Is Limited-Stage Mantle Cell Lymphoma Curable and How Is It Best Managed?

Limited-stage (stage I-II) mantle cell lymphoma (MCL) is rarely encountered. There is no standard approach to treatment and available data to guide management decisions mainly are retrospective studies. A thorough staging evaluation, including positron emission tomography/computed tomography, bone marrow biopsy, and gastrointestinal evaluation, should be completed because disseminated disease is common. Radiation therapy is effective for local control, and, although prolonged remission can be achieved, distant relapses are common and there are insufficient data to say that patients can be cured using this treatment. This article reviews literature pertaining to management of patients with limited-stage MCL and discusses approach to treatment.

The impact of histology in the outcomes of patients with early-stage non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT) and adjuvant chemotherapy

INTRODUCTION

Stereotactic body radiation therapy (SBRT) is the standard of care treatment for nonsurgical patients with early-stage non-small cell lung cancer (NSCLC). A recent report has indicated an improvement in overall survival (OS) with adjuvant chemotherapy in patients with tumors ≥ 4 cm treated with SBRT. We present a retrospective study evaluating the impact of histology in patients treated with SBRT and adjuvant chemotherapy.

MATERIALS AND METHODS

Patients (≥18 years) diagnosed with clinical stages I-II NSCLC from 2004 to 2013 were identified using the National Cancer Database (n = 12,055). The Kaplan-Meier method was used to estimate overall survival (OS) distributions and the log-rank test was used to compare distributions by treatment strategy. Clinical stages I and II were subdivided according to the TNM staging and log-rank tests was used to compare survival distributions by treatment strategy within each subgroup. We performed subgroup analysis for the three main NSCLC histologies (i.e., adenocarcinoma, squamous cell carcinoma (SCC), and large cell).

RESULTS

In patients with adenocarcinoma, SCC and, large cell carcinoma; adjuvant chemotherapy was associated with worse OS in tumors < 4 cm (P<.0001, P<.0099, and P=.0082, respectively). In patients with adenocarcinoma and tumor ≥ 4 cm, adjuvant chemotherapy was not associated with improved OS (P=.262); however, in patients with SCC and large cell, adjuvant chemotherapy improved OS (P<.0001, and P=.0129, respectively).

CONCLUSION

In patients with NSCLC ≥ 4 cm treated with SBRT, adjuvant chemotherapy was associated with improved OS in patients with SCC and large cell histologies.

Development of a predictive nomogram for cause-specific mortality in surgically resected early-stage oesophageal cancer: a Surveillance, Epidemiology, and End Results (SEER) analysis

Background

The aim of this population-based study was to perform competing risk analysis and estimate cancer- and other cause-specific mortality in patients who underwent oesophagectomy with pT1N0M0 oesophageal cancer (EC). A competing risks nomogram was also developed to predict the proportional of death from each specific cause.

Methods

A total of 1,144 patients who received oesophagectomy for pT1N0M0 EC between 2010 and 2015 from SEER database were included. The cumulative incidence function was used to evaluate each cause of death, and the significant difference was assessed by the Grey’s test. A nomogram was established using the proportional subdistribution hazard analysis to identify predictors for each cause-specific death.

Results

The 5-year cumulative incidence of cancer-specific death for surgically resected pT1N0M0 EC was 15.7%, and the incidence was 11.2% for other cause-specific death. Age, tumour length, pT1 substage, grade, history and primary site were identified as predictive factors for EC-specific death, but only age, tumor length and pT1 substage were associated with death from other cause. Our nomograms showed a relative good discriminative ability, with c-index of 0.663 for the EC-specific mortality model and 0.699 for the other cause-specific mortality model. The calibration curves showed a good match between the nomogram-predicted probabilities and the actual probabilities.

Conclusions

In patients who underwent curative-intent resection for pT1N0M0 EC, death from other causes was an important competing event. During clinical decision making and patient-clinician communication, our quantifiable nomograms could provide a rapid and precise judgement of the risk of death from each cause.

Trends in guideline-adherent fertility-sparing surgery for early-stage cervical cancer before and after the Affordable Care Act

OBJECTIVE

To assess trends in guideline-adherent fertility-sparing surgery (GA-FSS) for early-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation.

METHODS

National Cancer Database patients treated for Stage IA1-IB1 cervical cancer from 2004 to 2016 were included. Multivariable logistic regression was used to determined trends in GA-FSS relative to the ACA and identify patient factors independently associated with GA-FSS.

RESULTS

Odds of GA-FSS increased in the post- compared to pre-ACA cohort (aOR = 1.65; 95%CI: 1.34-2.03). Decreasing age, Asian/Pacific Islander race, higher education and income levels, more recent treatment year, and lower clinical stage were independently associated with increased odds of receiving GA-FSS. In the pre- and post-ACA samples, decreasing age (per 1 year age increase; pre-ACA aOR = 0.87, 95%CI:0.85-0.90; post-ACA aOR = 0.85, 95%CI:0.83-0.87), higher education level (top vs. lowest education quartile; pre-ACA aOR = 2.08, 95%CI:1.19-3.65; post-ACA aOR = 2.00, 95%CI:1.43-2.80), and lower clinical stage (stages IA2 [pre-ACA aOR = 0.19, 95%CI:0.09-0.41; post-ACA aOR = 0.29, 95%CI:0.19-0.45] and IB1 [pre-ACA aOR = 0.06, 95%CI:0.06-0.16; post-ACA aOR = 0.16, 95%CI: 0.12-0.20] relative to stage IA1) were independently associated with increased odds of GA-FSS receipt. After the ACA, Asian/Pacific Islander race (aOR = 2.81, 95%CI: 1.81-4.36) and more recent treatment year (Spearman's ρ = 0.0348, p-value = 0.008) were also independently associated with increased odds of GA-FSS receipt. When adjusted for the pre- vs. post-ACA treatment periods, Medicaid patients were less likely to undergo GA-FSS than privately-insured patients (aOR = 1.65; 95%CI:1.34-2.03).

CONCLUSIONS

Patients were more likely to receive GA-FSS post-ACA. Though the proportion of publicly-insured women increased after ACA implementation, women on Medicaid remained less likely to receive GA-FSS than women with private insurance.

Novel treatment strategies for early-stage lung cancer: the oncologist's perspective

Management of early-stage non-small cell lung cancer (NSCLC) consists in multimodal treatment, including surgery, radiotherapy and chemotherapy. The mainstay of treatment is radical surgery. Definitive radiotherapy using stereotactic techniques can provide adequate local disease control, and is the treatment of choice in medically inoperable patients. Most early-stage patients are at significant risk of disease relapse after local treatment. Adjuvant platinum-based chemotherapy has demonstrated to provide an absolute survival benefit of 5% compared to observation. However, unlike advanced/metastatic disease, little progress has been made in the treatment of early-stage NSCLC over the past decade. In recent years, plenty of research has focused on the optimization of adjuvant and neoadjuvant treatment. Several trials with novel drugs, such as targeted agents and immune-checkpoint inhibitors are currently underway, with preliminary positive results. Customization of treatment on patients’ characteristics before, and major pathological response after therapy, will further improve survival outcomes in this subset of patients.

