Utilization Of Adjuvant Therapy Research Articles

Survival impact of treatment utilization and margin status after resection of adrenocortical carcinoma

BackgroundThis study examines the combined impact of margin status and adjuvant therapy utilization on overall survival (OS) for adrenocortical carcinoma (ACC) patients undergoing surgery with curative intent. MethodsThe 2004–2020 National Cancer Database (NCDB) was queried for ACC patients ≥18yrs undergoing curative surgery (no debulking), subdivided into R0 and R1/R2-groups, and analyzed using inverse-probability-weighted Cox Proportional Hazard-model. ResultsOf 5023 ACC patients, 3193 underwent curative surgery, 2213 (69 ​%) had R0 margins. Compared to the R0, the R1/R2 group had a decreased OS by 15.6 months (HR ​= ​1.89, p ​= ​0.002). While there has been no significant improvement in margin status over the years studied (2008–2017), there has been an overall increase in the proportion of patients receiving adjuvant therapy regardless of margin status, and the adverse impact of a positive margin on survival has decreased [HR 2.20 vs 1.76] ConclusionsR1/R2 margins are associated with decreased OS. The adverse impact of R1/R2 margins on OS decreased over time while adjuvant therapy utilization increased for all patients.

Disparities in postoperative adjuvant therapy utilization and factors impacting survival among anaplastic thyroid cancer patients

BackgroundAnaplastic thyroid cancer (ATC) is highly aggressive with a poor prognosis. Adjuvant systemic therapy and radiation post-surgery are endorsed by NCCN and ATA guidelines. Our study aimed to identify those at risk of forgoing postoperative adjuvant treatment and to determine survival predictors. MethodsWe used the National Cancer Database (NCDB) to identify ATC patients who underwent upfront thyroidectomy from 2010 to 2017, excluding those opting for palliative care. We compared demographics, characteristics, treatments, and outcomes between those who received adjuvant therapy and those who did not. Predictors of receiving adjuvant therapy were identified using logistic regression, while Cox regression identified survival factors. ResultsOf 563 patients, 160 received no adjuvant treatment, 82 received radiation only, 16 received systemic therapy only, and 305 received combination therapy. Notably, over 75 ​% of patients who did not receive adjuvant treatment had it excluded from their treatment plan, not due to refusal. Older age (OR 0.92) and non-white race/ethnicity (OR 0.33) were significant predictors of not receiving adjuvant therapy. Undergoing a total thyroidectomy, an R0 or R1 resection, and radiation or combination therapy were associated with better survival, while non-metropolitan location, primary tumor size >7.5 ​cm, and stage IVC disease were negative factors. ConclusionTotal thyroidectomy, R0/R1 resection, and adjuvant therapy reduce mortality in ATC patients. However, older patients and minorities are less likely to receive adjuvant therapy, underscoring disparities in treatment adherence.

Clinicopathologic significance of heat shock protein 60 as a survival predictor in breast carcinoma.

While Heat Shock Protein 60 (HSP60) has been linked to human tumor, its clinic significance specifically in breast carcinoma is unclear. This investigation aims to retrospectively evaluate how HSP60 protein levels relate to survival outcomes among patients diagnosed with breast carcinoma. Evaluation of 206 patients diagnosed with breast carcinoma and receiving treatment from January 2012 to April 2018, carried out retrospectively. The protein level of HSP60 in breast carcinoma determined by immunohistochemical. The study provided evidence of a distinct upregulation of HSP60 expression in breast carcinoma tumor samples in contrast to adjacent normal tissue samples. Additionally, heightened HSP60 expression was linked to advanced T stage (P = 0.046), N stage (P = 0.034), tumor metastasis (P = 0.016), pathological grading (P = 0.012), and adjuvant therapy utilization (P = 0.004). Moreover, elevated levels of HSP60 proteins exhibited a significant inverse correlation with overall survival (OS) [hazard ratio (HR) 1.598, P = 0.018] and progression-free survival (PFS) (HR 1.600, P = 0.017) among breast carcinoma patients in univariate analyses. The results of multivariate analyses highlighted HSP60 may serve as an independent predictor for both OS and PFS in breast carcinoma patients (HR 1.525, P = 0.034; HR 1.528, P = 0.033, respectively). The involvement of HSP60 in breast carcinoma progression suggests its potential clinical relevance in treatment target validation and prognostic assessment of the disease.

