Rate Of Upstaging Research Articles

Short-term local control after VATS segmentectomy and lobectomy for solid NSCLC of less than 2 cm.

IntroductionVATS pulmonary segmentectomy is increasingly proposed as a parenchyma‐sparing resection for tumors smaller than 2 cm in diameter. The aim of this study was to compare short‐term oncological results and local control in solid non‐small cell lung cancers (NSCLCs) <2 cm surgically treated by intentional VATS segmentectomy or lobectomy.MethodsThis study was a single center retrospective study of consecutive patients undergoing VATS lobectomy (VL) or segmentectomy (VS) for solid <2 cm NSCLC from January 2014 to October 2019.ResultsIn total, 188 patients with a median age of 65 years (male/female: 99/89) underwent VS (n = 96) or VL (n = 92). Segmentectomies in the upper lobes were performed in 57% and as a single segment in 55% of cases. There was no statistically significant difference between VS and VL in terms of demographics, comorbidities, postoperative outcomes, dissected lymph node stations (2.89 ± 0.95 vs. 2.93 ± 1, P = 0.58), rate of pN1 (2.2% vs. 2.1%, P = 0.96) or pN2 upstaging (1.09% vs. 1.06%, P = 0.98). Adjuvant chemotherapy was given in 15% of patients in the VL and 11% in the VS group. During follow‐up (median: 23 months), no patients presented with local nodal recurrence or on the stapler line (VS group). Three patients on VL and two in VS groups presented with recurrence on the remnant operated lung. New primary pulmonary tumors were diagnosed in 3.3% and 6.3% of patients in the VL and VS groups, respectively.ConclusionsDespite the short follow‐up, our preliminary data shows that local control is comparable for VATS lobectomy and VATS segmentectomy for patients with NSCLC <2 cm.

Role of CA 125, CA19-9 and CEA in predicting outcome following neoadjuvant chemotherapy in muscle invasive bladder cancer

We have previously shown the prognostic value of three tumor markers (TMs) including Carbohydrate Antigen 125 (CA-125), Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) in muscle invasive bladder cancer (MIBC). Current report presents an update on TM levels before and after neoadjuvant chemotherapy (NAC) and their association with oncological outcomes. Serum levels of three TMs were prospectively measured in patients with MIBC who underwent NAC between 2011 and 2019. Rate of pathological upstaging (Path-U) and recurrence-free (RFS) was compared between patients with: (1) Elevated versus normal pre-NAC TM (2) Elevated versus normal post-NAC TM, and (3) Elevated pre-NAC TMs with normalized post-NAC TMs (TM responders) versus persistently elevated post-NAC TMs (TM non responders). Of a total of 199 patients, 63 patients had both pre- and post-NAC TMs. 33/63 (52%) patients had elevated pre-NAC TM of whom, 15/33 (45%) were TM responders. Patients with elevated pre-NAC TM had significantly higher rate of Path-U compared to those with normal pre-NAC TM (62% vs. 22.5%, respectively; P<0.001). There was no significant difference in Path-U in the other two comparison groups. Patients with elevated pre- and post-NAC TM had significantly lower RFS. Compared to TM responders, TM non responders had significantly higher rate of recurrence (70% vs 34%) and shorter median time to recurrence (4.2 months vs 13.5 months) (P=0.03). In six patients with recurrence who had complete post cystectomy TM, TM recurrence preceded clinical recurrence by median of 1.2 months (IQR 0.8 – 2.4 months). Elevated TM prior to NAC is associated with pathologic upstaging. TM elevation pre- or post-NAC predicts a worse outcome. Post-cystectomy TM might play a role in earlier detection of recurrence.

