T1 Cancer Research Articles

The ACPGBI recommends pause for reflection on transanal total mesorectal excision.

The ACPGBI recommends pause for reflection on transanal total mesorectal excision.

The impact of endoscopic submucosal dissection for gastric adenocarcinomas in the United States

Recent studies show promise for endoscopic submucosal dissection (ESD) in the United States, but do not identify the potential impact of ESD among newly diagnosed gastric cancers. We utilize the Veterans Health Administration to identify cancers suitable for ESD, to define the role of ESD in the United States. Retrospective cohort study using the Veterans Affairs Central Cancer Registry to identify patients with gastric cancer who underwent surgical resection from 1995 to 2018. TNM stage was used to categorize those who would meet absolute vs expanded indications for ESD. Primary outcome was lymph node status. Secondary analysis was performed with death as outcome. Of 12,584 primary gastric cancers, 4735 (37.6%) were nonmetastatic gastric adenocarcinomas. Median age at diagnosis was 70.3 years, 4676 (98.8%) male. Total 2306 (48.7%) underwent surgical resection, of which 636 (27.6%) were T1 lesions or cancer in situ. Of these, 44 (6.9%) met absolute indications for resection, 99 (15.6%) met established expanded criteria, and 98 (15.4%) may meet expanded criteria. Half of all tumors in each group were proximal in location. Rate of lymph node positivity was: 4.5%; 95% confidence interval [CI]: 0.5-15.5% in absolute group; 8.1%; 95% CI: 3.6-15.3% in expanded group; 13.3%; 95% CI: 7.3-21.6 in those potentially meeting expanded criteria. Lymph nodes positivity was associated with death (hazard ratio 1.49; 95% CI: 1.36-1.62, P < 0.001). Less than 10% of T1 or in situ cancers meet absolute criteria for ESD. Those that meet expanded criteria had higher risk for lymph node metastases, particularly proximal tumors. Future studies should evaluate the safety of ESD in proximal gastric tumors.

Mo1651 GENOMIC LANDSCAPES OF EARLY-STAGE UC-ASSOCIATED CANCER IN THE JAPANESE POPULATION

Patients with ulcerative colitis (UC) have an increased risk of developing colorectal cancer, known as UC-associated cancer (UCAC). Previous studies have shown that UCACs differ from colorectal tumors that develop in patients without UC, known as sporadic colorectal cancer (CRC), by mutation analysis of a limited number of genes. Although several studies on genomic alterations of advanced-stage UCACs have been reported, there are no reports on UCACs at early-stage. To fill in this knowledge gap, we investigated somatic alterations in UCACs atearly-stage. We extracted DNA from 36 early-stage colorectal tumor tissues (T1 cancer 9, Dysplasia 27) from 32 UC patients using microdissection and performed targeted sequencing of 43 genes that were reported to be strongly associated with Japanese UCACs in a previous report. Mutations from each cancer tissue were compared with counterpart dysplasia tissue and normal colitic mucosa tissue. We found 16 genes that were mutated in more than 3 patients and had a mutation rate of more than 10 mutations/Mb. The most frequently mutated gene in cancers of UC patients was APC (mutated in 47.2% of our cohort), followed by TP53 (44.4%), KRAS (27.8%), PRKDC (27.8%), CSMD3 (22.2%), LTBP4 (13.9%), KIF26B (13.9%), CREBBP (13.9%), TCF7L2 (11.1%), EP300 (11.1%), and ATM (11.1%). Next, we divided 36 early-stage colorectal tumors into 23 UC-associated colorectal neoplasms (UCANs) and 13 colorectal sporadic neoplasms with UC (UCSNs) and compared the mutated frequency of each gene between the UCAN and UCSN groups. We found a significantly higher frequency of somatic mutations of TP53 in the UCAN group than in the UCSN group. Moreover, only 1 out of 6 low-grade dysplasia surrounding UCANs with TP53 mutations had TP53 mutations themselves. In addition, among 11 UCACs tested for p53 immunostaining, all 7 lesions with TP53 somatic mutation were positive for p53 immunostaining and all 4 lesions without the TP53 somatic mutation were negative for p53 immunostaining. Finally, we compared the mutated frequency of each gene in the UCAN and UCSN groups with that of advanced UCAC and sporadic CRCs cases from the literature and The Cancer Genome Atlas. As a result of consideration, there was no difference in the frequency of TP53 somatic mutations between UCAN group, advanced UCAC cases, and TCGA's sporadic CRCs; however, the frequency of TP53 somatic mutations in UCSN groups was significantly lower than that in other 3 groups. TP53 mutations could be biomarkers to distinguish between UCAN and UCSN in early stages. Furthermore, the results of this research suggest that TP53 mutations could occur during the transition from low-grade dysplasia to high-grade dysplasia in UCANs.

