T1b Cancer Research Articles

The role of endoscopic submucosal dissection for Tis/T1 rectal cancer

Background: Colorectal endoscopic submucosal dis-section (ESD) is widely used as a minimally invasive treatment for neoplasms in the colon and rectum. Rectal ESD is generally thought to be less complex than ESD in other segments of the colon, however difficult time-consuming lesions can be en-countered. Here we investigated the short-term outcomes of ESD for lesions in the upper rectum, lower rectum and anal canal. Methods: From February 1998 to January 2017, 404 consecutive patients with 414 lesions of upper rectum (Ra), lower rectum (Rb) and anal canal (P), that underwent ESD at our hospital were analyzed. Age, gender, macroscopic feature, lesion size, location of the lesion, procedure time, histological diagnosis, depth of invasion and adverse effect such as intra-procedural perforation, delayed perforation and delayed bleeding, were evaluated as short-term outcomes. Univariate analysis between the lesions with depth of Tis/T1a and T1b was performed. Results: The number of the lesions located at Ra, Rb and P was 104, 292, and 12, respectively. Mean procedure time was 109.2 minutes (SD ±77.5) and en bloc resection ratio was 95.2%. The overall ratio of curative resection was 80.9%. The ratio of intra-procedural perforation, delayed perforation and delayed bleeding was 1.0%, 0% and 3.9%, respectively. When comparing T1b lesions to Tis/T1a lesions, there is no difference in lesion size, procedure time, intra-procedural or delayed perforation ratio and delayed bleeding ratio between the two groups. Positive margins were encountered more frequently in the T1b group compared to the Tis/T1a group (21.0% vs. 5.5%). Conclusions: ESD is feasible for Tis and T1a rectal cancers from the aspect of short-term outcomes and quality of life (QOL) for patients. Incomplete resection was still a problem for T1b cancers and collaboration between endoscopists who perform ESD and surgery has potential in the future.

The role of endoscopic submucosal dissection for Tis/T1 rectal cancer

Background: Colorectal endoscopic submucosal dis-section (ESD) is widely used as a minimally invasive treatment for neoplasms in the colon and rectum. Rectal ESD is generally thought to be less complex than ESD in other segments of the colon, however difficult time-consuming lesions can be en-countered. Here we investigated the short-term outcomes of ESD for lesions in the upper rectum, lower rectum and anal canal. Methods: From February 1998 to January 2017, 404 consecutive patients with 414 lesions of upper rectum (Ra), lower rectum (Rb) and anal canal (P), that underwent ESD at our hospital were analyzed. Age, gender, macroscopic feature, lesion size, location of the lesion, procedure time, histological diagnosis, depth of invasion and adverse effect such as intra-procedural perforation, delayed perforation and delayed bleeding, were evaluated as short-term outcomes. Univariate analysis between the lesions with depth of Tis/T1a and T1b was performed. Results: The number of the lesions located at Ra, Rb and P was 104, 292, and 12, respectively. Mean procedure time was 109.2 minutes (SD ±77.5) and en bloc resection ratio was 95.2%. The overall ratio of curative resection was 80.9%. The ratio of intra-procedural perforation, delayed perforation and delayed bleeding was 1.0%, 0% and 3.9%, respectively. When comparing T1b lesions to Tis/T1a lesions, there is no difference in lesion size, procedure time, intra-procedural or delayed perforation ratio and delayed bleeding ratio between the two groups. Positive margins were encountered more frequently in the T1b group compared to the Tis/T1a group (21.0% vs. 5.5%). Conclusions: ESD is feasible for Tis and T1a rectal cancers from the aspect of short-term outcomes and quality of life (QOL) for patients. Incomplete resection was still a problem for T1b cancers and collaboration between endoscopists who perform ESD and surgery has potential in the future.