Blue light cystoscopy for detection of invasive bladder tumor: Results from multi-institutional registry

The role of blue light cystoscopy in increasing detection and decreasing recurrence and possibly progression rates in non-muscle invasive bladder cancer compared to white light cystoscopy is well supported in the literature. Here we evaluated the role of blue light cystoscopy in detecting invasive tumors that were not visible on white light cystoscopy. Using the multi-institutional Cysview registry database, patients who had at least one white light negative/blue light positive lesion with invasive pathology (≥T1) as highest stage tumor were identified. All white light negative/blue light positive lesions and all invasive tumors in the database were used as denominators. Relevant baseline and outcome data were collected. A total of 3514 lesions from 1257 unique patients were evaluated. Of all the lesions in the database, 818 (23.2%) lesions were white light negative/blue light positive of which, 7% (55 lesions from 47 unique patients) were invasive. When all the invasive lesions in the database were considered (total of 494 lesions), 11% were white light negative/blue light positive. Of patients with complete follow up in the database (32), 22 (68%) patients underwent radical cystectomy and 11/22 (50%) showed pathologic upstaging including 4/22 (18%) patients with node positive disease. A considerable proportion of invasive lesions are only detectable by blue light cystoscopy and rate of pathologic upstaging is significant. Our findings suggest an additional benefit of blue light cystoscopy in detection of invasive bladder tumors that has implications for treatment approach.

Upstaging of basal cell and squamous cell carcinomas during definitive surgery: a review of predictive preoperative clinical and histologic features.

The incidence of nonmelanoma skin cancer (NMSC) in the United States is increasing with approximately 3.6 million cases diagnosed per year. The staging and treatment of NMSC is guided by histologic subtype based on skin biopsy, along with other tumor-specific factors. However, a biopsy only represents a portion of the tumor, so there is a risk of upstaging at the time of definitive surgery. We conducted a review of the literature and found that a significant proportion of NMSC were upstaged during surgery. The rate of upstaging of basal cell carcinoma (BCC) was 7-31% and that of squamous cell carcinoma in situ (SCCIS) to squamous cell carcinoma (SCC) was 3-39%. Biopsy sampling error and variability in interpreting and reporting by dermatopathologists contribute to these discrepancies. It is pertinent to consider more comprehensive treatment modalities for tumors at high risk for upstaging. Diligence to identify tumors at higher risk for upstaging will allow clinicians to optimize management.

Are Nomograms Useful in Predicting Upstage From Ductal Carcinoma In Situ to Invasive Carcinoma Requiring Sentinel Lymph Node Biopsy?

The upstage rate from ductal carcinoma in situ (DCIS) on core biopsy to invasive carcinoma at definitive excision ranges from 20 to 30%. Nomograms have been developed to aid in the prediction of upstaging so as to guide surgical planning with respect to performance of sentinel lymph node biopsy (SLNB). The aim of this study was to evaluate the ability of these nomograms to predict upstaging within our public hospital population. A retrospective review of patients with DCIS from 2013 to 2018 at a single institution was performed. Individualized probability of upstage was calculated using the Samsung Medical Center (SMC) and Annals of Surgical Oncology (ASO) nomograms. Areas under the receiver operating characteristic curves were calculated to assess the discriminative power of each. Of 105 patients with DCIS, 31 (29.5%) were upstaged to invasive disease. The SMC and ASO nomograms demonstrated area under the curves (AUCs) of .65 (OR = 1.023, 95% CI 1.004-1.042, P = .02) and .60 (OR = 1.035, 95% CI 1.003-1.068, P = .03), respectively. While SMC provided greater discrimination in our cohort, the performance of these nomograms as reliable clinical adjuncts to guide SLNB decision-making in this cohort was less than optimal and thus should not be the sole factor in determining individual upstage risk.

Squamous cell carcinoma in situ upstaging is not frequent in the nail unit: a tertiary cancer center experience.