Relative survival in early-stage cancers in the Netherlands: a population-based study

In this nationwide, population-based study, we assessed 10-year relative survival among 225,305 patients with ten early-stage cancers diagnosed in the Netherlands during 2004-2015. This study aimed to ascertain which early-stage cancer is associated with minimal or no excess mortality and likely to be diagnosed in individuals who are otherwise more healthy or health-conscious than their counterparts in the general population. Ten-year relative survival marginally exceeded 100% in patients with early-stage prostate cancer, while it was close to 100% for patients with ductal carcinoma in situ (DCIS) and stage I cancers of the breast, skin (melanoma), testis, and thyroid. In contrast, patients with early-stage oral/pharyngeal, bladder, lung, and pancreatic cancers experienced considerable excess mortality, reflected by a 10-year relative survival of 74.9%, 69.4%, 45.5%, and 33.9%, respectively. Collectively, the life expectancy of patients with DCIS and early-stage cancers of the prostate, breast, skin (melanoma), testis, and thyroid parallels the expected survival of an age-, sex-, and calendar year-matched group from the general population. Our study findings add to the controversy surrounding overdiagnosis of particular early-stage cancers that are generally not destined to metastasis or cause excess mortality.

Dynamic contrast-enhanced MRI with Gd-EOB-DTPA for the quantitative assessment of early-stage liver fibrosis induced by carbon tetrachloride in rabbits

PURPOSE

To explore quantitative parameters obtained by dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) with Gd-EOB-DTPA in discriminating early-stage liver fibrosis (LF) in a rabbit model.

MATERIALS AND METHODS

LF was established in 60 rabbits by the injection of 50% CCl₄ oil solution, whereas 30 rabbits served as the control group. All rabbits underwent pathological examination to determine the LF stage using the METAVIR classification system. DCE MRI was performed, and quantitative parameters, including K^trans, K_ep, V_e, V_p and Re were measured and evaluated among the different LF stages using spearman correlation coefficients and receiver operating characteristic curve.

RESULTS

In all, 24, 25, and 22 rabbits had stage F0, stage F1, and stage F2 LF, respectively. K^trans (r = 0.803) increased, and K_ep (r = -0.495) and Re (r = -0.701) decreased with LF stage progression (P < 0.001), while no significant correlation was found for V_e or V_p. K^trans and Re were significantly different between all LF stage pairs compared (F0 vs. F1, F0 vs. F2, F1 vs. F2, F0 vs. F1-F2, P < 0.05). With the exception of F0 vs. F1, K_ep differed significantly between stages (P < 0.05). The AUC of K^trans was higher than that of other quantitative parameters, with an AUC of 0.92, 0.99, 0.94 and 0.92 for staging F0 vs. F1, F0 vs. F2, F1 vs. F2, and F0 vs. F1-F2, respectively.

CONCLUSION

Among quantitative parameters of Gd-EOB-DTPA DCE MRI, K^trans was the best predictor for quantitatively differentiating early-stage LF.

Automated Hypofractionated IMRT treatment planning for early-stage breast Cancer

Background

Hypofractionated whole-breast irradiation is a standard adjuvant therapy for early-stage breast cancer. This study evaluates the plan quality and efficacy of an in-house-developed automated radiotherapy treatment planning algorithm for hypofractionated whole-breast radiotherapy.

Methods

A cohort of 99 node-negative left-sided breast cancer patients completed hypofractionated whole-breast irradiation with six-field IMRT for 42.56 Gy in 16 daily fractions from year 2016 to 2018 at a tertiary center were re-planned with an in-house-developed algorithm. The automated plan-generating C#-based program is developed in a Varian ESAPI research mode. The dose-volume histogram (DVH) and other dosimetric parameters of the automated and manual plans were directly compared.

Results

The average time for generating an autoplan was 5 to 6 min, while the manual planning time ranged from 1 to 1.5 h. There was only a small difference in both the gantry angles and the collimator angles between the autoplans and the manual plans (ranging from 2.2 to 5.3 degrees). Autoplans and manual plans performed similarly well in hotspot volume and PTV coverage, with the autoplans performing slightly better in the ipsilateral-lung-sparing dose parameters but were inferior in contralateral-breast-sparing. The autoplan dosimetric quality did not vary with different breast sizes, but for manual plans, there was worse ipsilateral-lung-sparing (V_4Gy) in larger or medium-sized breasts than in smaller breasts. Autoplans were generally superior than manual plans in CI (1.24 ± 0.06 vs. 1.30 ± 0.09, p < 0.01) and MU (1010 ± 46 vs. 1205 ± 187, p < 0.01).

Conclusions

Our study presents a well-designed standardized fully automated planning algorithm for optimized whole-breast radiotherapy treatment plan generation. A large cohort of 99 patients were re-planned and retrospectively analyzed. The automated plans demonstrated similar or even better dosimetric quality and efficacy in comparison with the manual plans. Our result suggested that the autoplanning algorithm has great clinical applicability potential.

Long Non-Coding RNA NANCI/NKX2-1 Duplex Impacts Prognosis in Stage I Non-Small-Cell Lung Cancer

BACKGROUND

NANCI, an intergenic long non-coding RNA (lncRNA) is essential for buffering NKX2-1 expression during embryonic development and in adult tissue. We analyzed NANCI and NKX2-1 in human lung embryonic samples and adult lung tissues and evaluated their potential as prognostic markers in stage I non-small cell lung cancer (NSCLC).

METHODS AND RESULTS

NANCI and NKX2-1 expression was assessed by TaqMan assays in 18 human embryonic samples from 8 to 13 weeks, 59 non-tumoral (NT) lung tissue samples, and 98 stage I NSCLC tumor samples. NANCI and NKX2-1 expression in embryonic and NSCLC samples were downregulated in comparison to adult NT tissue. Patients with low expression of NANCI had shorter disease-free survival (DFS) and overall survival (OS) than those with high levels (47.6 vs 69.3 months, P=0.032 and 57.7 vs 77.6 months, P=0.021, respectively). When the expression levels of NANCI and NKX2-1 were evaluated in combination, four groups were identified (high NANCI/high NKX2-1, low NANCI/high NKX2-1, high NANCI/low NKX2-1 and low NANCI/low NKX2-1) with differential impact on DFS (P=0.042) and OS (P=0.024). Interestingly, the high NANCI/high NKX2-1 duplex group had longer DFS and OS than the other three groups (71.25 vs 46.3 months, P=0.009 and 81.3 vs 56.1 months, P=0.004, respectively). In the multivariate analysis, the high NANCI/high NKX2-1 duplex was identified as an independent prognostic factor for longer DFS (HR 0.346, 95% CI, 0.169-0.709; P=0.004) and OS (HR 0.309, 95% CI, 0.121-0.786; P=0.014).

