The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM

Outcomes of neoadjuvant chemoradiotherapy in T4 rectal cancer patients: a real-world single institution experience

PURPOSE

Treatment outcomes of locally advanced rectal cancer have improved significantly in recent decades. This retrospective study aimed to assess the efficacy of neoadjuvant chemoradiotherapy (nCRT) followed by surgery in patients with T4 rectal cancer and the different outcomes between T4a and T4b patients.

MATERIALS AND METHODS

A total of 60 clinically T4 rectal cancer patients who underwent nCRT were included in the analysis. Patient characteristics, treatment regimens, down-staging rates, pathological response, and overall survival (OS) were evaluated.

RESULTS

Both T4a and T4b patients experienced down-staging following nCRT (36.6% and 6.2% respectively; p = 0.021). T4a patients exhibited a higher rate of pathological complete response (pCR) than T4b patients (13.3% in T4a vs. 0% in T4b; p = 0.122). After a median follow-up of 36 months, the OS and recurrence-free survival (RFS) of T4a patients were significantly higher compared to T4b patients (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.05-6.05, p = 0.038 for OS; HR = 2.32, 95% CI 1.09-4.92, p = 0.025 for RFS).

CONCLUSION

This study provides valuable insights into the effectiveness of nCRT in T4 rectal cancer patients. Although down-staging was observed in both T4a and T4b subgroups, achieving a pCR remains a challenge, particularly in T4b patients. Further research is needed to optimize treatment strategies and enhance pCR rates in T4 rectal cancer patients to improve oncologic outcomes.

Curative Approaches for Metaplastic Breast Cancer: A Retrospective Cohort Outcome Review

PURPOSE

Metaplastic breast cancer (MBC) is a rare and heterogeneous breast cancer subtype, and there are critical gaps in our understanding of its long-term outcomes. This retrospective cohort study aimed to address these gaps by scrutinizing the pathologic and clinical aspects of MBC to enhance clinical decision-making and refine patient care strategies.

METHODS AND MATERIALS

This registry-based retrospective cohort study included women aged ≥21 years diagnosed with MBC or matrix-producing carcinoma. The data were obtained from January 2001 to August 2020 from the Joint Breast Cancer Registry of Singapore Health Services, which included 23,935 patients. Demographic and clinicopathologic characteristics, neoadjuvant chemotherapy responses, and survival outcomes were analyzed. Statistical assessments involved univariate and multivariate Cox proportional hazards models and Kaplan-Meier survival analyses.

RESULTS

This study enrolled 170 patients; 87.1% had non-metastatic disease, and 12.9% had metastatic disease. The age of patients at diagnosis ranged from 46 to 65 years (median, 56 years). The cohort's predominant characteristics were triple negative breast cancer (64%), advanced clinical stage (77.6%), node negativity (67.6%), and grade 3 disease (74.1%). In patients receiving neoadjuvant chemotherapy with curative intent treatment (17.6%), neoadjuvant chemotherapy yielded a pathologic complete response of 19.2% and a disease progression rate of 46.2%. Multivariate analysis showed that adjuvant radiation therapy significantly improved overall survival and disease-free survival, with hazard ratios of 0.29 (95% CI, 0.13-0.62; P < .005) and 0.23 (95% CI, 0.10-0.50; P < .005), respectively. Clinical T3 and T4 stages and nodal involvement were associated with poor outcomes. Stable disease after neoadjuvant chemotherapy was associated with poor overall survival and disease-free survival.

CONCLUSIONS

This study sheds light on the complex landscape of MBC and emphasizes the pivotal role of adjuvant radiation therapy in enhancing patient outcomes. Despite advancements, challenges persist that warrant continued research to refine neoadjuvant chemotherapy strategies and delve into the nuanced factors that influence treatment responses.

Clinicopathological features and survival outcomes for gastric adenocarcinoma: Real-world single-center data

INTRODUCTION

Gastric cancer is the fifth most-common cancer and fourth common cause for cancer-related deaths globally. Surgery preceded or followed by chemotherapy or chemoradiotherapy is considered an optimal treatment for locally advanced gastric cancer. This study is a real-world data from a tertiary referral institute in southern India, in its experience with treating gastric adenocarcinoma over a period of four years with a minimum of two-year follow-up.

METHODS

This was a retrospective analysis of data of patients with histologically proven gastric adenocarcinoma enrolled in the Department of Medical Oncology from 2015 to 2018. The demographic details, presentation, staging, treatment received and outcomes of patients with gastric adenocarcinoma were collected and analyzed in this study.

RESULTS

Total 488 patients with gastric adenocarcinoma were included for the study. The stage-wise distribution of patients revealed early and locally advanced (45%) and metastatic (55%). The peritoneum and liver were the common sites of metastasis. The treatment distribution of these patients included perioperative chemotherapy followed by surgery (25 [5%]), surgery followed by adjuvant chemotherapy (65 [13%]), surgery alone (16 [3%]), perioperative chemotherapy alone (23 [4%]), palliative chemotherapy (274 [56%]) and supportive care (85 [17%]). The median overall survival for curative, palliative and supportive treatment was 23 (18-28), nine (7.6-10.4) and four (2.7-5.3) months, respectively. The two-year overall survival in the intention to treat population in the primary surgery (n = 81) and perioperative chemotherapy groups (n = 66) was 67.4% vs. 29.9% (p < 0.0001), respectively.

CONCLUSION

This study highlights the advanced nature of the presentation of gastric cancer patients and the poor rate of treatment completion. The median survival rates in curative patients remain to be dismally poor. The treatment sequence in curable gastric cancer of surgery followed by adjuvant chemotherapy vs. perioperative chemotherapy followed by surgery needs to be explored in our country.

Effectiveness of Colonoscopy in Reducing Incidence of Late-stage Colorectal Cancer Within an Opportunistic Screening Program

BACKGROUND

The effectiveness of colonoscopy in preventing colorectal cancer (CRC) within opportunistic screening programs has not been clearly established. The aim of this study was to analyze the effectiveness of colonoscopy within an opportunistic screening program using nested case-control study.

METHODS

Subjects who received a diagnosis of CRC (CG) between the ages of 50 and 90 years were included and matched by age and gender in a 1:5 ratio with patients without CRC diagnosis (COG) during the period 2015 to 2023. Using conditional regression analyses, we tested the association between screening colonoscopy and CRC. Subgroup analyses were then performed for CRC location, endoscopist specialty, and colonoscopy quality.

RESULTS

Of the 134 patients in CG, 19 (14.18%) had a colonoscopy in the preceding 5 years compared with 258 out of 670 (38.51%) in COG (AOR, 0.24; 95% CI: 0.14-0.41). Any colonoscopy was strongly associated with decreased odds for left-sided CRC (AOR, 0.09; 95% CI: 0.04-0.24) but not for right-sided CRC (AOR, 0.58; 95% CI: 0.29-1.17). Only complete colonoscopy (AOR, 0.41; 95% CI: 0.19-0.89) and colonoscopy with satisfactory bowel preparation (AOR, 0.38; 95% CI: 0.15-0.98) were associated with decreased odds for right-sided CRC. No significant differences in colonoscopy outcomes were found when stratifying by endoscopist specialty.

CONCLUSIONS

In the setting of an opportunistic screening program, exposure to any colonoscopy significantly reduced left-sided CRC incidence; however, only high-quality colonoscopy was associated with a lower incidence of right-sided CRC. Therefore, every possible effort should be made to optimize the quality and cost-effectiveness of colonoscopy within an opportunistic screening program.

Stereotactic Body Proton Therapy Versus Conventionally Fractionated Proton Therapy for Early Prostate Cancer: A Randomized, Controlled, Phase 3 Trial

PURPOSE

We aimed to determine if ultrahypofractionated proton therapy delivered via stereotactic body proton therapy (SBPT) is noninferior to conventionally fractionated proton therapy (CFPT) in patients with early prostate cancer.

METHODS AND MATERIALS

This study was a multicenter, randomized, controlled, noninferiority phase 3 trial that included patients with histologically confirmed low-risk prostate adenocarcinoma defined by Gleason score grouping 1, Prostate-specific antigen <10 ng/mL, and clinical stage T1-T2a N0 M0 according to 7th edition of the American Joint Committee on Cancer tumor-node-metastasis cancer staging system. Eligible participants were randomly assigned initially at a 1:1 ratio and later at a 2:1 ratio to SBPT (38 Gy in 5 fractions) or CFPT (79.2 Gy in 44 fractions). The primary endpoint was freedom from failure (FFF) at 2 years from the date of randomization. Noninferiority for FFF was determined based on 1-sided confidence intervals. Toxicities were compared at different time points using Fisher's exact test. Health-related quality-of-life (HRQoL) was analyzed at different time points using a mixed-effects linear model. This trial is registered with ClinicalTrials.gov, NCT01230866, and is closed to accrual.

RESULTS

Between December 10, 2010, and September 29, 2020, 144 patients were enrolled and 135 were randomly assigned (90 to the SBPT group and 45 to the CFPT group). The median follow-up was 5 years (IQR, 3.9-5.2). The 2-year FFF was 100% for both groups, with the 1-sided 5-year risk difference in FFF between groups reported as 2.63% (90% CI, -1.70% to 6.96%), favoring the SBRT arm, thus fulfilling the prespecified criteria for noninferiority of SBPT compared with CFPT. Rates of gastrointestinal and genitourinary G2 and G3 toxicities did not differ significantly between groups. Further, HRQoL metrics did not differ significantly between groups over the study's median follow-up.

CONCLUSIONS

SBPT is noninferior to CFPT regarding FFF, with similar long-term genitourinary and gastrointestinal toxicity rates and minimal impact in patient-reported HRQoL over time.

Induction Chemotherapy for Sinonasal Tumors in Patients Presenting with Brain Invasion and/or Neurological Deficits

Objective  The aim of this study was to investigate the safety of induction chemotherapy (IC) for patients with sinonasal malignancies with brain invasion or a neurological deficit. Methods  We conducted a retrospective analysis of patients who underwent IC for sinonasal malignancies with intracranial invasion or a neurological deficit at a single tertiary cancer center from 1992 to 2020. Results  In total, 460 patients with sinonasal malignancies were included in the study. Of the patients reviewed, 341 underwent IC and within this group 40 had brain invasion (BI) and 31 had a neurological deficit (ND) at presentation. The most prevalent malignancy was sinonasal undifferentiated carcinoma (BI 40%, ND 41.9%), followed by esthesioneuroblastoma (BI 27.5%, ND 9.7%). All tumors were stage T4 with the majority lacking nodal metastases (BI N0: 72.5%, ND N0: 77.5%). All patients completed at least two cycles of IC. Partial or complete response to IC was seen in 80% of BI and 71% of ND patients. No patients had cessation of treatment due to neurologic decline and none required urgent surgery. Five patients (12.5%) with BI and 2 (6.5%) with ND had interruption of IC for reasons other than neurological decline. In patients with ND, IC led to improvement of 54.5% NDs. Conclusion  In patients with sinonasal malignancies with BI or ND who underwent IC, no patients had cessation of treatment due to neurologic decline. In contrast, most patients had improvement of neurologic symptoms with IC. IC was safely administered without interruption due to neurological decline or symptom progression.