Predicting Residual Disease in Incidental Gallbladder Cancer: Risk Stratification for Modified Treatment Strategies

IntroductionRe-operation is advised for patients with T1b or greater incidental gallbladder cancer (GBCA). The presence of residual disease (RD) impacts resectability, chemotherapy, and survival. This study created a preoperative model to predict RD at re-operation. MethodsPatients with re-operation for incidental GBCA from 1992–2015 were included. The relationship between pathology data from initial cholecystectomy and RD at re-operation was assessed with logistic regression and classification and regression tree (CART) analysis. ResultsTwo hundred fifty-four patients were included and 188 underwent definitive re-resection (74.0%). Distant RD was identified in 69 (27.2%) patients and locoregional only RD in 82 (32.3%). On multivariate analysis, T3 (OR 22.7, 95% CI 5.5–94.4) and poorly differentiated tumors (OR 4.3, 95% CI 1.4–13.3) were associated with RD (p < 0.001–0.012). AUC of multivariate model was 0.78 (95% CI 0.72–0.83). CART analysis split patients into groups based on percentage with RD: 87% RD with T3, 67% RD with T1b/T2 and poorly differentiated, and 35% RD with T1b/T2 and well/moderate differentiated tumors. ConclusionBased on T stage and grade from cholecystectomy, this study developed a model for predicting RD at re-operation in incidental GBCA. This model delineates patient groups with variable percentages of RD and could be used to stratify high-risk patients for prospective trials.

Mo1032 - Clinical Outcomes and Risk of Lymph Node Metastases in Patients with T1B Esophageal Adenocarcinoma

Introduction Oesophageal adenocarcinoma (OAC) carries a poor prognosis compared to other gastrointestinal tract tumours. Advances in minimally invasive endoscopic therapy can provide curative intervention of early OAC arising in Barrett’s oesophagus (BE). Historically, patients with OAC and submucosal involvement (T1b) were offered surgery due to risk of lymph node metastases (LNM). Endoscopic resection (ER) is a viable alternative to surgery in T1b tumours with low risk (LR) histopathological features. Aim: To assess the overall risk of LNM and long-term outcomes of patients with LR and high risk (HR) T1b OAC. Method All patients with T1b OAC on endoscopic resection specimens at a single centre during 2008–2015 were included, with no sign of metastatic disease. All specimens were reviewed by two expert histopathologists. LR tumour was defined as completely resected, well or moderately differentiated, with only superficial submucosal involvement ( 500 µm) or lymphovascular invasion. Disease was considered metastatic if there was lymph node involvement in surgical resection specimens or advanced OAC on follow-up. Results 59 patients with T1b OAC on ER specimens were included: 13 (22%) had LR and 46 (78%) HR tumours. In total 37 patients were treated conservatively (12 LR, 25 hour) and 22 patients (37%) underwent oesophagectomy (1 LR, 21 hour). There was no surgery-related mortality. After a median follow-up of 38 months (range 12–87) no patients with LR OAC developed metastatic disease. Ten of the 46 hour patients (22%) developed metastatic disease at latest follow up; 4 of these had LNM in surgical resection specimens and 6 had metastatic disease detected on follow-up. In the HR group that were treated conservatively compared to those treated with surgery, although a trend was observed towards better survival in the surgery group, there was no statistically significant long-term survival benefit (log rank p=0.22). Conclusion Our results show rate of LNM in T1b OAC with LR histopathological features to be very low and endoscopic treatment in these patients is preferred to surgery. HR T1b cancers in our series carry a significant lymph node metastases risk of 22%. In selected HR patients in whom surgery may not be an option, a conservative approach is a valid alternative but rigorous follow-up is required due to the risk of LNM. Disclosure of Interest None Declared

T1a Versus T1b Differentiated Thyroid Cancers: Do We Need to Make the Distinction?