CONCLUSIONS

NANCI and the NANCI-NKX2-1 duplex impacts prognosis in stage I NSCLC patients.

Impact of examined lymph node count on long-term survival of T1-2N0M0 double primary NSCLC patients after surgery: a SEER study

Purpose

The relationship between examined lymph nodes (ELN) and survival has been confirmed in several single early-stage malignancies. We studied the association between the ELN count and the long-term survival of T1-2N0M0 double primary non-small cell lung cancer (DP-NSCLC) patients after surgery, based on the Surveillance, Epidemiology and End Results (SEER) database.

Methods

A total of 948 patients were identified and their independent prognostic factors were analyzed. These factors included the ELN count, which related to overall survival (OS) and the cancer-specific survival (CSS) of synchronous (n = 426) and metachronous (n = 522) T1-2N0M0 DP-NSCLC patients after surgery.

Results

X-tile analysis indicated that the cutoff value for the sum of ELNs was 22 for both OS and CSS in the synchronous DP-NSCLC group. Patients with a sum of ELNs >22 were statistically more likely to survive than those with ≤22 ELNs. X-tile analysis revealed that the ELN count of the second lesion was related to both OS and CSS in the metachronous DP-NSCLC group. The optimal cutoff value was nine. These results were confirmed using univariate and multivariate Cox regression analyses.

Conclusion

Our findings indicate that ELN count was highly correlated with the long-term survival of T1-2N0M0 double primary NSCLC patients after surgery.

The Mexican consensus on the detection and treatment of early gastric cancer

Gastric cancer is one of the most frequent neoplasias in the digestive tract and is the result of premalignant lesion progression in the majority of cases. Opportune detection of those lesions is relevant, given that timely treatment offers the possibility of cure. There is no consensus in Mexico on the early detection of gastric cancer, and therefore, the Asociación Mexicana de Gastroenterología brought together a group of experts and produced the "Mexican consensus on the detection and treatment of early gastric cancer" to establish useful recommendations for the medical community. The Delphi methodology was employed, and 38 recommendations related to early gastric cancer were formulated. The consensus defines early gastric cancer as that which at diagnosis is limited to the mucosa and submucosa, irrespective of lymph node metástasis. In Mexico, as in other parts of the world, factors associated with early gastric cancer include Helicobacter pylori infection, a family history of the disease, smoking, and diet. Chromoendoscopy, magnification endoscopy, and equipment-based image-enhanced endoscopy are recommended for making the diagnosis, and accurate histopathologic diagnosis is invaluable for making therapeutic decisions. The endoscopic treatment of early gastric cancer, whether dissection or resection of the mucosa, should be preferred to surgical management, when similar oncologic cure results can be obtained. Endoscopic surveillance should be individualized.

Early-stage T1b adenocarcinoma arising in the remnant cystic duct after laparoscopic cholecystectomy: a case report and literature review

Background

The cystic duct has been included in the staging classification scheme for gallbladder cancer since the 2010 publication of the AJCC Cancer Staging Manual (7th edition). To our knowledge, only seven other cases of adenocarcinoma arising in the remnant cystic duct following cholecystectomy have been reported in the English-language literature, and none has been reported as primary early-stage T1b remnant cystic duct cancer (CDC). We report, herein, a case of primary adenocarcinoma arising in the remnant cystic duct in a patient with history of laparoscopic cholecystectomy for gallstone disease.

Case presentation

An 81-year-old female presented with abdominal pain. Her medical history included a laparoscopic cholecystectomy for cholecystolithiasis two years prior. Jaundice was observed; imaging studies suggested that this was caused by choledocholithiasis. Blood chemistry findings showed severe liver dysfunction. Endoscopic retrograde cholangiography revealed haemobilia from the common bile duct with no evidence of choledocholithiasis. A bile sample showed Papanicolaou class IV cytology. As the extent of tumour spread was undetermined by abdominal ultrasonography and endoscopic ultrasonography, peroral cholangioscopy (POCS) was performed, which revealed tiny papillary lesions within the confluence of cystic duct, and fine granular lesions in the centre of bile ducts, signifying early-stage remnant CDC. Extrahepatic bile duct resection with regional lymphadenectomy was done. Histopathological findings revealed a 42-mm tubular adenocarcinoma originating from the remnant cystic duct with the considerable shallow spread across the extrahepatic bile ducts. It invaded the fibromuscular layer, with no lymphovascular or perineural invasion, no lymph node metastasis (13 nodes examined), and uninvolved surgical resection margin (R0 resection), and was staged as pT1bN0M0, Stage I.

Conclusions

Primary early-stage T1b remnant CDC is an uncommon condition for which early diagnosis is challenging; if intraoperatively recognized, it can complicate surgery. Our experience of this case and an overview of the English literature suggest that POCS is an efficient tool to diagnosis this tumour and assess its spread along the extrahepatic bile ducts.

Clinical significance of long non-coding RNA HOTTIP in early-stage non-small-cell lung cancer

Background

HOTTIP, a long non-coding RNA located in the HOXA cluster, plays a role in the patterning of tissues with mesodermal components, including the lung. Overexpression of HOXA genes, including HOTTIP, has been associated with a more aggressive phenotype in several cancers. However, the prognostic impact of HOTTIP has not yet been explored in non-small-cell lung cancer (NSCLC). We have correlated HOTTIP expression with time to relapse (TTR) and overall survival (OS) in early-stage NSCLC patients.

Methods

Ninety-nine early-stage NSCLC patients who underwent surgical resection in our center from June 2007 to November 2013 were included in the study. Mean age was 66; 77.8% were males; 73.7% had stage I disease; and 55.5% had adenocarcinoma. A validation data set comprised stage I-II patients from The Cancer Genome Atlas (TCGA) Research Network.

Results

HOTTIP was expressed in all tumor samples and was overexpressed in squamous cell carcinoma (p = 0.007) and in smokers (p = 0.018). Patients with high levels of HOTTIP had shorter TTR (78.3 vs 58 months; p = 0.048) and shorter OS (81.2 vs 61 months; p = 0.023) than those with low levels. In the multivariate analysis, HOTTIP emerged as an independent prognostic marker for TTR (OR: 2.05, 95%CI: 1–4.2; p = 0.05), and for OS (OR: 2.31, 95%CI: 1.04–5.1; p = 0.04). HOTTIP was validated as a prognostic marker for OS in the TCGA adenocarcinoma cohort (p = 0.025). Moreover, we identified a 1203-mRNA and a 61-miRNA signature that correlated with HOTTIP expression.

Conclusions

The lncRNA HOTTIP can be considered a prognostic biomarker in early-stage NSCLC.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0816-8) contains supplementary material, which is available to authorized users.

