Prognostic factors and outcome analysis of salivary duct carcinoma

OBJECTIVE

Salivary duct carcinoma (SDC) is highly aggressive, with high rates of recurrence and nodal and distant metastases. The aim of the current study was to evaluate the clinical implication of EGFR and HER2 expression for predicting prognosis and to identify the factors associated with outcome.

METHODS

The medical records of 28 patients with SDC underwent surgery and adjuvant RT. Expression of c-erbB-2 and EGFR was determined immunohistochemically on the 25 SDC specimens. Disease-free survival (DFS), overall survival (OS) and distant metastasis-free survival (DMFS) were analyzed.

RESULTS

Three-year DFS, OS and DMFS rates were 38.3%, 78.1% and 45.7%, respectively. Expression of c-erbB-2 and EGFR was seen in 64% and 40%. c-erbB-2 and EGFR expression did not correlate with recurrence or metastasis. Advanced N classification and perineural invasion (PNI) were significant predictors of DFS and DMFS.

CONCLUSION

c-erbB-2 and EGFR expression did not correlate with recurrence or metastasis. Despite aggressive surgery and RT, approximately 50% of SDCs failed systemically. More effective therapy to inhibit distant metastases in patients with advanced N classification and PNI should be considered.

Feasibility of mesorectal vascular invasion in predicting early distant metastasis in patients with stage T3 rectal cancer based on rectal MRI

OBJECTIVES

To evaluate the feasibility of mesorectal vascular invasion (MVI) in predicting early distant metastasis developed within 1 year of diagnosis of T3 rectal cancer using magnetic resonance imaging (MRI) METHODS: Sixty-five patients with T3 rectal cancer (early metastasis, n = 28; non-metastasis, n = 37) were enrolled in this study. Early distant metastases developed in 28 patients (liver, n = 15; lung, n = 9; both, n = 4). Logistic regression was used to determine the independent predictors for early distant metastasis.

RESULTS

In univariate analysis, tumour location, carcinoembryonic antigen (CEA), lymphovascular invasion (LVI), MRI-detected MVI, and mesorectal fat infiltration (MFI) (odds ratio [OR], 4.533, 9.583, 5.539, 27.046, and 5.539, respectively) were associated with early distant metastasis. Multivariate analysis demonstrated that MVI (OR, 29.949; P < 0.002) and LVI (OR, 6.684; P = 0.033) were independent factors for early distant metastasis. Specificity and positive predictive value (PPV) of MVI (94.59%, and 89.47%, respectively) were significantly higher than those of LVI (64.86%, and 61.76%), but sensitivity and negative predictive value were not significantly different between MVI (60.71%, and 76.09%) and LVI (75.00%, and 77.42%).

CONCLUSIONS

While sensitivity of MRI-detected MVI was equal to that of CEA in predicting early distant metastasis from T3 rectal cancer, specificity and PPV may be improved by assessing MVI.

KEY POINTS

• Mesorectal vascular invasion (MVI) may be a radiologic prognostic factor for rectal cancer. • Specificity of MVI was higher than lymphovascular invasion in predicting early metastasis. • Mesorectal vascular invasion may be a better predictor for early distant metastasis.

Risk factors and prediction-score model for distant metastasis in nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

The objective of this study is to identify the risk factors and construct a prediction-score model for distant metastasis (DM) in nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiotherapy (IMRT). A total of 520 nonmetastatic NPC patients were analysed retrospectively. The independent risk factors for DM were tested by multivariate Cox regression analysis. The prediction-score model was established according to the regression coefficient. The median follow-up was 88.4 months. The 5-year DM rate was 15.1%. N2-3, primary tumour volume of nasopharynx (GTVnx) >24.56 cm(3), haemoglobin change after treatment (ΔHGB) >25.8 g/L, albumin-globulin ratio (AGR) ≤1.34, pretreatment neutrophil-lymphocyte ratio (NLR) >2.81 and pretreatment serum lactate dehydrogenase (LDH) >245 U/L were significantly adverse independent predictive factors for DM. Three subgroups were defined based on the prediction-score model: low risk (0-2), intermediate risk (3-4) and high risk (5-8). The 5-year DM rates were 4.6, 21.8 and 50.8%, respectively (P < 0.001). The areas under the curve for DM in the prediction-score model and the UICC/AJCC staging system seventh edition were 0.748 and 0.627, respectively (P < 0.001). The scoring model is useful in evaluating the risk of DM in IMRT-treated NPC patients and guiding future therapeutic trials. Further prospective study is needed.

Prognostic value and clinical correlations of 18-fluorodeoxyglucose metabolism quantifiers in gastric cancer

AIM: To investigate the correlations of pre-treatment positron emission tomography-computer tomography (PET-CT) metabolic quantifiers with clinical data of unstratified gastric cancer (GC) patients.

