Stage IIIA Research Articles

Patterns of care for vulvar cancer and insights from revised FIGO staging: a retrospective study

BackgroundThe objective of this study was to evaluate the clinicopathological characteristics and patterns of care among women diagnosed with vulvar malignancy at a tertiary care teaching institute. Additionally, the study aimed to analyse the implications of revised FIGO staging system on stage shift and patient outcomes.MethodsA retrospective observational study was conducted, wherein hospital records of biopsy-proven cases of vulvar cancers managed over a period of 10 years were comprehensively reviewed. The assignment of FIGO staging was performed utilizing both 2009 and 2021 FIGO staging systems for comparative analysis. Statistical analysis was performed using STATA version 17. Survival curves were constructed using the Kaplan-Meier method, with differences assessed using the log-rank test. Additionally, multivariable analysis was conducted using the Cox proportional hazard model.ResultsA total of 82 cases meeting the inclusion criteria were enrolled in the study. Management patterns varied widely, with the majority undergoing surgery (73.2%), followed by definitive radiotherapy with or without chemotherapy (10.9%), neoadjuvant radiotherapy and subsequent surgery (4.9%), and palliative care (10.9%). Post-operative radiotherapy was administered in 31.7% of cases. The disease-specific recurrence rate was found to be 32.9%, and the mortality rate was 30.5%. The median Disease-Free Survival (DFS) was 17 months (interquartile range [IQR]: 1–36 months), while the Overall Survival (OS) was 27 months (IQR: 9–52 months). Upon application of the 2021 staging system, a stage shift was observed in 18% of cases of advanced vulvar cancer. The 3-year DFS and OS were reduced for stage IIIA and stage IVA, while showing improvement for stage IIIB.ConclusionsThe revised FIGO 2021 staging system offers enhanced simplicity in its application within clinical practice and demonstrates improved correlation with prognosis. Approximately 18% cases experienced restaging under the updated system.Trial registration numberNot applicable.

Defining high-risk patients: beyond the 8the AJCC melanoma staging system.

Since melanoma incidence is steadily increasing, guidelines regarding the diagnosis, staging, and treatment of melanoma are constantly being updated. In particular, the use of adjuvant therapy in stage IIb/c melanoma has been recently approved by the international regulatory agenicies. We performed a retrospective study with 92 melanoma patients namely 42 patients with IIb/c melanoma and 42 patients with IIIa stage melanoma, describing demographics, clinical, histology and disease course during the 5-year follow-up.Several significant evidences emerged between the two groups. Stage IIb/c patients possess a higher age of disease onset (69.6 vs. 55.5 years) with respect to stage III patients and the acral localization appeared as the most frequent (24% vs. 4%). Histologically, stage IIb/c melanomas more frequently exhibit ulceration (70% vs. 2%), angiotropism (54% vs. 8%) and are characterized by a greater presence of TILS (52% vs. 15%). Although it is not statistically significant, we observed a difference in terms of presence of metastasis during the 5-year follow-up: 15% of stage IIb/c patients showed metastasis vs. 4% of stage IIIa patients. Our data support the use of adiuvant immunotherapy in stage IIb/c patients.

The impact of extent of nodal involvement on Stage IIIA(N2) NSCLC outcomes

ObjectivesStage IIIA(N2) non-small cell lung cancer (NSCLC) treatment can depend on the extent of nodal involvement, with surgery considered for limited disease and definitive chemoradiation preferred for bulky or multi-station disease. Evidence to support management is limited. This study evaluated the impact of the extent of Stage IIIA(N2) nodal involvement on outcomes after surgery. MethodsPatients who underwent surgical resection of T1-2N2M0 NSCLC in the Surveillance, Epidemiology, and End Results (SEER) database from 2004-2019 were stratified as having limited (1 positive node) versus more extensive (>1 positive node) nodal disease, and survival was evaluated with Kaplan-Meier and Cox analyses. ResultsOf the 6,933 patients identified surgical patients, 2,129 (30.7%) had limited nodal disease while 4,804 (69.3%) had more extensive nodal involvement. The limited nodal group had higher 5-year overall survival than the more extensive node group (39.3% vs 30.3%, p<0.001), and more extensive nodal involvement (Hazard Ratio 1.26, p<0.001) was independently associated with worse survival in Cox analysis. Surgical patients had a higher 5-year overall survival than 1,644 comparable N2 patients with extensive nodal involvement who received definitive chemoradiation (30.9% vs 18.9%, p<0.001). ConclusionsIncreasing nodal involvement is associated with worse survival for Stage IIIA(N2) NSCLC patients but select patients with more extensive nodal disease may still benefit from surgery compared to chemoradiation.