Observational Research On Urban Public Awareness of Ayurveda as an Adjuvant Therapy During COVID-19

Ayurveda labels COVID-19 as Janapadodhwamsa Vikara (epidemic disease). Charaka Samhita: Vimana Sthana Chapter 3discusses epidemics; even though there is dissimilarity in the physical constitution of human beings; still there are such factorsthat are common to all individuals, and vitiation of these factors lead to the simultaneous manifestation of diseases having thesame set of symptoms leading to the destruction of countries. All citizens share air, water, location, and seasons. The subjectswere drawn from the general population who had tested positive for COVID-19. An accurate and comprehensive questionnairewas used to conduct the online survey. All of the responses were correctly completed. All information was gathered from theonline survey and properly analysed. This study included 250 COVID-19-positive participants. A questionnaire and verbaldialogue assessed COVID-19 ayurvedic adjuvant therapy utilization. 89.6% had COVID-19. 65.6% of patients have RTPCR toconfirm COVID-19. 81.2% of COVID-19 patients initially used allopathic medication, with 59.6% reporting negative effects. Afterthat, 87.2% received ayurvedic COVID-19 medicine. 96.4% of COVID-19 patients had a fever, cold, cough, and weakness.Mahasudarshana Kadha (71.2%), Samshavani Vati (66.4%), and Sitopaladi Churna (51.2%) were the top three COVID-19 medicines.Most nations treat COVID-19 with antiviral combinations for other viral infections. SARS-COV-2 antivirals may not workclinically. Ayurveda treats sickness via mind-body-physiology. Ayurvedic medicine boosts immunity and fights viruses. Ayurvedaadjuvant therapy helped COVID-19 patients. Ayurveda can treat COVID-19 symptoms without side effects.

Minimal Residual Disease in Colorectal Cancer: Are We Finding the Needle in a Haystack?

Despite significant advances in the surgical and systemic therapy of colorectal cancer (CRC) in recent decades, recurrence rates remain high. Apart from microsatellite instability status, the decision to offer adjuvant chemotherapy to patients with CRC is solely based on clinicopathologic factors, which offer an inaccurate risk stratification of patients who derive benefit from adjuvant therapy. Owing to the recent improvements of molecular techniques, it has been possible to detect small allelic fractions of circulating tumor DNA (ctDNA), and therefore, to identify patients with minimal residual disease (MRD) after curative-intent therapies. The incorporation of ctDNA identifying MRD in clinical practice may dramatically change the standard of care of CRC, refining the selection of patients who are candidates for escalation and de-escalation of adjuvant chemotherapy, and even for organ-preservation strategies in rectal cancer. In the present review, we describe the current standard of care and the DNA sequencing methodologies and assays, present the data from completed clinical studies and list ongoing potential landmark clinical trials whose results are eagerly awaited, as well as the impact and perspectives for the near future. The discussed data bring optimism for the future of oncologic care through the hope of refined utilization of adjuvant therapies with higher efficacy and safety for patients with both localized and advanced CRC.

Treatment patterns for leiomyosarcomas, endometrial stromal sarcomas and adenosarcomas: a national cancer database study

Uterine sarcomas are a rare, heterogenous, group of cancers with limited data on optimal adjuvant treatment. We examined patterns of care for leiomyosarcomas (LMS), endometrial stromal sarcomas (ESS), adenosarcomas (AS), and mixed uterine sarcomas and assessed the utilization of adjuvant therapy for each histology. The National Cancer Database (NCDB) was queried for patients with non-metastatic uterine sarcoma diagnosed between 2004 and 2018 treated with surgery. Uterine carcinosarcomas were excluded. Adjuvant patterns of care and temporal treatment trends are evaluated, stratified by histology. Multivariable logistic regression model was constructed to identify predictors of receipt of radiation adjuvant therapy. Among 12,806 patients, 88% received a total hysterectomy and bilateral salpingo-oophorectomy (TH+BSO) and 42% received lymph node sampling (LNS). Surgery alone was the most common treatment modality for all histology groups (59.0%). Surgery with chemotherapy was the second most common form of treatment for LMS (33.1%) and mixed type tumors (29.6%). Surgery with radiation was the second most common treatment for high-grade ESS (10.8%) and AS (11.8%). External beam radiation therapy (EBRT) was the most common type of adjuvant radiation therapy utilized. Adjuvant radiation therapy (RT) has declined in LMS, from 27% in 2004 to 3% in 2018. Adjuvant chemotherapy for all histology groups has increased in use from 10% in 2004 to 28% in 2018. For uterine sarcomas, TH+BSO without LNS was the main surgical modality. Adjuvant therapy for uterine sarcomas is not commonly used, however high risk features including stage II/III, high grade, and more extensive lymph node sampling appear to increase the likelihood of adjuvant RT. The utilization of adjuvant chemotherapy in uterine sarcomas has increased over time, while RT has been decreasing.

