Stage T1a Disease Research Articles

Abstract P2-14-07: Omission of Sentinel Lymph Node Biopsy in Patients with Early Stage Breast Cancer: Looking Beyond the Choosing Wisely Guidelines for Age < 70

Abstract Background: The Surgical Society of Oncology Choosing Wisely Campaign for breast cancer advocates against the routine use of sentinel lymph node biopsy (SLNB) for women ≥ 70 years with early stage estrogen positive (ER+), clinically node negative (cN0) disease, given the low likelihood of axillary involvement and axillary recurrence risk, absence of survival benefit and greater reliance on genomic testing for therapeutic decisions. We hypothesize that this practice may be extended to a younger cohort of patients. In this proof-of-concept feasibility study, we first sought to determine the incidence of node positive (N+) disease in our health system using natural language understanding (NLU) technology to extract relevant data from the electronic medical record (EMR). NLU of the clinical narrative has been proven to aid clinical decision support by extracting relevant information and can populate clinical databases to facilitate optimal population management strategies. The advantage of NLU over a cancer registry is the speed and efficiency of data extraction for a large number of patients in real time, plus the capture of data points not conventionally included in a registry. Methods: All patients with early stage ER+, cN0 breast cancer who had SLNB from January 2015-December 2017 were identified in an integrated academic health network comprised of 15 hospitals in Western Pennsylvania. Patitent clinical data were abstracted from the EMR using Realyze Intelligence™ NLU technology. The Realyze NLU pipeline uses a combination of machine learning algorithms and standard terminologies to create a breast cancer patient model that includes genomic, phenotypic, and clinical data. The pipeline gathers information from all data sources – structured and unstructured – and normalizes the information to create a complete model of patient clinical criteria. Realyze Information Models use clinical data formatting flexible enough to represent clinical disorders on a concept level as well as the encounter, patient, and population levels. A breast cancer model with focus on the lymph node identification, pathological as well as clinical tumor and node classification were developed and mapped to standard terminology. A Semantic Reasoning layer is provided by different mechanisms including a rule-based layer to render answers to the questions posed in this hypothesis. NLU performance was validated by manually verifying key clinical variables (i.e., clinical stage, pathologic stage, and nodal positivity) on a subset of patients. Statistical analysis to determine any difference in N+ rates by age was performed using Chi-square testing with significance set at p < 0.05. Results: We identified 602 pts with early stage ER+, cN0 breast cancer over this period who underwent SLNB. Average age was 59.6 years old. As a whole group, there was an increase in N+ rates as the stage increased (Table 1). When comparing incidence of N+ disease stratified by age (< 70 or >70), there was no difference in N+ rates across all stages. In addition, equally low rates of SLN positivity were seen for patients specifically with stage T1a and T1b disease. Conclusions: These data suggest that the Choosing Wisely recommendation to omit SLNB may be extended to a younger cohort of pts with ER+, cN0 disease, specifically those with stage T1a or T1b tumors. With low rates of N+ disease, and less reliance on axillary stage for treatment decision making, the harms of surgical axillary staging may outweigh the benefits. Future validation is needed with a larger sample size. Table 1 Citation Format: Neil Carleton, Gilan Saadawi, Steffi Oesterreich, ADRIAN V. LEE, Emilia Diego. Omission of Sentinel Lymph Node Biopsy in Patients with Early Stage Breast Cancer: Looking Beyond the Choosing Wisely Guidelines for Age < 70 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-07.

Endoscopic resection versus esophagectomy for patients with small-sized T1N0 esophageal cancer: A propensity-matched study

Endoscopic resection (ER) has been rapidly adopted in the treatment of early-stage esophageal cancer. We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized (≤2 cm) stage T1a and T1b esophageal cancer in a population-based cohort. We queried the Surveillance, Epidemiology, and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching (PSM). Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort. Subgroup analyses of T stage were also performed. We identified 702 patients; 309 (44.0 %) underwent ER, and 393 (56.0 %) underwent esophagectomy. In the unmatched cohort, patients who underwent ER were older, more likely to have a T1a stage, and less likely to receive lymph node sampling. In the entire matched cohort, multivariate analysis found esophagectomy were associated with better overall survival (OS) (HR: 0.62, 95 % CI: 0.40-0.96, p = 0.032) than ER, but no significant difference in esophageal cancer-specific survival (ECSS) (HR: 1.37, 95 % CI: 0.64-2.96, p = 0.420) between the two procedures. The results were similar for subgroup analyses of stage T1b patients. However, ER and esophagectomy were associated with similar OS (HR: 0.74, 95 % CI: 0.41-1.36; p = 0.334) and ECSS (HR: 3.69, 95 % CI: 0.95-14.39; p = 0.060) in patients with stage T1a disease. In patients with stage T1 esophageal cancer, ER was similar to esophagectomy in terms of oncologic outcomes. More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.