Mo1679 OUTCOMES OF ENDOSCOPIC RESECTION VERSUS LAPAROSCOPIC SURGERY FOR SUBMUCOSALLY INVASIVE COLORECTAL CANCERS: AN OBSERVATIONAL STUDY

Endoscopic resection (ER) has a distinct advantage for removing submucosally invasive (T1) colorectal cancers. Endoscopic submucosal dissection (ESD) enables en bloc resection regardless of tumor size, and offers appropriate treatment allowing precise histological assessment. The indications for laparoscopic colectomy (LC) overlap with those for ER. The aim of this study was to reconsider the treatment strategy for T1 cancers by comparing outcomes between ER and LC. Patients with T1 colorectal cancers resected from May 2013 to December 2018 in one institution were reviewed. Synchronous multiple cancers in any organs were excluded. T1 cancers were classified as T1a (<1mm invasion) or T1b (≥1mm invasion). Patients followed appropriate clinical pathways. Outcome measures included background characteristics, short-term and long-term outcomes. Complications are classified by Clavien-Dindo grades. Eighty-one patients (female 30, male 51; mean age 68.5±11.3 years) underwent ER (ESD 43%, endoscopic mucosal resection (EMR) 38%, polypectomy 19%) and 87 patients (female 36, male 51; mean age 67.3±10.6 years) underwent LC (additional LC after ER 57%, laparotomy 1%). There were no differences in age or gender between ER and LC, but a significant difference was observed in the proportion of T1b (ER65% vs. LC90%, p<0.0001). En bloc resection rate of ER was 91% (74/81, piecemeal; ESD 2, EMR 5). In ER, Clavien-Dindo grade II complications occurred in 9.9% (8/81; post-bleeding 5, intraprocedural perforation 2, post-penetration 1), all treated endoscopically or nonoperatively. In LC, Clavien-Dindo grade II or greater complications occurred in 9.2% (8/87; anastomotic leakage 2, severe delirium 2, intestinal perforation 1, intestinal obstruction 1, intraabdominal abscess 1 and anastomotic hemorrhage 1), and 2 patients underwent surgical intervention. Median days to oral intake (ER 1, LC 2, p = 0.0188) and hospital stay (ER 3, LC 9, p <0.00001) were shorter in ER. Quality of life was decreased in one patient with anastomotic leakage. Median observation time (interquartile range, months) was 26.7 (14.5-47.6) in ER alone (n=39), 34.0 (22.0-46.9) in LC alone (n=37) and 48.1 (24.1-61.1) in LC after ER (n=50). Recurrence occurred in one patient who had severe venous invasion in the specimen removed by ER, and a hepatic metastasis was detected and resected 49 weeks later, with no recurrence 5 years after surgery. ER was less invasive treatment for T1 cancers with shorter hospital stay and less frequent serious complications compared with LC. Although the observation period was short, recurrence rarely occurred when standard management was provided. A treatment strategy to precede ER and add LC based on histological assessment is recommended.

Mo1630 ENDOSCOPIC FULL THICKNESS RESECTION VERSUS ENDOSCOPIC SUBMUCOSAL DISSECTION IN COLORECTAL NEOPLASIA THERAPY – BICENTRIC PROSPECTIVE RANDOMIZED STUDY