Computer Assisted Nodule Analysis and Risk Yield is Associated with Occult Lymph Node Status in Clinical Stage I-IIA Lung Adenocarcinoma Undergoing Resection

BackgroundCurrent staging work-up does not capture all occult lymph node (OLN) disease. We sought to determine if Computer Assisted Nodule Analysis and Risk Yield (CANARY) analysis could help distinguish OLN status in early-stage lung adenocarcinoma. MethodsRetrospective review of resected lung cancer patients from 2016-2021 was performed. Patients with surgically resected clinical stage I-IIA lung adenocarcinoma were included. Preoperative imaging was entered into the CANARY software, and each lesion was categorized into good, intermediate, and poor risk. OLN status was determined per pathology results. Pearson's Chi-square correlation, univariate and multivariate logistic regression models were used to assess OLN metastases as a function of CANARY risk profile, with statistical significance at α=0.05. ResultsIn total, the study cohort included 228 patients with median age of 70. By clinical stage, 195 (85.5%), 24 (10.5%), and 9 (3.9%) patients were determined to be in IA, IB, and IIA, respectively. 28 (12.3%) patients were found to have OLN metastases. Among them, 1 (3.6%), 3 (10.7%), and 24 (85.7%) patients had a good, intermediate, and poor CANARY risk profile, respectively. CANARY risk profile was significantly associated with OLN metastases (χ2=9.9, p=0.007). Relative to the good/intermediate group, patients with poor risk had a more-than 3-fold increase in likelihood of having OLN metastases (odd ratio [OR]=3.3, 95% confidence interval [CI]:1.6-9.2, p=0.007). ConclusionCANARY analysis was able to risk-stratify the likelihood of OLN metastases in early-stage lung adenocarcinoma. CANARY can provide an adjunctive non-invasive tool to aid in determining an appropriate individualized treatment plan. Micro-abstractWe were able to identify potential prognostic capability of the Computer Assisted Nodule Analysis and Risk Yield (CANARY) program in the determination of occult lymph node metastasis in clinical stage I-IIA lung adenocarcinoma. In a single-institution cohort of 228 patients, those with poor risk determined by Score Indicative of Lung Cancer Aggression (SILA) has a 3-fold increase in likelihood of having occult lymph node metastasis (odds ratios = 3.3 [1.6-9.2]).

Alectinib (Alecensaro)

Canada’s Drug Agency (CDA-AMC) recommends that Alecensaro should be reimbursed by public drug plans for adjuvant treatment following tumour resection for patients with stage IB (tumours ≥ 4 cm) to IIIA (according to American Joint Committee on Cancer [AJCC] Cancer Staging Manual, seventh edition) ALK-positive non–small cell lung cancer (NSCLC) if certain conditions are met. Alecensaro should only be covered to treat adult patients (≥ 18 years) who have stage IB (tumour ≥ 4 cm) to stage IIIA (per the AJCC seventh edition) ALK-positive NSCLC, have had complete tumour resection, and are in relatively good health. Alecensaro should only be reimbursed if it is prescribed by clinicians with expertise in managing NSCLC and the cost of Alecensaro is reduced. Alecensaro should be discontinued if a patient’s cancer grows or spreads, if treatment is unacceptably toxic to the patient, or the patient has completed 2 years of therapy with Alecensaro.

Is postoperative radiotherapy effective in patients with completely resected pathologic stage IIIA(N2) non-small cell lung cancer? High-risk populations should consider it