Implementation of Melanoma Guidelines in the Multidisciplinary Setting: A Qualitative Analysis

INTRODUCTION: Treatment of advanced melanoma has evolved dramatically recently. Randomized trials now support omitting completion lymph node dissection (CLND) and offering adjuvant systemic therapy for many patients with sentinel lymph node–positive melanoma. Recent data from an international melanoma consortium suggest wide variation in CLND and adjuvant therapy utilization. We aimed to explore how providers consider multidisciplinary treatment options in this setting. METHODS: We conducted semi-structured interviews among surgical oncologists, medical oncologists, and otolaryngologists. Two researchers performed analysis through independent data abstraction of transcripts. Findings were discussed to reach consensus. RESULTS: All participants (n = 17) practiced at a cancer center in an academic setting. Melanoma comprised an estimated 30% to 80% of their practice (only 2% to 15% for otolaryngologists). Participants described melanoma care as inherently “multidisciplinary.” Many noted the importance of real-time conversations among providers, particularly those facilitated by shared clinic days or space, for everyday decision-making compared with formal tumor boards. Despite stating a belief that their practice mirrored other providers within and outside their institutions, participants revealed differing perspectives on CLND and adjuvant therapy (Table). Multidisciplinary care presented challenges for melanoma surveillance because surgical oncologists expressed desire to retain ownership of patients undergoing active surveillance but did not feel comfortable overseeing needs related to adjuvant therapy. Both surgical and medical oncologists noted potential redundancy in roles and burden to patients in the form of uncoordinated visits and scans. Table. - Differences in Perspectives on Completion Lymph Node Dissection (CLND) and Adjuvant Systemic Therapy Treatment option Representative example (surgical oncology) Representative example (medical oncology) Representative example (otolaryngology) Completion lymph node dissection At our institution almost never do patients get a [CLND]. Soon after the trials, there was some ambiguity about should some patients that may not have been as well represented in those trials be considered for completion, and there’s probably less issue there. Probably the main factor that pushes for dissection now would be ability to comply with routine surveillance. (Participant 7) I have seen somewhat of a push for surgery just because all of our adjuvant trials were done in patients who did have a nodal basin dissected. So it’s a little bit of a different population that we’re actually treating than was studied in [MSLT-II] because we may have patients who have residual disease. So to be more purely like the trial, there are sometimes people who push for a lymph node dissection. (Participant 1) Some of this really just relates to your philosophy of approaching cancer and surgical aggressiveness in general. I generally err on the side of being a more conservative surgeon, which applies not just to melanoma. So I am a bit more reticent to recommend a completion than some of my colleagues, but that’s not to say they’re wrong and I’m right. (Participant 14) Adjuvant systemic therapy So it’s really hard to give adjuvant therapy when there’s no survival benefit, and you see that the toxicity is so bad. From my standpoint, it’s very hard for me to think about let’s take a patient, let’s remove all of their disease, and then give them immunotherapy. Let’s boost the immune system. Oh—but I already took it all out. So the adjuvant therapy idea is hard for me. (Participant 2) We know with the Keynote 716 trial, pembrolizumab can be [used] in patients who have high risk stage II disease. Based on that trial, we are now recommending adjuvant immune therapy. So it’s kind of a continuum. Now we can justify [stage] IIIA patients that were excluded from the stage III trials. (Participant 15) A lot of these patients are going to get adjuvant therapy, no matter what, so both for immunotherapy and for like a dabrafenib or trametinib treatment. The question is not whether or not we do adjuvant therapy, the question is whether they get the [adjuvant] therapy with or without a completion lymphadenectomy. (Participant 10) CONCLUSION: Opportunities exist to improve multidisciplinary melanoma care through broader consensus of how to translate emerging data into patient care and delineating surveillance roles.

The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus.

To review our institutional experience with thesurgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion. Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20ng/mL within 14days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score. A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0-2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks. The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associatedwith improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.

Lymph Node Ratio Is a Reliable Prognostic Marker after Neoadjuvant Therapy and Pancreaticoduodenectomy for Pancreatic Cancer, but Does Not Predict the Utility of Adjuvant Therapy