Malignant peritoneal cytology and increased mortality risk in stage I non-endometrioid endometrial cancer

ObjectiveTo examine the survival of women with stage I non-endometrioid endometrial cancer with malignant peritoneal cytology. MethodsA retrospective observational cohort study was conducted to examine the National Cancer Institute's Surveillance, Epidemiology, and End Results Program from 2010 to 2016. Women with stage I serous, clear cell, carcinosarcoma, undifferentiated, and mixed endometrial cancer with known peritoneal cytology results at hysterectomy were examined (N = 4506). Propensity score inverse probability of treatment weighting was used to balance the measured covariates, and survival outcomes were assessed according to peritoneal cytology results. ResultsMalignant peritoneal cytology was reported in 401 (8.9%) women. In multivariable analysis, older age, serous histology, and large tumors were associated with an increased likelihood of malignant peritoneal cytology (all, P < 0.05). In a propensity score weighted model, malignant peritoneal cytology was associated with a nearly two-fold increase in all-cause mortality risk compared to negative peritoneal cytology (5-year rates, 63.4% versus 80.2%, hazard ratio 2.18, 95% confidence interval 1.78–2.66). In sensitivity analyses, malignant peritoneal cytology was associated with decreased overall survival in old and young age groups, serous, clear cell, carcinosarcoma, and mixed histology groups, stage T1a disease, and staged and unstaged cases, but not for stage T1b disease. Difference in 5-year overall survival rates between the malignant and negative peritoneal cytology groups was particularly large among those with clear cell histology (24.0%), stage T1a disease (19.4%), aged >78 years (18.2%), and serous tumors (17.6%). ConclusionMalignant peritoneal cytology can be prevalent in stage I non-endometrioid endometrial cancer. Our study suggests that malignant peritoneal cytology is a prognostic factor for decreased survival in stage I non-endometrioid endometrial cancer.

Clinical nomogram for lymph node metastasis in pathological T1 esophageal squamous cell carcinoma: a multicenter retrospective study

BackgroundEndoscopic resection is increasingly used to treat pathological T1 (pT1) esophageal cancer (EC) patients. However, the procedures are limited by lymph node metastasis (LNM) and remain controversial. We aimed to construct a nomogram to predict the risk of LNM in patients with pT1 esophageal squamous cell carcinoma (ESCC).MethodsA total of 243 patients with pT1 ESCC who underwent esophagectomy and lymph node dissection at two different institutes between February 2013 and June 2019 were analyzed retrospectively. Patients were categorized into the negative group and the positive group according to whether there was LNM. Risk factors for LNM were evaluated by univariate and multivariate analyses. The nomogram was used to estimate the individual risk of LNM.ResultsForty-six (18.9%) of the 243 patients with pT1 ESCC exhibited LNM. The LNM rate in patients with stage T1a disease was 5.7% (5/88), and the rate in patients with stage T1b disease was 26.5% (41/155). Multivariable logistic regression analysis showed that tumor differentiation [odds ratio (OR) =1.942, 95% confidence interval (CI): 1.067–3.536, P=0.030], the T1 sub-stage (OR =4.750, 95% CI: 1.658–13.611, P=0.004), the preoperative alanine aminotransferase/aspartate aminotransferase ratio (LSR) (OR =5.371, 95% CI: 1.676–17.210, P=0.005), and the high-density lipoprotein cholesterol (HDL-C) level (OR =5.894, 95% CI: 1.917–18.124, P=0.002) were independent risk factors for LNM. The nomogram had relatively high accuracy, with an area under the receiver operating characteristic curve (AUC) of 0.803 (95% CI: 0.732–0.873). The calibration curve showed that the predicted probability of LNM was in good agreement with the actual probability.ConclusionsClinicopathological and hematological parameters of tumor differentiation, the T1 sub-stage, the preoperative LSR, and the HDL-C level may predict the risk of LNM in T1 ESCC. The risk of LNM can be predicted by the nomogram.