Background and purposeWe aimed to assess the benefits of postoperative radiotherapy (PORT) in completely resected patients with pathologic stage IIIA(N2) non-small cell lung cancer (NSCLC) with a high risk of locoregional recurrence (LRR). Materials and methodsA prospective, randomized trial was conducted starting in July 2016 to explore the optimal timing of PORT in high-LRR-risk patients with completely resected IIIA(N2) NSCLC (NCT02974426). Patients were identified as high-LRR-risk patients via the prognostic index (PI) model and were randomly assigned to PORT-first or PORT-last treatment. To evaluate PORT for high-LRR-risk patients, all patients in this trial constituted the PORT cohort, whereas high-LRR-risk patients without PORT were selected from a retrospective cohort as the non-PORT cohort. Propensity score-matched (PSM) analyses were conducted to compare overall survival (OS), disease-free survival (DFS), locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS). ResultsBetween 2016 and 2022, 132 patients were included in the trial, with a median follow-up of 49.3 months. The 3-year OS rate was 83.2 %, and the 3-year DFS rate was 35.0 %. Among these patients, 122 patients (92 %) received planned PORT. For 132 intention-to-treat patients, PSM analysis with the non-PORT cohort (n = 307) resulted in 130 matched pairs. The results revealed that PORT improved LRFS (3-year LRFS, 77.6 % vs. 57.3 %; p = 0.00014), DFS (3-year DFS, 35.2 % vs. 28.6 %; p = 0.038), and OS (3-year OS, 83.0 % vs. 60.7 %; p = 0.00017), with no difference in DMFS (p = 0.17). ConclusionPORT could increase local control, DFS, and OS in high-LRR-risk patients with completely resected IIIA(N2) NSCLC. Future research should utilize multidimensional data to pinpoint more precise subgroups benefiting from PORT, with prospective trials validating these findings.

Features of late local failure of early‑stage non‑small cell lung cancer treated with stereotactic body radiotherapy.

Local failure of non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT) often occurs within 2 years and delayed local failure is uncommon. In the present study, features of late local failure (LLF; >2 years after SBRT) after SBRT were investigated and compared with those of early local failure (ELF; ≤2 years after SBRT) to explore whether these two local recurrence features have different prognostic implications. Patients who underwent SBRT for stage I-IIA NSCLC between July 2006 and March 2014 were retrospectively reviewed. Overall, 173 patients underwent SBRT for NSCLC. The median follow-up times after SBRT were 50 and 31 months for survival and computed tomography (CT) follow-up, respectively. LLF and ELF occurred in 7 and 13 patients, respectively. The median times to LLF and ELF were 42 months (range, 31-61 months) and 13 months (range, 4-16 months), respectively. Local-only failure occurred in 14% (1/7) of LLF cases and 77% (10/13) of ELF cases, which was significantly different (Fisher's exact test, P=0.02). Curative-intent salvage treatment was impossible in all of the LLF cases and 69% (9/13) of the ELF cases, which was significantly different (Fisher's exact test, P<0.01). The median survival times after local failure were 9 and 25 months for patients with LLF and ELF, respectively. Additionally, the 1-year overall survival rates after local failure were 29 and 83% in the LLF and ELF groups, respectively, which was significantly different (log-rank test, P<0.01 at 1-year). In summary, the prognosis after LLF was significantly unfavorable compared with after ELF. Curative-intent salvage treatment is often difficult for LLF due to metastases. Therefore, it seems reasonable to decrease the frequency of follow-up CT for detecting tumor recurrence after the first 2 years post-SBRT.

Prognostic nomograms for locally advanced cervical cancer based on the SEER database: Integrating Cox regression and competing risk analysis.

Locally advanced cervical carcinoma (LACC) remains a significant global health challenge owing to its high recurrence rates and poor outcomes, despite current treatments. This study aimed to develop a comprehensive risk stratification model for LACC by integrating Cox regression and competing risk analyses. This was done to improve clinical decision making. We analyzed data from 3428 patients with LACC registered in the Surveillance, Epidemiology, and End Results program and diagnosed them between 2010 and 2015. Cox regression and competing risk analyses were used to identify the prognostic factors. We constructed and validated nomograms for overall survival (OS) and disease-specific survival (DSS). Multivariate Cox regression identified key prognostic factors for OS, including advanced International Federation of Gynecology and Obstetrics stage, age, marital status, ethnicity, and tumor size. Notably, International Federation of Gynecology and Obstetrics stages IIIA, IIIB, and IVA had hazard ratios of 2.227, 2.451, and 4.852, respectively, significantly increasing the mortality risk compared to stage IB2. Ethnic disparities were evident, with African Americans facing a 39.8% higher risk than Caucasians did. Competing risk analyses confirmed the significance of these factors in DSS, particularly tumor size. Our nomogram demonstrated high predictive accuracy, with area under the curve values ranging from 0.706 to 0.784 for DSS and 0.717 to 0.781 for OS. Calibration plots and decision curve analyses further validated the clinical utility of this nomogram. We present effective nomograms for LACC risk stratification that incorporate multiple prognostic factors. These models provide a refined approach for individualized patient management and have the potential to significantly enhance therapeutic strategies for LACC.