Evaluation of AJCC Nodal Staging for Intraductal Papillary Mucinous Neoplasm-Derived Pancreatic Ductal Adenocarcinoma

BACKGROUND

The American Joint Committee on Cancer (AJCC) eighth edition is based on pancreatic intraepithelial neoplasia-derived pancreatic ductal adenocarcinoma (PDAC), a biologically distinct entity from intraductal papillary mucinous neoplasm (IPMN)-derived pancreatic cancer. The role of nodal disease and the AJCC's prognostic utility for IPMN-derived pancreatic cancer are unclear. This study aimed to evaluate the prognostic role of nodal disease and the AJCC eighth-edition N-staging for IPMN-derived pancreatic cancer.

METHODS

Upfront-surgery patients with IPMN-derived PDAC from four centers were stratified according to the AJCC eighth-edition N stage. Disease characteristics were compared using descriptive statistics, and both overall survival (OS) and recurrence-free survival (RFS) were evaluated using log-rank tests. Multivariable Cox regression was performed to determine the prognostic value of N stage for OS, presented as hazard ratios with 95 % confidence intervals (95 % CIs). A lowest p value log-rank statistic was used to derive the optimal cutoff for node-positive disease.

RESULTS

For 360 patients, advanced N stage was associated with worse T stage, grade, tubular histology, and perineural and lymphovascular invasion (all p < 0.05). The median OS was 98.3 months (95 % CI 82.8-122.0 months) for N0 disease, 27.8 months (95 % CI 24.4-41.7 months) for N1 disease, and 18.1 months (95 % CI 16.2-25.9 months) for N2 disease (p < 0.001). The AJCC N stage was validated and associated with worse OS (N1 [HR 1.64; range, 1.05-2.57], N2 [HR2.42; range, 1.48-3.96]) and RFS (N1 [HR 1.81; range, 1.23-2.68], N2 [HR 3.72; range, 2.40-5.77]). The optimal cutoff for positive nodes was five nodes.

CONCLUSION

The AJCC eighth-edition N-staging is valid and prognostic for both OS and RFS in IPMN-derived PDAC.

Facilitating cholangiocarcinoma inhibition by targeting CD47

Immune evasion is one of the mechanisms by which cancer cells acquire immunity during cancer development and progression. One of these is the increased expression of cluster of differentiation 47 (CD47), a transmembrane glycoprotein that protects cells from phagocytic elimination. The interaction between CD47 and signal regulatory protein alpha (SIRPα) on macrophages alleviates the phagocytic signal. The present group previously reported high CD47 expression in cholangiocarcinoma (CCA), a major health problem in Thailand and East Asia, and that blocking CD47 using anti-CD47 antibodies promoted the removal of CCA. However, the mechanism through which CD47 inhibition attenuates CCA growth remains unclear. This study explored the clinical significance of targeting CD47 in CCA. Expression levels of CD47 and the macrophage marker CD68 were determined in CCA tissues by immunohistochemistry and correlated with clinical parameters. The role of CD47 in CCA cells was established using CD47-deficient KKU-213A CCA clones in vitro and in vivo. The results showed that CD47 was highly expressed in CCA tissues and significantly correlated with lymph node metastasis (P = 0.038). Moderate-to-dense CD68-positive infiltrating cells in CCA tissues were significantly associated with shorter survival of patients (P = 0.019) and were an independent prognostic factor of CCA patients as determined by the Cox proportional hazard model (hazard ratio, 2.040; 95 % confidence interval, 1.109-3.752; P = 0.022). Three CD47-deficient KKU-213A clones (#19, #23, and #28) were generated. The elimination of CD47 did not affect cell proliferation but increased monocyte-derived macrophage-mediated phagocytosis in vitro. Decreased tumor weights and volumes were observed in mice injected with CD47-deficient CCA clones. This revealed a significant role for CD47 in CCA, with a focus on protecting cancer cells from macrophage phagocytosis.

Assessing risk of lymph node invasion in complete responders to neoadjuvant chemotherapy for muscle-invasive bladder cancer

OBJECTIVES

To investigate the lymph node invasion (LNI) rate in patients exhibiting complete pathological response (CR) to neoadjuvant chemotherapy (NAC) and to test the association of CR status with lower LNI and better survival outcomes.

MATERIALS AND METHODS

We included patients with bladder cancer (BCa; cT2-4a; cN0; cM0) treated with NAC and radical cystectomy (RC) + pelvic lymph node dissection (PLND) at our institution between 2012 and 2022 (N = 157). CR (ypT0) and LNI (ypN+) were defined at final pathology. Univariable and multivariable logistic regression analysis was performed to test the association between CR and LNI after adjusting for number of lymph nodes removed (NLR). Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS), metastasis-free survival (MFS) and disease free-survival (DFS) according to CR status.

RESULTS

Overall CR and LNI rates were 40.1% and 19%, respectively. The median (interquartile range [IQR]) NLR was 26 (19-36). The LNI rate was lower in patients with CR vs those without CR (2 [3.2%] vs 61 [29.8%]; P < 0.001). After adjusting for NLR, CR reduced the LNI risk by 93% (odds ratio 0.07, 95% confidence interval [CI] 0.01-0.25; P < 0.001). Kaplan-Meier plots depicted better 5-year OS (69.7 vs 52.2%), MFS (68.3 vs 45.5%) and DFS (66.6 vs 43.5%) in patients with CR vs those without CR. After multivariable adjustments, CR independently reduced the risk of death (hazard ratio [HR] 0.44, 95% CI 0.24-0.81; P = 0.008), metastatic progression (HR 0.41, 95% CI 0.23-0.71; P = 0.002) and disease progression (HR 0.41, 95% CI 0.24-0.70; P = 0.001).

CONCLUSION

Based on these findings, we postulate that PLND could potentially be omitted in patients exhibiting CR after NAC, due to negligible risk of LNI. Prospective Phase II trials are needed to explore this challenging hypothesis.

Lung-MAP Next-Generation Sequencing Analysis of Advanced Squamous Cell Lung Cancers (SWOG S1400)

INTRODUCTION

Squamous cell cancer (SqCC) is a lung cancer subtype with few targeted therapy options. Molecular characterization, that is, by next-generation sequencing (NGS), is needed to identify potential targets. Lung Cancer Master Protocol Southwest Oncology Group S1400 enrolled patients with previously treated stage IV or recurrent SqCC to assess NGS biomarkers for therapeutic sub-studies.

METHODS

Tumors underwent NGS using Foundation Medicine's FoundationOne research platform, which sequenced the exons and/or introns of 313 cancer-related genes. Mutually exclusive gene set analysis and Selected Events Linked by Evolutionary Conditions across Human Tumors were performed to identify mutually exclusive and co-occurring gene alterations. Comparisons were performed with data on 495 lung SqCC downloaded from The Cancer Genome Atlas. Cox proportional hazards models were used to assess associations between genetic variants and survival.

RESULTS

NGS data are reported for 1672 patients enrolled on S1400 between 2014 and 2019. Mutually exclusive gene set analysis identified two non-overlapping sets of mutually exclusive alterations with a false discovery rate of less than 15%: NFE2L2, KEAP1, and PARP4; and CDKN2A and RB1. PARP4, a relatively uncharacterized gene, showed three frequent mutations suggesting functional significance: 3116T>C (I1039T), 3176A>G (Q1059R), and 3509C>T (T1170I). When taken together, NFE2L2 and KEAP1 alterations were associated with poorer survival.

CONCLUSIONS

As the largest dataset to date of lung SqCC profiled on a clinical trial, the S1400 NGS dataset establishes a rich resource for biomarker discovery. Mutual exclusivity of PARP4 and NFE2L2 or KEAP1 alterations suggests that PARP4 may have an uncharacterized role in a key pathway known to impact oxidative stress response and treatment resistance.

Protective loop ileostomy or colostomy? A risk evaluation of all common complications

PURPOSE

Protective ileostomy and colostomy are performed in patients undergoing low anterior resection with a high leakage risk. We aimed to compare surgical, medical, and daily care complications between these 2 ostomies in order to make individual choice.

METHODS

Patients who underwent low anterior resection for rectal tumors with protective stomas between January 2011 and September 2018 were enrolled. Stoma-related complications were prospectively recorded by wound, ostomy, and continence nurses. The cancer stage and treatment data were obtained from the Taiwan Cancer Database of our Big Data Center. Other demographic data were collected retrospectively from medical notes. The complications after stoma creation and after the stoma reversal were compared.

RESULTS

There were 176 patients with protective colostomy and 234 with protective ileostomy. Protective ileostomy had higher proportions of high output from the stoma for 2 consecutive days than protective colostomy (11.1% vs. 0%, P<0.001). Protective colostomy resulted in more stoma retraction than protective ileostomy (21.6% vs. 9.4%, P=0.001). Female, open operation, ileostomy, and carrying stoma more than 4 months were also significantly associated with a higher risk of stoma-related complications during diversion. For stoma retraction, the multivariate analysis revealed that female (odds ratio [OR], 4.00; 95% confidence interval [CI], 2.13-7.69; P<0.001) and long diversion duration (≥4 months; OR, 2.33; 95% CI, 1.22-4.43; P=0.010) were independent risk factors, but ileostomy was an independent favorable factor (OR, 0.40; 95% CI, 0.22-0.72; P=0.003). The incidence of complication after stoma reversal did not differ between colostomy group and ileostomy group (24.3% vs. 20.9%, P=0.542).

CONCLUSION

We suggest avoiding colostomy in patients who are female and potential prolonged diversion when stoma retraction is a concern. Otherwise, ileostomy should be avoided for patients with impaired renal function. Wise selection and flexibility are more important than using one type of stoma routinely.