Optimal Lymph Node Examination and Adjuvant Chemotherapy for Stage I Lung Cancer

ObjectiveTo determine the optimal number of lymph nodes (LNs) examined and the role of adjuvant chemotherapy in stage I lung cancer. MethodsThe National Cancer Database was queried for surgically treated patients with pathologic stage I lung cancer between 2006 and 2014 (N = 65,438). The optimal LN numbers were determined in the multivariate Cox model and were further validated in the cohort with clinical stage I disease (N = 117,112) in terms of nodal upstaging and prognostic stratification. The role of adjuvant chemotherapy in patients with suboptimal staging (number of LNs examined was less than than the optimum) was evaluated in each T stage. ResultsThe number of LNs examined correlated with tumor size (p < 0.001). There were increasing survival benefits with each additional LN examined—up to eight, nine, 10, and 11 nodes for patients with T1a, T1b, T1c, and T2a, respectively. Validation from the cohort with clinically staged disease showed that the threshold of eight to 11 LNs was an independent predictor of nodal upstaging (OR = 1.706, 95% confidence interval [CI] 1.608–1.779) and survival outcome (hazard ratio = 0.890, 95% CI: 0.865–0.916). After propensity matching, adjuvant chemotherapy was associated with improved survival in patients with stage T2a disease having suboptimal staging (hazard ratio = 0.841, 95% CI: 0.714–0.990), but not in patients with stage T1a to T1c disease. ConclusionLN evaluation was important for accurate staging and adequate treatment, and examinations of an increasing number of nodes for progressively higher T components (i.e., eight, nine, 10, and 11 nodes for T1a, T1b, T1c, and T2a tumors, respectively) seemed crucial to predict upstaging and survival outcomes. Adjuvant chemotherapy might be beneficial to patients with stage T2a disease who have suboptimal nodal staging.

Mucinous borderline ovarian tumor versus invasive well-differentiated mucinous ovarian cancer: Difference in characteristics and outcomes

ObjectiveMucinous borderline ovarian tumor (mucinous-BOT) and invasive well-differentiated mucinous ovarian cancer (mucinous-OC) are often histopathologically misclassified. The objective of this study was to examine differences in clinico-pathological characteristics and outcomes of these two entities. MethodsThis is a retrospective population-based study examining the Surveillance, Epidemiology, and End Results Program from 1988 to 2000. Stage I mucinous-BOTs and stage I well-differentiated mucinous-OC were compared for patient demographics, tumor characteristics, and outcomes. Propensity score matching and multivariable analysis were used to assess cause-specific survival (CSS). ResultsA total of 2130 mucinous-BOT and 581 mucinous-OC cases were examined for analysis. On multivariable analysis, women with mucinous-OC were more likely to be older, Eastern U.S. residents, and have undergone hysterectomy or lymphadenectomy compared to those with mucinous-BOT, and the number of women diagnosed with mucinous-OC decreased over time (all, P < 0.05). Mucinous-OCs were more likely to be stage T1c and have a smaller tumor size as compared to mucinous-BOT (both, adjusted-P < 0.05). After propensity score matching, women with mucinous-OC had significantly poorer CSS compared to those with mucinous-BOT on multivariable analysis (10-year rates: 92.7% versus 97.5%, adjusted-hazard ratio [HR] 2.03, P = 0.007). Similar results were observed among subgroups for reproductive age, stage T1a disease, large tumor, and unstaged cases (all, P < 0.05). ConclusionStage I mucinous-BOT and stage I invasive well-differentiated mucinous-OC have distinct differences in clinical characteristics and patient survival. The inability to conduct centralized pathology review in our study limits our conclusions given the recognized issue of misclassification of mucinous-BOT and mucinous-OC, but further highlights the importance of making the proper histopathological diagnosis for invasive cancer when the ovarian tumor is of mucinous histology.