The 7th edition of the American Joint Committee on Cancer (AJCC) staging system trialed a subdivision of T1 tumors into T1a (<1 cm) and T1b (1.0-2 cm). The 2009 American Thyroid Association (ATA) guidelines recommended total thyroidectomy for tumors >1 cm, and lobectomy for those ≤1 cm. These AJCC staging parameters remain a focus of debate, and ATA guidelines are in transition. The aim of this study was to determine if the T1 staging subdivision is associated with different treatment strategies and patterns of patient survival. All adult patients with AJCC pT1 differentiated thyroid cancer (DTC) from the National Cancer Data Base (NCDB; 1998-2012) and Surveillance, Epidemiology, and End Results (SEER) program (2004-2012) were divided into two groups based on tumor size: T1a versus T1b. Demographic, clinical, and pathologic features were evaluated. Multivariate regression analysis was used to determine factors associated with undergoing total thyroidectomy and radioactive iodine. Cox proportional hazards models were performed to determine factors associated with overall and disease-specific survival. Among 149,912 DTC patients, 98,111 (65.4%) were T1a and 51,801 (34.6%) T1b in the NCDB; in SEER, among 18,381 patients, 11,208 (61.0%) had T1a and 7173 (39.0%) T1b tumors. Patients with T1b cancers were younger (48 vs. 51 years T1a) and more likely to have private insurance (76.2% vs. 74.1%), no comorbidities (86.0% vs. 83.8%), and undergo treatment at academic medical centers (41.4% vs. 40.3%; all p < 0.01). They also were more likely to undergo total thyroidectomy (87.7% vs. 74.3%), and had more lymphovascular invasion (10.2% vs. 3.3%), positive surgical margins (7.9% vs. 3.8%), metastatic lymph nodes (35.8% vs. 23.8%), and distant metastases (0.4% vs. 0.3%; all p < 0.01). Factors associated with radioactive-iodine use included younger patient age, lower income, having insurance, positive surgical margins, and T1b stage (p < 0.01). After adjustment, overall (p = 0.23) and disease-specific survival (p = 0.93) were similar among patients with T1a versus T1b tumors. These results illustrate that patients with pT1a versus pT1b tumors undergo different treatment strategies. Based on the newly published 2015 ATA guidelines, whereby either lobectomy or total thyroidectomy can be performed for low-risk tumors, it might be anticipated that treatment differences will diminish over time. Therefore, division of AJCC T1 staging into T1a versus T1b subgroups might become obsolete over time.

Outcomes of Surgical Resection of T1bN0 Esophageal Cancer and Assessment of Endoscopic Mucosal Resection for Identifying Low-Risk Cancers Appropriate for Endoscopic Therapy.

Invasive esophageal cancers have been managed historically with esophagectomy. Low-risk T1b patients are being proposed for nonsurgical management. The purpose of this study was to evaluate the ability of endoscopic mucosal resections (EMR) to identify low-risk T1b patients and to review surgical treatment outcomes for T1b cancer. All esophageal cancer patients, in an institutional review board-approved prospective database, between 2000 and 2013 with clinical stage (cT1bN0), pathological stage (pT1bN0), and no neoadjuvant therapy were retrospectively reviewed. Fifty-one patients, 38 pT1b and 13 cT1b, were assessed. All cT1b had preoperative EMR and five were found to be understaged at esophagectomy. pT1bN0 patients had a mean age of 66years, mean BMI of 30, and 95% had adenocarcinoma. Thirty-eight pT1bN0 patients underwent esophagectomy with a median hospital length of stay (LOS) of 9days. Complications occurred in 14 patients, but 71% were minor (Accordion score 1-2). In-hospital 30- and 90-day mortality was zero. EMR specimens were re-reviewed to assess low-risk criteria. Degree of differentiation and the presence of lymphovascular invasion could be assessed in all EMR specimens; however, assessment of submucosal invasion limited to the superficial submucosal layer could not be determined in the majority of cases. Kaplan-Meier 5-year overall survival in pT1bN0 patients was 78.7%. Clinical staging of superficial esophageal cancer can be inaccurate especially in submucosal tumors. EMR should be routinely used for preoperative staging. Healthy patients with clinical tumor stage greater than cT1a should undergo multidisciplinary review and be considered for surgical resection.

Abstract S6-06: The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?