[Surgery in early-stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Early stage ovarian epithelial cancer (stage I according to the FIGO classification, i.e. limited to ovaries) affects 20% to 33% of patients with ovarian cancer. This chapter only describes data on these presumed early stages. The rate of occult epiploic metastases varies from 2% to 4%, and leads to over-staging in stage III A of 3% to 11% of patients. Performing an omentectomy does not result in a change in survival in this situation (NP4). The rate of appendix metastasis ranges from 0% to 26.7% (NP4). In the mucinous subtype, this rate can reach 53% if the appendix is macroscopically abnormal (NP2). The rate of positive peritoneal cytology ranges from 20.9% to 27%. Positive peritoneal cytology is responsible for over-staging of patients in 4.3% to 52% of cases and appears as a poor prognostic factor on survival (NP4). The rate of occult peritoneal metastases varies from 1.1% to 16%. Performing these peritoneal biopsies results in over-staging of 4% to 7.1% (NP4). In the management of ovarian cancers at a presumed early stage, it is recommended to perform: omentectomy, peritoneal biopsies, cytology, appendectomy (grade C). In case of incomplete or incomplete initial staging, restaging including omentectomy, peritoneal biopsies and appendectomy (if not explored) is recommended; especially in the absence of a reported indication of chemotherapy. The lymph node invasion rate ranges from 6.3% to 22%. It is 4.5% to 18% for stages I and 17.5% to 31% in stages II. Between 8.5% and 13% of patients with suspected early stage ovarian cancer are reclassified to stage IIIA1 following the completion of lymphadenectomy (NP3). Pelvic and lumbo-aortic lymphadenectomy improves the survival of patients with ovarian cancer at a presumptive early stage (NP2). Pelvic and lumbo-aortic lymphadenectomy is recommended for presumed early ovarian stages (grade B). In case of initial treatment of early-stage ovarian cancer without lymph node staging, restadification including lymphadenectomy is recommended; especially in the absence of a stated indication of chemotherapy (grade B). No studies have shown any laparoscopic disadvantage compared to laparotomy for feasibility, safety, or postoperative rehabilitation (NP3) in surgical staging of patients with early-stage ovarian cancer. For the initial surgical management of these patients, the choice between laparoscopy or laparotomy depends on local conditions (tumor size) and surgical expertise. If complete surgery without risk of tumor rupture is possible, the laparoscopic approach is preferred (grade C). In the opposite case, median laparotomy is recommended. As part of surgical restadification, the laparoscopic approach is recommended (grade C). Intraoperative tumor rupture leads to a decrease in disease free survival (hazard ratio=2.28) and overall survival (hazard ratio=3.79) (NP2). It is recommended that all precautions be taken to avoid perioperative ovarian tumor rupture, including the intraoperative decision of laparoconversion (grade C). There is no specific study to answer the question of the feasibility of a one-time or two-time surgery during an extemporane diagnosis of an early stage ovarian cancer. The high sensitivity and specificity of this extemporane examination in this situation makes it possible to consider a surgical management of staging during the same operating time.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of clinically node-negative non-small cell lung cancer

One in four non-small cell lung cancer (NSCLC) patients are diagnosed at an early-stage. Following the results of the National Lung Screening Trial that demonstrated a survival benefit for low-dose computed tomography screening in high-risk patients, the incidence of early-stage NSCLC is expected to increase. Use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography during initial diagnosis of these early-stage lesions has been increasing. Traditionally, positron emission tomography/computed tomography scans have been utilized for mediastinal nodal staging and to rule out distant metastases in suspected early-stage NSCLC. In clinically node-negative NSCLC, the use of sublobar resection and selective lymph node dissection has been increasing as a therapeutic option. The higher rate of locoregional recurrences after limited resection and the significant incidence of occult lymph node metastases underscores the need to further stratify clinically node-negative NSCLC in order to select patients for limited resection versus lobectomy with complete mediastinal lymph node dissection. In this report, we review the published data, and discuss the significance and potential role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography evaluation for clinically node-negative NSCLC. Consequently, the literature review demonstrates that maximum standardized uptake value is a predictive factor for occult nodal metastasis with an accuracy of 55-77%. In addition, maximum standardized uptake value is a predictor for worse overall, as well as disease-free, survival.

Hypoglycemia in type 1A diabetes can develop before insulin therapy: A retrospective cohort study

AIMS

There are as yet no cohort studies of hypoglycemia in type 1 diabetes before starting insulin therapy. Our aim was to determine the frequency and clinical features of hypoglycemia in patients with type 1A diabetes prior to commencing insulin therapy.

METHODS

Eighty-seven patients with type 1A diabetes were enrolled, and a retrospective chart review of the patients was conducted.

RESULTS

Hypoglycemia before insulin therapy occurred in six of 87 patients (6.9%). The HbA1c levels at the diagnosis of type 1A diabetes in the hypoglycemia group were lower than in the non-hypoglycemia group (median: 7.3% (56 mmol/mol) vs. 11.9% (106 mmol/mol), p < 0.0001). Similarly, the 24-hour urinary C-peptide (UCPR) levels of the former group were higher than those of the latter group (16.5 μg/day/m² vs. 7.0 μg/day/m², p = 0.0075). Hypoglycemic episodes occurred mostly in the postprandial period and gradually disappeared with a decrease in insulin secretion.

CONCLUSIONS

We demonstrated that some patients with type 1A diabetes experience hypoglycemic episodes before insulin therapy. Patients with early-stage type 1A diabetes with relatively low HbA1c or high UCPR have a risk of hypoglycemia. These findings may impact when and how insulin is introduced in the treatment of early-stage type 1A diabetes.

Detection of high-risk human papillomavirus DNA in tissue from primary cervical cancer tumor, pelvic lymph nodes and recurrent disease

Objectives

The present study investigated Human Papillomavirus (HPV) DNA genotyping in primary tumor, pelvic lymph nodes (PLN) and recurrence in early-stage cervical cancer patients.

Methods

We conducted a hospital-based case-control study. From 2003 to 2015, 282 patients underwent surgery for cervical cancer in the Department of Gynecology, Aarhus University Hospital, Denmark. Twenty-nine recurrent cases were identified. HPV DNA genotyping was performed on formalin-fixed, paraffin-embedded tissue specimens from the primary tumor, PLN, and recurrent disease.

Results

In the primary tumor, HPV DNA was detectable in 18(72%) of 25 tissue specimens from recurrent cases and in 15(83%) of 18 controls. HPV DNA-positive PLN was significantly associated with recurrence, 83%(95%CI: 52–98%), compared to patients with HPV-negative PLN, 38%(95%CI: 18–62%)(p < 0.05). HPV DNA genotyping was positive in eight of 12(67%) patients with recurrent disease. The genotype was identical in all three tissues types.

The positive predictive value for recurrence was the same for detection of HPV-DNA and metastases in the PLN, with reasonable sensitivity. The negative predictive value for recurrence, however, was best for HPV-DNA, 62%(95%CI: 38–98%).

Conclusions

In conclusion, our data suggest that the presence of HPV in pelvic lymph nodes is associated with an increased risk of recurrence.