The First Year of the AEVD Primary Cutaneous Lymphoma Registry

Background and objectivePrimary cutaneous lymphomas are uncommon. This article describes the Primary Cutaneous Lymphoma Registry of the Spanish Academy of Dermatology and Venereology (AEDV) and reports on the results from the first year. Patients and methodsDisease registry for patients with primary cutaneous lymphoma. The participating hospitals prospectively recorded data on diagnosis, treatment, tests, and disease stage for all patients with primary cutaneous lymphoma. A descriptive analysis was performed. ResultsIn December 2017, the registry contained data on 639 patients (60% male) from 16 university hospitals. The most common diagnoses, in order of frequency, were mycosis fungoides/Sézary syndrome (MF/SS) (348 cases, 55%), primary cutaneous B-cell lymphoma (CBCL) (184 cases, 29%), primary cutaneous CD30+ T-cell lymphoproliferative disorder (CD30+ CLPD) (70 cases, 11%), and other types of T-cell lymphoma (37 cases, 5%). In total, 105 (16.5%) of the cases recorded were incident cases. The most common diagnosis in the MF/SS group was classic MF (77.3%). Half of the patients with MF had stage IA disease when diagnosed, and the majority were either in partial remission (32.5%) or had stable disease (33.1%). The most widely used treatments were topical corticosteroids (90.8%) and phototherapy. The most common form of primary CBCL was marginal zone lymphoma (50%). Almost all of the patients had cutaneous involvement only and nearly half had stage T1a disease. Most (76.1%) were in complete remission. The main treatments were surgery (55.4%) and radiotherapy (41.9%). The most common diagnosis in patients with CD30+ CLPD was lymphomatoid papulosis (68.8%). Most of the patients (31.4%) had stage T3b disease and half were in complete remission. The most common treatments were topical corticosteroids (68.8%) and systemic chemotherapy (32.9%). ConclusionThe characteristics of patients with primary cutaneous lymphoma in Spain do not differ from those described in other series in the literature. The registry will facilitate clinical research by the AEDV's lymphoma group.

Registro de linfomas cutáneos primarios de la AEDV: primer año de funcionamiento

Background and objectivePrimary cutaneous lymphomas are uncommon. This article describes the Primary Cutaneous Lymphoma Registry of the Spanish Academy of Dermatology and Venereology (AEDV) and reports on the results from the first year. Patients and methodsDisease registry for patients with primary cutaneous lymphoma. The participating hospitals prospectively recorded data on diagnosis, treatment, tests, and disease stage for all patients with primary cutaneous lymphoma. A descriptive analysis was performed. ResultsIn December 2017, the registry contained data on 639 patients (60% male) from 16 university hospitals. The most common diagnoses, in order of frequency, were mycosis fungoides/Sézary syndrome (MF/SS) (348 cases, 55%), primary cutaneous B-cell lymphoma (CBCL) (184 cases, 29%), primary cutaneous CD30+ T-cell lymphoproliferative disorder (CD30+ CLPD) (70 cases, 11%), and other types of T-cell lymphoma (37 cases, 5%). In total, 105 (16.5%) of the cases recorded were incident cases. The most common diagnosis in the MF/SS group was classic MF (77.3%). Half of the patients with MF had stage IA disease when diagnosed, and the majority were either in partial remission (32.5%) or had stable disease (33.1%). The most widely used treatments were topical corticosteroids (90.8%) and phototherapy. The most common form of primary CBCL was marginal zone lymphoma (50%). Almost all of the patients had cutaneous involvement only and nearly half had stage T1a disease. Most (76.1%) were in complete remission. The main treatments were surgery (55.4%) and radiotherapy (41.9%). The most common diagnosis in patients with CD30+ CLPD was lymphomatoid papulosis (68.8%). Most of the patients (31.4%) had stage T3b disease and half were in complete remission. The most common treatments were topical corticosteroids (68.8%) and systemic chemotherapy (32.9%). ConclusionThe characteristics of patients with primary cutaneous lymphoma in Spain do not differ from those described in other series in the literature. The registry will facilitate clinical research by the AEDV's lymphoma group.

Histologic subtype needs to be considered after partial nephrectomy in patients with pathologic T1a renal cell carcinoma: papillary vs. clear cell renal cell carcinoma.