METHODS: Forty PET-CT scans utilising 18-fluorodeoxyglucose in patients who received no prior treatment were analysed. Analysis involved measurements of maximum and mean standardised uptake volumes (SUV), coefficient of variation (COV), metabolic tumour volumes and total lesion glycolysis of different thresholds above which the tumor volumes were identified. The threshold values were: SUV absolute value of 2.5, 30% of SUVmax, 40% of SUVmax, and liver uptake-based (marked _2.5, ₃₀, ₄₀ and _liv, respectively). Clinical variables such as age, sex, clinical stage, performance index, weight loss, tumor histological type and grade, and CEA and CA19.9 levels were included in survival analysis. Patients received various treatment modalities appropriate to their disease stage and the outcome was defined by time to metastasis (TTM) and overall survival (OS). Clinical and metabolic parameters were evaluated by analysis of variance, receiver operating characteristics, univariate Kaplan-Meier, and multivariate Cox models. P < 0.05 was considered statistically significant.

RESULTS: Significant differences were observed between initially disseminated and non-disseminated patients in mean SUV (6.05 vs 4.13, P = 0.008), TLG_2.5 (802 cm³vs 226 cm³; P = 0.031), and TLG₃₀ (436 cm³vs 247 cm³, P = 0.018). Higher COV was associated with poor tumour differentiation (0.47 for G3 vs 0.28 for G1 and G2; P = 0.03). MTV_2.5 was positively correlated to patient weight loss (< 5%, 5%-10% and > 10%: 40.4 cm³vs 123.6 cm³vs 181.8 cm³, respectively, P = 0.003). In multivariate Cox analysis, TLG₃₀ was prognostic for OS (HR = 1.001, 95%CI: 1.0009-1.0017; P = 0.047) for the whole group of patients. In the same model yet only including patients without initial disease dissemination TLG₃₀ (HR = 1.009, 95%CI: 1.003-1.014; P = 0.004) and MTV_2.5 (HR = 1.02, 95%CI: 1.002-1.036; P = 0.025) were prognostic for OS; for TTM TLG₃₀ was the only significant prognostic variable (HR = 1.006, 95%CI: 1.001-1.012; P = 0.02).

CONCLUSION: PET-CT in GC may represent a valuable diagnostic and prognostic tool that requires further evaluation in highly standardised environments such as randomised clinical trials.

Activation of latent metastases in the lung after resection of a metastatic lymph node in a lymph node metastasis mouse model

Iatrogenic induction of regional and distant cancer metastases is a risk associated with clinical resection of tumor-positive sentinel lymph nodes. However, there have been no studies of this risk in a mouse model of cancer metastasis. Here, we report that resection of a tumor-bearing subiliac lymph node (SiLN) enhanced lung metastasis in a mouse model of lymph node metastasis. Bioluminescence imaging revealed that metastatic tumor cells in the secondary lymph node continued to grow after resection of the SiLN, and that the probability of metastasis to the lungs was increased when the interval between SiLN inoculation and resection was reduced. Futhermore, histological analysis demonstrated that latents in the lung were stimulated to grow after resection of the SiLN. Fluorescence imaging indicated that the route of tumor cell dissemination from SiLN to the lung was the venous system located over the SiLN. We speculate that our mouse model will be useful for studying the mechanisms of tumor cell latency, with a view to improving the detection and treatment of latent metastases.

Clinical and molecular characteristics of triple-negative breast cancer patients in Northern Israel: single center experience

INTRODUCTION

Triple-negative breast cancer (TNBC) lacks estrogen and progesterone receptors and does not overexpress HER2. It displays a distinct clinical behavior. This study aims to assess the clinical, molecular and prognostic characteristics of TNBC patients.

PATIENTS/METHODS

TNBC patients, referred to a tertiary medical center, 1/1/2000 - 31/12/2005, were included. Clinical, molecular and prognostic characteristics were retrospectively collected from patients' records.

RESULTS

Overall, 122 consecutive TNBC patients were included with a median age of 54 years. Among the TNBC patients, 101 (82.8%) were Jews and 21 (17.2%) were Arabs. Family history for breast cancer was reported in 30 patients (24.6%). Genetic counseling was conducted in 30 patients (24.6%); 22/30 (73.3%) had BRCA1/2 mutations. Median tumor size was 2 cm and positive lymph nodes were detected in pathological examination in 40 patients (34%). At the time of data analysis, 21/118 patients (17.8%), who initially presented with early disease, had developed metastasis. Local recurrence was detected in four patients (3.4%). The overall survival (OS) was significantly longer for patients younger than 60 years compared to those ≥ 60 years, (Hazard ratio (HR) =2.1, p=0.046). Nulliparous patients had significantly higher OS than patients with a reproductive history of ≥ 4 children. (HR=0.31, p= 0.041). Mortality rate was higher for Arabs versus Jews but did not reach significance, (HR=1.33; P=0.64).

CONCLUSIONS

TNBC represents an exclusive clinical behavior. Older age and parity were found to be poor prognostic factors. Further larger studies are needed to reaffirm our findings and explore the genetics among non-BRCA1/2 TNBC patients.

CT-based radiomic signature predicts distant metastasis in lung adenocarcinoma

BACKGROUND AND PURPOSE

Radiomics provides opportunities to quantify the tumor phenotype non-invasively by applying a large number of quantitative imaging features. This study evaluates computed-tomography (CT) radiomic features for their capability to predict distant metastasis (DM) for lung adenocarcinoma patients.