Abstract Background Since the addition of trastuzumab to (neo)adjuvant chemotherapy, the prognosis of patients with stage II and III HER2-positive breast cancer has significantly improved. Several reports have subsequently shown that small, node-negative tumors also carry a relatively poor prognosis and patients with HER2-positive tumors of 2cm or less increasingly receive trastuzumab-based chemotherapy. We sought to provide evidence for the effect of this approach in a population-based cohort. Methods All patients diagnosed with T1N0 HER2-positive breast cancer in the Netherlands between 2006 and 2012 were identified from the nationwide Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. The primary outcome was overall survival and analyses were performed for the whole group and for T1a, T1b, and T1c tumors separately. Kaplan-Meier survival rates were compared between groups with and without systemic treatment and multivariate cox regression analysis was performed to adjust for baseline characteristics. Results A total of 3512 eligible patients were identified of whom 385 had a T1a tumor (≤0.5cm, including 54 micro-invasive), 800 had a T1b tumor (&amp;gt;0.5 to 1cm), and 2327 had a T1c tumor (&amp;gt;1cm to 2cm). Systemic treatment with chemotherapy and/or trastuzumab was administered in 45% of patients: 7% in T1a, 19% in T1b, and 60% in T1c tumors. Of the treated patients, the majority (92%) received both chemotherapy and trastuzumab. The use of systemic treatment increased significantly over time and varied according to geographic region. Other factors associated with receiving systemic treatment in multivariate analysis were younger age, negative hormone receptor status, higher tumor grade, larger tumor size and presence of isolated tumor cells in the lymph nodes. At a median follow-up of 49 months (interquartile range [IQR] 30-69), 186 deaths had occurred. Treatment with chemotherapy and/or trastuzumab significantly improved overall survival at seven years follow-up (95% versus 87%; hazard ratio [HR] 0.30; 95% confidence interval [CI] 0.20-0.44, p&amp;lt;0.001). This effect was seen in all three tumor size groups: 100% versus 91% in T1a, 99% versus 91% in T1b, and 95% versus 83% in T1c tumors. When corrected for age the beneficial effect of systemic treatment on overall survival remained highly significant (HR 0.46; 95% CI 0.30-0.70, p&amp;lt;0.001). Due to the small number of events in the treated group, correction for additional variables in multivariate analysis was not feasible. However, the otherwise unfavorable prognostic profile in the treated patients (hormone receptor status, grade, size, isolated tumor cells), suggests an even stronger actual effect of systemic treatment. To ensure that the excess mortality in the non-treated group was due to breast cancer and not the result of other causes, breast-cancer specific survival analyses will follow. Conclusion Systemic treatment with chemotherapy and/or trastuzumab improves overall survival in T1a, T1b, and T1c node-negative HER2-positive breast cancer. Citation Format: van Ramshorst MS, van der Heijden-van der Loo M, Dackus GMHE, Linn SC, Sonke GS. The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S6-06.

Abstract PD5-02: The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?

Abstract Background Since the addition of trastuzumab to (neo)adjuvant chemotherapy, the prognosis of patients with stage II and III HER2-positive breast cancer has significantly improved. Several reports have subsequently shown that small, node-negative tumors also carry a relatively poor prognosis and patients with HER2-positive tumors of 2cm or less increasingly receive trastuzumab-based chemotherapy. We sought to provide evidence for the effect of this approach in a population-based cohort. Methods All patients diagnosed with T1N0 HER2-positive breast cancer in the Netherlands between 2006 and 2012 were identified from the nationwide Netherlands Cancer Registry. Patient, tumor, and treatment characteristics were recorded. The primary outcome was overall survival and analyses were performed for the whole group and for T1a, T1b, and T1c tumors separately. Kaplan-Meier survival rates were compared between groups with and without systemic treatment and multivariate cox regression analysis was performed to adjust for baseline characteristics. Results A total of 3512 eligible patients were identified of whom 385 had a T1a tumor (≤0.5cm, including 54 micro-invasive), 800 had a T1b tumor (&amp;gt;0.5 to 1cm), and 2327 had a T1c tumor (&amp;gt;1cm to 2cm). Systemic treatment with chemotherapy and/or trastuzumab was administered in 45% of patients: 7% in T1a, 19% in T1b, and 60% in T1c tumors. Of the treated patients, the majority (92%) received both chemotherapy and trastuzumab. The use of systemic treatment increased significantly over time and varied according to geographic region. Other factors associated with receiving systemic treatment in multivariate analysis were younger age, negative hormone receptor status, higher tumor grade, larger tumor size and presence of isolated tumor cells in the lymph nodes. At a median follow-up of 49 months (interquartile range [IQR] 30-69), 186 deaths had occurred. Treatment with chemotherapy and/or trastuzumab significantly improved overall survival at seven years follow-up (95% versus 87%; hazard ratio [HR] 0.30; 95% confidence interval [CI] 0.20-0.44, p&amp;lt;0.001). This effect was seen in all three tumor size groups: 100% versus 91% in T1a, 99% versus 91% in T1b, and 95% versus 83% in T1c tumors. When corrected for age the beneficial effect of systemic treatment on overall survival remained highly significant (HR 0.46; 95% CI 0.30-0.70, p&amp;lt;0.001). Due to the small number of events in the treated group, correction for additional variables in multivariate analysis was not feasible. However, the otherwise unfavorable prognostic profile in the treated patients (hormone receptor status, grade, size, isolated tumor cells), suggests an even stronger actual effect of systemic treatment. To ensure that the excess mortality in the non-treated group was due to breast cancer and not the result of other causes, breast-cancer specific survival analyses will follow. Conclusion Systemic treatment with chemotherapy and/or trastuzumab improves overall survival in T1a, T1b, and T1c node-negative HER2-positive breast cancer. Citation Format: van Ramshorst MS, van der Heijden-van der Loo M, Dackus GMHE, Linn SC, Sonke GS. The effect of trastuzumab-based therapy on overall survival in small, node-negative HER2-positive breast cancer: To treat or not to treat?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD5-02.