We compared the oncological outcomes of papillary renal cell carcinoma (pRCC) with clear cell renal cell carcinoma (ccRCC) after partial nephrectomy (PN) in patients with pathologic T1a RCC. After excluding patients with synchronous multiple renal tumors, familial RCC, and pathologic stage T1b or above, 759 patients with ccRCC and 84 patients with pRCC were included. We assessed the impact of histologic subtypes on oncologic outcomes after PN in patients with pathologic T1a RCC (median follow-up duration, 67months). There was no difference in patient and tumor characteristics between the 2 groups, except Fuhrman grade (p=0.006). Kaplan-Meier analysis identified 5-year recurrence-free survival of 98.7 and 95.6% in patients with ccRCC and pRCC, respectively. However, 10-year recurrence-free survival in patients with ccRCC and pRCC was 96.1 and 73.0%, respectively (p<0.001). Recurrence≥5 years post surgery was more common in patients with pRCC compared with those with ccRCC (0.3 vs. 4.8%; p<0.001). In multivariate analysis, pRCC [hazard ratio (HR) 5.309; p=0.001] was a significant risk factor for recurrence after PN in patients with pathologic T1a RCC, in addition to larger tumor size (HR 1.861; p=0.038) and Fuhrman grade≥3 (HR 5.176; p=0.003). In patients with pathologic T1a RCC, recurrence after PN occurred more commonly in pRCC compared with ccRCC. As over half of the recurrence cases in patients with pRCC occurred≥5years post surgery, a longer follow-up time is required, even for those with pathologic stage T1a disease.

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

ObjectiveTo examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery. MethodsThis is a retrospective study examining The Surveillance, Epidemiology, and End Results Program to identify surgically-treated stage T1 BOTs between 1988 and 2003 (n=4943). Association of surgery patterns and cause-specific survival (CSS) was examined in multivariable analysis. ResultsMean age was 48.7. The majority had stage T1a disease (75.3%). Median follow-up was 15.6years and 159 (3.2%) women died of BOTs. Hysterectomy and lymphadenectomy were performed in 1909 (38.6%) and 1295 (26.2%) cases, respectively. Most commonly, neither procedure was performed (46.5%), followed by hysterectomy alone (27.3%), lymphadenectomy alone (14.9%), and both procedures (11.3%). Surgery patterns for hysterectomy and lymphadenectomy significantly differed across age, ethnicity, marital status, registry area, year at diagnosis, histology type, sub-stage, and tumor size (all, P<0.001). On multivariable analysis, surgery patterns for hysterectomy and lymphadenectomy were not associated with CSS: 20-year rates for neither hysterectomy and lymphadenectomy 96.7%, hysterectomy alone 94.5%, lymphadenectomy alone 95.7%, and both procedures 95.2% (adjusted-P>0.05). Age≥50, T1b-c stages, and mucinous histology remained independent prognostic factors for decreased CSS (all, P<0.05). Among 3723 women with stage T1a disease, hysterectomy and lymphadenectomy patterns were not associated with CSS in 2115 women aged <50 (P=0.14) and 1608 women aged ≥50 (P=0.48). ConclusionOur study suggests that both hysterectomy and lymphadenectomy may be omitted in the surgical management of women with stage T1 BOTs, especially for those with T1a disease regardless of age.

Treatment outcomes of the patients with early glottic cancer treated with initial radiotherapy and salvaged by conservative surgery.

This retrospective study analyzed the oncological and treatment outcomes of the patients with T1-T2N0 glottic cancer, who were treated with radiotherapy as initial treatment and salvaged by conservative surgery for radiation failure. Between May 1999 and December 2010, 115 patients with glottic laryngeal cancer were treated at Kobe University Hospital. At presentation, 54 patients had stage T1a disease, 26 had stage T1b disease and 35 had stage T2 disease. Seventy-nine patients were treated with conventional radiotherapy and 36 patients were treated with hyperfractionated radiotherapy as initial treatment. Median duration of follow-up was 61 months. Five-year local control rates of radiotherapy were 92% in T1a, 83% in T1b and 86% in T2. Of 12 patients who developed local recurrence, larynx was successfully preserved in 3 patients by laryngomicrosurgery, 7 patients by vertical partial laryngectomy and one patient by subtotal laryngectomy. Ultimate 5-year laryngeal preservation rate and local control rate of all cases were 99 and 100%, respectively. Present results suggest that initial treatment with radiotherapy salvaged by organ preservation surgery is an effective strategy for laryngeal preservation in the treatment of T1-T2N0 glottic laryngeal cancer.

Prognostic role of substaging in T1G3 transitional cell carcinoma of the urinary bladder.