Surgical resection following chemoradiotherapy for thoracic SMARCA4-deficient undifferentiated tumor: a report of two cases

BackgroundThoracic SMARCA4-deficient undifferentiated tumor (SMARCA4-UT) is a high-grade malignant neoplasm with a poor prognosis. Most cases of SMARCA4-UT have extensive chest wall and mediastinum involvement. The efficacy of surgical resection has not been clearly established. Here, we report two surgical cases of SMARCA4-UT with chest wall invasion after chemoradiotherapy.Case presentationThe first patient was a 40-year-old man with back pain. Computed tomography revealed a 6.8 cm mass in contact with the thoracic vertebrae near the intervertebral foramen, which was suspected to involve the third to fifth ribs. The patient was diagnosed with SMARCA4-UT with clinical T3N0M0 stage IIB. The tumor shrank after chemoradiotherapy, and conversion surgery combined with partial vertebrectomy was performed. Histopathological findings revealed 30% residual tumor in the tumor bed. Thirty-six days after surgery, the patient developed multiple liver metastases and peritoneal dissemination. Chemotherapy combined with immune checkpoint inhibitor treatment was performed, resulting in tumor shrinkage. However, peritoneal dissemination recurred within a short interval. The patient died 5 months postoperatively. The second patient was a 74-year-old man with chest pain. Computed tomography revealed a 7.4-cm mass in the left upper lobe with invasion of the third and fourth ribs. The patient was initially diagnosed with non-small cell lung cancer with clinical T4N1M0 stage IIIA. The tumor shrank after induction chemoradiotherapy, and a left upper lobectomy combined with the chest wall resection was performed. Based on histopathological findings, the patient was diagnosed with SMARCA4-UT. The residual tumor percentage was 3%. The patient was followed up for 12 months postoperatively without recurrence.ConclusionsWe performed the complete resection of SMARCA4-UT following chemoradiotherapy. The two surgical cases had different postoperative courses. Radical surgery after chemoradiotherapy is effective for local control. However, its long-term prognostic efficacy remains unclear. Multidisciplinary approaches and further investigations of novel therapeutic options are required.

Lung stereotactic radiation therapy: Early results from the Salah Azaiez Institute.

Stereotactic Body Radiation Therapy (SBRT) has transformed lung cancer care, delivering precise treatment with minimal harm to healthy tissue. This study examined the experience at the Salah Azaiez Institute (SAI) in lung cancer patients. we conducted a retrospective study on patients treated with SBRT from 2019 to 2022. Planification imaging included four-dimensional CT scans and delineation of target volumes and organs-at-risk was done as per international guidelines. Treatment doses were tailored based on tumour location. A total of 10 cases were included. The male-to-female sex ratio was 4:1, with a median age of 69.5 years. Three had unconfirmed primary lung tumours, while five had inoperable stage I-IIA adenocarcinomas primarily due to compromised respiratory function. Two had oligometastatic lung diseases. All underwent recent thoracic-CT and PET-CT evaluations to exclude pulmonary fibrosis. The median lesion size was 40mm. Karnofsky's performance status ranged from 70 to 90, with no contraindications to the supine position. Eight out of 10 patients received 8 fractions of 7.5 Gy at the 80% isodose. For that regimen, the D95%, D99%, and Dmax were respectively, 60 Gy, 56 Gy, 73 Gy. All organs-at-risk dosimetric criteria were met. Acute toxicities included worsened coughs in 2 patients and fatigue in 6. After a mean follow-up of 23 months, no rib fractures or haemoptysis were observed, and no local recurrence was reported on the last chest CT scan. SBRT demonstrates promise for lung cancer treatment, though challenges persist in precise targeting and motion management. Effective multidisciplinary collaboration and local protocols are crucial for successful implementation.

High-Sensitivity and Conventional Cardiac Troponin-I Assays in AL Amyloidosis.

