Use Of Postoperative Adjuvant Therapy Research Articles

Impact of the COVID-19 pandemic on management of surgically treated laryngeal squamous cell carcinoma.

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the treatment of cancer patients, particularly in terms of treatment choices. This study aimed to assess the effects of the COVID-19 pandemic on the management of surgically treated laryngeal squamous cell carcinoma (LSCC) patients, focusing specifically on changes in treatment modalities. We retrospectively analyzed the data from 102 patients who underwent surgical treatment for LSCC between January 1, 2019, and December 31, 2021, at our tertiary medical center. Patient demographics, histological characteristics, and treatment modalities were extracted from electronic medical records and compared between two time periods: pre-COVID-19 and during COVID-19, marked by the introduction of the hospital entry triage. Of the total patients, 53 (52%) were in the pre-COVID-19 group, and 49 (48%) were in the COVID-19 group. No significant differences in patient characteristics at the initial work-up were observed between the two groups. However, a significant shift in treatment modalities was noted. Fewer patients received postoperative adjuvant therapy in the COVID-19 group (70.5%) compared to the pre-COVID-19 group (95.5%). Importantly, this change did not significantly impact the one-year overall survival (OS) rates. The reduction in the use of postoperative adjuvant therapy during the COVID-19 pandemic may be attributed to efforts to minimize hospital visits due to the risk of COVID-19 infection. Further research is warranted to validate these findings and to investigate the potential effects of such changes in treatment modalities on the long-term survival.

Clinical effect of surgical treatment for lung metastasis and prognostic risk factor analysis: a single-centred cohort study.

This study aimed to compare the clinical effects of lobectomy and sublobar resection in the treatment of lung metastasis and to analyse the factors affecting patient prognosis. A retrospective analysis was performed on the clinical data of patients with pulmonary metastasis who underwent thoracic surgery at the Affiliated Cancer Hospital of Xinjiang Medical University between March 2010 and May 2021. A total of 165 patients who underwent pulmonary metastasectomy (PM) for lung metastasis met the inclusion criteria. Compared with the lobectomy group, the sublobar resection group had shorter operation time for pulmonary metastases (P < 0.001), lower intraoperative blood loss (P < 0.001), lower drainage volume on the first day after surgery (P < 0.001), lower incidence of prolonged air leak (P = 0.004), shorter drainage tube indwelling time (P = 0.002), and shorter postoperative hospital stay (P = 0.023). Multivariate analysis showed that sex (95% confidence interval (CI), 0.390-0.974; P = 0.038), disease-free interval (DFI) (95% CI, 1.082-2.842; P = 0.023), and postoperative adjuvant therapy (95% CI, 1.352-5.147; P = 0.004) were independent influencing factors of disease-free survival of patients who underwent PM. DFI (95% CI, 1.062-3.894; P = 0.032) and preoperative carcinoembryonic antigen (CEA) level (95% CI, 1.420-5.163; P = 0.002) were independent factors influencing the overall survival of patients in this group. Sublobar resection provides a safe and effective treatment option for patients with pulmonary metastasis on the premise of ensuring resection of lung metastasis R0 . Female sex, longer DFI, the use of postoperative adjuvant therapy and a lower preoperative CEA level were all favourable prognostic factors.

Neoadjuvant chemotherapy combined with radical surgery for stage IB2/IIA2 cervical squamous cell carcinoma: a prospective, randomized controlled study of 35 patients

ObjectiveThis study aimed to evaluate the clinical outcomes for patients with stage IB2/IIA2 cervical squamous cell carcinoma treated with neoadjuvant chemotherapy combined with radical surgery.MethodsA total of 68 patients with cervical squamous cell carcinoma were randomly divided into the experimental group (n = 35) and the control group (n = 33). The patients in the experimental group received paclitaxel plus cisplatin neoadjuvant chemotherapy for two cycles, then underwent radical hysterectomy and bilateral adnexectomy at 2 weeks post-chemotherapy. The control group only underwent radical hysterectomy and bilateral adnexectomy after the diagnosis of cervical squamous cell carcinoma. The toxic and side effects of chemotherapy in the experimental group were observed. Also, the operation method, operation time, blood loss, grade of wound healing, complications, and postoperative pathology were noted in the two groups. Primary foci and pelvic lymph node recurrence and distant metastasis were observed, and 3-year and 5-year survival rates were calculated.ResultsOnly one patient in the experiment had grade III bone marrow suppression; no other grade III and IV chemotherapy toxic reactions were observed. The operation was successfully completed in all patients. The operation time, intraoperative blood loss, placement of the ureteral catheter, bladder injury, ureteric injury, postoperative urinary tub, pelvic drainage tube indwelling time, anal exhaust time, postoperative complications, and metastatic ratio of lymph nodes were not significantly different between the two groups (P > 0.05). The number of dissected lymph nodes, deep myometrial invasion, and vascular tumor emboli showed a significant difference in the experimental group compared with the control group (P < 0.05). The 3-year disease-free survival (82.9% vs 81.9%), 5-year disease-free survival (71.4% vs 60.6%), 3-year overall survival (91.4% vs 87.8%), and 5-year overall survival (82.9% vs 75.6%) were not statistically significantly different between the experimental group and the control group (P > 0.05).ConclusionsNeoadjuvant chemotherapy in IB2/IIA2 stage cervical squamous cell carcinoma showed low toxic side effects. Radical surgery after chemotherapy is safe and feasible. It plays a coordinating role in reducing the tumor infiltration depth of the deep muscle layer and the incidence of vascular tumor emboli, reducing the use of postoperative adjuvant therapy, and improving the quality of life of patients, but does not improve the 3-year/5-year survival rate.