MATERIAL AND METHODS

We included two datasets: 98 patients for discovery and 84 for validation. The phenotype of the primary tumor was quantified on pre-treatment CT-scans using 635 radiomic features. Univariate and multivariate analysis was performed to evaluate radiomics performance using the concordance index (CI).

RESULTS

Thirty-five radiomic features were found to be prognostic (CI>0.60, FDR<5%) for DM and twelve for survival. It is noteworthy that tumor volume was only moderately prognostic for DM (CI=0.55, p-value=2.77×10(-5)) in the discovery cohort. A radiomic-signature had strong power for predicting DM in the independent validation dataset (CI=0.61, p-value=1.79×10(-17)). Adding this radiomic-signature to a clinical model resulted in a significant improvement of predicting DM in the validation dataset (p-value=1.56×10(-11)).

CONCLUSIONS

Although only basic metrics are routinely quantified, this study shows that radiomic features capturing detailed information of the tumor phenotype can be used as a prognostic biomarker for clinically-relevant factors such as DM. Moreover, the radiomic-signature provided additional information to clinical data.

Serum ENA78/CXCL5, SDF-1/CXCL12, and their combinations as potential biomarkers for prediction of the presence and distant metastasis of primary gastric cancer

BACKGROUND

Chemokines play important roles in cancer development and progression. Epithelial-derived neutrophil-activating peptide-78 (ENA78/CXCL5) and stromal cell-derived factor (SDF-1/CXCL12) supposedly contribute to gastric cancer (GC) development and progression. This study aims to evaluate serum levels of ENA78/CXCL5 and SDF-1/CXCL12 along the GC carcinogenesis, and analyze their clinical significance, and diagnostic potentials through human serum samples.

METHODS

A total of 300 subjects were enrolled in this study. Serum levels of ENA78/CXCL5 and SDF-1/CXCL12, measured by chemiluminescent immunoassay, were compared among 4 disease groups; normal, high-risk (intestinal metaplasia and adenoma), early GC (EGC), and advanced GC (AGC) groups in both training (n=25 per group) and validation dataset (n=70, 30, 50, 50, respectively) by ANOVA test (post hoc Bonferroni). Correlations between serum ENA78/CXCL5 or SDF-1/CXCL12 levels and clinicopathological parameters of GC patients were evaluated (Spearman's correlation; γs). To validate the diagnostic accuracy, receiver operating characteristic (ROC) curve and logistic regression analysis was performed.

RESULTS

Serum ENA78/CXCL5 and SDF-1/CXCL12 levels were significantly higher in AGC groups than EGC, high-risk and normal groups in both training and validation dataset (Bonferroni, from p<0.01 to p<0.001). Clinicopathologically, serum ENA78/CXCL5 was correlated with T-stage (γs=0.231, p=0.021) and distant metastasis (γs=0.357, p<0.001), while serum SDF-1/CXCL12 was correlated with lymph node (γs=0.220, p=0.029) and distant (γs=0.425, p<0.001) metastasis. ROC curve and logistic regression demonstrated that serum ENA78/CXCL5 and SDF-1/CXCL12 showed higher diagnostic accuracy compared with carcinoembryonic antigen (CEA) in predicting GC. Serum ENA78/CXCL5 could predict both the presence of GC and distant metastasis, while serum SDF-1/CXCL12 could mainly predict its distant metastasis. All combination of serum ENA78/CXCL5, SDF-1/CXCL12, and CEA achieved 92.8% specificity at 75.0% sensitivity to predict distant metastasis of GC.

CONCLUSIONS

Combinations of initial serum ENA78/CXCL5, SDF-1/CXCL12, and CEA before any treatment for GC can produce valuable serum biomarker panels to predict the presence and distant metastasis of GC.

Positron emission tomography-computed tomography before treatment is highly prognostic of distant metastasis in nasopharyngeal carcinoma patients after intensity-modulated radiotherapy treatment: a prospective study with long-term follow-up

OBJECTIVES

The utility of [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) in the prediction of distant metastasis after definitive treatment for non-disseminated NPC patients is not clear. We prospectively investigated the prognostic significance of (18)F-FDG PET-CT performed before treatment for the distant metastasis-free survival (DMFS) of NPC patients treated with intensity-modulated radiotherapy (IMRT) ± chemotherapy.

MATERIALS AND METHODS

The results of PET-CT scans performed at initial diagnosis were recorded and analyzed prospectively. Patients then received standard treatment per protocol independent of the PET-CT result. IMRT was administered to the nasopharynx and neck. Early stage patients received IMRT alone, whereas loco-regionally advanced patients received concurrent chemoradiation. Patient outcomes were evaluated.

RESULTS

One hundred and seventy-nine patients were analyzable. DM occurred in 33 patients and the 3-year DMFS rate of the whole cohort was 84.1%. The cut-off of the SUVmax at the primary site (SUVmax-P) for DMFS was 10.22 by ROC curve. The 3-year DMFS rates of the higher and lower SUVmax-P groups (SUVmax-P⩽or>10.22) were 93.2% and 75.1%, respectively, with an 18.1% difference (P=0.003). Multivariate analysis indicated that SUVmax-P was a risk factor independently associated with DMFS (HR, 2.672; 95%CI, 1.236-5.776; P=0.012) and OS (HR, 2.417; 95%CI, 1.313-4.448; P=0.005). Subgroup analysis indicated that the 5-year DMFS and OS in loco-regionally advanced patients with SUVmax-P⩽10.22 were similar to those of early stage patients, whereas those of loco-regionally advanced patients with SUVmax-P>10.22 patients predicted worse outcome.