Circulating cardiac troponin-I (cTnI) plays a crucial role in biomarker staging systems, offering important information for prognostification and risk stratification of patients with AL amyloidosis. High-sensitivity cTnI (HS-cTnI) assays have been introduced in practice; however, the data on the concordance between conventional and HS-cTnI and the utility of HS-cTnI in cardiac biomarker staging are lacking. Seventy-eight consecutive patients with AL amyloidosis who were prospectively evaluated at the Boston University Amyloidosis Center from October 2022 through March 2023 were included. cTnI was measured using the Abbott Architect cTnI chemiluminescent microparticle immunoassay (CMIA) and HS-cTnI using the Abbott Alinity HS-cTnI CMIA assay. Assay results were compared by Deming regression and Bland-Altman analyses, and cardiac biomarker stages were assigned and compared using both assay results. Median cTnI and HS-cTnI concentrations were 13.0 and 7.0 ng/L, respectively. Bland-Altman analysis demonstrated a negative bias with HS-cTnI results (mean percent difference between assays: -49.8%) and the greatest variance occurring below 50 ng/L. Deming regression supported this negative discordance (slope, 0.66; intercept, -1.9). The use of HS-cTnI assay downgraded cardiac biomarker staging assignments from stage IIIA to stage II (n = 3) and from stage IIIB to stage II (n = 1). Overall agreement was demonstrated; however, a negative bias for HS-cTnI assay was noted at low concentrations. The application of the conventional cTnI threshold of >100 ng/L to HS-cTnI-based Boston University cardiac staging showed a trend toward downgraded staging assignments. The prognostic utility of HS-cTnI assay in biomarker staging warrants further investigation in patients with AL amyloidosis.

Evaluation of Treatment Strategies for Patients with Stage IIIA Non-Small Cell Lung Cancer in the Immunotherapy Era

BackgroundOptimal treatment for patients with stage IIIA NSCLC is controversial. Growing evidence indicates surgery with adjuvant or neoadjuvant chemotherapy (SC) may be superior to non-surgical treatments. Direct comparisons have not been performed between SC and chemoradiation with immunotherapy (CRI) among patients diagnosed with stage IIIA NSCLC since consolidation immunotherapy was added to treatment guidelines. MethodsThis retrospective study compared surgical and systemic non-surgical treatments (except targeted therapy) among adults diagnosed with stage IIIA NSCLC 2017-2021. Data was from ConcertAI's curated EHR Patient360™ NSCLC real-world care product. Real-world progression-free survival (rwPFS) and overall survival (rwOS) were evaluated among patients treated with SC or CRI using Kaplan-Meier and Cox proportional hazard methods. Baseline differences were balanced using propensity score-derived inverse probability treatment weights (IPTW). ResultsAmong 1718 eligible, the two main comparator groups (SC and CRI) had 431 (25%) and 576 (34%) patients; 711 patients received chemoradiation or monotherapy. A wide range of treatment strategies was observed across included oncology clinics (e.g., 0–67% clinic patients received surgery). IPTW-adjusted analyses showed reduced hazards in the SC group vs. CRI for rwPFS (HR 0.78, 95% CI: 0.63–0.97) and rwOS (HR 0.63, 95% CI: 0.49–0.82). SC was similarly beneficial for patients across nodal status groups and appeared especially beneficial for patients with resectable squamous-cell tumors. ConclusionStage IIIA NSCLC treatment is highly variable. Real-world studies can provide valuable evidence to support surgery as a treatment option for stage IIIA patients, who currently may only be offered chemoradiation with or without immunotherapy.

Disparities in Receipt of Adjuvant Immunotherapy among Stage III Melanoma Patients.

Melanoma survival has greatly improved with the advent of immunotherapy, but unequal access to these medications may exist due to nonmedical patient factors such as insurance status, educational background, and geographic proximity to treatment. We used the National Cancer Database to assess patients with nonmetastatic cutaneous melanoma who underwent surgical resection and sentinel lymph node biopsy (SLNB) with tumor involvement from 2015 to 2020. We evaluated rates of adjuvant immunotherapy among this patient population based on patient, tumor, and facility variables, including insurance status, socioeconomic status, pathologic stage (IIIA-IIID), and treatment facility type and volume. Adjuvant immunotherapy was associated with improved survival for stage III melanoma, with a slight increase in 5-year OS for stage IIIA (87.9% vs. 85.9%, P=0.044) and a higher increase in stages IIIB-D disease (70.3% vs. 59.6%, P<0.001). Receipt of adjuvant immunotherapy was less likely for patients who were older, low socioeconomic status, or uninsured. Low-volume and community cancer centers had higher rates of adjuvant immunotherapy overall for all stage III patients, whereas high-volume and academic centers used adjuvant immunotherapy much less often for stage IIIA patients compared with those in stages IIIB-D. Our results demonstrate inconsistent use of adjuvant immunotherapy among patients with stage III melanoma despite a significant association with improved survival. Notably, there was a lower use of adjuvant immunotherapy in patients of lower SES and those treated at high-volume centers. Equity in access to novel standards of care represents an opportunity to improve outcomes for patients with melanoma.