Prognostic histological factors in patients with esophageal squamous cell carcinoma after preoperative chemoradiation followed by surgery

BackgroundPathological response is an important marker for tumor aggressiveness in patients with esophageal squamous cell carcinoma (ESCC) who receive preoperative chemoradiation followed by esophagectomy. We aim to evaluate the prognostic value of histological factors after trimodality treatments.Methods91 patients who received preoperative chemoradiation followed by transthoracic esophagectomy between 2009 and 2014 were included. The pathological examination was reviewed. Overall survival and disease free survival were recorded. Survival analysis was performed using the Cox regression model, and the survival curves were compared by the log-rank test.ResultsSurvival analysis showed lymphovascular invasion (LVI, hazard ratio [HR]: 2.009, p = 0.029), perineural invasion (PNI, HR: 2.226, p = 0.019), ypN stage (HR: 2.041, p = 0.019), extracapsular invasion (ECI, HR: 2.804, p = 0.003), and incomplete resection (HR: 1.897, p = 0.039) as unfavorable prognostic factors affecting overall survival (OS). Moreover, tumor regression grade (TRG, HR: 1.834, p = 0.038), LVI (HR: 1.975, p = 0.038), ECI (HR: 2.836, p = 0.003), and incomplete resection (HR: 2.254, p = 0.007) adversely affected disease-free survival (DFS). Prognostic classification based on poor primary tumor (TRG2/3, LVI(+), and PNI (+)), lymph node (ypN(+) and ECI(+)), and surgical (incomplete resection) factors significantly predicts OS (p = 0.013) and DFS (p = 0.017). However, the use of postoperative adjuvant therapy was not a significant prognostic factor even in medium- and high-risk ESCC patients who underwent trimodality treatments.ConclusionsHistological factors, including primary tumor, lymph node, and surgical factors has high prognostic value for predicting outcomes in ESCC patients receiving preoperative chemoradiation followed by surgery.

Postoperative Adjuvant Therapy Improves Survival in Pathologic Nonresponders After Neoadjuvant Chemoradiation for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis

The prognosis of patients with esophageal cancer who have poor response to chemoradiotherapy (ie, pathologic nonresponders [pNRs]) remains poor. We investigated whether the use of postoperative adjuvant therapy (AT) could improve survival in this patient group. Among patients with esophageal squamous cell carcinoma who were treated with neoadjuvant chemoradiotherapy (nCRT) and operation between 2000 and 2012, pNRs (defined as those having a postoperative T stage of equal or greater pretreatment T stage or persistent nodal disease) were identified and divided into two groups according to their subsequent management (AT versus surveillance). Survival and recurrence were compared after propensity score matching for the following five factors: age, performance status, pathological lymph node status after treatment (ypN) status, severity of postoperative complications, and length of hospital stay (LOS). Of the 115 pNRs, 74 and 41 received AT and surveillance alone, respectively. Patients who received AT were younger, had less major postoperative complications, and a shorter LOS. A total of 32 pairs of well-balanced patients (n= 64) were selected by propensity matching. A significant benefit in terms of disease-free survival (DFS) was observed for pNRs treated with AT compared with those undergoing surveillance (3-year DFS rate: 45% versus 22.3%, p= 0.022). However, more patients in the AT group died of causes unrelated to cancer, resulting only in a borderline increase of overall survival (OS) [3-year OS rate: 34.4% versus 21.6%, p=0.13]. Postoperative AT can improve DFS in pNRs after nCRT. However, its use should be carefully weighed against a potential increase in the risk of treatment-related death.

A high risk group in the modified national institutes of health consensus criteria for the gastrointestinal stromal tumor: a clear indication of the adjuvant imatinib.