FOXE1 Gene is a Probable Tumor Suppressor Gene with Decreased Expression as Papillary Thyroid Cancers Grow, and is Absent in Anaplastic Thyroid Cancers

Papillary thyroid carcinoma (PTC), the most prevalent cancer of the thyroid, is more common in women than in men. To uncover the expression profile of FOXE1 gene in PTC tumor etiology. Microarray and RNA sequencing data on PTC in humans were analyzed. Eleven PTC tumor tissue samples and their neighboring normal tissue samples were collected. RT-qPCR was performed. Data normality, ROC construction, and logistic regression analysis were conducted. PTC tumors, normal tissues surrounding tumors, patients of different sexes and ages, metastasizing tumors, and tumor variants were assessed for FOXE1 expression. Eleven PTC tissues were obtained from seven women and four men. Among the PTC subtypes, there were two FV-PTCs, four C-PTCs, one microcarcinoma, and four tissues with an unknown subtype. FOXE1 gene expression was significantly increased in PTC tumors with dimensions less than 10 mm (relative expression = 14.437, p = 0.050). A significant increase in FOXE1 gene expression was observed in the normal tissue adjacent to the tumor, which was less than 10 mm in size, compared to the normal tissue adjacent to the tumor, which was larger than 10 mm (relative expression = 41.760, p = 0.0001). Females diagnosed with PTC showed a significant reduction in FOXE1 mRNA levels compared to their male counterparts (relative expression = 0.081, p = 0.042). In contrast to adjacent normal tissue, there was a significant reduction in FOXE1 gene expression in FV-PTC (relative expression = 0.044 and p = 0.0001). PTC tumors under 10mm had higher FOXE1 gene expression than larger tumors; normal tissue adjacent to smaller tumors also had higher FOXE1 expression. Females with PTC, regardless of their subtype, expressed less FOXE1 mRNA than males. FV-PTC tissues exhibited lower expression of FOXE1 mRNA than their adjacent normal tissues.

Overall Survival with Pembrolizumab in Early-Stage Triple-Negative Breast Cancer

BACKGROUND

In patients with early-stage triple-negative breast cancer, the phase 3 KEYNOTE-522 trial showed significant improvements in pathological complete response and event-free survival with the addition of pembrolizumab to platinum-containing chemotherapy. Here we report the final results for overall survival.

METHODS

We randomly assigned, in a 2:1 ratio, patients with previously untreated stage II or III triple-negative breast cancer to receive neoadjuvant therapy with four cycles of pembrolizumab (at a dose of 200 mg) or placebo every 3 weeks plus paclitaxel and carboplatin, followed by four cycles of pembrolizumab or placebo plus doxorubicin-cyclophosphamide or epirubicin-cyclophosphamide. After definitive surgery, patients received adjuvant pembrolizumab (pembrolizumab-chemotherapy group) or placebo (placebo-chemotherapy group) every 3 weeks for up to nine cycles. The primary end points were pathological complete response and event-free survival. Overall survival was a secondary end point.

RESULTS

Of the 1174 patients who underwent randomization, 784 were assigned to the pembrolizumab-chemotherapy group and 390 to the placebo-chemotherapy group. At the data-cutoff date (March 22, 2024), the median follow-up was 75.1 months (range, 65.9 to 84.0). The estimated overall survival at 60 months was 86.6% (95% confidence interval [CI], 84.0 to 88.8) in the pembrolizumab-chemotherapy group, as compared with 81.7% (95% CI, 77.5 to 85.2) in the placebo-chemotherapy group (P = 0.002). Adverse events were consistent with the established safety profiles of pembrolizumab and chemotherapy.

CONCLUSIONS

Neoadjuvant pembrolizumab plus chemotherapy followed by adjuvant pembrolizumab resulted in a significant improvement, as compared with neoadjuvant chemotherapy alone, in overall survival among patients with early-stage triple-negative breast cancer. (Funded by Merck Sharp and Dohme, a subsidiary of Merck [Rahway, NJ]; KEYNOTE-522 ClinicalTrials.gov number, NCT03036488.).

Pediatric Renal Cell Carcinoma (pRCC) Subpopulation Environmental Differentials in Survival Disadvantage of Black/African American Children in the United States: Large-Cohort Evidence

OBJECTIVE

Renal cell carcinoma (RCC) is a rare but severe and aggressive pediatric malignancy. While incidence is uncommon, survival is relatively low with respect to acute lymphocytic leukemia (ALL), AML, lymphoma, ependymoma, glioblastoma, and Wilms Tumor. The pediatric renal cell carcinoma (pRCC) incidence, cumulative incidence (period prevalence), and mortality vary by health disparities' indicators, namely sex, race, ethnicity, age at tumor diagnosis, and social determinants of health (SDHs) as well as Epigenomic Determinants of Health (EDHs). However, studies are unavailable on some pRCC risk determinants, such as area of residence and socio-economic status (SES). The current study aimed at assessing the temporal trends, cumulative incidence, household median income, urbanity, mortality, and pRCC survival differentials.

MATERIALS AND METHODS

A retrospective cohort design was utilized to examine the event-free survival of children (0-19) with RCC using the Surveillance Epidemiology and End Result Data, 1973-2015. While the time-dependent variable, namely survival months, was utilized, we assessed the predictors of pRCC survival, mainly sex, age at diagnosis, education, insurance status, income, and tumor grade, as prognostic factors. In examining the joint effect of area of residence and race, as an exposure function with time in survival, we utilized the Cox proportional hazard model, while the annual percent change was assessed using a generalized linear model, implying a weighted average.

RESULTS

Between 1973 and 2015, there were 174 cases of pRCC, of whom 49 experienced mortality (28.2%). The pRCC cumulative incidence tends to increase with advancing age. A significant survival differential was observed between black/AA children with RCC and their white counterparts. Compared with white children, black/AA children were almost three times as likely to die, hazard ratio (HR) = 2.90, 95% CI = 1.56-5.31, p = 0.001. A survival differential was observed in sex, with males presenting with a 21% increased likelihood of dying, HR = 1.21; 95% CI, 0.69-2.11. In the metropolitan area, the risk of dying was almost three times as likely among black/AA children compared to their white counterparts, HR = 2.78; 95% CI, 1.45-5.43, while in the urban area, the risk of dying was almost four times as likely among black/AA children compared to their white counterparts, HR = 4.18; 95% CI, 0.84-20.80. After controlling for age, sex, education, and insurance, the risk of dying increased amongst black/AA children in metropolitan areas, adjusted HR (aHR) = 3.37, 99% CI = 1.35-8.44. In the urban area, after adjustment for age, sex, and insurance, there was an increased risk of dying for black/AA children, compared with their white counterparts with pRCC, aHR = 8.87, 99% CI = 2.77-28.10.

CONCLUSION

pRCC indicates an increased trend in males and age at diagnosis between 10 and 14, as well as a survival disadvantage among black/AA children, compared with their white counterparts. Additionally, urbanity significantly influences the racial differences in survival. These data are suggestive of the conjoined effect of environment and race in pRCC survival, indicative of further assessment of gene-environment interaction (epigenomics) in incidence, mortality, and survival in pRCC.

Survival outcomes fifteen years after minimally invasive esophagectomy

BACKGROUND AND OBJECTIVES

Minimally invasive esophagectomy (MIO) offers a less traumatic resection for cancer patients resulting in improved quality of life. Concerns about the oncological efficacy of the procedure and potential impact on survival may have limited its wider adoption. This study reports survival outcomes fifteen years after patients underwent a total MIO for esophageal cancer.

METHODS

A single-centre analysis of survival outcomes was conducted on all patients who underwent MIO between 2004 and 2010 and had completed at least 15-years follow-up. Actual overall survival (OS) and disease-free survival (DFS) were evaluated with the Kaplan-Meier method. The pattern of association of patient factors with survival was assessed with the Cox regression analysis.

RESULTS

A total of 121 patients underwent resection, with 4 (3.3%) in-patient deaths. With a median follow-up time of 15.2 years, the median OS was 41 months. At 15-years there were 20 survivors (17.1%), with numbers at 10 and 5 years being 34 (29.1%) and 45 (38.5%) respectively. Median DFS was 27 months, with 19 (16.2%) patient disease free at 15 years, and 32 (27.4%) and 38 (32.5%) at 10 and 5 years respectively. Predictors of poor survival were the intracorporeal fashioning of the gastric conduit, perioperative blood transfusions, advanced disease stage and recurrence.

CONCLUSIONS

Long term survival outcomes following MIO support its increasing recognition as the standard of care as for curative resection in esophageal cancer.

Adjuvant Radiation Therapy in Macroscopic Regional Nodal Melanoma

Adjuvant radiation therapy (ART) for macroscopic regional nodal cutaneous melanoma has evolved. A significant step was the discovery of targeted therapies, particularly towards V600E-mutated melanoma, and immunotherapy under its different kinds. Prior to this, the defining trial was the Australia and New Zealand Melanoma Trials Group (ANZMTG) 01.02/Trans-Tasman Radiation Oncology Group (TROG) 02.01 phase III trial that showed that ART using three-dimensional conformal radiotherapy (3DCRT) decreased in-field recurrence by 50% (48 Gray (Gy) in 20 fractions). After the advent of systemic therapies, a trial of the combination targeted therapy of dabrafenib plus trametinib toward BRAF V600-mutant nodal cutaneous melanoma showed that all 35 patients achieved a pathological response. Radiotherapy (RT) was found to be safe to give with concurrent combination therapy. A retrospective immunotherapy study found that in 71 patients that received ART after a first recurrence, further in-field recurrence significantly decreased (p = 0.01). For those tumours that do recur in-field, there are now competing therapies like Talimogene laherparepvec or T-VEC. Generally, ART is now used at the first recurrence. The challenge now is to find which melanomas are truly radiosensitive if ART is to have any future role in this scenario.

Real-world treatment patterns and outcomes among unresectable stage III non-small cell lung cancer

BACKGROUND

In 2018, the treatment options for unresectable stage III non-small cell lung cancer (NSCLC) changed with durvalumab, an immune checkpoint inhibitor (ICI), which was approved for consolidation therapy following concurrent chemoradiotherapy (cCRT) without disease progression. Despite durvalumab's clinical benefit, many patients receiving this therapy developed progression. This study evaluated treatment patterns and clinical outcomes in real-world community oncology practices for patients with unresectable stage III NSCLC who received cCRT.

METHODS

This study used The US Oncology Network's (iKnowMed) electronic health record database supplemented by chart review and included adults diagnosed with unresectable stage III NSCLC initiating cCRT between 11/01/2017 and 10/31/2019, with follow-up through 04/30/2022. cCRT included concurrent treatment with platinum-based chemotherapy and radiation therapy (+/-14 days). Real-world overall survival (rwOS) and real-world progression-free survival (rwPFS) were estimated from cCRT initiation using the Kaplan-Meier method.

RESULTS

Among 426 patients, 61.5% received durvalumab post-cCRT (cCRT+durvalumab) and 38.5% did not (cCRT alone). Death (28.3%) and disease progression (22.2%) were the most common reasons for not initiating durvalumab. The median age for the cCRT+durvalumab and cCRT alone cohorts were 70 and 71 years, and 71.8% and 61.6% had Eastern Cooperative Oncology Group performance status of 0-1, respectively. 51.5% of cCRT+durvalumab discontinued durvalumab, primarily due to adverse events (35.8%) and disease progression (28.4%). Median rwOS was 50.2 (95% confidence interval [CI]:41.4, not reached) and 11.6 (95% CI:6.5,15.9) months for cCRT+durvalumab and cCRT alone, respectively. Median rwPFS was 28.5 (95% CI:23.3,36.4) months for cCRT+durvalumab and 6.3 (95% CI:4.3,9.3) months for cCRT alone, respectively. 23.7% (cCRT+durvalumab) and 26.2% (cCRT alone) received subsequent treatment, of which, 59.7% (cCRT+durvalumab) and 46.5% (cCRT alone) received ICI.