Programmed Cell Death-Ligand 1 Expression and Clinical Outcomes Among Patients with Resected, Early-Stage Non-Small Cell Lung Cancer: A Real-World Study.

Treatment options for non-small cell lung cancer (NSCLC) are evolving, given recent and expected approvals of immune checkpoint inhibitors (ICIs) targeting programmed cell death-(ligand) 1 (PD-1/PD-L1). We retrospectively evaluated outcomes among patients with resected stage IB-IIIA NSCLC tumors expressing PD-L1 using PALEOS (Pan-cAnadian Lung cancEr Observational Study) data (2016-2019). Key outcomes included PD-L1 expression rate and treatment patterns, recurrence, and median overall (mOS) and disease-free survival (mDFS) among PD-L1+ patients. Among 539 PD-L1-tested patients, 317 (58.8%) were PD-L1+ (≥1%). At diagnosis, 35.3%, 39.8%, and 24.9% of PD-L1+ patients had stage IB, II, or IIIA disease. Forty-one percent had received adjuvant therapy. At 22.6 months (median follow-up), first disease recurrence had occurred in 31.9% of patients, primarily at metastatic sites. After first metastatic recurrence, ICI regimens were the most common first systemic therapy (29.8%). mOS was not reached; mDFS was 40.0 months. At four years, DFS probability was 44%. Four-year OS and DFS rates were generally similar when stratified by PD-L1 expression (1-49% vs. ≥50%). These findings underscore the generally poor outcomes experienced by patients with early-stage, resected, PD-L1+ NSCLC after treatment with available adjuvant therapies, and provide context to recent and emerging trials of new treatment options.

Usefulness of pelvic lymphadenectomy in staging of ovarian dysgerminoma.

To determine the usefulness of pelvic lymphadenectomy in the staging of ovarian dysgerminoma. Patients with a histopathological diagnosis of ovarian dysgerminoma who were staged between January 1995 and December 2013 were retrospectively studied. We found 39 cases, the mean age was 23.5 years. Histologically, 34 were pure dysgerminomas and 5 were mixed associated with endodermal sinus tumors. According to FIGO, we found stage IA in 15 patients, stage IB in 1 patient, stage IC in 8 patients, stage IIB in 1 patient, stage IIIA in 1 patient, and stage IIIC in 13 patients. Pelvic nodes with metastases were not documented in any of the patients studied. The lymphatic spread pattern in ovarian dysgerminomas is always towards the retroperitoneal nodes, both paracaval and paraaortic, but there is no spread towards the pelvic lymph nodes. Therefore, we recommend not performing pelvic lymphadenectomy in surgical staging in these patients.

Comparison of Clinicopathological Features between Premenopausal and Postmenopausal Female Breast Cancer Patients in Kurdistan Region of Iraq: A Retrospective Single Institution Study of 671 Female Patients