Squamous cell carcinoma in situ (SCCIS) of the nail unit is a complex malignancy; with little understanding of rate of upstaging or occult invasion in these patients. We sought to evaluate the rate of upstaging in nail unit SCCIS after Mohs micrographic surgery (MMS). Retrospective review of 346 patients who referred for and underwent MMS for biopsy proven SCCIS on the hands and feet between January 1, 2000 and December 30, 2019. Only cases in the nail unit were included. Clinical, surgical details, histopathological features, HPV status, and rate of upstaging were recorded. Thirty-one cases met the inclusion criteria and were analyzed. Twenty-four patients were males (77.4%). The mean age was 55years (SD 17.26, range 27-84). The mean clinical size was 9.9mm; 19 cases tested for HPV, 15/19 were positive (78.9%), and 8/19 (42.1%) were associated with high-risk HPV. Three patients (9.7%) were upstaged to invasive on either MMS margins or tumor debulking. Limitations included a relatively small sample size and retrospective in nature. The rate of upstaging of SCCIS in the nail unit is not frequent, and when upstaging occurred it was focal, superficial, and with no PNI or bone invasion.

Is Sentinel Lymph Node Biopsy Necessary for Ductal Carcinoma In Situ Patients Undergoing Mastectomy?

Current treatment guidelines for ductal carcinoma in situ (DCIS) treated with mastectomy recommend sentinel lymph node biopsy (SLNB). In the modern era, there is a trend toward minimizing invasive staging and treatment of the axilla. In this study, we seek to determine the role of SLNB in patients undergoing mastectomy for the treatment of DCIS. Patients undergoing mastectomy were identified from our institution's SLNB database from 2012 to 2016. Patients were included if core needle biopsy demonstrated DCIS. Patient demographics, tumor characteristics, and pathologic variables were abstracted. Of 187 patients undergoing mastectomy with SLNB from 2012 to 2016 for DCIS or invasive ductal carcinoma, 39 (21%) were diagnosed with DCIS on core biopsy. Mean age was 57 years. 70% were Caucasian, 18% were African American, 8% were Asian, and the remaining 5% were unknown. One patient (3%) had positive nodes on SLNB and underwent axillary lymph node dissection. Of those with DCIS on core biopsy, 14 (36%) were upstaged to invasive disease on final surgical pathology, including the patient with positive SLNB. Of the remaining 25 (64%) patients with DCIS on final pathology, 0 (0%) had SLNB positivity. Only 3% of patients with DCIS undergoing mastectomy were found to have SLN metastases. However, a significant number of patients (36%) were upstaged due to invasive cancer. Although limited by a small sample size, our results suggest that SLNB should still be recommended to patients undergoing mastectomy for DCIS on core needle biopsy due to the high rate of upstage rate to invasive disease.

Development and Prospective Validation of a Risk Calculator That Predicts a Low Risk Cohort for Atypical Ductal Hyperplasia Upstaging to Malignancy: Evidence for a Watch and Wait Strategy of a High-Risk Lesion.

Guidelines recommend surgical excision of atypical ductal hyperplasia (ADH) due to the concern of undersampling a potential malignancy on core needle biopsy (CNB). The purpose of this study was to determine clinical, radiological and pathological variables associated with ADH upstaging to cancer and to develop a predictive risk calculator capable of identifying women who have a low oncological risk of upstaging. A prospectively collected database from a tertiary breast referral center was analyzed for women diagnosed with ADH on CNB between January 2013 to December 2017 who underwent surgical excision. CNB and surgical pathology reports were examined to determine rate of upstaging. The association between clinical, radiological and pathological variables were evaluated using regression analysis to determine predictors of ADH upstaging to cancer. Significant variables (p ≤ 0.05) identified on univariate analysis were assigned a score of "1" and were included in the ADH upstaging risk calculator. A total of 1986 patients underwent surgery for a high-risk lesion. We identified 318 (16.0%) patients who had ADH identified on their CNB who underwent surgery-of which 290 were included in our study. The upstage rate was 24.8%. Five variables were associated with upstaging and included in our calculator: (1) lesion > 5mm on ultrasound; (2) lesion > 5mm on mammogram; (3) one or more "high-risk" lesion(s) on CNB; (4) pathological suspicion for cancer and; (5) incomplete removal of calcifications on CNB. Patients with a score of 0 had a 2% risk of being upstaged to cancer and were deemed low risk with 17.2% of patients falling within this category. Patients with ADH on CNB can be stratified into a low oncological cohort who have a 2% risk of being upstaged to carcinoma. In the future, these select patients may be counselled and potentially offered observation as an alternative to surgery.