Since it is difficult to predict the prognosis of gastrointestinal stromal tumor (GIST) with the standard tumor-node-metastasis system, a system for assessment of the malignant potential according to risk stratification is commonly used in a clinical setting. Leading classification systems are the National Institutes of Health (NIH) consensus criteria,1 the modified NIH consensus criteria,2 the Armed Forces Institute of Pathology criteria and others. Jang et al.3 in this issue compared the most widely used NIH criteria and the modified NIH criteria. The NIH criteria1 proposed before 2002 classified the prognosis of GISTs into four subgroups (very low, low, intermediate or high risk) based on mitotic count and tumor size. The modified NIH criteria,2 developed by Dr. Joensuu in 2008, includes the primary tumor site and tumor rupture as two additional prognostic factors to the original NIH consensus criteria. According to the modified criteria, a part of individuals belonging to the intermediate risk group based on the NIH consensus criteria are re-classified into the high risk group. Based on the NIH consensus criteria, cases with mitotic count >10/50 high power fields (HPF) and tumor size >10 cm, or those with mitotic count >5/50 HPF and tumor size >5 cm are classified as the high risk group. This classification maintains identically only when GISTs are located in the stomach according to the modified NIH criteria. In contrast, when GISTs are detected in organs other than the stomach, cases with tumor size >5 cm are included in the high risk group, regardless of the mitotic count. If the mitotic activity is >5/50 HPF in the GISTs involving non-gastric organs cases with tumor size >2 cm are also classified into the high risk group. Thus, some non-gastric GISTs formerly grouped as the intermediate risk group are re-classified as the high risk group. All cases with the presence of a tumor rupture are classified as the high risk group, as well in the modified NIH consensus criteria. The need for re-classification has been raised to accurately determine the postoperative adjuvant Imatinib group. Although the effectiveness of postoperative adjuvant Imatinib has been clarified in the high risk group for GISTs, it still remains unclear in the intermediate risk group. The 2012 National Comprehensive Cancer Network (NCCN) guideline recommends postoperative adjuvant therapy for patients based on the following study results.4 A randomized trial (SSGXVIII/AIO) reported that 36 months, compared to 12 months, of adjuvant Imatinib was significantly better in extending relapse free survival and overall survival in patients with a high estimated risk of recurrence postoperatively (tumor >5 cm in size with a high mitotic rate [>5 mitoses/50 HPF] or a risk of recurrence greater than 50%).5 Moreover, the ACOSOG Z9001 study showed that adjuvant Imatinib significantly prolonged relapse free survival in patients with GISTs that were larger than 3 cm. In particular, the efficacy of Imatinib was noticeable in patients with a considerably higher risk of recurrence (intermediate and high-risk).6 When the parameters of these two studies are matched with the classification criteria, it is reasonable that the high risk group based on the modified NIH consensus criteria should be subject to adjuvant Imatinib treatment. From the aspects of clinical effectiveness, whether a classification system can better discriminate a single high risk group requiring adjuvant chemotherapy, the modified NIH consensus criteria are considered a more effective indicator. Follow-up without specific post-operative adjuvant treatment is required for very low, low and intermediate risk groups based on the modified NIH criteria, while adjuvant Imatinib treatment is recommended for the high risk group. In the study of Jang et al. in this issue, gastric GISTs were not included and there was no case involving a tumor rupture. For these reasons, evaluating the significance of the modified NIH criteria is difficult based on their study results. Moreover, additional chemotherapies, including postoperative use of Imatinib, were excluded to observe the natural progress of tumors. Considering the fact that the clinical effectiveness of the modified NIH criteria is critical in determining the use of postoperative adjuvant therapy, the study results would have been more useful if the differences in the prognosis had been compared between those with and without adjuvant therapy. However, this study demonstrated that some GISTs formerly categorized as the intermediate risk group, according to the original NIH criteria, were re-classified as the high risk group, and showed a significantly high recurrence rate. The study was meaningful in that it supported the view that the high risk group classified according to the modified NIH consensus criteria is subject to adjuvant Imatinib therapy.

Dual intervention with a lymph node (LN) specimen collection kit and enhanced specimen dissection to improve staging of resectable non-small cell lung cancer (NSCLC).