Introduction: The role of additional adjuvant chemotherapy(AT) after neoadjuvant chemotherapy(NAT) and surgical resection for pancreatic ductal adenocarcinoma(PDAC) remains unclear. Lymph node ratio(LNR), defined as number of positive nodes divided by total resected nodes, is a well-established prognostic indicator for PDAC. The objective of this analysis was to determine if LNR predicts survival benefit attained from receipt of AT following NAT and resection. Methods: Patients who underwent pancreaticoduodenectomy after NAT from 2006-2017 with pathologically node-positive PDAC were identified using the National Cancer Database. Patients with metastatic disease or unknown lymph node status were excluded. Patients were grouped as receiving NAT plus AT, or NAT only. LNR within node-positive groups were compared with a cutoff of 0.15. Five-year overall survival was determined by Kaplan-Meier analysis and multivariate(MV) Cox proportional hazards modeling. Results: A total of 1,182 patients were included: 623 with LNR=0.1-0.14 and 559 with LNR>=0.15. Median survival was higher among LNR=0.1-0.14 than with LNR>=0.15(28.8 vs 20.5mos, log-rank p<.001). 606 patients received NAT plus AT, and 576 received NAT only. For patients with LNR=0.1-0.14, receipt of additional AT was associated with improved median survival of 33.9mos compared to 27.3mos(log-rank p=0.050). For LNR>=0.15, receipt of additional AT was associated with improved median survival of 23.3mos vs 18.2mos(log-rank p=0.0024). MV analysis revealed similar survival benefit from AT, with hazard ratios of 0.807(95%CI 0.678-0.960, p=0.0156) for LNR=0.1-0.14 and 0.79(95%CI 0.669-0.942, p=0.0084) for LNR>=0.15. Conclusion: Although LNR is a reliable prognostic indicator for PDAC, it does not predict the utility of AT after receipt of NAT.

Comparison of laparoscopic versus open pancreaticoduodenectomy in patients with resectable pancreatic ductal adenocarcinoma: A propensity score-matching analysis of long-term survival

BackgroundMany studies have shown the short-term feasibility and effectiveness of laparoscopic pancreaticoduodenectomy (LPD) are comparable to open pancreaticoduodenectomy (OPD). However, the long-term oncological safety of LPD in patients with pancreatic ductal adenocarcinoma (PDAC) remains to be elucidated. MethodsPatients who underwent LPD or OPD between July 2014 and July 2018 at our institution were identified, and those with resectable, pathologically diagnosed PDAC were analyzed. The primary outcome was overall survival (OS). Propensity score-matching (PSM) analysis was performed to balance the baseline characteristics between groups. Cox proportional hazards model was constructed to determine independent predictors of OS. ResultsThe original cohort consisted of 64 LPD and 80 OPD cases, in which, the laparoscopic group had a significantly longer median OS (25 vs. 17 months; P = 0.034). A higher proportion of laparoscopic patients received adjuvant therapy (51.6 vs. 32.5%; P = 0.021). PSM analysis identified 47 patient pairs. No significant differences in OS (21 vs. 17 months; P = 0.220) or adjuvant therapy utilization (53.2 vs. 38.3%; P = 0.248) were observed between the matched groups. Multivariate Cox analyses showed that receiving adjuvant therapy (HR = 0.44; 95% CI, 0.28–0.68), histopathological differentiation (poor vs. moderate-to-well differentiation; HR = 1.93; 95% CI, 1.26–2.95), and sex (female vs. male, HR = 0.47, 95% CI, 0.30–0.75) were independent predictors of OS. ConclusionsLPD can be comparable to OPD in terms of long-term safety for patients with resectable pancreatic ductal adenocarcinoma when performed in a high-volume center.

Efficacy and safety of adjuvant therapy after curative surgery for ampullary carcinoma: A systematic review and meta-analysis

BackgroundAmpullary carcinoma patients require radical resection for optimal survival; however, the outcomes are often unsatisfactory. The utility of adjuvant therapy among such patients is unclear, probably owing to its potential side effects. Therefore, this study investigated the benefits and safety of adjuvant therapy in resected ampullary carcinoma. MethodsCochrane, Embase, Medline, and PubMed databases were systematically searched for eligible studies, and those comparing adjuvant therapy and surgical treatment alone were included. Hazard ratios for survival outcomes and the number of adverse events for safety endpoints were extracted and subjected to pooled analyses through a random-effects model. ResultsIn total, 27 studies involving 3,538 patients were included. Adjuvant therapy was significantly associated with decreased mortality risk (hazard ratio, 0.58; 95% confidence interval 0.40–0.84), especially for chemoradiotherapy (hazard ratio, 0.42; 95% confidence interval 0.28–0.62). Furthermore, adjuvant therapy was significantly associated with increased overall survival among high-risk patients (hazard ratio, 0.63; 95% confidence interval 0.48–0.82) or those with the pancreaticobiliary subtype (hazard ratio, 0.53; 95% confidence interval 0.32–0.85). By contrast, adjuvant therapy was not associated with improved overall survival among low-risk patients (hazard ratio, 0.93; 95% confidence interval 0.52–1.68) or those with the intestinal subtype (hazard ratio, 1.06; 95% confidence interval 0.57–1.95). Regarding the safety of adjuvant therapy, no intervention-related mortality occurred, and severe adverse events were within the acceptable range (risk difference, 0.04; 95% confidence interval 0.01–0.08). ConclusionThe present results suggest that adjuvant therapy is safe and extends survival in high-risk patients or those with the pancreaticobiliary subtype of ampullary carcinoma.