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer.

BackgroundAccurate intraoperative assessment of mediastinal lymph nodes is a critical aspect of lung cancer surgery. The efficacy and potential for upstaging implicit in these dissections must therefore be revisited in the current era of uniportal video-assisted thoracoscopic surgery (VATS).MethodsA retrospective study was conducted in which 544 patients with stage I (T1abc–T2a, N0, M0) primary lung cancer were analyzed. To assess risk factors for nodal upstaging and to limit any imbalance imposed by surgical choices, we constructed an inverse probability of treatment-weighted (IPTW) logistic regression model (in addition to non-weighted logistic models). We also evaluated risk factors for early locoregional recurrence using IPTW logistic regression analysis.ResultsIn the comparison of uniportal and multiportal VATS, the resected lymph node count (14.03±8.02 vs. 14.41±7.41, respectively; p=0.48) and rate of nodal upstaging (6.5% vs. 8.7%, respectively; p=0.51) appeared similar. Predictors of nodal upstaging included tumor size (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.12–2.70), carcinoembryonic antigen level (OR, 1.11; 95% CI, 1.04–1.18), and histologically confirmed pleural invasion (OR, 3.97; 95% CI, 1.89–8.34). The risk factors for locoregional recurrence within 1 year were found to be number of resected N2 nodes, age, and nodal upstaging.ConclusionUniportal and multiportal VATS appear similar with regard to accuracy and thoroughness, showing no significant difference in the extent of nodal dissection.

Upstaging of melanoma in situ and lentigo maligna treated with Mohs micrographic surgery rarely results in additional surgical management.

As Mohs micrographic surgery (MMS) is more widely utilized for melanoma in situ (MIS) and lentigo maligna (LM), there is increasing concern over whether the procedure can negatively affect the treatment of upstaged tumors. Previous studies have shown that about 1-2% of MIS/LM treated with MMS require sentinel lymph node biopsy, but little is still known regarding surgical outcomes. We performed a retrospective chart review of 117 MIS/LM lesions treated with MMS at Brigham and Women's Hospital. We found a low rate of tumor upstaging (8.5% or 10/117), and only 1.7% (2/117) required wide local excision and sentinel lymph node biopsy. In both patients, there was successful location of the sentinel nodes by surgical oncologists. This study highlights the low risk of MIS/LM upstaging, with the majority changing to T1a, and the low need for further surgical management after MMS. Collaboration with other surgical specialties ensures appropriate management of patients with upstaged tumors.

Pure flat epithelial atypia identified on core needle biopsy does not require excision

BackgroundRoutine excision of flat epithelial atypia (FEA) of the breast found on core needle biopsy (CNB) is being questioned and a policy of selective excision of FEA was adopted in our area. The purpose of this study was to evaluate the upstage rate to malignancy across multiple diagnostic centers in our area following the policy of selective excision and to identify factors predictive of malignancy. MethodsPatients having excision of CNB FEA at our regional Hospital between 2013 and 2017 were identified. The primary endpoint was upstage to malignancy after excision. We also assessed for clinical, radiological, and pathological features associated with malignancy. ResultsWe identified 187 patients. Eighty-nine had pure FEA, 71 had concurrent ADH, and 18 had other pathological lesions. Following surgical excision, 9 patients were upstaged to malignancy (4. 8%) with 8 having concurrent ADH (2 invasive ductal carcinoma, 6 DCIS) and 1 with concurrent Complex Sclerosing Lesion (DCIS). None of the pure FEA cases upstaged. The presence of ADH or CSL in the CNB were the only factors found to be predictive of upstaging (p = 0.001, p = 0.0001 respectively). ConclusionsThe upstage rate to malignancy after excision of pure FEA at out center is 0%. Therefore, we recommend that pure FEA with radiology and pathology concordance does not require surgical excision and can instead be followed with serial imaging. However, patients with FEA in association with other high-risk lesions should be managed as per indicated for the other high-risk lesion and FEA with ADH should be excised.

