Background
The oncologic safety of sentinel lymph node biopsy (SLNB) alone for clinically node-positive (cN1–2) patients who convert to pathologic node-negativity (ypN0) after neoadjuvant ...chemotherapy (NAC) is not well established.
Methods
This study retrospectively identified 244 consecutive patients with a diagnosis of cT1–3cN0–2 breast cancer who underwent NAC followed by SLNB at the authors’ institution between 2013 and 2018. The patients were categorized as clinically node-negative (cN0) or cN1–2 before the onset of NAC, and the Kaplan–Meier method was used to compare locoregional and distant recurrence rates after SLNB alone for ypN0 patients.
Results
Among 244 patients who underwent NAC followed by surgery with SLNB for axillary staging, 112 (45.9%) were cN0 at presentation, whereas 132 (54.5%) had biopsy-proven cN1–2 disease and converted to cN0 after treatment. Of the patients presenting with cN0 disease, 102 (91.1%) were ypN0 on SLNB pathology compared with 60 cN1/2 patients (45.5%;
p
< 0.001). Regional nodal irradiation was administered to 5% of the cN0/ypN0 patients compared with 70.7% of the cN1–2/ypN0 patients (
p
< 0.001). Overall, 211 patients were treated with SLNB alone and had a median follow-up period of 36 months (interquartile range IQR, 24–53 months). For 101 cN0/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 5.7% (95% confidence interval CI, 2.4–13.8) and 1% (95% CI 0.1–7.0). For 58 cN1–2/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 4.1% (95% CI 1.0–15.5) and 0%, with no axillary recurrences noted.
Conclusion
For ypN0 patients, SLNB alone after NAC is associated with low and acceptable short-term axillary recurrence rates. Additional follow-up data from prospective clinical trials are needed to confirm long-term oncologic safety and define optimal local therapy recommendations.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The neutrophil-to-lymphocyte ratio (NLR) is a measure of systemic inflammation and a prognostic factor for multiple malignancies. This study assesses the value of the NLR as an independent ...prognostic marker in triple-negative breast cancer (TNBC) and explores the association between dynamic NLR changes and patient outcomes.
Methods
The study retrospectively analyzed a prospectively maintained database including patients 18 to 80 years old with TNBC treated at the authors’ institution between 2006 to 2016. Clinical and demographic data were collected, including blood test results and treatments received. Age at diagnosis, stage of disease, and NLR scores were tested for association with overall and disease-free survival in uni- and multivariate Cox models.
Results
The inclusion criteria were met by 329 women with a median age of 58. Most of the patients had early-stage disease (30.1% with stage 1 and 47% with stage 2 malignancy). An NLR higher than 2.84 at diagnosis was associated with decreased overall survival (hazard ratio HR, 1.8; 95% confidence interval CI, 1.023–3.176), whereas an NLR higher than 7.82 at any time during the follow-up period was a strong predictor of 5-year mortality (HR, 10.76; 95% CI, 4.193–26.58), independent of age or stage of disease. Patients who experienced recurrence had a higher NLR than their counterparts during the 6 months before recurrence. The NLR also significantly rose during the final 18 months of life (
p
< 0.01).
Conclusion
The NLR is an important prognostic marker in TNBC, both at diagnosis and during the course of the disease. Moreover, dynamic changes in NLR strongly correlate with disease recurrence and the time of death.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
To optimize breast cancer care, the American College of Surgeons Commission on Cancer developed quality measures regarding receipt and timing of adjuvant radiotherapy (RT). Nationwide ...compliance with these measures and its impact on overall survival (OS) are evaluated herein.
Patients and Methods
Patients (
n
= 285,291) diagnosed with invasive breast cancer from 2004 to 2012 were identified from the National Cancer Database. Compliance with RT administration within 365 days from diagnosis was determined for patients with stage III disease with ≥ 4 positive lymph nodes post mastectomy and stage I–III disease post breast-conserving surgery (BCS). Univariate and multivariate logistic regression and Cox proportional hazard models were used to assess factors associated with compliance and OS, respectively.
Results
In the mastectomy cohort, 66.9% received timely RT, showing improved OS versus no RT patients (HR 0.70, 95% CI 0.67–0.73). Delayed RT patients (≥ 365 days) achieved equivalent OS to those receiving timely RT (HR 1.07, 95% CI 0.93–1.23) and superior OS to no RT patients (HR 0.74, 95% CI 0.65–0.85). In the BCS cohort, 89.4% received timely RT, showing improved OS versus no RT patients (HR 0.47, 95% CI 0.45–0.49). Delayed RT was associated with improved OS versus no RT (HR 0.64, 95% CI 0.56–0.74) and decreased OS versus timely RT (HR 1.37, 95% CI 1.19–1.58). Factors associated with noncompliance included insurance type and distance to hospital.