This study was conducted to test a new substaging system in a population of patients with stage T1 bladder cancer (BC) at diagnosis and assess its prognostic role in terms of disease progression and disease-specific survival (DSS). Patients with primary stage T1G3 urothelial carcinoma of the bladder were stratified according to the following models: i) T1a [the tumour does not infiltrate the muscularis mucosae-vascular plexus, (MM-VP)]; T1b (the tumour partially infiltrates the MM-VP); and T1c (the tumour infiltrates and invades the MM-VP). ii) T1m (diameter of tumour infiltrating the lamina propria ≤0.5 mm under a high-resolution microscope; and T1e (diameter of tumour infiltrating the lamina propria >0.5 mm). Age, gender, tumour size and multifocality were not found to be of statistical significance. Using the T1a/T1b/T1c system, patients with stage T1a disease exhibited a 5- and 10-year progression rate of 13.3 and 20%, respectively, without reaching statistical significance. Moreover, patients with stage T1a disease exhibited a 5- and 10-year DSS of 93.3 and 73.3%, respectively, which was higher compared to T1b and T1c but not statistically significant. Using the T1m/T1e system, patients with stage T1m disease exhibited a disease progression rate of 8.3 and 16.7% at 5 and 10 years, respectively, which was not statistically significant. Moreover, patients in group T1m presented with DSS rates of 91.7 and 83.3% at 5 and 10 years, respectively, which were higher compared to those in the T1e group (71.4 and 60.7%), although not reaching statistical significance. In conclusion, in our study, neither of the two substaging systems of stage T1 BC reached the prognostic conventional significance level for tumour progression or DSS.

Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: a population-based study

Outcome data comparing endoscopic eradication therapy (EET) and esophagectomy are limited in patients with early esophageal cancer (EC). To compare overall survival and EC-related mortality in patients with early EC treated with EET and esophagectomy. Population-based study. Patients with early EC (stages T0 and T1) were identified from the Surveillance, Epidemiology, and End Results database (1998-2009). Demographics, tumor specific data, and survival were compared. Cox proportional hazards regression models were used to evaluate the association between treatment and EC-specific mortality. EET and esophagectomy. Mid- (2 years) and long- (5 years) term overall survival and EC-specific mortality, outcomes based on histology and stage, treatment patterns, and predictors of cancer-specific mortality. A total of 430 (21%) and 1586 (79%) patients underwent EET and esophagectomy, respectively. There was no difference in the 2-year (EET: 10.5% vs esophagectomy: 12.7%, P = .27).and 5-year (EET: 36.7% vs esophagectomy: 42.8%, P = .16) EC-related mortality rates between the 2 groups. EET patients had higher mortality rates attributed to non-EC causes (5 years: 46.6% vs 20.6%, P < .001). Similar results were noted when comparisons were limited to patients with stage T0 and T1a disease and esophageal adenocarcinoma. There was no difference in EC-specific mortality in the EET compared with the surgery group (hazard ratio 1.4; 95% confidence interval, 0.9-2.03). Variables associated with mortality were older age, year of diagnosis, radiation therapy, higher stage, and esophageal squamous cell carcinoma. Comorbidities and recurrence rates were not available. This population-based study demonstrates comparable mid- and long-term EC-related mortality in patients with early EC undergoing EET and surgical resection.

Commentary on “Off-clamp vs. complete hilar control laparoscopic partial nephrectomy: Comparison by clinical stage.” Rais-Bahrami S, George AK, Herati AS, Srinivasan AK, Richstone L, Kavoussi LR, Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, NY: BJU Int 2012;109(9):1376–81 (Epub 2011 Oct 12)

Study type-therapy (case series). Level of evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp (OC) laparoscopic partial nephrectomy (LPN) have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated OC LPN for tumors with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared with a contemporary cohort of standard LPN with complete hilar clamping performed by a single surgeon. To compare the operative outcomes and oncological efficacy of OC LPN vs. complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). Perioperative and postoperative parameters were analyzed comparing patients who underwent OC LPN (n = 126) with those who had HC LPN (n = 264) collectively and within each clinical stage cohort. There was no significant difference in the proportion of OC LPN for cT1a tumors compared with cT1b and cT2, P = 0.21. OC vs. HC LPN patients had a greater estimated blood loss but with no significant difference in perioperative blood transfusion rates. When compared by clinical stage, estimated blood loss was greater only for clinical stage T1a disease (P = 0.02) but not cT1b (P = 0.91) or cT2 (P = 0.42) tumors. There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P = 0.77 and P = 0.17), cT1b (P = 0.77 and P = 0.07) and cT2 (P = 0.42 and P = 0.66), respectively. In our series, 1 case (0.3%) of HC LPN had a positive margin on final pathology, 1 case was converted to open partial nephrectomy (0.3%), and 2 cases of OC LPN (1.6%) were intraoperatively converted to HC LPN. OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischemic injury, with the benefits of minimally invasive surgery. LPN can be performed OC in patients with larger, more complex renal tumors without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN.