Effect of time to surgery on outcomes in stage I esophageal adenocarcinoma

BackgroundThere are limited data on the safe interval from diagnosis to surgery in patients with stage I esophageal adenocarcinoma. We hypothesized that increased time to surgery would be associated with worse survival and increased nodal upstaging. MethodsThe National Cancer Database was used to identify patients with cT1N0M0 esophageal adenocarcinoma (2004-2015) who underwent esophagectomy without induction therapy. The primary outcome was survival, and the secondary outcomes were the rate of margin-positive resection and pathologic nodal upstaging. Time to surgery was modeled as a categoric variable, dividing patients into quartiles (Q1-4), and as a continuous variable using piecewise linear splines centered on 50 and 100 days. ResultsA total of 2495 patients met study criteria. When examined in quartiles, there was no difference in survival between groups based on time to surgery in both unadjusted and multivariable analyses. As a continuous variable, increasing time to surgery less than 50 days was associated with improved survival (hazard ratio, 0.99; 95% confidence interval, 0.98-1.00), and time to surgery greater than 100 days was associated with worse survival (hazard ratio, 1.00; 95% confidence interval, 1.00-1.01) and increased margin-positive resection (odds ratio, 1.01; 95% confidence interval, 1.00-1.02). Treatment at a high-volume center, government insurance, and diagnosis and treatment at different centers were associated with surgery beyond 100 days. ConclusionsIncreasing time to surgery greater than 100 days is associated with worse outcomes in patients with stage I esophageal adenocarcinoma. In this patient population, esophagectomy should be offered as soon as safely possible.

Flat epithelial atypia on core needle biopsy does not always mandate excisional biopsy

Flat Epithelia Atypia (FEA) is a proliferative lesion of the breast where cells demonstrate columnar change and cytologic atypia. This lesion has been identified as distinct from the classic atypical hyperplasias (AH). While many patients undergo excisional biopsy, management of FEA identified on core needle biopsy (CNB) is controversial, and the rate of associated ductal carcinoma in situ (DCIS) or invasive cancer is not well defined. The aim of this study was to determine the upstage rate of FEA diagnosed by CNB. We identified patients from a prospectively maintained data base who had FEA diagnosed by CNB from 01/2010 to 07/2015. Patient variables collected included age at presentation, imaging findings, pathologic findings following surgical excision, and subsequent development of breast cancer. Of 132 patients, 62 (n=62/132, 47.0%) patients had FEA associated with DCIS and invasive ductal carcinoma (IDC) on CNB and were excluded from analysis. Of the remaining 70 patients, median age was 52 (range 31-84) years. Thirty-two (45.7%) patients had FEA plus AH, 4 (5.7%) patients had FEA plus lobular carcinoma in situ (LCIS), and 34 (48.6%) patients had FEA alone or with another non-pathologic finding (pure FEA). Two (6.3%) patients with FEA plus AH had DCIS or IDC on subsequent excisional biopsy. Of the 34 patients with pure FEA who underwent excisional biopsy, only one (2.9%) was found to have IDC. Twenty-two (64.7%) patients with pure FEA who underwent excisional biopsy presented with calcifications on mammography. None of these patients had cancer on excisional biopsy, and 10 (45.5%) patients had AH (3 ADH, 3 ALH, and 4 both ALH and ADH). Twelve (n=12/34, 35.3%) patients with pure FEA underwent CNB for a mass or asymmetry noted on imaging. Of these 12 patients, 9 (75.0%) had benign findings on excisional biopsy, two (16.7%) patients had AH, and one (8.3%) patient had IDC. Median follow-up was 4.6years (IQR 3.1-6.5years). Three (4.3%) patients subsequently developed IDC, two of which were in the contralateral breast. FEA is often found in combination with ADH and ALH as well as carcinoma on CNB. In our study, pure FEA was upstaged to cancer in only 2.9% of patients. Mammographic findings unlikely predict upstaging to malignancy. These findings suggest that excisional biopsy may not be warranted in patients with pure FEA and could be managed with close imaging surveillance.