Stereotactic body radiotherapy with adjuvant systemic therapy for early-stage non-small cell lung carcinoma: A multi-institutional analysis

PURPOSE

Although adjuvant systemic therapy (ST) is often recommended for the treatment of patients with high-risk, early-stage non-small cell lung carcinoma (NSCLC) after surgery, there is little evidence supporting the use of ST with stereotactic body radiotherapy (SBRT).

METHODS

We conducted a retrospective cohort study using a multi-institutional database to identify consecutive patients with T1-3N0M0 NSCLC treated with definitive SBRT from 2006-2015. Treatment groups were defined as those who received SBRT + ST or SBRT alone. Regional-distant failure (RDF) was analyzed with Fine and Gray competing risks regression. Progression-free (PFS) and overall survival (OS) were analyzed with the Kaplan-Meier method and Cox regression. Additional comparisons were made after 2:1 nearest-neighbor propensity-score matching on clinical risk factors.

RESULTS

We identified 54 patients who received SBRT + ST. The most common ST regimen was a platinum doublet (n = 38; 70.4%). Compared with patients receiving SBRT (n = 1269), SBRT + ST patients were younger (median age: 70 v 77 years, p < 0.001), had larger tumors (>3 cm: 38.9% v 21.6%, p = 0.02) and higher T-stage (T2-3: 42.6% v 22.5%, p = 0.002). Compared with SBRT patients, SBRT + ST patients had lower 2-year RDF (3.1% v 16.9%, p = 0.02). On multivariable analysis, SBRT + ST was associated with reduced RDF (HR: 0.15, 95%CI: 0.04-0.62), with a trend toward improved PFS (HR: 0.70, 95%CI: 0.48-1.03), but not OS (HR: 0.74, 95%CI: 0.49-1.11). After propensity-score matching, the SBRT + ST cohort demonstrated improved RDF (HR: 0.17, 95%CI: 0.04-0.76) and PFS (HR: 0.59, 95%CI: 0.38-0.93).

CONCLUSION

In this multi-institutional analysis, adjuvant ST was independently associated with reduced RDF in early-stage NSCLC patients treated with SBRT.

Significance of spread through air spaces in early-stage lung adenocarcinomas undergoing limited resection

Background

In early‐stage lung adenocarcinomas, spread through air spaces (STAS) are reported to be a prognostic factor in patients who have undergone sublobar resection, but not lobectomy. In contrast, reports have also shown that STAS is significantly associated with poor survival outcomes after lobectomy, but not after limited resection. Thus, the prognostic impact of STAS differs according to published reports.

Methods

A total of 82 patients with early‐stage adenocarcinomas who underwent limited resection and whose STAS status could be examined were enrolled in this retrospective study. We evaluated the association between STAS and clinicopathological characteristics and postoperative survival.

Results

Among 82 patients, 31 (37.8%) were positive for STAS, while 51 (62.2%) were negative. STAS was significantly associated with advanced tumor stage (P < 0.01), lower histological differentiation (P = 0.01), and the presence of pleural invasion (P = 0.01). Patients with STAS had significantly shorter recurrence‐free survival (RFS) and overall survival (OS) than those without STAS (P < 0.01 and P = 0.02, respectively). According to multivariate analysis, positivity for STAS was an independent prognostic parameter for RFS (P < 0.01), but not OS (P = 0.45). Three patients who developed surgical margin recurrence and one patient who developed distant recurrence were all positive for STAS.

Conclusions

STAS was predictive of poor postoperative survival in patients with early‐stage adenocarcinomas treated with limited resection and was associated with surgical margin recurrence.

Impact of Regional Nodal Irradiation on the Outcomes of N1 Breast Cancer Patients Referred for Adjuvant Treatment: A Patient-Level Pooled Analysis of 2 Clinical Trials

PURPOSE

To evaluate the impact of regional nodal irradiation (RNI) among N1 operable breast cancer patients who underwent adequate axillary dissection and received adjuvant chemotherapy.

PATIENTS AND METHODS

This is a pooled analysis of 812 breast cancer patients referred for adjuvant systemic therapy in 2 prospective randomized studies: NCT00174655 (BIG 02/98) and NCT00312208 (BCIRG005). Overall survival was assessed according to whether patients received supraclavicular and/or internal mammary radiotherapy through Kaplan-Meier estimates. Univariate and multivariate analyses of variables affecting overall and relapse-free survival were performed through Cox regression analysis. Additionally, recurrence rates were analyzed according to regional irradiation patterns.

RESULTS

Regional relapse rates (after a median follow-up of 76 months) were 1.5% in both groups of patients who received or did not receive supraclavicular radiotherapy. The risk of regional recurrence was 0.7% in patients who received internal mammary node radiotherapy versus 1.6% in patients who did not receive internal mammary node radiotherapy. The following factors were associated with worse overall survival in multivariate Cox regression analysis: age < 40 years (P < .0001), > T1 stage (P = .003), and negative hormone receptor status (P = .002). Neither supraclavicular nor internal mammary radiotherapy was associated with improvement in overall or relapse-free survival in Cox regression analysis.

CONCLUSION

The current analysis does not endorse the routine use of supraclavicular or internal mammary radiotherapy among N1 operable breast cancer patients who have undergone adequate dissection of axillary lymph nodes and who have received standard adjuvant systemic therapy. Given the limited power and potential selection bias of the current analysis, further prospective studies are needed to tackle this research question.

Small oral tongue cancers (≤ 4 cm in diameter) with clinically negative neck: from the 7th to the 8th edition of the American Joint Committee on Cancer

One of the main changes in the 8th edition of the American Joint Committee on Cancer (AJCC) for staging of oral cancer is the inclusion of depth of invasion (DOI) in the T category. However, cancers in different oral subsites have variable behavior, with oral tongue squamous cell carcinoma (OTSCC) being the most aggressive one even at early stage. Thus, it is necessary to evaluate the performance of this new T category in homogenous cohort of early OTSCC. Therefore, we analyzed a large cohort of patients with a small (≤ 4 cm) OTSCC to demonstrate the differences in T stage between the AJCC 7th and 8th editions. A total of 311 early-stage cases (AJCC 7th) of OTSCC were analyzed. We used 5 mm and 10 mm DOI for upstaging from T1 to T2 and from T2 to T3 respectively, as in the AJCC 8th. We further reclassified the cases according to our own proposal suggesting 2 mm to upstage to T2 and 4 mm to upstage to T3. According to AJCC 7th, there were no significant differences in the survival analysis. When we applied the 8th edition, many cases were upstaged to T3 and thus associated with worse disease-specific survival (HR 2.37, 95% CI 1.12-4.99) and disease-free survival (HR 2.12, 95% CI 1.09-4.08). Based on our proposal, T3 cases were associated with even worse disease-specific survival (HR 4.19, 95% CI 2.27-7.74). The 8th edition provides better survival prediction for OTSCC than the 7th and can be further optimized by lowering the DOI cutoffs.

Identification of a low risk population for parametrial invasion in patients with early-stage cervical cancer

Background

Recent studies have challenged radical procedures for less extensive surgery in selected patients with early-stage cervical cancer at low risk of parametrial invasion. Our objective was to identify a subgroup of patients at low risk of parametrial invasion among women having undergone surgical treatment.