7569 Background: LN metastasis impairs survival of resectable NSCLC, but routine pathologic nodal staging is suboptimal. We tested the impact of a dual intervention (a surgical specimen collection kit with specific, pre-labeled LN collection cups, to improve intraoperative hilar/mediastinal LN dissection; and a fastidious gross dissection of the resected lung specimen for perihilar/intrapulmonary LNs) on the rate of detection of LN metastasis. Methods: We matched dual intervention cases with controls performed with standard surgical specimen collection and pathology examination protocols. Controls were hierarchically matched for extent of resection, laterality, surgeon, pathologist and T-stage. All statistical comparisons were made with Exact Conditional Logistic Regression, to account for the matched case-control design. Results: Patient demographic, tumor histology, and size characteristics were similar between the groups. The impact of the dual interventions is shown in the Table. Conclusions: The dual interventions significantly increased retrieval of N1 and N2 LNs, the rate of detection of LN metastasis, and nodal up-staging. There were strong trends towards higher aggregate stage and increased adjuvant therapy eligibility. The interventions may improve stage-adjusted survival by improving stage accuracy, and improve aggregate survival by increasing the appropriate use of post-operative adjuvant therapy. A prospective randomized trial to test survival impact of the dual interventions is at an advanced planning phase. [Table: see text]

Postoperative Chemotherapy in Resected Gastric Cancer: Results of a Single Center Experience

Gastric cancer remains a major health problem despite its decline in incidence in Western countries. Although radical surgery represents the primary curative option for gastric cancer patients, most of them relapse and die due to their disease despite an R0 resection. At present the routine use of postoperative adjuvant therapy to reduce disease recurrence is still considered an investigational approach. Out of a total of 275 patients (stage IB through IV M0 AJCC/UICC) who underwent surgery for gastric cancer at our Surgery Unit between 1993 and 2001, 156 were eligible for adjuvant chemotherapy, of whom only 52 accepted to undergo this treatment. This group of patients was retrospectively compared with a control group (1:2) and overall survival was assessed using hazard ratio and Kaplan-Meier estimates. Five-year survival was 40% in the chemotherapy group and 37.8% in the group which underwent surgery alone. Indeed, chemotherapy did not reduce the risk of death (HR 0.87, 95% CI = 0.57-1.34, p=0.54). Serosal involvement and the invasion of more than 6 lymph nodes were the main independent prognostic factors identified by multivariate analysis. The current study did not show a clear advantage of chemotherapy over surgery alone. However, our results can help to define strategies for future clinical trials with the use of new regimens based on more effective and less toxic drugs.

Local Excision of Rectal Cancer—Clinical Decision-Making

A small group of patients with “early” rectal cancers that have favorable characteristics can be cured by local excision, without the need for a radical resection. The key is very careful selection of patients, precise surgical techniques, fastidious histologic review of the specimens, and judicious use of postoperative adjuvant therapy. Recurrence after a local excision significantly worsens the prognosis of patients who had a relatively localized rectal cancer that has a high cure rate by radical resection alone. This article focuses on the indications and limitations of local excision of rectal cancer and highlights gaps in our knowledge that mandates further study.

Node status in transmural esophageal adenocarcinoma and outcome after en bloc esophagectomy

Objective: Adenocarcinoma has replaced squamous cell as the most common esophageal cancer in the United States. The purpose of this study was to determine the prevalence and location of lymph node metastases, the feasibility of performing an R 0 resection, and disease recurrence and survival in patients with transmural adenocarcinoma of the lower esophagus and gastroesophageal junction. Methods: Forty-four patients with transmural adenocarcinoma underwent en bloc esophagectomy with systematic thoracic and abdominal lymphadenectomy. They were followed up for a median of 23 months. Results: Actuarial survival for the entire group was 26% at 5 years. The most important predictors of the likelihood of recurrent disease and 5-year survival were the presence and number of lymph node metastases and the ratio of involved to total removed nodes. Seven patients (16%) were found to have no lymph node metastases and had an 85% 5-year survival. In contrast, patients with more than 4 involved nodes or a node ratio greater than 0.1 had a high likelihood of recurrence and death. Location of involved lymph nodes did not predict the likelihood of recurrence or death. Despite all patients having transmural tumors, recurrence within the field of the en bloc resection occurred in only 1 patient (2%). Conclusions: En bloc esophagectomy in patients with transmural esophageal adenocarcinoma is required to obtain the survival benefit of an R 0 resection, to adequately assess lymphatic tumor burden, and to be able to predict the likelihood of recurrence and death and thereby guide the use of postoperative adjuvant therapy. (J Thorac Cardiovasc Surg 1999;117:960-8)

Prognostic factors in ductal pancreatic cancer.

The diagnosis of pancreatic adenocarcinoma remains a devastating life event for most patients and their families. Many patients with this relatively common malignancy present at a stage of disease not amenable to cancer-directed resectional therapy, and are treated via nonoperative palliative measures, with median survival of 4-8 months post-diagnosis. A minority of patients present with disease limited to the pancreas and periampullary region and are candidates for resectional therapy. The prognosis for these patients is determined by several factors: clinicopathologic staging, tumor biology and molecular genetics, perioperative factors and the use of postoperative adjuvant therapy.