Colorectal neoplasia can be treated by several established endoscopic methods such as endoscopic submucosal dissection (ESD). Recently new method allowing the endoscopic full thickness resection (EFTR) of the colorectal wall has been introduced. Bicentric (2 academic tertiary centers) prospective randomized study comparing two methods (newly available EFTR versus standardized ESD) in endoscopic therapy of colorectal neoplasia (size ≤ 3 cm) with high risk of incomplete removal. Primary endpoint was R0 resection. Analysis was done by Fisher exact test and Mann-Whitney test and interim data are presented. 35 patients were included (71 % men, mean age 66 years), main indication were T1 cancers (46 %), non-lifting adenomas (29 %) and local residual neoplasia (23 %). EFTR was technically successful in 90 % and ESD in 94 % (p-value 0.999). Comparing the lesions treated by EFTR (N = 19; 54 %) and ESD (N = 16; 46 %), the mean size was 18 mm and 20 mm respectively (both groups range 10 – 30 mm), the localization was dominantly in right colon (63 %) for EFTR group and rectum (62 %) for ESD group. In both groups most lesions were assessed as 0-IIa + II c (26 % and 50 % respectively) according to the Paris classification. The histopathology results for EFTR and ESD were as follows: 14 benign lesions (40 %; 64 % of them with high-grade dysplasia) and 21 (60 %) malignant lesions (7 intramucosal cancers, 12 T1 cancers and two T2 cancers). R0 resection was achieved in 17 patients (90 %) in EFTR group and 13 patients (81 %) in ESD group (p-value 0,785), curative resection of malignant lesions was performed in 46 % (5/11; EFTR) and 60% (6/10; ESD) patients (p-value 0,670). There were 4 cases of perforation (11%; all in ESD group), 2 (6 %) were treated endoscopically and in 2 cases (6 %) surgical therapy was necessary. Both EFTR and ESD are technically effective methods for therapy of colorectal neoplasia with high risk of incomplete removal. EFTR is non-significantly superior in achieving R0 resections and ESD is more effective in early cancers curative resections. EFTR seems to be more safe method comparing to ESD.

Mo1689 DOUBLE SCOPE COLORECTAL ESD USING A GEL-BASED TAMIS ACCESS PLATFORM

Endoscopic submucosal dissection (ESD) is a promising endoscopic procedure that is increasingly being used for endoscopic resection of large colorectal lesions that may be difficult to remove en-bloc by snare polypectomy. The greatest challenge for ESD remains technical difficulty in achieving optimal traction. In the following study, we evaluate the use of Gel-based Transanal Access Platform, typically used for Transanal Minimally Invasive Surgery (TAMIS) to facilitate ESD of colorectal lesions by facilitating use of two separate endoscopes simultaneously. Patients undergoing colorectal ESD were consented for use of this device during their procedure. If difficulty with traction occurred during the submucosal dissection portion of the procedure, the device was employed as follows: A 4x4 cm Gel based-TAMIS access device was inserted into the anal canal. Two access holes were made in the gel cover 2cm apart with the pre-supplied trocars to allow for the passage of a 1T therapeutic gastroscope and an ultraslim gastroscope. After submucosal injection and circumferential incision, the pediatric forceps were passed through the working channel of the ultraslim scope, and the edge of the lesion was grasped and then manipulated to allow for dynamic traction of the lesion. Outcomes measured included procedure time, traction assessment, interference between two scopes and adverse events including anal discomfort and post procedure incontinence. Over the study period 5 subjects have required the TAMIS device to assist with traction. All cases have been performed by a single endoscopist. The average procedure time with use of the device over 5 cases was 19mins per 1cm of lesion. Traction was felt to be excellent in all cases. There was minimal to no interference with the second scope. All cases resulted in en-bloc and R0 resections. 1 case was a T2 cancer with R0 resection. 1 case was intramucosal cancer. 3 cases were tubulovillous adenoma with high grade dysplasia. There were no complications in all 5 cases. Zero patients complained of anorectal pain after the procedure or experienced incontinence. By using a commercially available Transanal Access Platform for the first time in an endoscopic procedure, there was greater ease performing ESD. This device allowed the insertion of an additional scope which provided more traction and assisted in resecting each lesion without any reported friction between the two scopes. The set-up of this device is simple and this device appears suitable not only for laparoscopic surgical procedures but also for endoscopic interventions. This is a lower cost option for ESD traction than other proprietary traction devices on the market. Further studies are underway to determine the technical success, easy of use, and safety of this dual scope with TAMIS platform technique for colorectal ESD.Second scope with Traction assisting with Dual Knife DissectionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

671 SENTINEL LYMPH NODE SAMPLING AND EMPIRIC CHEMORADIATION AS AN ORGAN SPARING APPROACH AFTER ENDOSCOPIC RESECTION OF INTERMEDIATE RISK EARLY FOREGUT CANCERS: A US PILOT STUDY