CONCLUSION

Four out of ten patients did not receive consolidation durvalumab mainly due to disease progression. Even among patients who initiated durvalumab, many patients relapsed and were retreated with ICIs. These findings underscore the need to refine treatment strategies for better outcomes in stage III unresectable NSCLC.

Modified Textbook Outcome was a Predictor for Early Mortality After Oral Cancer Surgery

BACKGROUND

To explore prognostic factors for early mortality among patients undergoing surgery for oral cavity cancer (OCC) and identify valuable strategies to improve patient outcomes.

PATIENTS AND METHODS

A total of 397 patients treated by primary tumor resection and neck dissection between 2017 and 2021 were retrospectively analyzed. Univariate and multivariate Cox regression analysis were used to explore the relationships between the study factors and early death (within 12 months). Predictors were further incorporated into a nomogram for estimation of 1-year overall survival (OS).

RESULTS

The mean age was 57.2 (SD, 9.8) years and 92.9% patients were male. The early death rate was 12.6% overall, 35.6% in patients with pN2-3, 22.3% in patients with tumor size > 3 cm, and 36.2% in patients with lymphovascular invasion. A non-modified textbook outcome (mTO), pN2-3, tumor size > 3 cm, and lymphovascular permeation were independent prognosticators for early mortality. A nomogram with the above-mentioned four factors were created with good discrimination and calibration. Among the pN2-3 or tumor size > 3 cm subgroup, a non-mTO, cancer resource center (CRC) visits, perineural invasion, and lymphovascular permeation were independent prognostic factors for early death.

CONCLUSIONS

In addition to traditional clinicopathological features, a non-mTO and CRC visits could serve as prognostic factors for early death in OCC. A novel nomogram had good discrimination and calibration. Quality improvements in terms of mTO and patients demanding resource support could improve survival outcomes in OCC.

Magnetic Resonance Imaging Texture Analysis Based on Intraosseous and Extraosseous Lesions to Predict Prognosis in Patients with Osteosarcoma

Objectives: To construct an optimal magnetic resonance imaging (MRI) texture model to evaluate histological patterns and predict prognosis in patients with osteosarcoma (OS). Methods: Thirty-four patients underwent pretreatment MRI and were diagnosed as having OS by surgical resection or biopsy between September 2008 and June 2018. Histological patterns and 3-year survival were recorded. Manual segmentation was performed in intraosseous, extraosseous, and entire lesions on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images to extract texture features and perform principal component analysis. A support vector machine algorithm with 3-fold cross-validation was used to construct and validate the models. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate diagnostic performance in evaluating histological patterns and 3-year survival. Results: Eight patients were chondroblastic and the remaining twenty-six patients were non-chondroblastic patterns. Twenty-seven patients were 3-year survivors, and the remaining seven patients were non-survivors. In discriminating chondroblastic from non-chondroblastic patterns, the model from extraosseous lesions on the T2-weighted images showed the highest diagnostic performance (AUCs of 0.94 and 0.89 in the training and validation sets). The model from intraosseous lesions on the T1-weighted images showed the highest diagnostic performance in discriminating 3-year non-survivors from survivors (AUCs of 0.99 and 0.88 in the training and validation sets) with a sensitivity, specificity, positive predictive value, and negative predictive value of 85.7%, 92.6%, 75.0%, and 96.2%, respectively. Conclusions: The texture models of extraosseous lesions on T2-weighted images can discriminate the chondroblastic pattern from non-chondroblastic patterns, while the texture models of intraosseous lesions on T1-weighted images can discriminate 3-year non-survivors from survivors.

Evaluation of SNaPshot and Sanger sequencing for the detection of KRAS and NRAS mutations in a sample of Venezuelan patients with colorectal cancer

Colorectal cancer (CRC) is the third most commonly occurring cancer in men and the second most commonly occurring cancer in women. The epidermal growth factor receptor (EGFR) is relevant in the development and progression of CRC, because it is part of multiple signaling pathways involved in processes of the cell cycle, their malfunction causes dysregulation and subsequently carcinogenesis. Consequently, therapies were developed with anti-EGFR monoclonal antibodies (MAbs) that improve the survival of patients with CRC. However, mutations in the oncogenes Kirsten rat sarcoma (KRAS) and Neuroblastoma RAS (NRAS), modulators of the EGFR signaling pathway (downstream) activate a pathway independent in which such drugs have no effect. Patients with these mutations have a low response to MAb therapies. In this research, the SNaPshot sequencing method was used for the first time in Venezuela for the diagnosis of mutations in exon 2 of the KRAS and NRAS genes, from DNA extracted from tumor tissue samples fixed with formalin and included in paraffin (FFPE) and was compared with Sanger's method to determine the specificity and sensitivity, in the detection of mutations in the KRAS and NRAS genes. Of the 33 samples analysed, 27.3% presented mutations in KRAS and 15.1% in NRAS. With the obtained, it was carried out for the first time in the country the assignment of the geographical distribution of the polymorphisms found in these genes. The mutational status of the KRAS and NRAS genes showed no relationship statistically significant with clinical-histopathological variables. For this study, the SNaPshot method showed greater accuracy, sensitivity and specificity in the detection of single nucleotide polymorphisms than the Sanger method.

Glucose chemical exchange saturation transfer MRI for predicting the histological grade of rectal cancer: a comparative study with amide proton transfer-weighted and diffusion-weighted imaging

BACKGROUND

To evaluate the utility of glucose chemical exchange saturation transfer (glucoCEST) MRI with non-contrast injection in predicting the histological grade of rectal cancer.

METHODS

This prospective analysis included 60 patients with preoperative rectal cancer who underwent pelvic glucoCEST, amide proton transfer-weighted imaging (APTWI), and diffusion-weighted imaging (DWI). In total, 21 low-grade and 39 high-grade cases were confirmed by postoperative pathology. The MTRasym (1.2 ppm), MTRasym (3.5 ppm), and apparent diffusion coefficient (ADC) values of lesions between the low-grade and high-grade groups were compared. The area under the receiver operating characteristic curve (AUC) was generated to evaluate the diagnostic performance of each technique. Logistic regression (LR) analysis was applied to determine independent predictors and for multi-parameter combined diagnosis.

RESULTS

Elevated MTRasym (1.2 ppm), MTRasym (3.5 ppm) values and lower ADC values were observed in the high-grade group compared with low-grade cases (all p < 0.01). The AUCs of MTRasym (1.2 ppm), MTRasym (3.5 ppm), and ADC for differentiating between low- and high-grade rectal cancer cases were 0.792, 0.839, and 0.855, respectively. The diagnostic performance of the combination of the three indexes was improved (AUC, 0.969; sensitivity, 95.24%; specificity, 87.18%). The good consistency and reliability of the combination of independent predictors were demonstrated by calibration curve analysis and DCA.

CONCLUSION

The glucoCEST MRI without contrast injection, APTWI, and DWI all facilitate the assessment of histological grade in rectal cancer, and the combination of the three can effectively discriminate between high- and low-grade rectal cancer, which is expected to be a promising imaging marker.

CRITICAL RELEVANCE STATEMENT

The glucose chemical exchange saturation transfer MRI method facilitates the assessment of histological grade in rectal cancer and offers additional information to improve the diagnostic performance of amide proton transfer-weighted imaging, and diffusion-weighted imaging.

KEY POINTS

Glucose chemical exchange saturation transfer imaging could differentiate histological grade. Amide proton transfer-weighted and diffusion-weighted were associated with histological grade. The combination of different parameters showed the best diagnostic performance.

Predicting lymph node metastasis in papillary thyroid carcinoma with Hashimoto's thyroiditis using regression and network analysis

The comprehensive study of the relationship between lymph node metastasis (LNM) and its associated factors in patients with concurrent papillary thyroid carcinoma (PTC) and Hashimoto's thyroiditis (HT) remains insufficient. Building upon the initial investigation of factors associated with LNM in patients with concurrent PTC and HT, we further analyzed the complex relationships between different severity indicators of LNM and these associated factors. This study included patients confirmed PTC with HT who underwent total thyroidectomy at Xiangya Hospital, from January 2020 to December 2021. A total of 271 patients from 2020 were used as the training set, and 300 patients from 2021 as the validation set. Univariate analysis and regression modeling were used to identify key factors associated with LNM. Model reliability was assessed using the area under the receiver operating characteristic curve (AUC). Network analysis was employed to explore associations between LNM severity and its related factors. The regression model indicated that age, calcification, free triiodothyronine (FT3), and tumor maximum diameter (TMD) are independent factors for LNM. The severity model showed free thyroxine (FT4) and hemoglobin (Hb) are independent protective factors for the region and quantity of LNM, respectively, while TMD is an independent risk factor for both. Network analysis revealed TMD has a closer relationship with LNM severity compared to other associated factors. This study innovatively combined regression models and network analysis to investigate factors related to LNM in patients with PTC and HT, providing a theoretical basis for predicting preoperative LNM in future clinical practice.

Prognostic nomograms for locally advanced cervical cancer based on the SEER database: Integrating Cox regression and competing risk analysis

Locally advanced cervical carcinoma (LACC) remains a significant global health challenge owing to its high recurrence rates and poor outcomes, despite current treatments. This study aimed to develop a comprehensive risk stratification model for LACC by integrating Cox regression and competing risk analyses. This was done to improve clinical decision making. We analyzed data from 3428 patients with LACC registered in the Surveillance, Epidemiology, and End Results program and diagnosed them between 2010 and 2015. Cox regression and competing risk analyses were used to identify the prognostic factors. We constructed and validated nomograms for overall survival (OS) and disease-specific survival (DSS). Multivariate Cox regression identified key prognostic factors for OS, including advanced International Federation of Gynecology and Obstetrics stage, age, marital status, ethnicity, and tumor size. Notably, International Federation of Gynecology and Obstetrics stages IIIA, IIIB, and IVA had hazard ratios of 2.227, 2.451, and 4.852, respectively, significantly increasing the mortality risk compared to stage IB2. Ethnic disparities were evident, with African Americans facing a 39.8% higher risk than Caucasians did. Competing risk analyses confirmed the significance of these factors in DSS, particularly tumor size. Our nomogram demonstrated high predictive accuracy, with area under the curve values ranging from 0.706 to 0.784 for DSS and 0.717 to 0.781 for OS. Calibration plots and decision curve analyses further validated the clinical utility of this nomogram. We present effective nomograms for LACC risk stratification that incorporate multiple prognostic factors. These models provide a refined approach for individualized patient management and have the potential to significantly enhance therapeutic strategies for LACC.