Conclusions
Quality measure compliance with adjuvant RT improves OS, regardless of timing after mastectomy. However, timeliness does impact OS after BCS. Focus on modifiable factors to improve compliance such as access to care may lead to improved compliance and OS.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
IMPORTANCE: In patients with intrahepatic cholangiocarcinoma (ICC), the oncologic benefit of surgery and perioperative outcomes for large multifocal tumors or tumors with contiguous organ involvement ...remain to be defined. OBJECTIVES: To develop and externally validate a simplified prognostic score for ICC and to determine perioperative outcomes for large multifocal ICCs or tumors with contiguous organ involvement. DESIGN, SETTING, AND PARTICIPANTS: This study of a contemporary cohort merged data from the California Cancer Registry (January 1, 2004, through December 31, 2011) and the Office of Statewide Health Planning and Development inpatient database. Clinicopathologic variables were compared between tumors that were intrahepatic, small (<7 cm), and solitary (ISS) and those that had extrahepatic extension and were large (≥7 cm) and multifocal (ELM). External validation of the prognostic model was performed using an independent data set from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database from January 1, 2004, through December 31, 2013. MAIN OUTCOMES AND MEASURES: Patient overall survival after hepatectomy. RESULTS: A total of 275 patients (123 men 44.7% and 152 women 55.3%; median interquartile range age, 65 55-72 years) met the inclusion criteria. No significant differences in overall complication rate (ISS, 48 34.5%; ELM, 37 27.2%; P = .19) and mortality rate (ISS, 10 7.2%; ELM, 6 4.4%; P = .32) were found. A multivariate Cox proportional hazards model demonstrated that multifocality, extrahepatic extension, grade, node positivity, and age greater than 60 years are independently associated with worse overall survival. These variables were used to develop the MEGNA prognostic score. The prognostic separation/discrimination index was improved with the MEGNA prognostic score (0.21; 95% CI, 0.11-0.33) compared with the staging systems of the American Joint Committee on Cancer sixth (0.17; 95% CI, 0.09-0.29) and seventh (0.18; 95% CI, 0.08-0.30) editions. CONCLUSIONS AND RELEVANCE: The MEGNA prognostic score allows more accurate and superior estimation of patient survival after hepatectomy compared with current staging systems.
We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic operations are performed, suggesting that ...hospital-related factors are important for choice of usage of minimally invasive platforms.
We queried the National Inpatient Sample from 2010 to 2014 for patients who underwent stomach, gallbladder, pancreas, spleen, colon and rectum, or hernia (general surgery), prostate or kidney (urologic surgery), and ovarian or uterine surgery (gynecologic surgery). Hospitals were grouped into quartiles according to percent volume of robotic urologic or gynecologic operations. Multivariable logistic regression modeling determined independent variables associated with robotics.
Survey-weighted results represented 482,227 open, 240,360 laparoscopic, and 42,177 robotic general surgical operations at 3,933 hospitals. Robotics use increased with each year studied and was more likely to be performed on younger men with private insurance. The odds of a general surgery patient receiving a robotic operation increased with urologic and gynecologic use at the hospital. Patients at top quartile hospitals for robotic urologic surgery had 1.34 times greater odds of receiving robotic general surgery operations (confidence interval 1.15–1.57, P < .001) and 1.53 times greater odds (confidence interval 1.32–1.79, P < .001) at top quartile robotic gynecologic hospitals. These findings were independent of study year, surgical site, insurance type, and hospital type and persisted when only comparing laparoscopic to robotic procedures.
Use of robotics in general surgery is independently associated with use in urologic and gynecologic surgery at a hospital, suggesting that institutional factors are important drivers of use when considering laparoscopy versus robotics in general surgery.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Consensus guidelines call for complete resection of retroperitoneal sarcoma with consideration of neoadjuvant radiation for curative-intent treatment. The 15-month delay from the initial presentation ...of an abstract to the final publication of the STRASS trial results assessing the impact of neoadjuvant radiation led to a dilemma of how patients should be managed in the interim. This study aims to (1) understand perspectives regarding neoadjuvant radiation for RPS during this period; and (2) assess the process of integrating data into practice. A survey was distributed to international organizations including all specialties treating RPS. Eighty clinicians responded, including surgical (60.5%), radiation (21.0%) and medical oncologists (18.5%). Low kappa correlation coefficients on a series of clinical scenarios querying individual recommendations before and after initial presentation as an abstract indicate considerable change. Over 62% of respondents identified a practice change; however, most also noted discomfort in adopting changes without a manuscript available. Of the 45 respondents indicating discomfort with practice changes without a full manuscript, 28 (62%) indicated that their practice changed in response to the abstract. There was substantial variability in recommendations for neoadjuvant radiation between the presentation of the abstract and the publication of trial results. The difference in the proportion of clinicians describing comfort with changing practice based on the presentation of the abstract versus those that had done so shows that indications for proper integration of data into practice are not clear. Endeavors to resolve this ambiguity and expedite availability of practice-changing data are warranted.
Full text
Available for:
IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
Retroperitoneal sarcoma (RPS) is a rare tumor whose diagnosis and management can be challenging and for which management requires a multidisciplinary team in a specialized center. An important part ...of the diagnosis-identification of the histologic subtype-depends on pathology; identifying the histologic subtype is important because this can affect prognosis and treatment options. Complete surgical resection with negative margins remains the cornerstone of treatment of nonmetastatic RPS and is the only chance for cure. In order to achieve negative margins, multivisceral en bloc resection is often necessary. Neoadjuvant therapies (chemotherapy, external beam radiation, or combination radiation and chemotherapy) are safe in well-selected patients and may be considered after careful review by a multidisciplinary sarcoma tumor board when the recurrence risk is high.
PDF
