngeal Carcinoma with Intensity-Modulated Radiotherapy.

PurposeThis study was conducted is to identify the prognostic value and staging categories of magnetic resonance imaging (MRI)–detected intracranial extension in nasopharyngeal carcinoma (NPC) with intensity-modulated radiotherapy (IMRT) to determine whether it is necessary to subclassify the T4 classification NPC.Materials and MethodsA total of 335 nonmetastatic T4 classification NPC patients with MRI treated between March 2004 and June 2011 by radical IMRT were included. The T4 classification patients were subclassified into two grades (T4a, without intracranial extension vs. T4b, with intracranial extension) according to the site of invasion.ResultsThe frequency of intracranial extension was 40.9% (137 of 335 patients). Multivariate analysis identified subclassification (T4a vs. T4b) as an independent prognostic factor for local failure-free survival (p=0.049; hazard ratio [HR], 0.498) and overall survival (p=0.004; HR, 0.572); however, it had no effect on regional failure-free survival or distant failure-free survival (p > 0.050).ConclusionFor patients with T4 classification NPC, those with MRI-detected intracranial extension are more likely to experience local failure and death after IMRT than patients without intracranial extension. According to the site of invasion, subclassification of T4 patients as T4a or T4b has prognostic value in NPC.