Predicting Upstage Rate As a Function of Delay from Diagnostic Imaging for Locally-Advanced Lung Cancer Radiotherapy

This study combines data from three institutions to examine the rate of tumor progression as defined by comparing TNM (AJCC TNM, 7th edition) staging from diagnostic to that from treatment planning PET/CT images for patients with locally-advanced non-small cell lung cancer (LA-NSCLC). In this retrospective study of prospectively acquired data, TNM and overall stage records from patients treated for LA-NSCLC treated between 2004 and 2011were pooled from three international institutions. While data from 100 patients were pooled, only 78 provided full TNM staging. For each patient, changes in T, N, M (N=78), and overall stage (N=100) were recorded, as well as the time elapsed between the diagnostic and treatment planning PET/CT images. The inverse Kaplan-Meier product-limit method was used to define the probability of disease progression as a function of the time lapsed. The median time lapse between PET/CT scans for all 100 patients was 29 days (range: 2 – 341). Using the inverse Kaplan-Meier method, the upstage rate for a time lapse of 21 days (3 weeks) in T, N, M (N=78), and overall (N=100) stage were 2% (95% CI: 0-18%), 6% (2-15%), 7% (3-17%), and 8% (4-16)%, respectively. The converse rates for a 28-day (4 weeks) lapse were 4% (1-15%), 10% (4-21%), 8% (4-19%), and 13% (8-23%). The 95% CI reported here are smaller than those calculated from the individual cohorts. Our model demonstrates that the upstage rate for LA-NSCLC patients, over one month, is noteworthy. It is worrisome that, in the span of four weeks, upstage in M occurred for 8% of patients who are no longer eligible radical treatment and lowered expectation of survival. Therefore, LA-NSCLC patients require a reduction of the time elapsed between diagnostic imaging and radiotherapy; barring that, a treatment planning PET/CT scan should be acquired to ensure radiotherapy is planned using current data.

Predictive Factors for Residual Cancer in Second Transurethral Resection for Non-muscle-invasive Bladder Cancer.

The significance of second transurethral resection (TUR), and identification of predictive factors for residual cancer remain unrevealed. This study aimed to find residual cancer and up-staging rates, as well as predictive factors for residual cancer, in patients who undergo second TUR for non-muscle-invasive bladder cancer (NMIBC). Patients who underwent second TURs for NMIBC between 2015 and 2017, were included in the study and their clinicopathological characteristics were analyzed for predictors of residual cancer. Among 143 Japanese patients whose tumors were initially diagnosed as high-risk NMIBC, residual cancers detected at second TURs were, Tis: n=22 (15.4%), Ta: n=15 (10.5%) and T1: n=29 (20.3%). No patients showed up-staging from NMIBC to MIBC. The presence of carcinoma-in situ at initial TUR was an independent risk factor for any residual cancer (Tis, Ta and T1), non-flat residual cancer (Ta and T1), and flat residual cancer (Tis). The presence of carcinoma-in situ is suggested to be an independent predictor of residual cancer. This may help guide decisions to perform second TUR.

Ductal Carcinoma In Situ with Microinvasion on Core Biopsy: Evaluating Tumor Upstaging Rate, Lymph Node Metastasis Rate, and Associated Predictive Variables.