Determining the extent of cholecystectomy using intraoperative specimen ultrasonography in patients with suspected early gallbladder cancer.

Accumulating evidence and guidelines recommend extended cholecystectomy for T1b or greater gallbladder cancers. This study aimed to evaluate the feasibility of intraoperative ultrasonography of a resected gallbladder specimen (specimen US) for the determination of the extent of cholecystectomy. We included 45 patients (34 women; median [interquartile range] age, 66 [57-74] years) who underwent specimen US. After simple laparoscopic cholecystectomy, a gallbladder specimen was examined to evaluate the depth of tumor invasion by specimen US and frozen section examination. With the results of those two examinations, the operating surgeon decided whether to perform extended cholecystectomy. The sensitivity and specificity of specimen US and frozen section examination in diagnosing T1b or greater cancer were, respectively, measured using permanent pathology as the reference standard. The surgeons' final decisions were evaluated in the same manner as the intraoperative examinations. Among 22 patients in whom adenocarcinomas were confirmed, 17 patients had T1b or greater cancers. The sensitivity and specificity of specimen US alone were 81% (95% CI, 54-96%) and 85% (65-96%), respectively. The sensitivity and specificity of frozen section examination alone were 43% (10-82%) and 95% (75-100%), respectively. Except one patient in whom extended cholecystectomy was intentionally not performed, 14 out of 16 patients (88%; 95% CI, 62-98%) who were finally confirmed as having T1b or greater cancers underwent extended cholecystectomy by the surgeons' decision based on both specimen US and frozen examination. Out of 28 patients who were finally confirmed as having benign lesions or T1a cancers, 25(89 %; 72-98%) underwent simple cholecystectomy. Specimen US was feasible to be incorporated in clinical practice. Although the diagnostic accuracy of specimen US alone was moderate, the combined use of specimen US and frozen section examination could help the surgeons make correct decisions on the extent of cholecystectomy.

Endoscopic Management of Early Esophageal Cancer.

The absolute incidence of esophageal adenocarcinoma has increased 7-fold over the past 5 decades, and esophageal adenocarcinoma is the most rapidly increasing epithelial malignancy in the United States. The incidence of early esophageal cancer has also increased proportionately. In the past decade, radiofrequency ablation has become the standard first-line therapy for high-grade dysplasia when found in the precursor lesion to esophageal adenocarcinoma, Barrett's esophagus. Success in the endoscopic management of high-grade dysplasia has furthered efforts to treat early esophageal cancers endoscopically. Although surgery remains the mainstay of treatment for more advanced tumors, national guidelines now recommend endoscopic mucosal resection followed by radiofrequency ablation for intramucosal carcinomas and T1a cancers. T1b cancers represent a more challenging group-very good results have been reported in highly selected subsets of patients with T1b tumors; however, many recommendations favor individualization or a surgical approach for this stage. This review examines the current data and recommendations regarding the endoscopic management of early esophageal adenocarcinomas.