Inaccurate Clinical Stage Is Common for Gastric Adenocarcinoma and Is Associated with Undertreatment and Worse Outcomes.

Accurate clinical staging (CS) of gastric cancer is critical for appropriate treatment selection and prognostication, but CS remains highly imprecise. Our study evaluates factors associated with inaccurate CS, the impact of inaccurate CS on outcomes, and utilization of adjuvant therapy in patients who are understaged. We conducted a retrospective review of NCDB patients diagnosed with clinical early stage gastric adenocarcinoma (cT1-2N0M0) between 2004 and 2016. Patients not undergoing upfront gastrectomy or with missing pathologic staging were excluded. Patients were classified as accurately staged, inaccurately staged with receipt of adjuvant therapy (IS+), and inaccurately staged with no receipt of adjuvant therapy (IS-). Logistic regression was utilized to assess the impact of factors on CS accuracy and receipt of adjuvant therapies. Kaplan-Meier and Cox proportional hazard methods were used for survival analysis. Approximately 40% of patients were inaccurately staged (IS). cT2, moderately/poorly differentiated, and site-overlapping tumors were associated with increased likelihood of being IS. Treatment at an academic facility was associated with decreased likelihood of understaging. Only 54% of patients who were IS received adjuvant therapy. Accurate CS of gastric cancer remains inadequate. Understaging is associated with detrimental effects on receiving guideline-concordant care and, possibly, patient outcomes. Targeted interventions reducing the proportion of understaged patients and ensuring receipt of appropriate therapy is needed to optimize outcomes. Patients with high-risk disease that are frequently understaged may benefit from selective neoadjuvant therapy. Centralization of gastric cancer care may also be a key strategy in improving receipt of guideline-concordant therapies.

Lymph node ratio is a reliable prognostic marker after neoadjuvant therapy and pancreaticoduodenectomy for pancreatic cancer, but does not predict the utility of adjuvant therapy

Presenter: Alexandra Adams MD, MPH | Brooke Army Medical Center Background: Neoadjuvant chemotherapy (NAT) has been increasingly utilized for patients with pancreatic ductal adenocarcinoma (PDAC). However, the role of additional adjuvant chemotherapy (AT) after NAT and surgical resection remains unclear. The lymph node ratio (LNR), defined as the number of positive nodes divided by total resected nodes, is a well-established prognostic indicator for patients with resected PDAC, and could potentially help decipher which patients could avoid AT after NAT. The objective of this analysis was to determine if LNR predicts survival benefit from receipt of AT following NAT and surgical resection. Methods: Patients who underwent pancreaticoduodenectomy after NAT from 2006-2017 and had pathologically node positive PDAC were identified using the National Cancer Database. Patients with metastatic disease or unknown lymph node status were excluded. Patients were grouped as receiving NAT plus AT, or NAT only. The LNR within the node-positive groups were compared, with a cutoff of 0.15. Five-year overall survival was determined by Kaplan-Meier analysis and multivariate (MV) Cox proportional hazards modeling. Results: A total of 1,182 patients were included: 623 patients with LNR=0.01-0.14 and 559 with LNR>=0.15. Median survival was higher among patients with LNR=0.01-0.14 than those with LNR>=0.15 (28.8 vs 20.5 months, log-rank p=0.15, receipt of additional AT was associated with improved median survival of 23.3 months vs 18.2 months without AT (log-rank p=0.0024). MV analysis by Cox proportional hazards revealed similar survival benefit from AT, with hazard ratios of 0.807 (95% CI 0.678-0.960, p=0.0156) for LNR=0.01-0.14 and 0.794 (95% CI 0.669-0.942, p=0.0084) for LNR>=0.15. Conclusion: Although LNR is a reliable prognostic indicator for PDAC, it does not predict the utility of AT after receipt of NAT. Thus, while LNR may be useful in counseling patients regarding prognosis, we advise against using it as a discriminator for decisions regarding adjuvant therapy. Further investigation is needed into the best selection criteria for patients that would benefit from additional AT after receipt of NAT and pancreaticoduodenectomy.