CONCLUSION

SUVmax-P is a useful biomarker to predict distant metastasis of NPC patients treated with IMRT. Combining SUVmax-P with tumor overall stage, a more precise picture could be obtained to predict treatment outcome.

Therapeutic strategy for postoperative recurrence in patients with non-small cell lung cancer

Postoperative recurrence occurs in approximately half of patients with non-small cell lung cancer (NSCLC), even after complete resection. Disease recurrence after surgical resection reduces the patient’s life expectancy sharply. The prognosis after postoperative recurrence is considered to largely depend on both the mode of first recurrence (distant, locoregional or combined) and the treatment modality: (1) The majority of cases of postoperative recurrence involve distant metastasis with or without locoregional recurrence. Platinum-based systemic chemotherapy is practically accepted as the treatment for these diseases on the basis of evidence for original stage IV disease. The advent of both pemetrexed and molecular-targeted drugs has improved the survival of nonsquamous NSCLC and changed the chemotherapeutic algorithm for NSCLC; (2) Among patients with distant metastatic recurrence without locoregional recurrence at the primary tumor site, the metastasis is often limited in both organ and number. Such metastases are referred to as oligometastases. Local therapy, such as surgical resection and radiotherapy, has been suggested to be the first-line treatment of choice for oligometastatic recurrence; and (3) While locoregional recurrence is likely to cause troublesome symptoms, it is a potentially limited disease. Therefore, providing local control is important, and radiation is usually beneficial for treating local recurrence. In order to obtain better control of the disease and provide treatment with curative intent in patients with limited disease, the administration of concurrent platinum-based chemoradiotherapy is recommended according to the results of originally nonresectable stage IIIA and IIIB disease.

Role of induction chemotherapy for N3 head and neck squamous cell carcinoma

OBJECTIVE

The treatment of head and neck squamous cell carcinoma (HNSCC) with N3 (>6cm) lymph nodes remains difficult, and the best treatment strategy has not been elucidated. The aim of this study was to evaluate the outcomes of various treatment modalities.

METHODS

Sixty-nine patients with HNSCC and N3 neck disease treated with definitive therapy in our institute between 1987 and 2013 were included in the analysis. We compared the clinical outcomes of radiotherapy (RT) alone, chemoradiotherapy (CRT) and surgery with or without induction chemotherapy (ICT).

RESULTS

The overall survival (OS) at three years for the patients with N3 neck disease was 41%. The three-year OS rates of patients treated with definitive surgery and definitive CRT were 41% and 48%, respectively. There were no significant differences between these two treatments (P=0.82). The OS of patients who received ICT followed by definitive therapy was significantly better than that of patients who did not (P<0.001). The most common recurrence pattern was distant metastases. The rate of distant metastases was 61% of all treatment failures (20/33).

CONCLUSION

The high rate of distant metastases in patients with N3 neck disease suggests that prevention of distant metastases can improve survival. Based on this study, we consider that ICT may play an important role in the treatment of N3 neck disease.

Optimal surveillance for postoperative metastasis in breast cancer patients

PURPOSE

To establish an optimal surveillance schedule after surgery for breast cancer, patients included in an institutional database were retrospectively investigated with respect to the first metastatic site and timing of recurrence.

PATIENTS AND METHODS

We investigated 11,676 pT1-4pN0-2M0 breast cancer patients treated from 1985 to 2009 and followed up until June 2014. Our surveillance protocol included physician visits and examinations with bone scans, liver echography, chest roentgenography and laboratory tests. We evaluated the liver, bones, lungs and pleura as surveillance covering sites (SCS) in addition to parameters such as time points exceeding 80 % with respect to the accumulated percentage of patients of recurrence and the number of surveillance per one recurrence (NSR), calculated by dividing the number of patients at risk of recurrence at the start of a particular time frame by the number of patients of recurrence at SCS within that period.

RESULTS

There were a total of 1,962 recurrent patients, including 601 patients with locoregional recurrence, nine patients with recurrence in the opposite breast, 1,349 patients with recurrence at distant sites and three unknown patients. The number of patients with the bones, lungs, liver and pleura as the first site of recurrence was 447, 324, 144 and 69, respectively, and 72.9 % of the distant metastatic lesions belonged to SCS. The five-year overall survival rate after recurrence among the patients with single recurrent site was longer than that observed among the patients with multiple sites of recurrence (43.3 vs 25.3 %; p < 0.0001). In addition, more than 80 % of the patients of liver metastasis were detected within 5 years after surgery, while 80 % of the patients of pleura metastasis were detected within 10 years. The NSR was below 200 for the 10-year period, as was the NSR of the patients with lymph node metastasis and a positive hormone receptor status. In contrast, the NSR of the patients with a negative hormone receptor status was above 200 after 5 years.