Predictive Factors for Late Recurrence in Patients With Stage T1 Clear Cell Renal Cell Carcinoma: A Multiinstitutional Study

BackgroundThe purpose of this study was to identify predictive factors for late recurrence in Korean patients with stage T1 clear cell renal cell carcinoma (RCC) more than 5 years after treatment with radical nephrectomy (RN) or partial nephrectomy (PN). Patients and MethodsBetween 1999 and 2011, 3567 patients with RCC underwent RN or PN at 5 institutions in Korea. Of these, 423 patients with pathologically confirmed stage T1 clear cell RCC remained free of disease for at least 5 years. To determine the pathologic and clinical factors that influenced late recurrence, univariate and multivariate analyses using the Cox proportional hazards model were performed. Recurrence-free survival curves were estimated by using the Kaplan-Meier method. ResultsDuring a median follow-up period of 83.9 months (range 60.0-156.4 months), late recurrence was observed in 14 of the 423 (3.3%) patients. Univariate and multivariate analyses revealed that symptoms at diagnosis and pathologic T stage were independent predictive factors for late recurrence. Patients with symptoms at diagnosis or stage T1b disease had a significantly shorter time to late recurrence than did those who were asymptomatic or had stage T1a disease (log-rank test P = .027 and P = .034, respectively). ConclusionsLate recurrence in stage T1 clear cell RCC is a relatively rare event. Predictive factors for late recurrence were identified in the present study. Careful long-term follow-up is necessary, especially in patients who have symptoms at diagnosis or stage T1b tumors, even if they have been free of disease for more than 5 years.

Preoperative Predictors of Pathologic Stage T2a in Low-Risk Prostate Cancer: Implications for Focal Therapy

Objective: To assess preoperative parameters that may be predictive of pathologic stage T2a disease in low-risk prostate cancer patients. Methods: Data from a cohort of 1,495 consecutive men with low-risk prostate cancer who underwent a radical prostatectomy between 1993 and 2009 were evaluated. Preoperative parameter assessment focused on age, race, clinical stage, diagnostic PSA level, biopsy tumor laterality and diagnostic Gleason score. Preoperative parameters were analyzed by univariate and multivariate methods. Kaplan-Meier method was used to evaluate the biochemical disease-free survival. Results: Among the 1,495 men, 236 (15.8%) had pT2a disease. In univariate analysis, biopsy tumor unilaterality (p < 0.001), diagnostic PSA ≤4 ng/ml (p < 0.001) and non-African-American race (p = 0.009) were significant variables. In multivariate analysis, biopsy tumor laterality (OR 0.377; p < 0.001), diagnostic PSA ≤4 ng/ml (OR 0.621; p = 0.002) and race (OR 0.583; p = 0.029) were independent predictors. Low-risk patients with pT2a disease showed a better PSA recurrence-free survival rate, compared with men with >pT2a diseases (p = 0.012). Conclusions: Biopsy tumor unilaterality, diagnostic PSA ≤4 ng/ml and race are independent predictors of pT2a in low-risk prostate cancer. These three preclinical variables may be a useful reference to begin the selection process for focal therapy in men with low-risk prostate cancer.

Is Limited Resection Appropriate for Radiologically “Solid” Tumors in Small Lung Cancers?

Small lung cancers showing a wide area of ground-grass opacity (GGO) on thin-section computed tomography (CT) are considered good candidates for limited surgical resection because of its minimally invasive nature. Conversely, the validity of limited resection for radiologically "solid" tumors is still controversial in small non-small cell lung carcinomas. Between 2008 and 2010, 680 consecutive patients underwent pulmonary resection for lung cancer. The findings obtained by preoperative CT were reviewed for all 680 patients and categorized as pure GGO, mixed GGO, or purely solid. All patients were evaluated by positron emission tomography (PET) and the maximum standardized uptake value (SUV(max)) was recorded. Several clinicopathologic features were investigated to identify predictors of hilar or mediastinal lymph node metastasis using univariate or multivariate analysis. Two hundred twenty-seven of the patients with clinical stage IA lung cancer showed a solid or mixed GGO appearance on thin-section CT. Among them, nodal involvement was found pathologically in 42 (26%) patients with pure solid tumors, but in only 4 (6%) patients with mixed GGO tumors (p = 0.0002). Among the 131 patients with stage T1a disease, 94 (71.8%) had solid tumors, and nodal involvement was observed in 15 (16.0%). Among the 94 pure solid stage T1a tumors, the carcinoembryonic antigen (CEA) level and SUV(max) were significant predictors of lymph node involvement by tumor based on a multivariate analysis. The frequency of lymph node metastasis was approximately 27% for patients with pure "solid" lung cancer and high SUV(max), even for stage T1a tumor. Lymph node metastasis is frequently observed for pure solid lung cancer, especially for tumors that show a high SUV(max). If limited resection is indicated for solid lung cancer, a thorough intraoperative evaluation of lymph nodes is needed to prevent locoregional failure.