Prognostic Factors for Adjuvant Therapy after Trans-Oral Robotic Surgery in Patients with Oropharyngeal Squamous Cell Carcinoma

To identify predictors of adjuvant therapy after Trans-Oral Robotic Surgery (TORS) for Oropharyngeal Squamous Cell Carcinoma (OPSCC). We used the National Cancer Database (NCDB) registry to identify patients with newly diagnosed clinical (AJCC 7th edition) T1-T4 N0-N3 OPSCC treated with TORS between 2010 and 2016. Exclusion criteria were patients with metastatic disease (n = 1,997), biopsy only disease (n = 227), unknown stage (n = 771), and unknown surgical margin status (n = 78). A multivariable logistic regression was performed to determine predictors of adjuvant chemotherapy use after TORS. Variables included in the multivariable analysis include T stage, N stage, HPV status, margin status, performance status, age, case year surgery was performed (2010-2013 vs 2014-2016), and case volume. Case volume was divided into quintiles to assess the impact of case volume per institution with need for adjuvant therapy. Kaplan Meier Survival analysis was used to estimate overall survival (OS). We identified 3,337 patients who underwent TORS between 2010-2016. 3,232 patients (95.03%) underwent a lymph node dissection and the median number of lymph nodes removed was 31. 82.0% of patients were HPV positive and 18.0% were HPV negative. 2,940 patients (88%) were T1/T2 and 397 patients (12%) were T3/T4. Only 44 patients (1.3%) had N3 disease. The percentage of patients with positive and negative margins was 14.9% and 86.1% percent, respectively. The 5-year OS for the entire cohort was 80.8%. The 5-year OS for the HPV+ versus HPV- cohort was 85.2% and 63.5%, respectively (log-rank, p<0.001). Of all patients who received TORS, 1,166 (35.6%) received no further adjuvant therapy, 1,088 (33.2%) received adjuvant RT alone and 1,022 (31.2%) received adjuvant chemotherapy in addition to radiation. Among patients with only T1-T2 disease (n = 3050), 929 (29.6%) required adjuvant chemoradiation. For patients treated at institutions with the highest quintile for case volume, 27.2% required adjuvant radiotherapy and 35.0% required adjuvant chemotherapy. On multivariable logistic regression, patients with higher T stage (OR: 1.28, p<0.001), N stage (OR: 2.32, p<0.001), and positive margins (OR:1.64, p<0.001) were more likely to receive adjuvant chemotherapy. Patients who were treated between 2014-2016 were less likely to receive adjuvant chemotherapy compared to those treated between 2010-2013 (OR: 0.80, p = 0.029). The utilization of adjuvant therapy after TORS remains high, even in high volume centers, which suggests better patient selection is needed to identify a subset of patients that can be treated with TORS alone and undergo treatment de-escalation.

The impact of sarcopenia on patients undergoing treatment for pancreatic ductal adenocarcinoma

Abstract Introduction: Pancreatic ductal adenocarcinoma (PDAC) is a deadly cancer that disproportionately affects geriatric patients. Combination therapy with surge. ry and chemotherapy is associated with longer survival than medical treatment or supportive care. Preoperative selection of patients for surgical treatment, based on patient-specific factors such as sarcopenia, may help risk-stratify patients and improve outcomes. This paper aims to review the current literature on the impact of sarcopenia and sarcopenic obesity on patients undergoing treatment for PDAC. Outcomes: The impact of sarcopenia and sarcopenia obesity on perioperative and long-term outcomes after treatment for PDAC is variable. Sarcopenia has been associated with high-grade complications, longer length of hospital, and intensive care unit stays, more frequent discharge to skilled nursing facilities and decreased utilization of adjuvant therapy in patients treated with curative intent surgery. Sarcopenic obesity has been associated with more complications, high-grade complications, and hematologic toxicities. Patients with sarcopenic obesity may have even lower overall survival than sarcopenic patients. Discussion: The effect of a pre-treatment diagnosis of sarcopenia or sarcopenic obesity on outcomes for patients undergoing treatment for PDAC remains unknown, in part due to the heterogeneity of studies and definitions. Prehabilitation programs including resistance exercise and nutritional supplementation have shown benefit in sarcopenic patients. Conclusion: PDAC remains a deadly disease and patient-specific factors such as sarcopenia and sarcopenic obesity identified at the time of cancer diagnosis offer potential as risk stratification measures and points of intervention. Currently, a paucity of standardized measurement tools, definitions, and prehabilitation regimens limits the clinical implementation of such knowledge.

Characterizing the efficacy and trends of adjuvant therapy versus observation in women with early stage (uterine confined) leiomyosarcoma: a National Cancer Database study.

