Breast cancer preoperative 18FDG-PET, overall survival prognostic separation compared with the lymph node ratio

Sternum Metastases: From Case-Identifying Strategy to Multidisciplinary Management

We aimed to overview the most recent data on sternal metastases from a multidisciplinary approach (diagnosis strategies, outcome, and histological reports). This narrative review based on a PubMed search (between January 2020 and 22 July 2023) using key words such as "sternal", "manubrium", and "metastasis" within the title and/or abstract only included original papers that specifically addressed secondary sternal spreading of cancer in adults, for a total of 48 original articles (14 studies and 34 single case reports). A prior unpublished case in point is also introduced (percutaneous incisional biopsy was used to address a 10 cm sternal tumour upon first admission on an apparently healthy male). The studies (n = 14) may be classified into one of three groups: studies addressing the incidence of bone metastases (including sternum) amid different primary cancers, such as prostate cancer (N = 122 with bone metastases, 83% of them with chest wall metastases), head and neck cancers (N = 3620, 0.8% with bone metastases, and 10.34% of this subgroup with sternum involvement); and glioblastoma (N = 92 with bone metastases, 37% of them with non-vertebral metastases, including the sternum); assessment cohorts, including breast cancer (N = 410; accuracy and sensitivity of PET/CT vs. bone scintigraphy is superior with concern to sternum spreading) and bone metastases of unknown origin (N = 83, including a subgroup with sternum metastases; some features of PET/CT help the differentiation with multiple myeloma); and cohorts with various therapeutic approaches, such as palliative arterial embolization (N = 10), thymic neuroendocrine neoplasia (1/5 detected with sternum metastases), survival rates for sternum metastases vs. non-sternum chest wall involvement (N = 87), oligo-metastatic (sternal) breast cancer (3 studies, N = 16 for all of them), oligo-metastatic head and neck cancer (N = 81), conformal radiotherapy (N = 24,215, including an analysis on sternum spreading), and EBRT followed by MR-HIFU (N = 6). Core data coming from the isolated case reports (N = 34) showed a female to male ratio of 1.6; the females' ages were between 34 and 80 (mean of 57.28) and the males' ages varied between 33 and 79 (average of 58.78) years. The originating tumour profile revealed that the most frequent types were mammary (N = 8, all females) and thyroid (N = 9, both women and men), followed by bladder (N = 3), lung (N = 2), and kidney (N = 2). There was also one case for each of the following: adenoid cystic carcinoma of the jaw, malignant melanoma, caecum MiNEN, a brain and an extracranial meningioma, tongue carcinoma, cholangiocarcinoma, osteosarcoma, and hepatocellular carcinoma. To our knowledge, this is the most complex and the largest analysis of prior published data within the time frame of our methods. These data open up new perspectives of this intricate, dynamic, and challenging domain of sternum metastases. Awareness is a mandatory factor since the patients may have a complex multidisciplinary medical and/or surgical background or they are admitted for the first time with this condition; thus, the convolute puzzle will start from this newly detected sternal lump. Abbreviations: N = number of patients; n = number of studies; PET/CT = positron emission tomography/computed tomography; EVRT = external beam radiotherapy; MR-HIFU = magnetic resonance-guided high-intensity focused ultrasound; MiNEN = mixed neuroendocrine-non-neuroendocrine tumour.

Gini's mean difference and the long-term prognostic value of nodal quanta classes after pre-operative chemotherapy in advanced breast cancer

Gini's mean difference (GMD, mean absolute difference between any two distinct quantities) of the restricted mean survival times (RMSTs, expectation of life at a given time limit) has been proposed as a new metric where higher GMD indicates better prognostic value. GMD is applied to the RMSTs at 25 years time-horizon to evaluate the long-term overall survival of women with breast cancer who received neoadjuvant chemotherapy, comparing a classification based on the number (pN) versus a classification based on the ratio (LNRc) of positive nodes found at axillary surgery. A total of 233 patients treated in 1980-2009 with documented number of positive nodes (npos) and number of nodes examined (ntot) were identified. The numbers were categorized into pN0, npos = 0; pN1, npos = [1,3]; pN2, npos = [4,9]; pN3, npos ≥ 10. The ratios npnx = npos/ntot were categorized into Lnr0, npnx = 0; Lnr1, npnx = (0,0.20]; Lnr2, npnx = (0.20,0.65]; Lnr3, npnx > 0.65. The GMD for pN-classification was 5.5 (standard error: ± 0.9) years, not much improved over a simple node-negative vs. node-positive that showed a GMD of 5.0 (± 1.4) years. The GMD for LNRc-classification was larger, 6.7 (± 0.8) years. Among other conventional metrics, Cox-model LNRc's c-index was 0.668 vs. pN's c = 0.641, indicating commensurate superiority of LNRc-classification. The usability of GMD-RMSTs warrants further investigation.

Lymph Node Ratio after Neoadjuvant Chemotherapy for Stage II/III Breast Cancer: Prognostic Value Measured with Gini's Mean Difference of Restricted Mean Survival Times

Restricted mean survival time (RMST), recommended for reporting survival, lacks a tool to evaluate multilevel factors. The potential of the Gini’s mean difference of RMSTs (Δ) is explored in a comparison of a lymph node ratio-based classification (LNRc) versus a number-based classification (ypN) applied to stage II/III breast cancer patients who received neoadjuvant chemotherapy and underwent axillary dissection. Number of positive nodes (npos) classified patients into ypN0, npos = 0, ypN1, npos = [1,3], ypN2, npos = [4,9], and ypN3, npos ⩾ 10. Ratio npos/(number of nodes examined) of 0, (0,0.20], (0.20,0.65], and >0.65, classified patients into Lnr0 to Lnr3, respectively. Unadjusted and Cox-adjusted RMSTs were computed for the ypN and LNRc’s. At a follow-up time horizon of 72 months for 114 node-negative and 254 node-positive patients, unadjusted ypN0-ypN3 RMSTs were 62.4-41.4 months, Δ = 11.9 months (95%CI: 7.4-16.9), and Lnr0-Lnr3 62.4 to 36.3 months, Δ = 14.0 months (95%CI: 10.1-18.1). Cox models’ ypN1-ypN3 hazard ratios were 1.81-3.30, and Lnr1-Lnr3 1.52-4.39. Δ from Cox-fitted survival were ypN 8.1 months (95%CI: 5.9-10.5), LNRc 10.5 months (95%CI: 8.4-12.8). In conclusion, Gini’s mean difference is applicable to well established data in keeping with the literature on LNRc. It provides an alternative view on the improvement gained with a lymph node ratio-classification over using a number-classification.