PTH-187 Treatment of barrett’s early neoplasia (EN) in the UK: results of a survey of gastroenterologists and upper GI surgeons

Introduction Oesophagectomy (S) and endoscopic treatment (ET – endoscopic resection [ER] &/or ablation) for Barrett’s Early Neoplasia (EN) are both established options but have never been directly compared. Method An e mail questionnaire was sent to consultant upper GI surgeon AUGIS members and UK BOSS trial PIs to establish attitudes towards S and ET and explore feasibility of a trial to compare them. A number of clinical scenarios were presented. Results There were 70 responses (29 surgeons, 40 physicians, 1 not stated). In response to the question ‘How should Barrett’s EN be treated?’ most (52%) felt there was a role for both S and ET, with 3% favouring S and 45% ET. Most (86%) felt it depended on the scenario: some centres routinely discuss surgery as an option. Several scenarios were presented. For HGD patients unfit for S, 49% felt patients should have ET, 2% surveillance, 49% gave 2 or 3 options including 24% no treatment. In a patient fit for S 83% felt ET was the treatment of choice if unifocal (after staging ER if visible abnormality) but 17% opted for S, especially in young patients. For multifocal HGD, 44% favoured S (an additional 13% after staging ET) and 43% ET. Scenarios relating to T1 tumours fit for surgery were presented: for 91%, choice of treatment depended on histology of staging ER. 97% favoured ET (3% S) for T1a (m 1 –3). Several commented on importance of tumour differentiation and lymphovascular invasion for decision. For T1b (sm1), 39% favoured S, 12% ET, 49% unsure (several commented that patient preference and age were important factors). 76% believed that an RCT comparing S to ET is needed to inform future practice, but among dissenters were comments: ‘difficulty in blinding/numbers needed’, ‘too late as endoscopy already established and observational data convincing’, ‘unethical for trial’. 70% thought such a trial might be possible in the UK. In terms of what types of patients respondents might be prepared to offer entry into such a trial, patients with multifocal HGD, T1a (m 1 –3) or T1sm1 tumours had the highest support for inclusion, while patients with flat/ unifocal HGD had the least. Conclusion This snapshot of UK current opinion and practice shows that for patients with HGD (if unifocal) and T1a cancers with histologically good prognostic features ET is preferred by most respondents. Most disagreement was for patients with multifocal HGD and T1b (sm1) cancers. Both these and T1a cancers were the most strongly supported for an RCT comparing S and ET. Disclosure of interest None Declared.

Evolving Early Lung Cancers Detected During Follow-Up of Idiopathic Interstitial Pneumonia: Serial CT Features.

The purpose of this study was to evaluate the CT characteristics of newly developed lung cancer on CT studies obtained during follow-up of idiopathic interstitial pneumonia (IIP) before the appearance of identifiable tumors to the time of detectable lung cancer and thereafter. The study sample included 66 cancers diagnosed in 63 patients with IIP and lung cancer (59 men, four women; median age, 64 years; range, 40-85 years) between October 1998 and July 2012. Two radiologists independently reviewed 193 CT scans, determined the earliest presence of cancer and IIP, and evaluated tumor size, lobar and axial location, shape, and tumor density. Delay in clinical diagnosis and doubling time were measured with first and second follow-up CT examinations. Interobserver agreement was good (κ > 0.77). The median tumor size was 17 mm (range, 5-30 mm) for the 46 T1a and 20 T1b cancers. Most of the tumors (42 [63.6%]) were located in the lower lobes. Thirty-five tumors (53.0%) were at the interface between fibrotic cyst and normal lung, and 21 (31.8%) were in the midst of fibrotic lung cysts. Most of the tumors had a round or oval shape (52 [78.8%]) and were solid (62 [93.9%]). The median delay in diagnosis was 46 days (range, 8-760 days). The first median doubling time was 77 days (range, 15-525 days), and the second was 53 days (27-248). New lung cancers during CT follow-up of IIP usually appear as small solid nodules with a round or oval shape. Most cancers are located at the interface between fibrotic cyst and normal lung or in the midst of fibrotic cysts of the lower lobes of subpleural lung.