ObjectiveThe utility of adjuvant therapy for women with uterine confined leiomyosarcoma remains uncertain. We sought to identify trends, analyze efficacy, and assess survival impact of adjuvant therapy in this patients.MethodsWe performed an observational cohort study of 1030 women with early stage leiomyosarcoma from the 2008–2014 National Cancer Database. Multi-nominal logistic regression was used to identify trends in receipt of adjuvant treatment. Demographic and clinical characteristics were compared. Kaplan-Meier curves were used to estimate survival.ResultsThere were 547 who (53.1%) received observation, 79 (7.7%) received radiation alone, 340 (33.0%) received chemotherapy alone, and 64 (6.2%) received chemoradiation. Patients were more likely to be observed if tumor size was <5 cm (hazard ratio [HR]=0.97; 95% confidence interval [CI]=0.95–0.99; p=0.017) and less likely to be observed if lymphovascular space invasion (LVSI) was present (HR=0.60; 95% CI=0.41–0.89; p=0.010). Patients were more likely to receive chemotherapy if they were younger (HR=0.78; 95% CI=0.65–0.94; p=0.010) and if they had LVSI (HR=1.47; 95% CI=1.01–2.16; p=0.040). There was an independent association between older age, tumor size >5 cm, and LVSI with worsened survival, with the strongest predictor of mortality being the presence of LVSI. With a median survival of 61.9 months, there was no difference in estimated overall survival at 1 and 3 years based on receipt of adjuvant treatment as compared to observation (p=0.500).ConclusionAlthough women with uterine confined leiomyosarcoma experience high recurrence rates and poor survival outcomes, adjuvant treatment does not appear to confer a survival benefit.

Pancreatic islet cell tumors in adolescents and young adults

BackgroundPancreatic islet cell tumors are rare in adolescents, and most studies published to date focus on older patients. We utilized a national database to describe the histology and clinical pattern of pancreatic islet cell tumors in adolescent and young adult (AYA) patients, and to compare AYAs to older adults. We hypothesized that AYAs with pancreatic islet cell tumors would have better overall survival. MethodsThe National Cancer Data Base (NCDB, 1998–2012) was queried for AYA patients (15–39 years) with a pancreatic islet cell tumor diagnosis. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 years). Results383 patients (56.4% female, 65% non-Hispanic Whites) were identified, with a median age of 27 (IQR 16–34) years. Islet cell carcinoma was the most common histology. Of patients with known stage of disease, 49% presented with early stage (I or II). Seventy percent of patients underwent surgical resection, including local excision 44%, Whipple procedure 37.5%, or total pancreatectomy 19%. Chemotherapy was utilized in 27% and radiotherapy in 7%. All-cause mortality was 36%. AYA patients underwent more extensive resections (p = 0.001) and had lower mortality rates (p < 0.001), with no differences in tumor stage or use of adjuvant therapies, when compared to adults. ConclusionsAYA patients with pancreatic islet cell tumors had comparable utilization of adjuvant therapies but underwent more extensive resections and demonstrated a higher overall survival rate than adult counterparts. Further investigation into approaches to earlier diagnosis and tailoring of multimodality therapy of these neoplasms in the AYA population is needed. Levels of evidencePrognostic Study, Level II — retrospective study.

The Impact of Tumor Location on Resection and Survival for Pancreatic Ductal Adenocarcinoma

BackgroundDifferences in clinical staging and survival among pancreatic head, body, and tail cancers are not well defined. We aim to identify the prognostic relevance of primary tumor location in patients undergoing treatment for pancreatic ductal adenocarcinoma (PDAC). Materials and methodsThe National Cancer Database was used to identify patients with PDAC from 1998 to 2011 (n = 175,556). Patients were categorized by primary tumor site into head (67.5%, n = 118,343), body (15.5%, n = 27,218), and tail (17.0%, n = 29,885) groups. Univariate and Cox regression analyses were used to determine covariates associated with overall survival (OS). ResultsPatients with head PDAC presented with earlier stage disease (39.2% Stage I/II versus 19.7% versus 16.0%, P < 0.001) and underwent resection more often (27.9% versus 10.7% versus 17.0%, P < 0.001) than those with body or tail tumors. Of surgically resected PDAC, those localized to the head had advanced pathologic stage (84.8% stage II/III versus 66.6% versus 65.6%, P < 0.001), higher nodal positivity (64.9% versus 45.8% versus 45%, P < 0.001), and worse tumor grade (35.9% poorly differentiated versus 29.5% versus 27.8%, P < 0.001). Despite increased utilization of adjuvant therapies (54.4% versus 45.6% versus 42.0%, P < 0.001), patients with head PDAC had inferior OS compared with those with body and tail tumors (P < 0.001). ConclusionsWhen examining patients with PDAC undergoing resection, tumor localization to the head is associated with improved resectability because they present earlier. Of resected PDACs, however, those localized to the head have worse OS compared with body and tail tumors. This discrepancy may represent a combination of lead time and selection biases and biologic differences between tumor sites.