For low risk early foregut cancers, endoscopic submucosal dissection (ESD) is curative. For high-risk cancers, esophagectomy/gastrectomy is required for definitive staging and treatment. For ‘intermediate risk’ patients at ∼5-20% risk of lymph node (LN) metastasis, however, local resection in conjunction with systemic therapy could rival radical surgery. In this context, after local resection, Sentinel LN sampling (SLNS) may offer added value compared to a ‘wait and watch’ or ‘empiric chemotherapy’ approach. SLNS has not been used in clinical practice after ESD of T1 Barrett’s cancers. For gastric cancers it represents an emerging technique limited to Asia. We report the 1st US pilot study on SLNS after ESD for these foregut cancers. Patients who had ESD for T1 Barrett’s or gastric carcinomas and met both criteria below were offered SLNS: 1) ESD pathology with high-risk T1 cancer (deep invasion; lymhovascular invasion, G3,4 grade). 2) Patient with high surgical risk or refusing surgery. Indocyanine green (ICG) was injected endoscopically in the submucosa around the ESD site intra-operatively and fluorescent LNs were harvested including paraesophageal/EGJ stations in Barrett’s patients. Pts with positive SLNs and high-risk patients with negative SLNs were offered adjuvant therapy. 10 pts received ESD with SLNS. Mean age 70 (50-79). 9 males. The ASA class was 3 in 8 and 2 in 2 patients. There were 7 EGJ Barrett’s cancers (5 with T1a m3 invasion as the only risk factor) and 3 gastric cancers. We consider Barrett’s T1a m3 carcinomas as high-risk based on reports of LN involvement in up to 5%. Our finding of a positive SLN in 1/5 of these patients supports this. Median cancer size 1.3 cm (0.5-3.5). Grade: G1 in 4 patients, G2 in 5 and G4 in 1. T stage was T1a m3 in 5 and T1b in 5. R0 ESD achieved in 8 patients. SLNS was successful in all patients and returned a median of 9 LNs (4-20). 9 pts discharged on the same day and 1 on the next day. No significant adverse events. 4 patients had positive SLNs (1 N1, 2 N2, and 1 N3) and received adjuvant chemotherapy +/- radiation. Of the 6 N0 patients 1 received a 2nd ESD for indeterminate lateral margin and one with SM2 Barrett’s cancer and only 4 SLNs sampled was offered chemotherapy. After a median follow-up of 30 months (range 15-64), 8 patients including all 6 with negative SLNs were in remission. 2/4 patients with positive SLNs died, one from disseminated cancer, and one while in remission, from unrelated cause. This pilot study in patients with ESD of T1 Barrett’s and gastric cancers with high risk histologic features suggests potential feasibility of SLNS to risk-stratify and direct further treatment in patients in whom the standard of care of organ resection and lymphadenectomy is not possible due to high surgical risk or patient preference.

Sa2062 TRANSANAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING THE FLEX® ROBOTIC SYSTEM (MEDROBOTICS) BY A GASTROENTEROLOGIST: A CASE SERIES

Precancerous rectal lesions not amenable to standard mucosal resection and early T1a cancers are effectively treated with endoscopic submucosal dissection. Recently, a robotic endoscope with potential to expand and improve efficiency of transanal procedures has been approved by the FDA for transanal use. This scope provides access for two accessories capable of multiple freedoms of movement allowing effective dissection of tissue. The endoscopic surgeon uses both his hands, divorced from the scope controls for the dissection. We present the first case series of a gastroenterologist using the Flex® Robotic System for endoscopic submucosal resection of advanced rectal lesions. A retrospective review of patients was approved by the Institutional Review Board at Penn State Hershey Medical Center. Clinical data for the 7 consecutive patients was collected including length of the procedure, length of stay, location of mass, size of mass, and details of the procedure. Data on patient demographics including BMI, age, and ASA score were also collected. Procedural notes from prior to the robotic resection, the robotic resection itself, and follow-up endoscopic evaluation after robotic resection were all reviewed. Of the 7 patients listed for procedure, 2 cases were abandoned; one due to evidence of T2 cancer and another due to anal stenosis. Among the rest, 3 used the robotic device alone while 2 of the cases used traditional ESD in addition to the robotic device. Reasons for needing to use conventional methods included equipment issues with suctioning using the robotic device and need for improved visualization of a bleed occurring in a difficult location. Average age of the patients was 62, BMI was 30, and ASA score was 3. Average size of the lesions resected was 4.4cm x 5.0cm. Final pathology included one tubulovillous adenoma, one tubular adenoma with high grade dysplasia, one tubulovillous adenoma with high grade dysplasia, and two with adenocarcinoma. The robotic scope represents a true advancement in the endoscopic surgical platform. Advantages of the robotic system include the ability to use traction and counter-traction which allow for precise control and ease of dissection as well as stabilization of the resection field, allowing for faster dissection with seemingly less bleeding. In addition, the 3D vision of the robotic system allows for excellent sense of tissue planes, even without the use of submucosal elevation. Disadvantages include the need for anal dilation and general anesthesia. The current robot lacks suction and submucosal injection capabilities. Additional weaknesses include limited length reached within the rectum and maneuverability of the device. With improvement of technique and technology, endoscopists skilled in both conventional and robotic ESD could minimize the need for proctectomy.Figue 2Endoscopic robotic suturing after dissection of the rectal mass lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Transoral laser microsurgery for Tis, T1, and T2 glottic carcinoma: 5-year follow-up.