CONCLUSIONS

In this study, the prognosis of the patients with a single site of recurrence was superior to that of the patients with multiple sites. Curable patients with distant metastases included those with single metastatic sites. The optimal surveillance schedule should be established taking into consideration that the incidence of metastasis differs among metastatic sites during follow-up.

Cytological diagnosis of follicular carcinoma thyroid metastasis in pelvic muscles-a rare and unusual site

Distant metastasis of thyroid neoplasm as an initial presentation is rarely encountered. The present case report describes a chance diagnosis of follicular carcinoma thyroid (FCT) metastasis in a 75-year-old female who was presented with symptoms related to pelvic mass. This is a rare site of reporting as only three cases have been reported previously at the first diagnosis. It is important to identify the presence of distant metastasis as it is the most important prognostic indicator (associated with 50% mortality). This is significant as this has a direct bearing upon its treatment and managing the patient. Hence more awareness is required by both diagnosticians and clinicians regarding this.

Human papillomavirus 16/18 E7 viral loads predict distant metastasis in oral cavity squamous cell carcinoma

BACKGROUND

Human papillomaviruses (HPV) seem to be related to distant metastasis (DM) in advanced oral cavity squamous cell carcinoma (OSCC) patients.

OBJECTIVES

This study aimed to investigate whether high-risk HPV viral load may predict DM among OSCC patients and stratify patients for risk-adapted treatment.

STUDY DESIGN

Viral loads of E7 oncogenes for HPV 16/18 were measured by quantitative PCR tests in paraffin-embedded lesional specimens from 312 OSCC of which the HPV genotypes had been determined previously. Multivariable Cox regression analysis was used to identify the independent prognostic factors for 5-year DM and C statistics were further computed.

RESULTS

By multivariable analysis, high HPV 16 E7 viral load (≥15.0 copies/genome); high HPV 18 E7 viral load (≥15.0 copies/genome); pathological N2 status (pN2); tumor depth ≥11 mm; extracapsular spread (ECS); and level IV/V metastases were independent risk factors for DM. We further identified three prognostic groups. In the high-risk group (level IV/V metastases or high HPV 16/18 E7 viral load plus pN2, tumor depth ≥11 mm, or ECS), the 5-year distant metastasis rate was 74%. In the intermediate-risk group (high HPV 16/18 E7 viral load, pN2, tumor depth ≥11 mm, or ECS), the 5-year DM rate was 17%. Finally, the 5-year DM rate was 1% in the low-risk group (no risk factors). The value of the C statistics was 0.78.

CONCLUSIONS

Among OSCC patients, high HPV 16/18 E7 viral load identifies a small subgroup of patients at high-risk of 5-year DM and suggest the need for more intensive treatments and follow-up strategies.

Subtype-dependent prognostic relevance of an interferon-induced pathway metagene in node-negative breast cancer

The majority of gene expression signatures developed to predict the likelihood to relapse in breast cancer (BC) patients assigns a high risk score to patients with Estrogen Receptor (ER) negative or highly proliferating tumors. We aimed to identify a signature of differentially expressed (DE) metagenes, rather than single DE genes, associated with distant metastases beyond classical risk factors. We used 105 gene expression profiles from consecutive BCs to identify metagenes whose prognostic role was defined on an independent series of 92 ESR1+/ERBB2- node-negative BCs (42 cases developing metastases within 5 years from diagnosis and 50 cases metastasis-free for more than 5 years, comparable for age, tumor size, ER status and surgery). Findings were validated on publicly available datasets of 684 node-negative BCs including all the subtypes. Only a metagene containing interferon-induced genes (IFN metagene) proved to be predictive of distant metastasis in our series of patients with ESR1+/ERBB2- tumors (P = 0.029), and such a finding was validated on 457 ESR1+/ERBB2- BCs from public datasets (P = 0.0424). Conversely, the IFN metagene was associated with a low risk of metastasis in 104 ERBB2+ tumors (P = 0.0099) whereas it did not prove to significantly affect prognosis in 123 ESR1-/ERBB2- tumors (P = 0.2235). A complex prognostic interaction was revealed in ESR1+/ERBB2- and ERBB2+ tumors when the association between the IFN metagene and a T-cell metagene was considered. The study confirms the importance of analyzing prognostic variables separately within BC subtypes, highlights the advantages of using metagenes rather than genes, and finally identifies in node-negative ESR1+/ERBB2- BCs, the unfavorable role of high IFN metagene expression.

Age at diagnosis and distant metastasis in breast cancer--a surprising inverse relationship

INTRODUCTION

Predictors for site of distant metastasis and impact on survival in breast cancer are incompletely understood.

METHODS

Clinico-pathological risk factors for site of distant metastasis and survival were analysed in patients with invasive breast cancer treated between 1986 and 2006.