Introduction: Breast cancer is the most common cancer in women, and its incidence is increasing annually worldwide. It accounts for 24% of new cancer cases and 15% of cancer deaths in 2018, and according to the GLOBOCAN Cancer Tomorrow prediction tool, incident cases are expected to increase by more than 46% by 2040. Studies carried out thus far have shown that risk factors and histopathological features of breast malignancies may vary among different age groups. Menopausal status is an essential factor influencing clinicopathological characteristics of patients with breast cancer. Prognostic factors are used to estimate how aggressive the tumor may evolve and to decide on a treatment approach. In Iraq, breast cancer is most frequently seen in younger women in their fourth and fifth decades of life, who often show in advanced stages at the time of diagnosis, according to previous surveys. Objectives: The main objective of this study was to assess the clinicopathologic features between premenopausal and postmenopausal breast cancers to provide valuable insights into what may influence the age at diagnosis of breast cancer in the Kurdistan region of Iraq. Methods: This retrospective study included 671 non-metastatic breast cancer patients referred to Zhianawa Cancer Center between January 2015 and December 2017. Disease stage was determined using the American Joint Committee on Cancer and Union for International Cancer Control (UICC) (“Tumour,” “Nodes,” “Metastases”) TNM systems. The patients were divided into premenopausal and postmenopausal groups. The chi-square test was used to evaluate the association between the variables. Results: The mean age of the participants was 47.5 years. The most prevalent age group was 40-49, followed by the age group 50-59. Of the participants, 60.5% were premenopausal, and 39.4% were postmenopausal. Stage IIIA was the most common stage at diagnosis. At the same time, the most minor stage at diagnosis was stage 0. The second most common stage was IIB. There was a strong association between menopausal status with grade (P value 0.001) and LVI (P value 0.01); however, there was a non-significant correlation between menopausal status and stage at diagnosis (P value 0.529). Conclusion: Most patients included in this study had locally advanced disease stages. Menopausal status affected grade and LVI but not stage. Further professional efforts, endorsed by practical policy decisions, are recommended to down stage breast cancer through promoting evidence based protocol guidelines and adopting comprehensive well designed diagnostic, screening and cancer control strategies.

Efficacy and feasibility of tunnel esophagogastrostomy to perform proximal gastrectomy

Objective: To analyze the efficacy and feasibility of performing a new surgical procedure, tunnel esophagogastrostomy, to perform proximal gastrectomy. Methods: The study cohort comprised 10 consecutive patients who had undergone esophagogastrostomy by the tunnel technique in Jiangsu Cancer Hospital between October 2019 and July 2022. All patients were male. Their average age was (64.2±8.1) years and body mass index (25.5±3.2) kg/m2. Nine had upper gastric body adenocarcinoma, the remaining one having signet ring cell carcinoma. TNM staging of the tumors showed that seven were Stage IA, one Stage IB, one Stage IIA, and one Stage IIIA. Briefly, tunnel esophagogastrostomy is performed as follows: After performing a proximal gastrectomy, a rectangular seromuscular flap (3.0 cm × 3.5 cm) is created. The posterior esophageal wall is sutured to the gastric wall at the orad end of the seromuscular flap 5 cm from the stump with three to four stitches. Next, the stump of the esophagus is opened, the posterior esophageal wall is sutured to the gastric mucosa and submucosa, and the anterior esophageal wall is sutured to the full layer of the stomach. Finally, the caudad end of the seromuscular flap is closed. Data on surgical safety, postoperative morbidity, and postoperative reflux esophagitis were analyzed. All enrolled patients completed endoscopic follow-up 1 year and 2 years after surgery. Results: All procedures were completed. They comprised four cases of laparoscopic assisted surgery, four of DaVinci robotic surgery, and two of open surgery. The mean operation time was 212.7±33.2 mins, mean anastomosis time (51.6±5.3) minutes, mean tunnel preparation time (20.0±3.5) minutes, and mean operative blood loss (90.0±51.6) mL. The time to first postoperative passage of flatus was (64.8±11.5) hours. The mean hospital stay after surgery was (9.2±1.7) days. There were no postoperative complications above Clavien-Dindo Grade II. The mean preoperative Reflux Disease Questionnaire score was (3.3± 0.4) before the surgery, (3.8±1.0) 1 month postoperatively, and (3.3±0.4) 12 months postoperatively. All patients underwent endoscopic follow-up; no anastomotic stenoses were found. However, one patient had Grade A reflux esophagitis 1 year after surgery and another Grade B reflux esophagitis 2 years after surgery. Conclusion: Esophagogastrostomy by the tunnel technique is a safe and feasible means of performing proximal gastrectomy.

Precision Strikes: Personalising Potentially Surgically Resectable Stage IIIA Lung Cancer Treatment with Targeted and Immune Therapies

Precision Strikes: Personalising Potentially Surgically Resectable Stage IIIA Lung Cancer Treatment with Targeted and Immune Therapies

Long-Term Survival Outcomes in Locally Advanced Breast Cancer after Mastectomy with or without Breast Reconstruction