The aim of this retrospective study is to evaluate the results obtained with CO2 TOLMS in patients with Tis, T1, and T2 glottic tumors at our Department from 2004 to 2016 treated with CO2 TOLMS. One hundred eighty-five patients having a median age of 67years (range 42-88) were included in the present analysis. The tumor stages of the patients included 134 pTis-T1a, 12 pT1b, and 39 pT2 cases. Median duration of follow-up for the whole study cohort was 55months (range 24-108months). At 5-year follow-up, local control was 91%, 83%, and 79.4% for T1a, T1b, and T2 respectively. Disease-specific survival was 95.5%, 91.6%, and 92.3%. Overall survival was 73.8%, 91.6%, and 82%, and larynx preservation was 96.2%, 83%, and 84.6%. This study confirms that CO2 TOLMS is a safe and standard therapy for selected T1 and T2 glottic carcinoma, and our review on T2 glottic cancer suggests that CO2 TOLMS represents a reliable option in terms of overall survival, disease-specific survival, and laryngeal preservation. However, patients with anterior commissure involvement and T2 cancer should be evaluated with a preoperative MRI in order to exclude the infiltration of the laryngeal framework and to quantify the neoplastic involvement of para-glottic space.

Risk factors for lymph node metastasis in early colon cancer.

The aim of the study was to determine factors predicting lymph node metastasis in patients with T1 or T2 colon cancer. A total of 906 patients with T1 or T2 colon cancer who underwent colon resection with regional lymphadenectomy in a tertiary hospital, from January 2008 to December 2013, were analyzed. The prognostic factors for LN metastasis and the risk factors for survival were analyzed. There were 728 patients (80.4%) without lymph node metastasis (LN-negative group) and 178 patients (19.6%) with lymph node metastasis (LN-positive group). Tumor invasion depth (P < 0.001), lymphatic invasion (P < 0.001), and perineural invasion (P = 0.008) were significantly different between the two groups. During the median follow-up period of 69 months, the 5-year disease-free survival rate was 98.6% for the LN-negative group and 92.8% for the LN-positive group (P ≤ 0.001). In multivariate analysis, influencing factors associated with disease-free survival rate were LN metastasis (P = 0.001) and perineural invasion (P = 0.040). Female, depth of tumor invasion (P = 0.001), and lymphatic invasion (P < 0.001) were significant independent predictive factors for lymph node metastasis in multivariate analysis. Positive LN status predicted poor disease-free survival in patients with early cancer. This suggests that depth of tumor invasion ≥ sm2 and the presence of lymphatic invasion in early colon cancer provide useful information to determine which patients would benefit from radical surgery.

Factors associated with the use of adjuvant neratinib in stage I-III HER2-positive breast cancer.

e12517 Background: HER2-positive breast cancers have a higher risk of recurrence, though systemic chemotherapy in combination with HER2-targeted agents significantly reduces this risk. Neratinib (N) is a small molecule inhibitor of HER2 that was shown in the ExteNET trial to improve invasive disease-free survival in patients with stage II-III breast cancer. The purpose of this study was to investigate factors associated with the use of adjuvant N in patients with HER2-positive breast cancer treated in the University of Colorado Health system (UCH). Methods: We performed a retrospective chart review of women diagnosed with stage I-III breast cancer who received adjuvant trastuzumab (T) between July 2016 and April 2019 at UCH to coincide with the approval of N in July 2017. We collected patient demographics, baseline characteristics, and cancer treatments. Results: A total of 350 patients were identified who received adjuvant T for treatment of stage I-III HER2-positive breast cancer within the inclusion timeframe. 234 patients (74.1%) were either ≥ T2 and/or node-positive at diagnosis as in the inclusion criteria of ExteNET. Of these, only 31 (13.3%) were prescribed adjuvant N within 2 months of completing adjuvant T. 81 (34.6%) received adjuvant pertuzumab (P) in addition to T. Of those who received N, 78.8% were ≥ T2 and 78.8% were node-positive. The average age of those receiving N was 49.3 versus 54.9 years in those not receiving N. Hormone receptor (HR)-positive disease was noted in 72.7% of those receiving N and 68.6% in those who did not (P = 0.624). The vast majority (97.0%) of patients were prescribed diarrheal prophylaxis with N. Patients receiving adjuvant N were less likely to have had a pathologic complete response (pCR) following neoadjuvant chemotherapy than those who did not receive N (23.1% versus 51.0%, P = 0.008). Of those who received N, 18 (54.5%) were treated at an academic hospital, where 34.2% of the total studied patient population was treated. Conclusions: The use of adjuvant N in patients with ≥ T2 or node-positive HER2-positive breast cancer in our patient population was low. Patients who did receive adjuvant N were more likely to have residual disease following adjuvant chemotherapy and be treated at an academic hospital. Despite the greater benefit of adjuvant N in HR-positive HER2-positive breast cancer in ExteNET, HR status did not correlate with the use of adjuvant N in our study. Trials assessing the additional benefit of adjuvant N in patients receiving adjuvant P or trastuzumab emtansine will likely be required prior to widespread use of adjuvant N.