Adoption of AJCC 8th Edition for p16+ Oropharynx Cancers May Result in Decreased Utilization of Adjuvant Therapies Due to Shifts in Pathologic Nodal Staging

The 8th edition of the AJCC (American Joint Committee on Cancer) system no longer includes nodal laterality or size in the pN staging system for p16+ oropharynx cancers. This is because number of involved lymph nodes provides better discriminatory ability for recurrence than laterality, size, or presence of high risk nodal features (i.e. extracapsular extension [ECE]). At our institution, we have routinely offered adjuvant radiotherapy (+/- chemotherapy) for patients with traditional intermediate or high risk features independent of p16 status as per NCCN guidelines. Here, we examine a cohort of p16+ patients staged and treated according to AJCC 7th edition and reclassify them according to the 8th edition to determine rate of nodal downstaging based on the new system. Patients with pathologically node positive p16+ oropharyngeal cancer treated with primary surgery (most commonly TORS with selective neck dissection) followed by adjuvant intensity modulated radiation therapy (+/- chemotherapy) were included for analysis. Demographics, pathology, and treatment details were collected from the electronic medical record. Indications for adjuvant therapy were recorded and patients were re-staged according to the AJCC 8th edition. Rates of nodal downstaging were recorded. A total of 28 patients met inclusion criteria and were treated from 2012 to 2017. 93% were male. 24 (85%) primaries were tonsillar and 4 (15%) base of tongue. An ipsilateral selective neck dissection was performed in 17 (61%) cases. A total of 27 patients had pre-operative imaging (CT or PET) consistent with nodal involvement. The median number of involved lymph nodes was 2 (range 1-8). 13 (46%) had pathologic evidence of ECE, one (4%) microscopic perineural invasion (PNI), and five (18%) had lymphovascular space invasion (LVSI). Five patients (18%) had a microscopically positive margin. AJCC 7th edition N staging was as follows: N1: 10 (36%), N2a: 1 (4%), and N2b: 17 (60%). 15 of 18 (83%) AJCC 7th N2 patients were downstaged to AJCC 8th N1. Seven of these 15 (47%) patients did not have other adverse pathologic features (i.e. pT3, ECE, positive margin, PNI, LVSI). Radiation therapy was delivered using a simultaneous integrated boost technique in all cases. The median dose to the highest risk volume was 60 Gy (range 60-66 Gy). 13 patients (46%) received concurrent chemotherapy. At a median follow up of 25 months (range 3 months to 10 years), there have been no recurrences in this cohort. Nodal downstaging from pN2 to pN1 with the adoption of AJCC 8th edition is common for surgically-treated node positive p16+ oropharynx cancer. Although number of positive nodes has high discriminatory ability for recurrence, it is unknown whether the omission of adjuvant therapy in patients with < 5 positive nodes is safe. Until this is known, the decision to recommend adjuvant therapy should be highly dependent on a thorough understanding of pathologic findings rather than relying purely on the new pathologic N stage.

Patterns of Adjuvant Therapy Utilization in Uterine Carcinosarcoma Stages I to III: A National Cancer Database Analysis.

The objective of this study is to characterize patterns of utilization of adjuvant chemotherapy (CT) and radiotherapy (RT) in the posthysterectomy management of uterine carcinosarcoma (UCS) in the United States. We queried the National Cancer Database for women diagnosed with UCS between 2004 and 2012 and undergoing hysterectomy. Logistic regression was performed to identify sociodemographic, facility-specific, and treatment-related predictors of receiving multiagent chemotherapy, external beam radiotherapy (EBRT), or brachytherapy (BT). In total 4272 patients were included, with 2 in 5 (40.5%) receiving no adjuvant therapy. Regarding RT, 2357 (55.1%) received neither EBRT nor BT, 929 (21.7%) received EBRT alone, 518 (12.1%) received BT alone, and 468 (11.0%) received EBRT+BT. Most women (70.8%) received no CT, a minority (1.5%) received single-agent CT, and the rest (27.8%) received multiagent chemotherapy. Logistic regression demonstrated disparities in receipt of adjuvant therapies by age, diagnosis year, insurance, facility volume, facility type, stage, and margin status, with patients with positive surgical margins less likely to receive BT. Following hysterectomy for UCS, a large proportion of women receives no CT and no RT in the United States. Multispecialty evaluation is critical for individualization of therapy and may address disparities in this aggressive disease.