Digital Breast Tomosynthesis Screening Improves Early Breast Cancer Detection and Survival in Taiwan

OBJECTIVE

Our objective was to compare the efficacy of digital breast tomosynthesis (DBT) and digital mammography (DM) in breast cancer screening and their impact on long-term overall survival (OS).

METHODS

The study involved 48 549 consecutive mammography examinations between 2011 and 2015 at a medical center in Taiwan, identifying 545 women who were screened and diagnosed with breast cancer. Digital mammography and DBT examinations were alternated on different days. Patients were categorized based on mammographic modality, breast density, and American Joint Committee on Cancer (AJCC) stage. To determine the long-term outcome until August 2021, survival rates were analyzed using the Kaplan-Meier (K-M) survival analysis.

RESULTS

The mean age at breast cancer diagnosis was 53.2 years. Digital breast tomosynthesis examinations were significantly associated with early breast cancer (AJCC stage 0 to 2) (P = .022). The 5- and 9-year OS rates for all patients were 96.8% and 93.0%, respectively. The 5- and 9-year OS was significantly greater in the DBT group (98.4% and 96.8%) compared with the DM group (95.0% and 90.4%) (P = .030 for all). The K-M survival analysis demonstrated a significantly higher OS in the DBT group than the DM group (P = .037). Furthermore, DBT significantly improved OS in a cohort of women with stage II and III cancer (P = .032) and heterogeneously dense breasts (P = .045).

CONCLUSION

Screening with DBT is associated with early breast cancer diagnosis and higher survival rates compared with DM.

Integrated pan-cancer analysis and experimental verification of the roles of ZBED3 in kidney renal clear cell carcinoma

The present study investigated the Zinc finger BED-type containing 3 (ZBED3) mRNA expression levels, diagnostic and prognostic values, co-expressed and differentially expressed genes, immune infiltration, and functional enrichment analysis in patients with kidney renal clear cell carcinoma (KIRC) using various public databases such as The Cancer Genome Atlas, Genotype-Tissue Expression Project, LinkedOmics, Gene Set Enrichment Analysis databases, and the Xiantao academic tool. Through extensive data mining, our study revealed differential expression of ZBED3 in various tumor and paired normal tissues. Specifically, ZBED3 expression was found to be significantly decreased in KIRC, particularly in advanced pathologic stages and histologic grades, when compared to corresponding control tissues. Our analysis revealed that the overexpression of ZBED3 is associated with a favorable overall survival outcome in KIRC patients. Moreover, functional enrichment analysis identified key pathways related to inflammation response and DNA methylation of ZBED3 in KIRC. Additionally, our findings suggest that the upregulation of ZBED3 leads to the inhibition of cell proliferation by modulating cell-cycle progression in KIRC cell lines. Taken together, these results suggest that ZBED3 may serve as a promising biomarker and prognostic indicator for individuals diagnosed with KIRC.

Impact of Contemporary Redlining on Healthcare Disparities Among Patients with Gastrointestinal Cancer: A Mediation Analysis

BACKGROUND

Historically, housing policies have perpetuated the marginalization and economic disinvestment of redlined neighborhoods. Residential segregation persists nowadays in the form of contemporary redlining, promoting healthcare disparities. The current study sought to assess the effect of redlining on oncological outcomes of patients with gastrointestinal cancer and identify mediators of the association.

METHODS

Patients with colorectal or hepatobiliary cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2019). The contemporary redlining index, a measure of mortgage lending bias, was assessed relative to disease stage at diagnosis, receipt of appropriate treatment, textbook outcome, and mortality. Mediation analysis was used to identify socioeconomic, structural, and clinical mediating factors.

RESULTS

Among 94,988 patients, 32.2% resided in high (n = 23,872) and highest (n = 6,791) redlining census tracts compared with 46.2% in neutral and 21.6% in low redlining tracts. The proportion of Black, Hispanic, and White patients experiencing high and highest redlining was 65.9%, 41.6%, and 27.9%, respectively. Highest redlining was associated with 18.2% higher odds of advanced disease at diagnosis, greater odds of not undergoing surgery for localized disease (adjusted odds ratio [aOR] 1.363, 95% confidence interval [CI] 1.219-1.524) or not receiving chemotherapy for advanced disease (aOR 1.385, 95% CI 1.216-1.577), and 26.7% lower odds of textbook outcome achievement. Mediation analysis for appropriate treatment quantified the proportion of the association driven by socioeconomic status, racial/ethnic minority status, racial/economic segregation, primary care shortage, and housing/transportation.

CONCLUSIONS

Contemporary redlining contributed both directly, and via downstream factors, to disparities in oncological care and outcomes of patients with gastrointestinal cancer.

Multivariable prognostic modelling to improve prediction of colorectal cancer recurrence: the PROSPeCT trial

OBJECTIVE

Improving prognostication to direct personalised therapy remains an unmet need. This study prospectively investigated promising CT, genetic, and immunohistochemical markers to improve the prediction of colorectal cancer recurrence.

MATERIAL AND METHODS

This multicentre trial (ISRCTN 95037515) recruited patients with primary colorectal cancer undergoing CT staging from 13 hospitals. Follow-up identified cancer recurrence and death. A baseline model for cancer recurrence at 3 years was developed from pre-specified clinicopathological variables (age, sex, tumour-node stage, tumour size, location, extramural venous invasion, and treatment). Then, CT perfusion (blood flow, blood volume, transit time and permeability), genetic (RAS, RAF, and DNA mismatch repair), and immunohistochemical markers of angiogenesis and hypoxia (CD105, vascular endothelial growth factor, glucose transporter protein, and hypoxia-inducible factor) were added to assess whether prediction improved over tumour-node staging alone as the main outcome measure.

RESULTS

Three hundred twenty-six of 448 participants formed the final cohort (226 male; mean 66 ± 10 years. 227 (70%) had ≥ T3 stage cancers; 151 (46%) were node-positive; 81 (25%) developed subsequent recurrence. The sensitivity and specificity of staging alone for recurrence were 0.56 [95% CI: 0.44, 0.67] and 0.58 [0.51, 0.64], respectively. The baseline clinicopathologic model improved specificity (0.74 [0.68, 0.79], with equivalent sensitivity of 0.57 [0.45, 0.68] for high vs medium/low-risk participants. The addition of prespecified CT perfusion, genetic, and immunohistochemical markers did not improve prediction over and above the clinicopathologic model (sensitivity, 0.58-0.68; specificity, 0.75-0.76).

CONCLUSION

A multivariable clinicopathological model outperformed staging in identifying patients at high risk of recurrence. Promising CT, genetic, and immunohistochemical markers investigated did not further improve prognostication in rigorous prospective evaluation.

CLINICAL RELEVANCE STATEMENT

A prognostic model based on clinicopathological variables including age, sex, tumour-node stage, size, location, and extramural venous invasion better identifies colorectal cancer patients at high risk of recurrence for neoadjuvant/adjuvant therapy than stage alone.

KEY POINTS

Identification of colorectal cancer patients at high risk of recurrence is an unmet need for treatment personalisation. This model for recurrence, incorporating many patient variables, had higher specificity than staging alone. Continued optimisation of risk stratification schema will help individualise treatment plans and follow-up schedules.

Angiopoietin-Like Protein 2 Expression in Tumor Cells Supports Tumor-Associated Macrophage-Induced Tumor Progression in Esophageal Cancer

BACKGROUND

Tumor-associated macrophages (TAM), a major component of the tumor microenvironment, play key roles in tumor formation and progression; however, mechanisms underlying TAM-induced tumor progression are complex and not well known. We previously reported that tumor cell-derived angiopoietin-like protein 2 (ANGPTL2) functions as a tumor promoter in some cancer contexts.

METHODS

We examined ANGPTL2 expression in paraffin-embedded tumor samples from resected specimens of 221 patients with esophageal cancer. Patients were subdivided into four groups based on immunohistochemistry scores described above: ANGPTL2-low/TAM-low, ANGPTL2-low/TAM-high, ANGPTL2-high/TAM-low, and ANGPTL2-high/TAM-high groups. Gene expression datasets of esophageal cancer cell lines were obtained from the cancer cell line encyclopedia public database.

RESULTS

In this study, we demonstrate that TAM infiltration is associated with poor prognosis in patients with esophageal cancer whose tumor cells show relatively higher ANGPTL2 expression levels; however, TAM infiltration did not affect prognosis in patients with ANGPTL2-low-expressing esophageal cancer, suggesting that ANGPTL2 expression in esophageal cancer cells is required for TAM-induced tumor progression. Our analysis of public datasets indicates a potential positive correlation of ANGPTL2 expression levels with that of transforming growth factor (TGF)-β, a TAM-activating factor, in esophageal cancer cell lines.

CONCLUSION

We conclude that ANGPTL2 signaling in tumor cells supports TAM-induced tumor progression and contributes to poor prognosis in patients with esophageal cancer. These findings overall provide novel insight into pro-tumor ANGPTL2 functions and illustrate the essential role of cancer cell/TAM crosstalk in cancer progression.

Association between tumor necrosis factor receptor 2 and progression and poor prognosis of tumor stage 2‑3 esophageal squamous cell carcinoma and stratified analysis

Although tumor necrosis factor receptor 2 (TNFR2) may serve a protumor role in several types of tumors, the clinical significance of TNFR2, including the diagnostic and prognostic value in tumor (T) stage 2-3 esophageal squamous cell carcinoma (ESCC), remains unclear. Therefore, the present study aimed to explore the clinical significance of TNFR2 in stage T2-3 ESCC. The present study collected the mRNA expression data of TNFR2 from two databases and confirmed the high expression of TNFR2 in ESCC tissue. TNFR2 expression in stage T2-3 ESCC tissue (n=404) was detected using immunohistochemistry and a stratified analysis was performed. For all patients with stage T2-3 ESCC, TNFR2 expression was associated with clinical stage, invasion depth and metastatic lymph nodes. Stage T3 and low differentiation was associated with an increase in the risk of lymph node metastasis, but older age was associated with a decrease. TNFR2 expression was associated with poor overall survival (OS) of all patients with stage T2-3 ESCC and stratified patients with stage T3 ESCC. Moreover, TNFR2 expression and metastatic lymph nodes were independent prognostic factors for these patients. For stratified patients aged ≤60 years, TNFR2 expression was associated with clinical stage and metastatic lymph nodes. In addition, TNFR2 expression was associated with poor OS in stratified patients with stage T2 ESCC. The presence of metastatic lymph nodes was also an independent prognostic factor for these patients. For stratified patients aged >60 years, TNFR2 expression was associated with invasion depth. TNFR2 expression was also associated with poor OS in all patients with stage T2-3 ESCC and stratified patients with stage T3 ESCC. TNFR2 expression and metastatic lymph nodes were identified as independent prognostic factors for these patients. In conclusion, TNFR2 expression is associated with progression and poor prognosis in patients with stage T2-3 ESCC as an independent prognostic factor, except in the subgroup of patients with stage T2-3 ESCC aged ≤60 years.