RESULTS

Of 3553 patients, with median follow-up 6.32years, 825 (23%) developed distant metastasis. The site of metastasis was bone in 196/825 (24%), viscera in 540/825 (65%) and unknown in 89 (11%). Larger primary invasive tumour size, higher tumour grade and axillary nodal positivity increased risk of metastasis to all sites. Lobular carcinoma was more likely to first metastasise to bone compared to invasive ductal carcinoma (NST). Oestrogen receptor (ER) negative, progesterone receptor (PgR) negative and/or Human epidermal growth factor (HER2) positive tumours were more likely to metastasise to viscera. A striking relationship between increasing age at diagnosis and a reduction in risk of distant metastasis to bone and viscera was observed. Median time to death from onset of metastatic disease was 1.52 (Interquartile range (IQR) 0.7-2.9)years for patients with bone metastasis and 0.7 (IQR 0.2-1.5)years for visceral metastasis. On multivariate analysis, despite the decrease in risk of distant metastasis with increasing age, there was an elevated hazard for death in patients >50years at diagnosis of metastasis if they developed bone metastasis, with a similar trend observed in the >70years age group if they developed visceral metastasis.

CONCLUSION

These findings indicate that there are biological mechanisms underlying the impact of age on the development of distant metastasis and subsequent death. This may have important implications in the treatment of breast cancer.

Distant metastasis in patients with cervical cancer after primary radiotherapy with or without chemotherapy and image guided adaptive brachytherapy

OBJECTIVE

The aim of this study is to investigate patterns of distant relapse after primary radiochemotherapy in cervical cancer patients.

METHODS

All patients with cervical cancer treated in curative intent with external beam radiotherapy +/- chemotherapy and image-guided adaptive brachytherapy between January 1998 and June 2009 at the Medical University of Vienna were included in this retrospective analysis. Patients with locoregional recurrences were excluded from this study. Presence, site of and time to distant metastases were recorded. For identifying prognostic factors, uni- and multivariate analyses using Cox regression analysis were performed. Based on the result from the multivariate analysis, patients were stratified into a high and a low risk group. The Kaplan-Meier method was used to estimate distant-metastasis-free-survival in the overall cohort, in the risk groups and for analysing the impact of chemotherapy within the risk groups.

RESULTS

A total number of 189 patients were included in this study. After a median follow-up of 54 months, 49 patients developed distant metastases. Overall, distant-metastasis-free-survival 5 years after treatment was 73%. FIGO stage, lymph node status and the extent of tumour regression during treatment were significant predictors for distant metastasis. Distant-metastasis-free-survival 5 years after treatment was 91% and 60% in the low and high risk groups, respectively. The number of the cycles of chemotherapy had a significant impact on the occurrence of distant metastasis in high risk patients, but not in low risk patients.

CONCLUSION

Patients with high risk factors have a 40% probability of developing distant metastasis within 5 years. In these patients, decreasing the number of cycles of cisplatin may increase their probability of developing distant metastasis.

Application of circulating plasma/serum EBV DNA in the clinical management of nasopharyngeal carcinoma

Elevated levels of circulating cell-free Epstein-Barr virus (EBV) DNA have been detected in plasma and serum samples from nasopharyngeal cancer (NPC) patients by quantitative real time PCR (qPCR) test. This qPCR test for circulating EBV DNA was found to be useful in the clinical management of NPC patients. For instance, EBV DNA qPCR test has good sensitivity and specificity in the detection of NPC at disease onset. Increase of the viral DNA load was found in NPC patients at late stages of disease. High EBV DNA load at disease onset or detectable viral load post-treatment was associated with poor survival or frequent relapse in NPC patients. Residual EBV DNA load after primary treatment could be a useful indicator to justify adjuvant chemotherapy. The qPCR test might also be applied to define a poor prognostic group in patients at early stage (I/II) for implementing concurrent chemo-radiotherapy (chemo-RT) to improve patients' outcome. The test is also useful to monitor distant metastases or response to radiotherapy, chemo-RT or surgery. Supplementary tests, however, are needed to pick up EBV negative WHO type I NPC and test improvement is needed to increase sensitivity in detecting stage I disease and local recurrence.

Prognostic value of prepontine cistern invasion in nasopharyngeal carcinoma treated by intensity-modulated radiotherapy

OBJECTIVES

To investigate the prognostic value of prepontine cistern invasion (PPCI) in nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Five hundred and four non-disseminated NPC patients who underwent magnetic resonance imaging examination before radical IMRT between November 2000 and December 2008 were retrospectively reviewed. The diagnostic criteria for PPCI were tumor invasion through the posterior cortex of clivus and extension into the prepontine cistern.

RESULTS

The median follow-up of the patients in this study was 63.5 months. PPCI was found in 44 patients (25% of T4 patients). The 5-year progression-free survival (PFS), local control (LC), distant metastasis-free survival (DMFS), and overall survival (OS) of all patients, with and without PPCI, were 44.3% and 70.5% (p<0.001), 84.4% and 89.1% (p=0.376), 66.6% and 87.3% (p<0.001), and 59.6% and 80.2% (p<0.001), respectively. In T4 patients with PPCI and without PPCI, the 5-year PFS, LC, DMFS, and OS were 44.3% and 62.5% (p=0.023), 84.4% and 84.9% (p=0.946), 66.6% and 83.1% (p=0.022), and 59.6% and 71.0% (p=0.045), respectively. Using multivariate analysis, PPCI was found to be an independent poor prognostic factor for PFS (HR=1.816; p=0.007), DMFS (HR=1.928; p=0.045), and OS (HR=1.798; p=0.016).