Methods

Data of 1447 patients with cervical cancer treated between 1996 and 2016 were extracted from maintained databases of 10 French University hospitals. Patients with early-stage (IA2–IIA) disease treated by radical surgery including hysterectomy and trachelectomy, were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariate analysis, was used to account for the influence of multiple variables.

Results

Out of the 263 patients included for analysis, on final pathology analysis 28 (10.6%) had parametrial invasion and 235 (89.4%) did not. Factors significantly associated with parametrial invasion on multivariate analysis were: age > 65 years, tumor > 30 mm in diameter measured by MRI, lymphovascular space invasion (LVSI) on pathologic analysis. Among the 235 patients with negative pelvic lymph nodes, parametrial disease was seen in only 7.6% compared with 30.8% of those with positive pelvic nodes (p < 0.001). In a subgroup of patients presenting tumors < 30 mm, negative pelvic status and no LVSI, the risk of parametrial invasion fell to 0.6% (1/173 patients).

Conclusion

Our analysis suggests that there is a subgroup of patients at very low risk of parametrial invasion, potentially eligible for less radical procedures.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1531-6) contains supplementary material, which is available to authorized users.

Adequate pelvic lymphadenectomy and survival of women with early-stage epithelial ovarian cancer

OBJECTIVE

To examine the trends and survival for women with early-stage epithelial ovarian cancer who underwent adequate lymphadenectomy during surgical treatment.

METHODS

This is a retrospective observational study examining the Surveillance, Epidemiology, End Results program between 1988 and 2013. We evaluated 21,537 cases of stage I-II epithelial ovarian cancer including serous (n=7,466), clear cell (n=6,903), mucinous (n=4,066), and endometrioid (n=3,102) histology. A time-trend analysis of the proportion of patients who underwent adequate pelvic lymphadenectomy (≥8 per Gynecologic Oncology Group [GOG] criteria, ≥12 per Collaborative Group Report [CGR] criteria for bladder cancer, and >22 per Mayo criteria for endometrial cancer) and a survival analysis associated with adequate pelvic lymphadenectomy were performed.

RESULTS

There were significant increases in the proportion of women who underwent adequate lymphadenectomy: GOG criteria 3.6% to 28.6% (1988-2010); CGR criteria 2.4% to 22.4% (1988-2013); and Mayo criteria 0.7% to 9.5% (1988-2013) (all, p<0.05). On multivariable analysis, adequate lymphadenectomy was independently associated with improved cause-specific survival compared to inadequate lymphadenectomy: GOG criteria, adjusted-hazard ratio (HR)=0.75, CGR criteria, adjusted-HR=0.77, and Mayo criteria, adjusted-HR=0.85 (all, p<0.05). Compared to inadequate lymphadenectomy, adequate lymphadenectomy was significantly associated with improved cause-specific survival for serous (HR range=0.67-0.73), endometrioid (HR range=0.59-0.61), and clear cell types (HR range=0.66-0.73) (all, p<0.05) but not in mucinous type (HR range=0.80-0.91; p>0.05).

CONCLUSION

Quality of lymphadenectomy during the surgical treatment for early-stage epithelial ovarian cancer has significantly improved. Adequate lymphadenectomy is associated with a 15%-25% reduction in ovarian cancer mortality compared to inadequate lymphadenectomy.

Exploration of the platelet proteome in patients with early-stage cancer

Platelets play an important role in tumor growth and, at the same time, platelet characteristics are affected by cancer presence. Therefore, we investigated whether the platelet proteome harbors differentially expressed proteins associated with early-stage cancer. For this proof-of-concept study, patients with early-stage lung (n = 8) or head of pancreas cancer (n = 4) were included, as were healthy sex- and age-matched controls for both subgroups. Blood samples were collected from controls and from patients before surgery. Furthermore, from six of the patients, a second sample was collected two months after surgery. NanoLC-MS/MS-based proteomics of gel-fractionated platelet proteins was used for comparative spectral count analyses of patients to controls and before to after surgery samples. The total platelet proteome dataset included 4384 unique proteins of which 85 were significantly (criteria Fc > 1.5 and p < 0.05) changed in early-stage cancer compared to controls. In addition, the levels of 81 platelet proteins normalized after tumor resection. When filtering for the most discriminatory proteins, we identified seven promising platelet proteins associated with early-stage cancer. In conclusion, this pioneering study on the platelet proteome in cancer patients clearly identifies platelets as a new source of candidate protein biomarkers of early-stage cancer.

BIOLOGICAL SIGNIFICANCE

Currently, most blood-based diagnostics/biomarker research is performed in serum or plasma, while the content of blood cells is usually neglected. It is known that especially blood platelets, which are the main circulating pool of many bioactive proteins, such as growth factors, chemokines, and cytokines, are a potentially rich source of biomarkers. The current study is the first to measure the effect of early-stage cancer on the platelet proteome of patients. Our study demonstrates that the platelet proteome of patients with early-stage lung or head of pancreas cancer differs considerably compared to that of healthy individuals of matched sex and age. In addition, the platelet proteome of cancer patients normalized after surgical resection of the tumor. Exploiting platelet proteome differences linked to both tumor presence and disease status, we were able to demonstrate that the platelet proteome can be mined for potential biomarkers of cancer.

Practice Patterns and Outcomes in Elderly Stage I Non-Small-cell Lung Cancer: A 2004 to 2012 SEER Analysis

BACKGROUND

We reviewed the population-based treatment patterns and outcomes for elderly patients with stage I non-small-cell lung cancer (NSCLC) treated from 2004 to 2012.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified biopsy-proven stage I NSCLC cases diagnosed from 2004 to 2012. The patients were divided into 5-year age subsets (60-64, 65-69, 70-74, 75-79, 80-84, 85-89, and ≥ 90 years). The demographic data, therapy, and survival were compared by year. Trends in overall survival (OS), cancer-specific survival (CSS), and practice patterns were analyzed.

RESULTS

A total of 62,213 cases were identified. The use of surgery declined sharply with age. Patients aged 60 to 64 years had a surgical rate of 81% compared with 21% for those aged ≥ 90 years (P < .0001). Radiation use increased (from 11% to 39%; P < .0001), as did the receipt of neither surgery nor radiation (from 7% to 40%; P < .0001). When analyzing the annual trends, radiation use increased, with fewer patients forgoing treatment from 2004 to 2012 (P < .0001). From 2004 to 2011, CSS at 2 years improved significantly for patients treated with radiation alone (from 48% to 72%; P < .0001) and more subtly for those receiving surgery alone (from 87% to 91%; P < .0001). The outcomes were stable for those receiving neither surgery nor radiation (38% to 45%; P = NS). Surgical outcomes declined with advancing age (P < .0001); however, the radiation outcomes did not (P = NS).