The role of sentinel lymph node biopsy (SLNB) when ductal carcinoma in situ with microinvasion (DCISM) is identified on core biopsy is unclear. Our aim was to assess the upstage rate to invasive cancer and axillary lymph node metastasis in patients diagnosed with DCISM, and whether predictive variables could be identified that may help inform who would most likely benefit from a surgical axillary evaluation. We performed a retrospective review of 70 patients diagnosed with DCISM on core biopsy. Patients with concomitant or prior invasive cancer were excluded. Demographic, clinical, radiographic, histologic, and treatment data were collected. Fisher's exact test and univariable and multivariable logistic regression were performed to identify variables that may be associated with tumor upstaging and nodal metastasis. Time-to-event distributions were summarized using the Kaplan-Meier method. On final surgical pathology, 49 patients (70%) had a final diagnosis of DCISM or T1mi cancer, whereas 21 patients (30%) were upstaged to measurable invasive cancer (> 1mm). One of 49 patients (2%) with DCISM on final pathology and 4 of 21 patients (19%) with measurable invasive cancer showed sentinel lymph node metastases. Although the upstage rate to measurable invasive cancer in our cohort of patients with DCISM on core biopsy was 30%, findings of a positive SLNB remain low at 7%. No predictive variables were identified to inform whether the routine practice of SLNB may be omitted in some patients with DCISM.

Risk of malignancy in papillary neoplasms of the breast.

In recent years, routine excision of papillary neoplasms (PN) of the breast has been questioned and controversy exists over when excision is necessary. The aim of this study was to evaluate the upstage rate to malignancy of core needle biopsy (CNB) diagnosed PNs from multiple diagnostic centers in our area and to identify factors predictive of malignancy. Patients presenting to our surgical center between 2013 and 2017 for excision of CNB PN were evaluated. The primary endpoint was upstage to malignancy. The association of age, diagnostic center where CNB performed, type of CNB, palpability, discharge, clinical exam size, imaging size, family history of breast cancer, and presence of atypia, as risk factors for upstaging to cancer were also evaluated. Of the 317 PN cases, 83 upstaged to malignancy following surgical excision. 77% of patients with CNB of Atypical PN upstaged, 39% of PN with concurrent atypical ductal hyperplasia, and 0% of PN with concurrent atypical lobular hyperplasia/flat epithelial atypia. Of the 206 non-atypical PNs on CNB, 3.4% upstaged to malignancy, but further review demonstrated a 1% upstage rate when atypia excluded. Factors found to be associated with malignancy included: older patient age, larger size, and presence of atypia. We recommend excision of PN with atypia, concurrent cancerous lesion, or radiologic-pathologic non-concordance, and serial imaging follow up may be considered for image detected PN, less than 1cm, with no atypia.

Imaging Follow-up Versus Surgical Excision for Radial Scars Identified on Tomosynthesis-Guided Core Needle Biopsy

We investigated if imaging or pathology features could determine when imaging follow-up is appropriate after diagnosis of radial scar on digital breast tomosynthesis (DBT)-guided core needle biopsy (CNB). We conducted a retrospective review of all patients diagnosed with radial scars on DBT-guided CNB at our institution between November 2014 and December 2016. Cases were excluded if DCIS or invasive malignancy was present in the same core specimens. Patient age; needle size; number of cores; visibility on full-field digital mammography versus DBT; lesion size; presence of architectural distortion, mass, or calcifications; imaging stability; presence or absence of atypia; length of imaging follow-up, and excisional pathology were collected. Of 45 eligible biopsies, 6 cases had radial scars with associated atypia and 39 cases had no associated atypia. Twenty-four patients underwent surgical excision, including all patients with atypia on CNB. One case (4%) was upstaged to DCIS on surgical excision after CNB revealed a radial scar with associated ADH. There was also a case without atypia on CNB, but excisional pathology revealed associated ADH. In cases with radial scars and associated atypia on CNB, the upstage rate was 17%. In cases without atypia on CNB that underwent surgical excision, the upstage rate was 0%. Imaging follow-up was available in 13 patients who did not undergo surgical excision, with stability in all 13 with a median follow-up of 18 months. Annual imaging follow-up appears reasonable in selected patients with radial scars but no atypia on DBT-guided CNB.