CONCLUSION

Prepontine cistern invasion was an independent prognostic factor for poor DMFS and OS but not LC in NPC patients treated with IMRT, even within T4 patients.

Role of metastasectomy on overall survival of patients with metastatic gastric cancer

PURPOSE

The role of metastasectomy has been debatable and unclear in the treatment for patients with metastatic gastric cancer. Therefore, this study was designed to evaluate the role of metastasectomy on the overall survival of these patients.

MATERIALS AND METHODS

In 2,406 patients who underwent gastrectomy for gastric cancer between 1998 and 2010, 188 (7.8%) patients had their first surgery for metastatic gastric cancer. To minimize the bias of systemic chemotherapy, 99 patients who received postoperative chemotherapy (fewer than 2 cycles) were excluded. The primary gastrectomy or metastasectomy had not been enforced in the following cases. Patients with far advanced peritoneal dissemination, multiple liver and lung metastasis (more than 2), and a poor general condition (Eastern Cooperative Oncology Group>2) were excluded. Based on the metastasectomy, the patients were classified into two groups, gastrectomy with metastasectomy and gastrectomy only group.

RESULTS

There was no significant difference between both groups in clinicopathological characteristics except for the mean age (P=0.047). The univariate analysis for overall survival show statistical significances in metastasectomy (P=0.026), distal gastrectomy (P=0.047), and combined resection of another organ (P=0.047) group. With a multivariate analysis, metastasectomy was a significant factor in patient survival after surgery (odds ratio 1.679; P=0.034).

CONCLUSIONS

Based on our results, we assume that a detailed strategy for surgery is needed to improve the overall survival of patients with metastatic gastric cancer. Therefore, we suggest that a metastasectomy can help prolong overall survival in some patients with metastatic gastric cancer.

Long-term survival after distant metastasis in patients with oropharyngeal cancer

OBJECTIVES

For patients with oropharyngeal squamous cell carcinoma (OPSCC), especially for those with HPV-positive tumors, locoregional control is excellent. Distant metastasis, however, remains a substantial problem. The purpose of our study was to evaluate outcomes and predictors of survival after distant metastasis in OPSCC.

MATERIALS AND METHODS

Between June 2002 and January 2011, 25 OPSCC patients treated with curative intent subsequently developed distant metastasis. The primary end-points evaluated were time-to-distant metastasis and overall survival after development of distant metastasis. Predictors of outcome were evaluated with median regression analysis or Cox regression. Best subset models were chosen to minimize the Bayesian Information Criterion (BIC). A prognostic index for survival after distant failure was created based on the selected model.

RESULTS

Median time-to-distant metastasis after completion of radiation was 7.9 months (range, 1.6-25.4). Median overall survival from distant metastasis was 18.3 months (95% CI, 14.3-39.8). The overall survival rates at 1- and 2-year after development of distant metastasis were 72.0% (95% confidence interval [CI], 53.4-89.6) and 40.8% (95% CI, 20.6-61.0), respectively. In multivariate analysis, Karnofsky Performance Status score (KPS) > or = 80 (p=0.01, hazard ratio [HR] 0.15, 95% CI, 0.04-0.52) and limited, single-organ disease (p=0.003, HR 0.13, 95% CI 0.03-0.61) predicted for increased survival from distant metastasis. Patients with both limited disease and good KPS formed the most favorable risk group with a 2-year survival of 100%. Two patients with human papilloma virus (HPV)-positive tumors were alive without any evidence of disease at 64.6 and 60.4 months, respectively, after aggressive local treatment of solitary metastasis.

CONCLUSION

For OPSCC patients with limited, single-organ disease and good KPS, long-term survival can be achieved.

Distant metastasis in p16-positive oropharyngeal squamous cell carcinoma: a critical analysis of patterns and outcomes

OBJECTIVE

With good loco-regional control, disease failure in p16-positive oropharyngeal squamous cell carcinoma (OPSCC) mainly results from distant metastasis (DM). Our objective was to characterize the patterns and clinical outcomes of DM in p16-positive OPSCC and compare these to patients with p16-negative disease.

METHODS

Primary OPSCC patients who developed DM after completing surgical or non-surgical treatment were identified and p16 status was evaluated. Patterns of DM and post-DM progression-free (PFS) and disease-specific survival (DSS) were assessed.

RESULTS

Forty-one of the 66 (62%) patients with DM were p16-positive. DM patterns were not statistically different by p16 status. However, p16-positive patients developed DM later in their course and had longer survival. All p16-negative patients either had progression or died within 24 months of DM detection whereas the 2-year post-DM PFS in the p16-positive group was 20% (95% CI: 8-32.5%, p=0.003). The 3-year post-DM disease-specific survival (DSS) estimate in the p16-positive patients was 16% (95% CI: 7-18%) while all p16-negative patients died within 34 months (p<0.001). p16-negativity, loco-regional disease, and no/palliative versus curative intent treatment were all associated with reduced post-DM DSS in multivariate analysis.