CONCLUSION

With advancing age, radiation replaces surgery as the most used treatment for early-stage NSCLC. OS and CSS have improved significantly for elderly stage I NSCLC patients treated with radiation alone during a timeline concurrent with the widespread adoption of stereotactic body radiation therapy. Dedicated prospective studies are indicated, because these findings are limited by the inherent biases of using the SEER database alone.

Stereotactic ablative radiotherapy in treatment of early-stage non-small cell lung cancer: Unsolved questions and frontiers ahead

Stereotactic ablative radiotherapy (SABR) has been recognized as a standard alternative treatment to surgery for inoperable early stage non-small cell lung cancer (NSCLC). Guaranteed local control rates over 90% makes oncologists wonder whether SABR is qualified enough to challenge surgery in operable patients. The role of SABR for centrally located lesions would be another question because of the increased risk of severe toxic effect. Plenty of studies suggest that optimization of dose regimen and appropriate case selection would be helpful. Additionally, the effect of adjuvant therapy following SABR in selected patients is worth looking forward, given that it significantly reduced risk of recurrence after complete resection. A consensus about salvage treatment after SABR also needs, given the current diversity of options. Finally, witnessing the emergence of proton therapy and immunotherapy, we believe that the future of SABR lay behind these novel forms of treatment.

Clinical significance of tumor cavitation in surgically resected early-stage primary lung cancer

OBJECTIVES

The prognostic impact of tumor cavitation is unclear in patients with early-stage primary lung cancer. The aim of the present study was to examine the clinicopathological features and prognoses of patients with pathological stage I-IIA (p-stage I-IIA) primary lung cancers harboring tumor cavitation. This study was conducted according to the eighth edition of the TNM classification for lung cancer.

MATERIALS AND METHODS

We examined 602 patients with p-stage I-IIA primary lung cancer out of 890 patients who underwent pulmonary resection from January 2007 through March 2014 and searched for the presence of tumor cavitation, which is defined as the presence of air space within the primary tumor.

RESULTS

A total of 59 out of the 602 patients had tumor cavitation (10%). Compared with patients without tumor cavitation, those with tumor cavitation had a significantly higher frequency of the following characteristics: high serum carcinoembryonic antigen (CEA) level (≥5ng/ml, p=0.027), interstitial pneumonia (p=0.0001), high SUVmax value on FDG-PET scan (≥4.2, p=0.023), tumors located in the lower lobe (p=0.024), large tumor size (>3cm, p=0.002), vascular invasion (66% vs 17%, p<0.0001) and non-adenocarcinoma histology (p=0.025). The overall survival period of patients with tumor cavitation was significantly shorter than that of patients without tumor cavitation (log-rank test: p<0.0001, 5-year OS rate: 56% vs 81%). Tumor cavitation was found to be an independent and significant factor associated with poor prognosis in the multivariate analysis (hazard ratio: 1.76, 95% confidence interval: 1.02-3.10, p=0.042).

CONCLUSIONS

Tumor cavitation is an independent factor for poor prognosis in patients with resected p-stage I-IIA primary lung cancer. Based on our analyses, patients with tumor cavitation should be regarded as a separate cohort that requires more intensive follow-up.

Robot-assisted versus open radical hysterectomy: A multi-institutional experience for early-stage cervical cancer

OBJECTIVE

To compare perioperative and clinico-pathological outcomes of patients with early-stage cervical cancer who underwent robot-assisted radical hysterectomy (RRH) and open radical hysterectomy (ORH).

METHODS

This retrospective multi-center study abstracted demographic, clinico-pathological and perioperative outcomes data from medical records of 491 cervical cancer patients treated with RRH (n = 259) ORH (n = 232) between 2005 and 2011 at two American and one Norwegian University Cancer Centres.

RESULTS

Mean estimated blood loss (EBL) and transfusion rates were less for RRH than for ORH (97 vs. 49 mL, p < 0.001, and 3% vs. 7%, p = 0.018, respectively). Mean length of hospital stay (LOS) was significantly shorter in RRH versus ORH (1.8 vs. 5.1 days, p < 0.001). Mean operative time was longer for RRH than ORH (220 vs. 156 min, p < 0.001). Although overall complications were similar (p = 0.49), intra-operative complications were less common in the RRH group than ORH (4% vs. 10%, p = 0.004). In multivariate regression analyses longer operative time, less EBL and intra-operative complications, shorter LOS, and more pre-operative cone were significantly associated with RRH versus ORH. Recurrence and death rates were not statistically different for the two groups at a mean follow-up time of 39 months (p = 1.00 and p = 0.48, respectively).

CONCLUSIONS

RRH had improved clinical outcomes compared to ORH in the treatment of early-stage cervical cancer in terms of EBL, intra-operative complications, transfusion rates, LOS, and pre-operative cone. Disease recurrence and survival were comparable for the two procedures.

Features of fatigue in patients with early-stage non-small cell lung cancer

BACKGROUND

The objective of this study was to investigate the fatigue status and related factors in patients with early-stage non-small cell lung cancer (NSCLC) 1-5 years after surgery.

MATERIALS AND METHODS

This cross-sectional study included 254 patients with stage IA or IB NSCLC, who had undergone surgery. They completed several surveys, including the Brief Fatigue Inventory, Karnofsky Performance Scale, Physical Activity Questionnaire, Baseline Dyspnea Index, Hospital Anxiety and Depression Scale. The association between fatigue and functional status was assessed using Chi-square analysis. Spearman rank correlation and multivariate logistic regression analysis were used to assess the correlation between fatigue and various other factors.

RESULTS

The overall incidence of postoperative fatigue was 59.8%. Among patients with moderate to severe fatigue, 21.1% had obvious dysfunction, whereas only 9.6% of patients with mild or no fatigue (χ(2) = 5.369; P = 0.02) showed obvious dysfunction. Multivariate logistic regression analysis showed that functional status (odds ratio [OR]: 3.57; 95% confidence interval [CI]: 1.17-6.19), concurrent lung disease (OR: 2.34; 95% CI: 1.08-4.99), depression (OR: 6.39; 95% CI: 2.42-17.35), and anxiety (OR: 2.45; 95% CI: 1.13-4.87) were independent risk factors for fatigue, whereas physical activity (OR: 0.27; 95% CI: 0.11-0.73) could prevent fatigue.

CONCLUSION

More than half of the patients with early-stage NSCLC experienced fatigue 1-5 years after surgery, and moderate to severe fatigue was often associated with obvious dysfunction. The strong association of fatigue with anxiety, depression, and lung complications suggests that fatigue and other symptoms constitute a symptom cluster. Therefore, comprehensive treatment methods may achieve better therapeutic results.

Intravenous or oral administration of vinorelbine in adjuvant chemotherapy with cisplatin and vinorelbine for resected NSCLC

OBJECTIVES

Cisplatin and vinorelbine given intravenously is a well-established adjuvant chemotherapy regimen after surgery for early-stage NSCLC. Vinorelbine can also be administered orally. However, the efficacy of orally administrated vinorelbine in adjuvant treatment of NSCLC is unknown. We assessed the overall survival (OS) and disease-free survival (DFS) of patients treated with adjuvant i.v. vinorelbine or p.o. vinorelbine, in combination with i.v. cisplatin.