Quantifying Upstage Rate as a Function of Delay from Diagnostic Imaging for Locally-Advanced Lung Cancer Patients

Diagnosis and characterization of non-small cell lung cancer is done with diagnostic F18-FDG PET imaging as it is superior in sensitivity and specificity compared to conventional helical CT scans. Due to the aggressive nature of NSCLC, upstaging of disease is a concern for patients scheduled to undergo radical radiotherapy. We have reviewed our institution’s experience with treatment planning PET-CT scans and quantified the upstage rates. As part of a REB-approved study, PET-CT images acquired for treatment planning purposes. They were compared with PET-CT scans used for initial staging by two independent assessors. Patients’ age at diagnosis, sex, tumor histology, stage & date at diagnostic PET-CT, stage & date at treatment PET-CT and survival/follow-up were collected prospectively. AJCC 7th edition TNM Staging System was applied. Reported stages were compared and differences were reconciled by a third independent party. Descriptive statistics were calculated and the estimates of the upstage rates were obtained using the Kaplan-Meier product-limit method. Between October 2009 and February 2012, 28 patients were accrued to the study. The mean age was 64 years (range: 41-81). Eight were female and 19 were male. The majority of patients had Stage IIIA disease (15), with others having Stage IIIB (11), Stage IIA (1) and Stage IIB (1) disease. Predominant tumor histology was adenocarcinoma (71%). Median time between diagnostic and planning PET-CT scans was 21 days (range: 2-73). Overall upstaging occurred in 25% of patients. The TNM upstage breakdown was as follows: T-stage 7%, N-stage 14% and M-stage 11%. The 3 patients were found to have metastatic disease were switched to treatment with palliative intent. New nodal stations were found in 32% of patients, thereby necessitating a change in the treatment volumes. With the Kaplan-Meier product limit method the rate of overall upstaging increased with delay between staging and treatment planning PET-CT scans: 13% at 20 days (95% CI: 4%-95%), 33% at 40 days (95% CI: 14%-86%), and 56% at 60 days (95% CI: 29%-71%). The use of a treatment planning PET-CT demonstrated upstaging which altered patients’ treatment plans. Lengthened interval period between diagnostic PET and planning PET scans showed an increase in upstaging. Our data is consistent with two published studies which showed similar upstaging rates.

The Impact of Lymphovascular Invasion on Risk of Upstaging and Lymph Node Metastasis at the Time of Radical Cystectomy

BackgroundLymphovascular invasion (LVI) in muscle-invasive bladder cancer is associated with a poor prognosis when identified from radical cystectomy (RC) specimens. However, LVI is not clearly emphasized in any risk models to guide clinical decision-making. The impact of LVI on the risk of lymph node (LN) metastasis after a transurethral resection of bladder tumor (TURBT) specimen is less understood. ObjectiveThe goal was to describe the impact of LVI and the risk of LN metastasis at each clinical stage of urothelial carcinoma of the bladder (UC). Design, setting, and participantsThe National Cancer Database was queried for patients with bladder cancer who underwent RC with LN dissection from 2004 to 2014. Patients with non-bladder primary, non-UC histology, clinical metastatic disease, and having received chemotherapy/radiation were excluded. Pathologic LN positive rates at RC were determined. Outcome measurements and statistical analysisThe primary outcome was pathologic upstaging at RC and pathologic node positivity. Secondary outcomes included determining overall survival (OS). All hypotheses testing were two-sided and a p value of <0.05 was considered statistically significant. All statistical analyses were performed using Stata version 13.1. Results and limitationsA total of 3007 patients with UC underwent RC with pelvic LN dissection. In patients with LVI, the risk of LN metastasis was significantly higher at each clinical stage as was the rate of pathologic upstaging. Patients with LVI on TURBT had worse OS stage for stage in pure UC (p<0.001). Limitations include that there was no central pathologic review and the number of TURBTs per patient was not known. ConclusionsPatients with UC with LVI had worse OS and are at higher risk for LN-positive disease and pathologic upstaging at surgery than patients without LVI. Patient summaryIn this report we examined the impact of lymphovascular invasion (LVI) at transurethral resection of bladder tumor on pathologic upstaging and lymph node metastasis at radical cystectomy using the National Cancer Database. We identified LVI as being prognostic at each stage of urothelial carcinoma.