MON-475 Discrepant Thyroid Function Tests in Adenocarcinoma-Is This a True Thyroid Disorder?

Background: Many causes of abnormal thyroid function tests (TFTs) occur that may or may not reflect a true thyroid disorder. The most common include: immune check point inhibitors therapies (ICI) used to treat various types of cancers; biotin supplements, which may interfere with thyroid function test assays; euthyroid sick syndrome; as well as amiodarone therapy for cardiac disorders. Clinical Case: A 67-year old female patient with type 2 diabetes mellitus, taking insulin and oral antihyperglycemic agents, with hyperlipidemia, hypertension and coronary artery disease, who had abnormal TFTs (TSH was 3.7 to 4.9 uIIu/ml; ref range 0.27-4.2 uIU/mL), and Free T4 was 0.92 to 1.06 ng/dL; ref range 0.55-1.6 ng/dl) prior to the diagnosis of metastatic adenocarcinoma of the lungs. She was initially treated with radiation. TFTs were unchanged. Her CEA was noted to be 129.5 (0-3.0 ng/mL). However, following chemotherapy with Tarceva (Erlotinib) 50 mg po daily, the TSH increased to 7.6 uIU/ml with Free T4 of 3.19 ng/dL. She remained clinically euthyroid. A thyroid ultrasound showed 1 -small sub centimeter nodule in each thyroid lobe. The patient later admitted to also taking biotin for an unknown period of time. TSH antibodies and TSI were both negative. Free T4 by dialysis was normal. While still taking Tarceva her TSH was noted to be 2.5 to 3.8 uIU/ml and both Free T4 and Free T3 were elevated and was 6.57 pg/ml;ref range=2.52-4.34 pg/mL). Six months later, the Free T4 decreased to 1.08 ng/dL. Thyroid antibodies and thyroglobulin remain normal. The patient remained clinically euthyroid. Conclusion: It is important to note that several factors can cause abnormal thyroid function tests, such as Immune check point inhibitors therapy, with the exact mechanism for abnormal TFTs unknown, and can also be associated with either Grave’s hyperthyroidism or Hashimoto’s hypothyroidism,as well as other autoimmune endocrine disorders. Biotin, a common supplement, has also been reported to interfere with the thyroid function test assays for free thyroxine (T4), total T4, free triiodothyronine (T3), total T3, TSH, and various cancer markers. However, It is important to clinically evaluate the patient for thyroid disorders, and recognize that therapy may not always be required, when discrepant and fluctuating thyroid function tests are obtained, such as in this patient.

Sentinel Lymph Node Biopsy in T3 and T4b Breast Cancer Patients: Analysis in a Tertiary Cancer Hospital and Systematic Literature Review

Introduction: Breast cancer represents the most common type of cancer among women in the world. The presence and extent of axillary lymph node involvement represent an important prognostic factor. Sentinel lymph node biopsy (SLNB) is currently accepted for T1 and T2 with negative axillae (N0); however, many patients with T3-T4b tumors with N0 are often submitted to unnecessarily axillary lymph node dissection. Materials and Methods: This is a retrospective, observational study of patients treated for breast cancer between 2008 and 2015, with T3/T4b tumors and N0, who underwent SLNB. A systematic review of the literature was also carried out in 5 bases. Results: We analyzed 73 patients, and SLNB was negative for macrometastasis in 60.3% of the cases. With a mean follow-up of 45 months, no ipsilateral axillary local recurrence was observed. In the systematic review, only 7 articles presented data for analysis. Grouping these studies with the present series, the rate of N0 was 32.1% for T3 and 61.0% for T4b; grouping all studies (T3 and T4b n = 431) the rate was 32.5%. Conclusions: SLNB in T3/T4b tumors is a feasible and safe procedure from the oncological point of view, as it has not been associated with ipsilateral axillary relapse.