Association Between Changes in Skeletal Muscle Quality and Prognosis in Postoperative Patients with Early Gastric Cancer

BACKGROUND

Identifying accurate prognostic factors is crucial for postoperative management of early gastric cancer (EGC) patients. Skeletal muscle quality (SMQ), defined by muscle density on computed tomography (CT) images, has been proposed as a novel prognostic factor. This study compared the prognostic significance of SMQ changes with the well-established factor of body weight (BW) loss in the postoperative EGC setting.

METHODS

This single-center retrospective study included 297 postoperative EGC patients (median age 69 years, 68.4% male) who had preoperative and 1-year-postoperative gastrectomy CT images. SMQ was defined as the modified intramuscular adipose tissue content (mIMAC = skeletal muscle density-subcutaneous fat density on CT images) and the change as ΔmIMAC. Log-rank test, Kaplan-Meier survival, and Cox proportional hazards regression analyses were used to assess the associations between prognosis and either ΔmIMAC or BW change (ΔBW). Prognosis prediction by ΔmIMAC and ΔBW was compared by using the area under the curve (AUC) of the receiver operating characteristic curve.

RESULTS

ΔmIMAC was significantly associated with prognosis (log-rank test; P = 0.037), but ΔBW was not (P = 0.243). Prognosis was significantly poorer in the severely decreased mIMAC group than in the preserved group (multivariate Cox proportional hazards regression analysis; P = 0.030) but was unaffected by BW changes (P = 0.697). The AUC indicated a higher prognostic value for ΔmIMAC than ΔBW (ΔmIMAC: AUC = 0.697, ΔBW: AUC = 0.542).

CONCLUSIONS

One-year post-gastrectomy SMQ changes may be better prognostic EGC predictors than BW changes.

Comparing SEER and NCDB: a case study using colorectal cancer

Nationwide datasets are frequently used to examine cancer trends and outcomes in the U.S. Understanding the strengths and limitations of the commonly used Surveillance, Epidemiology, and End Results (SEER) Program and the National Cancer Database (NCDB) is important when designing studies and interpreting results. We used colorectal cancer (CRC) as a case study to compare information available. We identified 575,128 (SEER) and 1,578,046 (NCDB) adults diagnosed with CRC between 2004 and 2021. The distribution of age, tumor location, stage, and treatment did not meaningfully differ between SEER and NCDB. SEER represents racially and ethnically diverse populations, including a higher proportion of Hispanic (11.7% vs 5.8%) and Asian/Pacific Islander (8.6% vs 3.3%) persons. SEER includes more information on area-level characteristics, such as county-level measures of poverty, unemployment, and migration and census tract-level measures of socioeconomic status. Age-adjusted incidence, mortality rates, and cause-specific survival are only available in SEER, facilitating detailed analyses of racial, ethnic, and socioeconomic differences in cancer incidence and mortality. NCDB provides information on tumor characteristics and treatment not available in SEER, including microsatellite instability, KRAS mutation, palliative treatment, unplanned readmissions, and 30-day mortality after surgery, facilitating analyses of treatment effectiveness and outcomes. Five-year overall survival was similar in SEER (55.6%) vs NCDB (57.5%).

Survival Outcomes According to NCCN Criteria for Resection Following Neoadjuvant Therapy for Patients with Localized Pancreatic Cancer

BACKGROUND

This study aimed to assess the prognostic value of the National Comprehensive Cancer Network (NCCN) criteria for resection following neoadjuvant therapy for patients with localized pancreatic ductal adenocarcinoma (PDAC).

METHODS

This retrospective single-center study assessed 193 consecutive patients with localized PDAC (104 males and 89 females; mean age, 61.1 ± 9.4 years) who underwent neoadjuvant therapy followed by surgery between January 2010 and March 2021. Combined resectability and carbohydrate antigen (CA) 19-9 evaluation before and after neoadjuvant therapy was used to determine whether patients were eligible for resection according to the NCCN criteria. Post-surgical overall survival (OS), recurrence free survival (RFS), and pathologic results were evaluated and compared between patients considered eligible according to the NCCN criteria and those considered ineligible. Preoperative factors associated with better OS and RFS also were investigated.

RESULTS

Of the 193 patients, 168 (87.0 %) were eligible for resection according to the NCCN criteria. The patients eligible according to the NCCN criteria showed marginally longer OS than those considered ineligible (p = 0.056). After adjustment of variables, meeting the NCCN criteria for resection was an independent predictor of better OS (hazard ratio, 0.57; 95 % confidence interval, 0.34-0.96; p = 0.034). The two groups had similar RFS. Lower T-staging (T2 or less) and less lympho-vascular invasion and peri-neural invasion were noted in the patients who met the NCCN criteria (p ≤ 0.045).

CONCLUSIONS

The patients eligible for resection according to the NCCN criteria showed a trend toward longer OS and better pathologic results than the patients considered ineligible.

Rates of Pathologic Complete Response and Overall Survival in Patients with Inflammatory Breast Cancer: A National Cancer Database Study

BACKGROUND

Patients with inflammatory breast cancer (IBC) have worse survival compared with stage III non-IBC matched cohorts; however, the prognostic significance of achieving pathologic complete response (pCR) in the setting of IBC is not well described. We evaluated overall survival (OS) between IBC patients and non-IBC patients who achieved pCR.

METHODS

Adult females diagnosed in 2010-2018 with clinical prognostic stage III unilateral invasive breast cancer treated with neoadjuvant chemotherapy (NAC) followed by surgery were selected from the National Cancer Database. Unadjusted OS from surgery was estimated using the Kaplan-Meier method, and log-rank tests were used to compare groups. Cox proportional hazard models were used to estimate the association of study groups with OS after adjustment for available covariates.

RESULTS

The study included 38,390 patients; n = 4600 (12.0%) IBC and n = 33,790 (88.0%) non-IBC. Overall pCR rates were lower for IBC compared with non-IBC (20.7% vs. 23.3%; p < 0.001). Among those achieving pCR, 5-year mortality was higher for IBC patients (16.4%, 95% confidence interval [CI] 13.9-19.1%) versus non-IBC patients (9.1%, 95% CI 8.4-9.8%; log-rank p < 0.001). Among all patients achieving pCR, IBC remained associated with worse OS compared with non-IBC (hazard ratio 1.48, 95% CI 1.19-1.85; p < 0.001).

CONCLUSION

We found a lower pCR rate and worse OS in IBC patients compared with non-IBC stage III patients. Despite effective systemic therapies, achieving a pCR for IBC patients may not carry the same prognostic impact compared with non-IBC stage III patients.

Ten-Year Efficacy of Transoral Surgery for Squamous Carcinoma of the Lateral Oropharynx

OBJECTIVES

To document the 10-year results of transoral mandibular preservation surgery for patients with T1-2 squamous cell carcinoma (SCC) arising from the lateral oropharynx.

METHODS

This was a retrospective 30-year review using STROBE guidelines at an academic, tertiary referral center. A total of 294 patients with T1-2 SCC of the lateral oropharynx were reviewed. Only 19% of patients were never-smokers, suggesting a predominantly HPV-negative population. All patients had transoral mandibular preservation surgery. Follow-up therapy included neck dissection (76.5%), induction chemotherapy (57.8%), and postoperative radiation therapy (31.6%) Local control, survival, and functional endpoints, as well as the consequences of local recurrence, were analyzed.

RESULTS

The 10-year local disease control was 88.3%. Local recurrence was salvaged in 50% of cases, resulting in an overall 94.5% local control rate. The overall 10-year survival was 50%. Mortality was related to metachronous second primary cancer (MSPC) (29.2%), medical comorbidities (25.7%), uncontrolled local recurrence (10%), and complications following transoral resection (4.2%). In multivariate analysis, the development of an MSPC significantly increased (p < 0.005) the risk of death. Overall, 95.2% of patients achieved mandibular preservation. However, gastrostomy and tracheostomy dependence occurred in 1% and 0.3% of cases, respectively.

CONCLUSIONS

For a patient population with a significant percentage of tobacco-associated oropharyngeal cancer (OPC), transoral surgery was associated with long-term minimal postoperative complications and a high rate of local control. MSPC was the main cause of death during the first 10 postoperative years. Such long-term figures support transoral surgery as an effective first-line treatment for early-stage predominantly tobacco-related OPC.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4564-4572, 2024.

Survival Benefits of Postoperative Chemotherapy in Patients With Colorectal Mucinous Adenocarcinoma: An Analysis Utilizing Propensity Score Matching From the Surveillance, Epidemiology, and End Results Database

OBJECTIVE

This study aimed to investigate the characteristics of patients with colorectal mucinous adenocarcinoma (MAC) who benefit from postoperative chemotherapy (POCT) and to develop effective postoperative survival nomograms for predicting overall survival (OS) in colorectal MAC patients.

METHODS

Data of colorectal MAC patients who underwent surgery from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2020 were collected. Patients were grouped based on POCT, and intergroup analysis was performed using 1:1 propensity score matching (PSM). Kaplan-Meier (K-M) curves were used to compare the prognosis between the 2 groups. Cox analysis was employed to identify factors associated with OS in patients with colorectal MAC who underwent POCT. The variance inflation factor (VIF) and bilateral stepwise regression were used to determine factors included in the model. Additionally, a nomogram was constructed to predict postoperative survival outcomes for patients. The discriminative ability of the nomograms was evaluated using the C-index and calibration curve analysis, the decision curve analysis (DCA) assessed the clinical utility of the nomogram, and the receiver operating characteristic (ROC) curve evaluated the nomograms' performance.

RESULTS

This study encompassed 6829 patients with colorectal MAC, among whom 2258 received POCT, and 4571 did not. Whether pre or post PSM, patients in the POCT group consistently exhibited a superior median OS compared to those in the postoperative non-chemotherapy group (P < .0001). For colorectal MAC patients undergoing POCT, OS was correlated with factors such as patient age, carcinoembryonic antigen levels, tumor deposits, perineural invasion (PNI), lymph node examination count, T staging, and Grade staging. Notably, a significant chemotherapy advantage was observed in patients without perineural invasion, those with lymph node examination counts exceeding 12, and patients with moderately differentiated tumors. The overall colorectal MAC patient postoperative OS predictive nomogram demonstrated a C-index of .74, with a calibration curve near the diagonal and a DCA curve indicating positive net benefits. In comparison to TNM staging, the ROC curves of the nomogram at 1 year, 3 years, and 5 years demonstrated superior predictive capabilities (AUC: .80 vs .71, .78 vs .71, .77 vs .70).