Off‐clamp versus complete hilar control laparoscopic partial nephrectomy: comparison by clinical stage

Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp laparoscopic partial nephrectomy have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated off-clamp laparoscopic partial nephrectomy for tumours with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared to a contemporary cohort of standard laparoscopic partial nephrectomy with complete hilar clamping performed by a single surgeon. • To compare the operative outcomes and oncological efficacy of off-clamp (OC) laparoscopic partial nephrectomy (LPN) vs complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. • Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). • Perioperative and postoperative parameters were analysed comparing patients who underwent OC LPN (n= 126) with those who had HC LPN (n= 264) collectively and within each clinical stage cohort. • There was no significant difference in the proportion of OC LPN for cT1a tumours compared with cT1b and cT2, P= 0.21. • OC vs HC LPN patients had a greater estimated blood loss (EBL) but with no significant difference in perioperative blood transfusion rates. • When compared by clinical stage, EBL was greater only for clinical stage T1a disease (P= 0.02) but not cT1b (P= 0.91) or cT2 (P= 0.42) tumours. • There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P= 0.77 and P= 0.17), cT1b (P= 0.77 and P= 0.07) and cT2 (P= 0.42 and P= 0.66), respectively. • In our series, one case (0.3%) of HC LPN had a positive margin on final pathology, one case was converted to open partial nephrectomy (0.3%), and two cases of OC LPN (1.6%) were intraoperatively converted to HC LPN. • OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischaemic injury with the benefits of minimally invasive surgery. • LPN can be performed OC in patients with larger, more complex renal tumours without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN.

Persistent Overuse of Radical Nephrectomy in the Elderly

To analyze the use of radical nephrectomy (RN) and partial nephrectomy during a 10-year period in patients aged≥75 years compared with their younger counterparts. Using the Surveillance, Epidemiology, and End Results registry, we identified 18 045 cases of localized renal cell carcinoma of ≤4 cm diagnosed from 1998 to 2007. The baseline differences in demographic and tumor characteristics were compared between the 2 age cohorts (<75 vs ≥75 years), and the rates of RN were determined, stratified by tumor size. A multivariate logistic regression analysis was conducted to predict the odds of undergoing radical nephrectomy for clinical Stage T1a disease. Overall, 2733 patients (15%) were aged≥75 years. The use of radical nephrectomy for clinical Stage T1a renal cell carcinoma decreased during the study period for all patients (79% in 1998 to 49% in 2007). Overall, 66% of patients aged≥75 years underwent RN for their disease compared with 59% of patients aged<75 years (P<.001). For patients with tumors of ≤2 cm, 51% of those aged≥75 years underwent RN compared with 41% of the younger cohort. In a multivariate logistic regression model, age≥75 years independently predicted the use of radical nephrectomy (odds ratio 1.18, 95% confidence interval 1.08-1.29). A 1-year increase in age was associated with a 1% increase in the risk of undergoing RN (odds ratio 1.01, 95% confidence interval 1.01-1.01). Elderly patients with clinically localized small renal masses are treated with RN more frequently than younger patients. Additional studies should address the medical implications of the increased use of radical surgery within the geriatric population.

285 True recurrences and new primary tumours have different clinical features in invasive breast cancer patients with ipsilateral breast tumour relapse after breast-conserving treatment

We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morpho-metrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence.Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or a PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%. Using this model, we accurately predicted 73% of cases with insignificant tumor. Although most impalpable prostate cancers diagnosed by needle biopsy are significant tumors that warrant definitive therapy, it may be reasonable to follow some patients whose tumors are most likely insignificant with serial PSA measurements and repeat biopsies.