Laparoscopic versus open radical cystectomy in the treatment of locally advanced T3 and T4 bladder cancer: Perioperative and Mid-term oncological outcomes.

In this study, we aim to compare the perioperative and midterm oncological outcomes in patients with advanced bladder cancer and those who had laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). We retrospectively reviewed medical records of patients who underwent LRC or ORC in a single center between 2008 and 2014 with a pathological diagnosis of pT3 and pT4 bladder cancer. Thirty-five and 39 patients were included in the study as part of the LRC and ORC groups, respectively. There was no statistically significant difference between the two groups in terms of disease-free survival (LRC, 39.8±4.86 months; ORC, 45.47±8.92 months, P=0.896). Average estimated blood loss and length of hospitalization were significantly less in the LRC group. The overall survival rates of patients at 1, 2, and 3 years were 73%, 46%, and 46% in the ORC group and 78%, 65%, and 40% in the LRC group, respectively, and there was no statistically significant difference between the two groups. One patient in the ORC group experienced rectal injury in the form of a serosal tear, which was repaired primarily without any postoperative sequelae. There were no conversions in the laparoscopic group. Similarly, in 1 patient, rectal serosal tear was repaired preoperatively. Our study showed that LRC provides midterm oncological outcomes similar to ORC in the treatment of locally advanced T3 and T4 bladder cancer. However, long-term oncological and functional outcomes are required.

Efficacy of non-surgical larynx-preservation comprehensive treatment in advanced laryngeal carcinoma.

Efficacy of non-surgical larynx-preservation comprehensive treatment in advanced laryngeal carcinoma.

The efficacy of tumor characterization and tumor detectability of linked color imaging and blue laser imaging with an LED endoscope compared to a LASER endoscope

An endoscope with a light-emitting diode (LED) light source which has a 2-mm close-distance observation function without magnification, has been marketed, enabling linked color imaging (LCI) and blue laser imaging (BLI) for tumor detection and characterization. We analyzed the efficacy of a LED endoscope compared to a LASER endoscope. We retrospectively reviewed 272 lesions observed using the LED endoscopic system (FujifilmCo., Tokyo, Japan) from May 2018 to September 2019. The Japanese NBI Classification was used for tumor characterization. We analyzed the diagnostic accuracy and confidence level. Sixty-one lesions observed with both the LED and magnified LASER endoscopes were alsoanalyzed to compare the diagnostic accuracy. Regarding the tumor detectability, we calculated color difference values (CDVs) and brightness values (BVs) of white-light imaging, BLI, and LCI modes between the two endoscopes for each tumor. The mean polyp size was 9.2 ± 11.3mm. Histology showed 71 sessile serrated lesions, 193 adenoma and high-grade dysplasias, and 8 T1 cancers. The diagnostic accuracy of tumors ≥ 10 and < 10mm was 72.0% and 92.9% (p < 0.001), respectively and the high confidence rate was 93.8%. The diagnostic accuracy of LED (77.0%) was a littlehigher than that of LASER without magnification (65.6%, p = 0.16) but was not inferior to that of LASER with magnification (82.0%, p = 0.50). The respective CDVs of LED and LASER endoscopes were 20.6 ± 11.2 and 21.6 ± 11.2 for LCI (p = 0.30), and the respective BVs were 210.0 ± 24.2 and 175.9 ± 21.1 (p < 0.001). A LED endoscope with close-distance observation improved tumor detection and characterization due to high brightness.

A modern assessment of the surgical pathologic spread and nodal dissemination of endometrial cancer