MATERIALS AND METHODS

We reviewed two time-separated cohorts of patients referred to the Department of Oncology at Aarhus University Hospital (Denmark) from 2005 to 2012 for adjuvant chemotherapy after surgery for NSCLC.

RESULTS AND CONCLUSION

Of the 265 patients included in this study, 126 patients received i.v. and 139 received p.o. vinorelbine/cisplatin. The two groups were comparable with respect to important baseline characteristics. Median OS for all patients was 78.7 months and the median DFS was 35.7 months. No statistically significant difference in OS or DFS for patients treated with i.v. or oral vinorelbine was detected. The DFS rates of the two groups were comparable across all variables in subgroup analysis. In conclusion we observed that intravenous or oral administration of vinorelbine in combination with cisplatin after surgery for NSCLC appear equally effective in terms of overall and disease-free survival.

Robotic transperitoneal infra-renal aortic lymphadenectomy in early-stage endometrial cancer

OBJECTIVES

To assess the clinical performance of robotic-assisted infra-renal aortic lymphadenectomy (IRL) using a single center-docked approach for patients with endometrial cancer.

METHODS

Robotic-assisted hysterectomy with pelvic and aortic lymphadenectomy was performed in 97 clinical stage I endometrial cancer (EC) patients with the intent to remove infra-renal aortic lymph nodes. Peri-operative data was contemporaneously accessioned and a retrospective database analysis was performed to examine clinical outcomes.

RESULTS

IRL versus infra-mesenteric artery (IMA) dissections were accomplished in 88 (90.7%) and nine (9.3%) cases, respectively. There were no laparotomy conversions. Histology included 20.6% G1, 41.2% G2, and 38.1% G3 (endometrioid and Type II histologies). Forty-four (45.4%) cases had >50% depth-of-invasion and 43 (44.3%) cases had lymphovascular space invasion. Lymph node metastases were detected in 39 (40.2%) cases [37 (38.1%) pelvic, 16 (16.5%) pelvic+aortic, two (2.1%) isolated aortic lymph nodes]. Aortic metastasis was identified in 16/37 (43.2%) pelvic node positive cases, and 6/34 (17.7%) IRL cases with positive pelvic nodes had infra-renal metastasis, yet normal aortic nodes below the IMA. Harvested aortic lymph nodes for IRL exceeded IMA cases (15.9±6.3 vs. 8.9±4.6; p<0.01). Mean BMI for IMA cases exceeded IRL cases (37.4±3.3 vs. 31.4±7.1kg/m(2); p<0.001). Twenty-five (81%) patients with BMI >35kg/m(2) underwent successful IRL (range 36-47kg/m(2)) compared to 95% of cases <35kg/m(2) (p=0.03).

CONCLUSIONS

IRL was accomplished in 95% of EC patients with BMI <35kg/m(2) and 81% with BMI >35kg/m(2) using a single center-docked approach. A strict 35kg/m(2) BMI cut-off for avoiding IRL is therefore not advised.

Phase II study of the GI-4000 KRAS vaccine after curative therapy in patients with stage I-III lung adenocarcinoma harboring a KRAS G12C, G12D, or G12V mutation

INTRODUCTION

Patients with early-stage lung cancer have a high risk of recurrence despite multimodality therapy. KRAS-mutant lung adenocarcinomas are the largest genetically defined subgroup, representing 25% of patients. GI-4000 is a heat-killed recombinant Saccharomyces cerevisiae yeast-derived vaccine expressing mutant KRAS proteins. The present phase II study assessed the feasibility, immunogenicity, and safety of the GI-4000 vaccine in patients with early-stage, KRAS-mutant lung cancer.

MATERIALS AND METHODS

Patients with stage I-III KRAS-mutant lung cancer who completed curative therapy were enrolled. The patients received the genotype matched GI-4000 vaccine for ≤ 3 years or until intolerance, disease recurrence, or death. The KRAS antigen T-cell response was assessed using the interferon-gamma enzyme-linked immunospot assay in peripheral blood mononuclear cells. The study was powered to detect an immune response in ≥ 25% of patients.

RESULTS

A total of 24 patients were enrolled over 28 months. No vaccine-related serious adverse events occurred. One patient withdrew consent because of pain at the injection site. The study met its primary endpoint, with 50% of patients developing an immune response to mutant KRAS. The median number of vaccinations received was 15 (range, 1-19). Ten patients experienced disease recurrence, and 6 died. Compared with the genotypically matched historical controls, the recurrence rates were equivalent but overall survival showed a favorable trend.

CONCLUSION

GI-4000 was well tolerated and immunogenic when used as consolidation therapy in patients with stage I-III KRAS-mutant lung cancer. The patterns of recurrence and death observed in the present study can be used to design a randomized study of GI-4000 with overall survival as the primary endpoint.

A randomised trial comparing preoperative to perioperative chemotherapy in early-stage non-small-cell lung cancer (IFCT 0002 trial)

HYPOTHESIS

There will be a detectable increase in overall survival (OS) using preoperative (PRE) as opposed to perioperative (PERI) chemotherapy in resectable StageI-II non-small-cell lung cancer (NSCLC).

METHODS

This multicenter, open-label, randomised trial with a 2×2 factorial design first compared two chemotherapy strategies (PRE versus PERI), then two chemotherapy regimens (gemcitabine-cisplatin [GP] versus paclitaxel-carboplatin [TC]). The PRE group received two preoperative cycles followed by two additional preoperative cycles, while the PERI group underwent two preoperative cycles followed by two postoperative cycles, the 3rd and 4th cycles being given only to responders in both cases.

RESULTS

A total of 528 patients were randomised, 267 of which were assigned to the PRE group and 261 to the PERI group. Three-year OS did not differ between the two groups (67.4% and 67.7%, respectively; hazard ratio (HR)=1.01 [0.79-1.30], p=0.92), nor did 3-year disease-free survival, response rates, toxicity, or postoperative mortality. Pathological complete response was observed in 22 (8.2%) and 16 patients (6.1%), respectively. Although quality of life did not differ significantly, chemotherapy compliance was significantly higher in the PRE group. The proportion of responders who received Cycles 3 and 4 was significantly higher in the PRE group (90.4% versus 75.2%, p=0.001). In responders, the dose intensity of Cycles 3 and 4 was higher in the PRE group than in the PERI group (mean relative dose intensity of 90.4% versus 82.6%, respectively; p=0.0007). There was no difference between GP and TC in 3-year OS (HR=0.97 [95% confidence interval (CI): 0.76-1.25], p=0.80) or response rates. However, the regimens' toxicity profiles differed.

CONCLUSIONS

This study failed to demonstrate any difference in survival between patients receiving preoperative and perioperative chemotherapy in early-stage NSCLC. The increase from two to four preoperative chemotherapy cycles did not increase the pathological response rate.