CONCLUSIONS

The DM pattern did not differ remarkably between p16-positive and negative OPSCC patients in our practice. In p16-positive OPSCC with pulmonary oligometastatic disease, curative intent treatment and optimized locoregional control for the index primary prolonged survival.

Locoregional and distant recurrences after breast conserving therapy in patients with triple-negative breast cancer: a meta-analysis

BACKGROUND

With higher incidence of recurrence, ongoing dispute exists on whether triple-negative breast cancer (TNBC) is a good candidate for breast conserving therapy (BCT).

OBJECTIVE

We aimed to appraise the safety of BCT in treating TNBC, in comparison with modified radical mastectomy. The prognostic effect of TN phenotype in conservatively managed patients was also assessed.

METHODS

A systematic search for studies regarding recurrences in patients with TNBC or treated by BCT was conducted up to March 2013. Summary relative risks (RRs) for ipsilateral locoregional recurrence (ILRR) and distant metastasis (DM) were calculated in a fixed-effects model.

RESULTS

Twenty-two studies concerning 15,312 breast cancer patients were analyzed. In the cohort of TNBC, the patients receiving BCT were less likely to develop ILRR and DM in comparison with mastectomy (RR 0.75, 95% CI 0.65-0.87; RR 0.68, 95% CI 0.60-0.76). In the cohort of BCT, the TN subtype increased the risks of both ILRR and DM than non-TN subtypes (RR 1.88, 95% CI 1.58-2.22; RR 2.12, 95% CI 1.72-2.62). Further subgroup analyses of BCT cohort revealed that the luminal phenotype had the most favorable prognosis. Notably, TN subtype was less likely to develop ILRR than HER-2 subtype (RR 0.69, 95% CI 0.53-0.91), there was no difference in DM rate between them.

CONCLUSIONS

BCT benefits patients with TNBC than mastectomy does. However, TN subtype predicts a poorer prognosis than non-TN subtype, suggesting more aggressive adjuvant therapy for TNBC be established in future trials.

The pretreatment platelet and plasma fibrinogen level correlate with tumor progression and metastasis in patients with pancreatic cancer

Cancer patients frequently present with activated coagulation pathways and thrombocytosis, which are potentially associated with tumor progression and prognosis. However, the prognostic value of abnormal plasma fibrinogen and platelet levels for the treatment of pancreatic cancer is unclear. The purpose of our study was to evaluate the prognostic value of plasma fibrinogen and platelet levels in pancreatic cancer, and to devise a prognostic model to identify the patients with greatest risk for a poor overall survival. One hundred and twenty-five patients diagnosed with pancreatic ductal adenocarcinoma in our hospital between May 2000 and June 2005 were included in this study. The plasma fibrinogen and platelet levels were examined before treatment and analyzed along with patient clinicopathological parameters and overall survival. The foundation of prognostic model was based on the risk factors according to the Cox proportional hazard model. The incidence of hyperfibrinogenemia and thrombocytosis was 24.8% (31/125) and 15.2% (19/125), respectively. The mean fibrinogen concentration differed significantly between the early (I/II) and late (III/IV) stage patients (3.19 ± 0.70 vs. 3.65 ± 0.90 g/l, p = 0.008). Patients with a higher concentration of plasma fibrinogen and platelets had a worse prognosis (p < 0.05). There also existed a significant correlation between higher fibrinogen/platelet levels and distant organ metastasis (p < 0.05, respectively). Bivariate correlation analysis showed that plasma fibrinogen levels correlated significantly with platelet levels (p = 0.000). Multivariate analysis revealed that pretreatment plasma fibrinogen levels (p = 0.027), tumor stage (p = 0.026) and distant metastasis (p = 0.027) were independent prognostic factors. The median survival time for the low-, intermediate-, and high-risk groups was 9.6 months (95% CI 6.2-13.0), 3.8 months (95% CI 2.3-5.3), and 2.3 months (95% CI 0.9-3.7), respectively (p = 0.000). Pretreatment plasma fibrinogen and platelet levels closely correlated with tumor progression, metastasis and overall survival in pancreatic cancer. The foundation of prognostic model may help us identify the greatest risk populations with pancreatic cancer.

T1 colorectal cancer with synchronous liver metastasis

The patient was a 68-year-old man who was admitted to our hospital with a liver tumor. Abdominal ultrasonography and computed tomography revealed a liver tumor 30 mm in diameter. On colonoscopy, a pedunculated tumor with a central depression (20 mm in diameter) was observed in the ascending colon, and this tumor was considered to be invading deeply into the submucosal layer. Right hemicolectomy with D3 lymphadenectomy and partial hepatectomy were performed simultaneously. On histopathological examination of the resected specimen, the tumor was a well-differentiated tubular adenocarcinoma with 3,000 μm invasion of the submucosal layer. The liver tumor showed histological findings similar to those of the primary colorectal carcinoma. The pathological stage according to the 7th edition of the TNM classification was stage IV (T1N0M1). Nine months after the operation, computed tomography revealed hepatic hilar lymph node metastases and a great deal of ascites. The patient ultimately died 14 months after the operation.