ObjectiveTo examine the risk of nodal metastases in a contemporary cohort of women based on pathologic risk factors including histology, depth of invasion, tumor grade, and lymphovascular space invasion. MethodsWomen with endometrial cancer who underwent hysterectomy from 2004 to 2016 who were registered in the National Cancer Database were analyzed. Patients were stratified by T stage: T1A (<50% myometrial invasion), T1B (>50% myometrial invasion) and T2 (cervical involvement). Lymph node metastases were assessed in relation to tumor T stage and grade, and further stratified by lymphovascular space invasion. ResultsWe identified 161,960 patients. The rate of nodal metastases within the endometrioid histology cohort was 2.2% for T1A cancers, 12.8% for T1B cancers and 19.9% for T2 cancers. For stage TIA cancers, the percent of patients with positive nodes increased from 1.1% for grade 1 cancers, to 2.9% for grade 2 cancers to 4.8% for grade 3 cancers. The corresponding rates of nodal metastases for stage T1B cancers were 8.6%, 13.7%, and 16.9%, respectively. For T1A cancers without lymphovascular space invasion, nodal metastases ranged from 0.6% in those with grade 1 cancers to 3.0% for grade 3 cancers. The corresponding risk of nodal disease ranged from 11.8% to 13.9% for T1A cancers with lymphovascular space invasion. ConclusionsThere was a sequential increase in the risk of lymph node metastases based on depth of uterine invasion, tumor grade, and the presence of lymphovascular space invasion. The overall rate of nodal metastasis is lower than reported in the original GOG 33.

Detection of Occult Metastases in Patients with T1 and T2 Stage Lower Lip Squamous Cell Carcinomas after Positive Lymphoscintigraphy.

The aim of this study was to detect lower lip squamous cell carcinomas (SCC) that had metastasized to the lymph nodes and to evaluate if neck dissection was necessary for patients with T1 or T2-stage lip cancer after a sentinel lymph node biopsy (SLNB). The study was conducted as a prospective clinical study to detect occult neck metastases in patients with T1 or T2 stage SCC of the lower lip. Thirty-one patients were eligible and underwent echo-ultrasound, computer tomography, magnetic resonance and lymphoscintigraphy (LSG) as diagnostic procedures. LSG was performed on the same day as the surgical procedure, after intradermal injection of 37 Mbq Tc99m-Sn-colloid/mL at four peritumoral sites. In patients with positive LSG results, the sentinel lymph nodes were extracted surgically. The risk factors for cancer development were sun exposure and smoking. The highest accuracy for detecting lymph node enlargements was achieved with magnetic resonance imaging (MRI; 80.7%). LSG showed excellent sensitivity (100%) and negative predictive value (NPV; 100%). Overall, occult metastases were diagnosed with an SLNB in eight (25.8%) patients. According to the results, with great caution, we suggest that an SLNB is reasonable to initiate only for patients with positive sentinel nodes by positive LSG, to be used as a lower morbidity approach for selected patients with T1 and T2 stage cancers.

Local excision after preoperative chemoradiation for T2 and T3 rectal cancers: is the wait over?

Local excision after preoperative chemoradiation for T2 and T3 rectal cancers: is the wait over?

Short-term outcomes of laparoscopic intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for primary locally advanced low rectal cancer: a single center experience

BackgroundEven with the augmentative application of anal-preservation surgery in low rectal cancer, the role and indications of laparoscopic intersphincteric resection (Lap ISR) are still under debate, especially for T3 or node-positive (T3N0M0, T1–3N+M0) cancer, mainly due to the oncological safety and functional outcomes. INTRABEAM (Carl Zeiss, Germany) intraoperative radiotherapy (IORT) using low-energy X-rays features in accurate irradiation, less exposure, and reduced complications. Taking advantages of Lap ISR and INTRABEAM IORT, this innovative approach aims to increase the probability of the anal preservation with acceptable postoperative outcomes.Materials and methodsFrom December 2015 to August 2019, we retrospectively analyzed the short-term outcomes of 12 patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer. They all had received Lap ISR and INTRABEAM IORT with a dose of 16–18 Gy applied by an applicator through the anus (natural orifice). Then, with no pre- or postoperative radiotherapy given, the patients were suggested to receive 6–8 cycles of the XELOX chemotherapy regimen (oxaliplatin, 130 mg/m2 and capecitabine, 1000 mg/m2).ResultsAll patients achieved R0 resection. The median radiation time was 27 min and 15 s, and the mean radiative dose was 17.3 Gy (range 16–18 Gy). The median follow-up time was 18.5 months (range 3–45 months). Two patients experienced local recurrence. Two male patients experienced anastomotic stenosis. Furthermore, one of them experienced perianal abscess and the other one experienced pulmonary metastasis after refusing to receive chemotherapy. One female patient with internal anal sphincter invasion experienced distant metastases to the liver and gluteus maximus muscle 35 months after IORT. No acute radiation injuries or symptoms were observed. Although they experienced a reduction in anal function, every patient was satisfied with the postoperative outcomes.ConclusionsFor patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer, Lap ISR with INTRABEAM IORT may be a safe and feasible approach for anal preservation without compromising oncological outcomes.