CONCLUSION

This study revealed the characteristics of colorectal MAC patients who benefit from POCT and established effective prognostic nomograms, which can aid clinicians in designing personalized treatment plans for individual patients and promote precision medicine.

Tumor burden score is superior to primary liver cancer stages in predicting prognosis for patients with combined hepatocellular-cholangiocarcinoma after surgery: A multi-center study

BACKGROUND

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is poorly understood, while the predictive value of the staging in which it is included is controversial.

METHODS

Patients with cHCC-CCA underwent radical hepatectomy in two medical centers in China were enrolled and staged based on optimal cut-off values of tumor burden score (TBS), determined using the X-Tile. The association between TBS and prognosis was evaluated by Cox proportional hazard models and Kaplan-Meier curves with Log-rank test. TBS model and primary liver cancer (PLC) stages were compared by discrimination, consistency, and clinical utility, which were further validated by a 5-folds cross-validation.

RESULTS

A total of 192 patients were stratified into low, medium, and high TBS, comprising 92, 51 and 49 patients, respectively. Prognoses worsened with elevated TBS in both the training and validation cohorts. TBS was not only an independent prognostic indicator in univariate and multivariate cox regression, but also a stable risk factor in subgroup analysis according to baseline variables. TBS exhibited best discrimination within these predictive models, as evidenced by the highest c-index and area under curve values of time-dependent receiver operating curves within 5 years post-surgery. TBS calibration plots revealed favorable consistency between prediction and observation. Decision curve analysis suggested higher net benefits for TBS. A 5-folds cross-validation revealed consistent results.

CONCLUSIONS

TBS could be applied to stratify cHCC-CCA patients after surgery into groups with statistically different prognoses. Moreover, TBS exhibited optimal prognostic value over all available PLC stages and may inform clinical decisions.

Fibroblast Growth Factor Receptor (FGFR) Alterations in HPV Oropharyngeal Cancers

HPV viral E6 and E7 onco-proteins play a well-known role in carcinogenesis. Host genomic alterations also play a key role in the development of HPV-related oropharyngeal cancer and have been under-recognized. We describe a case series of 6 metastatic/locoregionally recurrent HPVOPSCC patients with FGFR alterations. HPVOPSCC presents with distinct pattern of spread both temporally and sites of recurrence compared to  non-HPV-related oropharyngeal cancer. Identification and reporting of genomic alterations in HPV are crucial to the understanding of disease biology and could aid in development of novel therapeutics for these patients. In addition, use of circulating tumor DNA may lead to early detection and supplement imaging in the follow up of these patients. Loco-regional treatments may also play a key role in the management of metastatic HPV OPSCC depending on the pattern of presentation. Our case series highlights all these novelties that could lead to better treatment outcomes.

Machine learning discrimination of Gleason scores below GG3 and above GG4 for HSPC patients diagnosis

This study aims to develop machine learning (ML)-assisted models for analyzing datasets related to Gleason scores in prostate cancer, conducting statistical analyses on the datasets, and identifying meaningful features. We retrospectively collected data from 717 hormone-sensitive prostate cancer (HSPC) patients at Yunnan Cancer Hospital. Of these, data from 526 patients were used for modeling. Seven auxiliary models were established using Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF), Decision Tree (DT), Extreme gradient boosting tree (XGBoost), Adaptive Boosting (Adaboost), and artificial neural network (ANN) based on 21 clinical biochemical indicators and features. Evaluation metrics included accuracy (ACC), precision (PRE), specificity (SPE), sensitivity (SEN) or regression rate(Recall), and f1 score. Evaluation metrics for the models primarily included ACC, PRE, SPE, SEN or Recall, f1 score, and area under the curve(AUC). Evaluation metrics were visualized using confusion matrices and ROC curves. Among the ensemble learning methods, RF, XGBoost, and Adaboost performed the best. RF achieved a training dataset score of 0.769 (95% CI: 0.759-0.835) and a testing dataset score of 0.755 (95% CI: 0.660-0.760) (AUC: 0.786, 95%CI: 0.722-0.803), while XGBoost achieved a training dataset score of 0.755 (95% CI: 95%CI: 0.711-0.809) and a testing dataset score of 0.745 (95% CI: 0.660-0.764) (AUC: 0.777, 95% CI: 0.726-0.798). Adaboost scored 0.789 on the training dataset (95% CI: 0.782-0.857) and 0.774 on the testing dataset (95% CI: 0.651-0.774) (AUC: 0.799, 95% CI: 0.703-0.802). In terms of feature importance (FI) in ensemble learning, Bone metastases at first visit, prostatic volume, age, and T1-T2 have significant proportions in RF's FI. fPSA, TPSA, and tumor burden have significant proportions in Adaboost's FI, while f/TPSA, LDH, and testosterone have the highest proportions in XGBoost. Our findings indicate that ensemble learning methods demonstrate good performance in classifying HSPC patient data, with TNM staging and fPSA being important classification indicators. These discoveries provide valuable references for distinguishing different Gleason scores, facilitating more accurate patient assessments and personalized treatment plans.

Estimating Costs Associated with Adverse Events in Patients with Advanced Lung Cancer

Purpose

This study aimed to estimate the costs associated with adverse events (AEs) in advanced lung cancer patients treated with first-line therapies.

Subjects and Methods

All patients with advanced lung cancer diagnosed between 2011 and 2019 were identified from the Taiwan National Cancer Registry. First-line treatment was defined as a therapy that began within 30 days before and 90 days after the diagnosis. We defined a newly-developed AE as one established after first-line treatment had commenced, with the contingency that the patient had not been diagnosed with the AE within one year prior to the outset of therapy. One patient with a specific AE was matched on age, sex, and regimens with four patients without the AE. Payments incurred over the same period of time in the two groups were compared to estimate the AE-related costs.

Results

A total of 27,376 patients receiving first-line targeted therapy, immunotherapy, or chemotherapy were identified. Clinical characteristics of 15,454 treatment episodes with a specific AE and 61,816 treatment episodes without the AE were well balanced. The costliest AEs of any severity were sepsis/septicemia, neuropathy, and acute kidney injury, with the respective average incremental costs of 10101, 9982, and 7839 USD. The costliest severe AEs requiring hospitalization were sepsis/septicemia, interstitial lung disease/pneumonitis, and neuropathy, with mean incremental costs of 22483, 10645, and 10120 USD, respectively.

Conclusion

Costs associated with AEs in advanced lung cancer patients treated with first-line therapies were substantial. These estimates could be adopted for future cost-effectiveness analyses of new lung cancer treatments.

DST regulates cisplatin resistance in colorectal cancer via PI3K/Akt pathway

OBJECTIVES

Dystonin (DST), a potential tumor suppressor gene, plays a crucial role in regulating cancer cell proliferation and resistance to chemotherapy. However, DST's specific role in colorectal cancer (CRC) has not been thoroughly investigated, and this study aims to elucidate its molecular role in modulating cisplatin (DDP) resistance in CRC.

METHODS

DST expression was analyzed in CRC tumors, DDP-resistant CRC tissues, paracancer tissues, and normal tissues. Lentiviral overexpression and shRNA knockdown were conducted in advanced CRC and DDP-resistant cell lines to assess cell viability, apoptosis, invasion, migration, proliferation, and angiogenesis. Xenograft mouse models studied DST's impact on CRC tumor growth and DDP resistance in vivo.

RESULTS

DST expression was significantly reduced in CRC tumor and DDP-resistant CRC tissues compared to paracancer and normal tissues (P < .001). Upregulating DST inhibited CRC and DDP-resistant cell viability, proliferation, invasion, and migration while promoting apoptosis. DST overexpression also reduced angiogenesis and attenuated DDP-induced cytotoxicity in CRC cells. Mechanistically, DST upregulation suppressed DDP resistance in CRC cells via the PI3K/Akt signaling pathway. DST upregulation reduced CRC tumor growth and mitigated DDP resistance, in vivo.

CONCLUSION

DST plays a crucial role in limiting CRC progression and overcoming DDP resistance, suggesting potential for targeted CRC therapies.

Urticaria and the risk of cancer: a Danish population-based cohort study

BACKGROUND

Urticaria has been tentatively linked to cancer, but epidemiological evidence supporting this link is sparse and conflicting. We conducted a population-based cohort study using healthcare databases covering the Danish population (January 1980-December 2022). We followed 87 507 people for a median of 10.1 years after their first hospital contact for urticaria.

OBJECTIVES

To examine associations of a hospital diagnosis of urticaria with incident cancer.

METHODS

We computed the absolute risk of cancer and standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) standardized to Danish national cancer rates. In a cross-sectional analysis, we examined whether the extent of cancer spread differed between people with vs. without a previous urticaria diagnosis.

RESULTS

The overall SIR for all types of cancer was 1.09 (95% CI 1.06-1.11) based on 7788 observed vs. 7161 expected cases. The risk for any cancer was 0.7% (95% CI 0.6-0.7) for the first year of follow-up. Cancer was diagnosed in 588 people with urticaria during the first year of follow-up (SIR 1.49, 95% CI 1.38-1.62) and in 7200 people thereafter (SIR 1.06, 95% CI 1.04-1.09). During the first year of follow-up, we found strong associations with haematological cancers (e.g. non-Hodgkin lymphoma; SIR 2.91, 95% CI 1.92-4.23). Cancer stage was similar in people with vs. without a previous urticaria diagnosis.

CONCLUSIONS

At the time of urticaria diagnosis, or in the first year afterward, we found a large increase in the risk of cancer. In subsequent years, a persistent 6% increase in risk remained. Diagnostic efforts may partly explain the elevated short-term risk, but occult cancer may promote urticaria, or cancer and urticaria share common risk factors.

Long-term functional outcome of limb-sparing surgery for paediatric bone sarcoma around the knee

Aims

Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery.

Methods

We reviewed 40 patients aged under 14 years who underwent limb-sparing surgery for knee bone sarcoma (15 cases in the proximal tibia and 25 in the distal femur) between January 2000 and December 2013, and were followed up for a minimum of five years. A total of 35 patients underwent reconstruction using artificial materials, and five underwent biological reconstruction. We evaluated the patients' postoperative complications, survival rate of reconstruction material, and limb, limb function, and leg-length discrepancy at the final follow-up, as well as the risk factors for each.