Diagnostic performance of EUS for evaluating the invasion depth of early colorectal cancers

EUS is one technique used to estimate the invasion depth of early colorectal cancer (CRC), but its diagnostic accuracy remains a matter of debate. To assess the accuracy of EUS for estimating the invasion depth of early CRC. Retrospective analysis. Tertiary-care academic medical center. The invasion depth of early CRC was estimated by EUS from 1989 through2012. Accuracy of EUS diagnosis, risk factors for misdiagnosis, and characteristics of lesions that were difficult to image. We estimated the invasion depth of 714 cases of early CRC on EUS. Of the lesions able to be visualized on EUS, the overall diagnostic accuracy of EUS for differentiating between lesions that could be resected endoscopically (Tis and T1a cancers), and those that required colectomy (T1b cancers) was 89%. Submucosal cancer and a macroscopic classification of superficial type were independent risk factors for misdiagnosis. Ninety lesions (13%) were difficult to image. Risk factors for difficulty in imaging were protruding-type morphology and tumor location in the sigmoid colon or from the descending colon to the cecum. Single center, retrospective. Experienced endoscopists performed EUS. Although some lesions that were protruding or located in the proximal colon were difficult to visualize, EUS is considered a useful technique for the diagnosis of invasion depth and the selection of treatment in patients with early CRC.

Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer.

Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer.

Optimized Lymphadenectomy for Early Gastric Cancer Based on the Analysis of 1141 Cases from a Single Institution

Background: According to the treatment guidelines for gastric cancer in Japan (3rd edition), D1 lymphadenectomy is recommended for T1a cancer (out of indication for endoscopic resection) and a group of T1b cancer (differentiated type, not larger than 1.5cm and clinically N0). D1+ lymphadenectomy is recommended for T1b cancer other than above group. D2 lymphadenectomy is for clinically N+ early gastric cancer (EGC). Methods: Consecutive 1141 resected EGC cases in our institution from January 1991 to December 2013 were analyzed. The size, depth of wall invasion, presence of ulcer, histological type and distribution of metastasis positive lymph node were evaluated. Results: There were 678 T1a and 463 T1b cancers. Lymph node metastasis positive T1a were 11 cases. All of them were undifferentiated type and the metastasis positive lymph nodes were all confined to the D1 area. Lymph node metastasis positive T1b cancer was 82 cases. Among them, 70 cases were within D1 area, 77 cases were within D1+ area and 79 cases were within D2 area. The other 3 cases had metastasis positive lymph node in beyond the D2 area. Conclusion: D1 lymphadenectomy is enough for T1a EGC that is out of indication of endoscopic resection and D1+ lymphadenectomy is reasonable for T1b EGC. These cases are good indication of laparoscopic surgery. D2 lymphadenectomy is required for T1b undifferentiated cancers which size is larger than 4 cm.

Prognostic analysis of submucosa-invasive gastric cancer with lymph node metastasis

The aims of this study were to identify prognostic factors of patients with submucosa-invasive (T1b) gastric cancer and to verify the validity of adjuvant chemotherapy for this disease. We retrospectively examined the cases of 1,236 consecutive patients in our prospectively maintained database with T1b gastric cancer who underwent gastrectomy in 1995-2012. We used 11 clinicopathologic characteristics to identify prognostic factors by univariate and multivariate analyses. We compared the survival of the 160 node-positive T1b gastric cancer patients with that of 133 patients in the same database who had node-positive muscularis propria-invasive (T2) gastric cancer and had undergone gastrectomy without adjuvant chemotherapy during the same period, as a reference cohort. The 5-year overall survival rate was 91.4% for all 1,236 patients. Advanced age (hazard ratio [HR] 4.51; 95% confidence interval [CI] 3.26-6.24; P < .01), male sex (HR 2.26; 95% CI 1.56-3.26; P < .01), and the presence of lymph node metastasis (HR 1.89; 95% CI 1.33-2.70; P < .01) were independent prognostic factors. The 5-year overall survival rates were 92.5% in node-negative patients, 84.5% in patients with 1 or 2 metastatic nodes, and 80.1% in patients with 3 or more metastatic nodes (P < .01). The 5-year overall survival rates of the node-positive T1b and T2 gastric cancer patients were 83.6% and 81.2%, respectively (P = .73). The prognosis of node-positive T1b gastric cancer patients after curative gastrectomy was unsatisfactory. Adjuvant chemotherapy should be considered for these patients, especially those with 3 or more metastatic nodes.

Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer.

Endoscopic resection is increasingly used to treat localized, early-stage esophageal cancer. We sought to assess its adoption, characterize the risks of nodal metastases, and define differences in procedural mortality and 5-year survival between endoscopic and surgical resection in the United States. From the National Cancer Data Base, patients with T1a and T1b lesions were identified. Treatment patterns were characterized, and hierarchical regression methods were used to define predictors and evaluate outcomes. All statistical tests were two-sided. Five thousand three hundred ninety patients were identified and underwent endoscopic (26.5%) or surgical resection (73.5%). Endoscopic resection increased from 19.0% to 53.0% for T1a lesions (P < .001) and from 6.6% to 20.9% for T1b cancers (P < .001). The strongest predictors of endoscopic resection were depth of invasion (T1a vs T1b: odds ratio [OR] = 4.45; 95% confidence interval [CI] = 3.76 to 5.27) and patient age of 75 years or older (vs age less than 55 years: OR = 4.86; 95% CI = 3.60 to 6.57). Among patients undergoing surgery, lymph node metastasis was 5.0% for T1a and 16.6% for T1b lesions. Predictors of nodal metastases included tumor size greater than 2 cm (vs. <2 cm) and intermediate-/high-grade lesions (vs low grade). For example, 0.5% of patients with low-grade T1a lesions less than 2 cm had lymph node involvement. The risk of 30-day mortality was less after endoscopic resection (hazard ratio [HR] = 0.33; 95% CI = 0.19 to 0.58) but greater for conditional 5-year survival (HR = 1.63; 95% CI = 1.07 to 2.47). Endoscopic resection has become the most common treatment of T1a esophageal cancer and has increased for T1b cancers. It remains important to balance the risk of nodal metastases and procedural risk when counseling patients regarding their treatment options.

PD-0013 - Endoscopic Treatment of Early Esophageal Carcinoma: A Prospective Evaluation of 40 Consecutive Cases with Promising Results in Patients with T1B Cancers

Introduction: Endoscopic therapy has become an accepted treatment option for T1a esophageal carcinoma (adenocarcinoma or squamous carcinoma) while for T1b cancers, surgery is still considered as a treatment of choice. Endoscopic resection (or dissection) allows precise histopathologic staging which is used to guide therapeutic decisions (surgery or continuation with endoscopic treatment).

Effectiveness of transoral laser microsurgery for precancerous lesions and early glottic cancer guided by analysis of voice quality

The purpose of this study was to show our comparison of the quality of voice obtained after superficial transoral endoscopic cordectomies (types I, II, and III) according to the European Laryngological Society classification versus the more extended cordectomy (types IV and V) among patients with glottic precancerous lesions or early glottic cancer. Sixty-two patients underwent vocal assessment after cordectomy (types I-V) for dysplasia, Tis, T1a, T1b, and T2 lesions. Cordectomy (types I-III) had good vocal outcomes. Cordectomy (types IV-V) showed less favorable outcomes, p < .005 in common parameters of voice range profile and symmetry in stroboscopy after cordectomy (types IV-V), with significant voice handicap index. Recurrences were found in 4 patients with T1b and T2 cancer. Two cases were managed by a higher type of cordectomy, and the other 2 by total laryngectomy. Effect of transoral laser microsurgery on quality of voice depends on the type of cordectomy and the site of the lesion.

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/T1b esophageal neoplasms. A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most important predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559), P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P < 0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+). Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma in-situ component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.