Introduction: There is ongoing debate about the safety of breast reconstruction for patients with locally advanced breast cancer (LABC) who have undergone total mastectomy (TM). More and more LABC patients are undergoing breast reconstruction after TM, but its long-term survival outcomes remain unclear. This study aimed to compare the survival outcomes of LABC patients who underwent breast reconstruction after TM with those who did not, based on a large sample. Methods: We collected data for all LABC patients who underwent TM with or without breast reconstruction in the Surveillance, Epidemiology, and End Results (SEER) database. We divided patients into two groups: TM group and total mastectomy with reconstruction (TM+R) group. The primary outcomes were overall survival (OS) and breast cancer-specific survival (BCSS). Propensity score matching (PSM) analysis was used to eliminate imbalances of baseline data between the two groups. Data were analyzed using χ2 tests, Kaplan-Meier methods, and univariate and multivariate Cox regression analyses. Result: We identified 39,112 eligible patients (33,169 patients received TM and 5,943 received TM+R), and 8,680 patients were matched after PSM (4,340 patients received TM and 4,340 received TM+R). Patients with middle age, white, married, lived in urban, IIB–IIIA stage, invasive ductal carcinoma, pathological grade II–III, hormone receptor-positive, and undergone chemotherapy were more likely to receive breast reconstruction. After PSM, Kaplan-Meier survival analysis showed better OS and BCSS in the TM+R group versus the TM group (OS: p < 0.001; BCSS: p = 0.008). Multivariate Cox regression analysis showed that TM+R significantly improved OS and BCSS (OS: hazard ratio 0.73, 95% confidence interval [CI] [0.68, 0.79], p < 0.001; BCSS: 95% CI [0.79, 0.94], p = 0.001). Subgroup analysis showed that patients with old age, white, and hormone receptor-positive had better OS and BCSS by TM+R compared to TM. Conclusions: Breast reconstruction after TM is associated with better OS and BCSS in patients with LABC.

Clinical Outcomes of Maintenance Durvalumab After Definitive Concurrent Chemoradiotherapy in Unresectable Locally Advanced Stage III NSCLC According to EGFR and ALK Status: Korean Cancer Study Group LU-22-18

IntroductionThe role of maintenance durvalumab after definitive concurrent chemoradiotherapy (CCRT) in unresectable locally advanced NSCLC with EGFR mutation or ALK translocation remains unclear. We compared the effectiveness of durvalumab maintenance therapy in groups with EGFR/ALK wild-type versus those with EGFR or ALK mutations. MethodsIn this retrospective multicenter observational study, patients with locally advanced NSCLC without progression after CCRT followed by maintenance durvalumab and available molecular test results (EGFR and ALK) were eligible. The primary objective was to compare progression-free survival (PFS) between EGFR/ALK wild-type and EGFR or ALK mutant NSCLC. Secondary objectives include overall survival according to EGFR or ALK mutation and programmed death-ligand 1 (PD-L1) expression. ResultsAmong 339 patients, 279 had wild-type EGFR/ALK, 41 had EGFR mutations and 19 had ALK translocations. The median age was 68 years with 276 male individuals (81.4%) and 63 female individuals (18.6%), 165 (49.3%) had adenocarcinoma, 149 (44.5%) had squamous cell carcinoma, and 21 (6.3%) had other histologic types, 120 (35.4%) had stage IIIA, 168 (49.6%) stage IIIB, and 51 (15.0%) had stage IIIC. Most of the patients (n = 288, 85%) achieved partial response to CCRT, two (0.6%) had a complete response, and 49 patients (14.4%) had stable disease. Excluding four patients with unknown PD-L1 tumor proportion score (TPS), 16 (4.8%) had a PD-L1 TPS of 0, 168 (50.1%) had 1 to 49, and 151 (45.1%) had 50 or higher. The median PFS was 21.4 months (95% confidence interval [CI]: 17.3–25.3) for the EGFR/ALK wild-type group and 21.0 months (95% CI: 15.7–not available [NA]) for the EGFR or ALK mutant group with no significant difference (p = 0.74). Significant differences occurred in PFS on the basis of PD-L1 expression with values of 13.6 (95% CI: 10.5–NA), 18.7 (95% CI: 15.1–26.9), and 24.7 (95% CI: 20.7–NA) months for TPS of 0, 1–49, and 50 or higher, respectively (p = 0.02). ConclusionsDurvalumab maintenance therapy after definitive CCRT in unresectable locally advanced NSCLC patients with EGFR or ALK mutation demonstrates comparable clinical outcomes to those with wild-type EGFR/ALK when PD-L1 expression is present.