Results

Complications were observed in 55% (22/40) of patients. The limb survival and reconstruction material rates at five and ten years were 95% and 91%, and 88% and 66%, respectively. Infection was the only risk factor in both survivals (p < 0.001, p = 0.019). In the 35 patients with limb preservation, the median International Society of Limb Salvage (ISOLS) score at the final follow-up was 80 (47% to 97%). Younger age (p = 0.027) and complications (p = 0.005) were poor prognostic factors. A negative correlation was found between age and leg-length discrepancy (R = -0.426; p = 0.011). The ISOLS scores were significantly lower in patients with a leg-length discrepancy of more than 5 cm (p = 0.005).

Conclusion

Young age and complications were linked to an unfavourable functional prognosis. Leg-length correction was insufficient, especially in very young children, resulting in decreased function of the affected limb. Limb-sparing surgery for these children remains a considerable challenge.

Probabilistic bias analysis for exposure misclassification of household income by neighbourhood in a cohort of individuals with colorectal cancer

INTRODUCTION

Despite poor agreement, neighbourhood income is used as a proxy for household income, due to a lack of data availability. We quantified misclassification between household and neighbourhood income and demonstrate quantitative bias analysis (QBA) in scenarios where only neighbourhood income is available in assessing income inequalities on colorectal cancer mortality.

METHODS

This was a retrospective study of adults with colorectal cancer diagnosed 2006-14 from Statistics Canada's Canadian Census Health and Environment Cohort. Neighbourhood income quintiles from Statistics Canada were used. Census household income quintiles were used to determine bias parameters and confirm results of the QBA. We calculated positive and negative predictive values using multinomial models, adjusting for age, sex and rural residence. Probabilistic QBA was conducted to explore the implication of exposure misclassification when estimating the effect of income on 5-year mortality.

RESULTS

We found poor agreement between neighbourhood and household income: positive predictive values ranged from 21% to 37%. The bias-adjusted risk of neighbourhood income on 5-year mortality was similar to the risk of mortality by household income. The bias-adjusted relative risk of the lowest income quintile compared with the highest was 1.42 [95% simulation interval (SI) 1.32-1.53] compared with 1.46 [95% confidence interval (CI) 1.39-1.54] for household income and 1.18 (95% CI 1.12-1.24) for neighbourhood income.

CONCLUSION

QBA can be used to estimate adjusted effects of neighbourhood income on mortality which represent household income. The predictive values from our study can be applied to similar cohorts with only neighbourhood income to estimate the effects of household income on cancer mortality.

Development and Validation of a Computed Tomography-Based Model for Noninvasive Prediction of the T Stage in Gastric Cancer: Multicenter Retrospective Study

BACKGROUND

As part of the TNM (tumor-node-metastasis) staging system, T staging based on tumor depth is crucial for developing treatment plans. Previous studies have constructed a deep learning model based on computed tomographic (CT) radiomic signatures to predict the number of lymph node metastases and survival in patients with resected gastric cancer (GC). However, few studies have reported the combination of deep learning and radiomics in predicting T staging in GC.

OBJECTIVE

This study aimed to develop a CT-based model for automatic prediction of the T stage of GC via radiomics and deep learning.

METHODS

A total of 771 GC patients from 3 centers were retrospectively enrolled and divided into training, validation, and testing cohorts. Patients with GC were classified into mild (stage T1 and T2), moderate (stage T3), and severe (stage T4) groups. Three predictive models based on the labeled CT images were constructed using the radiomics features (radiomics model), deep features (deep learning model), and a combination of both (hybrid model).

RESULTS

The overall classification accuracy of the radiomics model was 64.3% in the internal testing data set. The deep learning model and hybrid model showed better performance than the radiomics model, with overall classification accuracies of 75.7% (P=.04) and 81.4% (P=.001), respectively. On the subtasks of binary classification of tumor severity, the areas under the curve of the radiomics, deep learning, and hybrid models were 0.875, 0.866, and 0.886 in the internal testing data set and 0.820, 0.818, and 0.972 in the external testing data set, respectively, for differentiating mild (stage T1~T2) from nonmild (stage T3~T4) patients, and were 0.815, 0.892, and 0.894 in the internal testing data set and 0.685, 0.808, and 0.897 in the external testing data set, respectively, for differentiating nonsevere (stage T1~T3) from severe (stage T4) patients.

CONCLUSIONS

The hybrid model integrating radiomics features and deep features showed favorable performance in diagnosing the pathological stage of GC.

Prognostic value of nutrition and immune‑related biomarkers in patients with locally advanced rectal cancer treated with chemoradiotherapy

The ability of nutrition and immune-related biomarkers to predict outcomes in patients with locally advanced rectal cancer (LARC) treated with neoadjuvant therapy followed by surgery remains controversial due to the lack of evidence regarding the accuracy and reliability of these biomarkers in predicting outcomes for such patients. Therefore, the present study aimed to investigate the prognostic potential of nutrition and immune-related biomarkers in patients with LARC who underwent chemoradiotherapy followed by curative surgery. The clinical data of patients with LARC treated with neoadjuvant therapy followed by surgery between January 2010 and December 2019 were analyzed. In total, 214 consecutive patients were enrolled into the present study, who were then categorized into low and high prognostic nutritional index (PNI) groups. The X-tile 3.6.1 program was used to calculate and then determine the optimal cut-off values for PNI. Disease-free survival (DFS) and overall survival (OS) were compared between the low and high PNI groups. Cox regression analysis demonstrated that low PNI and high post-chemoradiotherapy carcinoembryonic antigen levels were significantly associated with reduced disease-free survival and overall survival. Specifically, a low PNI was associated with inferior 5-year DFS (P=0.025) and OS (P=0.018). These findings suggest that amongst the nutritional and immune-related biomarkers, PNI is a significant predictive factor for disease recurrence and mortality in patients with LARC treated with neoadjuvant therapy followed by surgery.

Predictive MINT Pathologic Risk Score for Adjuvant Chemotherapy in Resected Cholangiocarcinoma: A Propensity Score-Matched Multicenter Study in Thailand

PURPOSE

This study aims to clarify the benefit of adjuvant chemotherapy (AC) in resectable cholangiocarcinoma (CCA) and develop a predictive risk score for treatment selection.

METHODS

Patients with resected CCA undergoing curative surgery, with or without AC, were identified from three centers in Thailand. Patients with R2 resection and 30 days postoperative death were excluded. Using the largest center as the discovery cohort, we generated propensity score matching (PSM). A predictive model for overall survival (OS) was identified, and a predictive risk score was developed from the PSM discovery cohort, classifying patients into high- and low-risk groups. The proposed risk score was validated in the other two centers.

RESULTS

In the discovery cohort, 493 patients were identified. After PSM, 328 patients were categorized into surgery (n = 164) and surgery + AC (n = 164) groups. The baseline characteristics in the PSM discovery cohort were well-balanced. In the validation cohort (n = 83), patients with positive lymph node 1 received AC more frequently than those under observation (47% v 18%; P = .02). A MINT pathologic risk score was developed from multivariate analysis for OS. The score includes margin, perineural invasion, pathologic nodal status, and pathologic tumor size. In the PSM discovery cohort, for the low-risk score group, the surgery group had significantly longer OS compared with the surgery + AC group (49.4 v 31.5 months; hazard ratio [HR], 1.78 [95% CI, 1.11 to 2.86]; P = .016). Conversely, for the high-risk score group, the surgery + AC group had better OS than the surgery group (18.8 v 8 months; HR, 0.60 [95% CI, 0.46 to 0.79]; P < .001). The results were comparable in the validation cohort.

CONCLUSION

Patients with resected CCA with a high-risk MINT pathologic risk score were likely to benefit from AC, whereas those with a low-risk score were not. Further validation in a larger prospective cohort is warranted.

The Impact of Neoadjuvant Chemotherapy on Patients With T1N0M0 Triple-Negative and HER-2 Positive Breast Cancer: A Retrospective Analysis Based on the SEER Database

BACKGROUND

The utilization of neoadjuvant chemotherapy (NAC) originated in the treatment of locally advanced breast cancer (BC). Our study is designed to elucidate the effects of NAC on patients with T1N0M0 triple-negative and HER-2 positive BC.

METHODS

This study involved the selection of 10,614 patients diagnosed with T1N0M0 triple-negative and HER-2 positive breast cancer (BC) from the surveillance, epidemiology, and end results (SEER) database. To ascertain the impact of neoadjuvant chemotherapy (NAC) on T1a, T1b, and T1c N0M0 BC, we conducted multivariate Cox regression analyses. Similarly, we performed multivariate Cox regression analyses to compare the effects of neoadjuvant chemotherapy against adjuvant chemotherapy on T1N0M0 BC. The Kaplan-Meier method was employed to delineate survival curves for different molecular subtypes and clinical stages.

RESULTS

The data results from the SEER database reveal a significant enhancement of overall survival (OS) in T1c BC patients as a result of NAC. For T1b BC patients, NAC does not present any significant effect. Contrarily, NAC seems to adversely impact the OS of T1a triple-negative BC patients. However, the prognosis comparison between neoadjuvant and adjuvant chemotherapy for T1N0M0 breast cancer did not show any significant difference, with the exception of T1a triple-negative BC.

CONCLUSIONS

Patients with T1cN0M0 triple-negative and HER-2 positive BC may derive OS benefits from NAC. Additionally, NAC could be detrimental to T1a triple-negative BC.

MRE11 as a plausible biomarker and prognostic bioindicator for head and neck squamous cell carcinoma

OBJECTIVE

Head and Neck Squamous Cell Carcinoma (HNSCC) ranks as the sixth most prevalent form of cancer worldwide. MRE11 protein contains multiple domains that play a role in the initiation of DNA repair. This study aimed to elucidate the expression and prognostic significance of MRE11 in HNSCC.

MATERIAL AND METHODS

The Cancer Genome Atlas (TCGA-HNSCC) dataset comprising 520 HNSCC tissues and 44 normal tissues was initially used to evaluate the association between MRE11 expression and clinicopathologic characteristics. Kaplan-Meier plot was utilized for survival analysis. MRE11-immune cell interaction was analyzed using Tumor Immune Estimation Resource (TIMER) database. Further, Insilco methods were used to explore the protein network and its association with other pathways. Quantitative reverse transcription PCR (RT-qPCR) was used to validate the MRE11 mRNA expression in oral squamous cell carcinoma (OSCC) tissues in patient samples.

RESULTS

MRE11 expression was upregulated in HNSCC, and the expression significantly varied across different clinical stages, pathological grades, and initial treatment outcomes. Further, high MRE11 expression is associated with poorer survival outcomes. MRE11 overexpression is also linked to the activation of the HIPPO signaling pathway, the mTOR signaling pathway, and the MYC/MYCN signaling pathway.

CONCLUSION

MRE 11 can be considered a novel prognostic biomarker for HNSCC, which can be leveraged for promising treatment outcomes. This research highlights MRE11 as a novel molecular biomarker for HNSCC and offers a new direction for its treatment, explicitly targeting MRE11 and its network for therapeutic intervention.