A Prospective Phase II Trial of Induction Chemotherapy with Docetaxel/Cisplatin for Masaoka Stage III/IV thymic Epithelial Tumors

A Re-Examination of Neoadjuvant Therapy for Thymic Tumors: A Long and Winding Road

For most patients with advanced thymic epithelial tumors (TETs), a complete resection is a strong indicator of a better prognosis. But sometimes, primary surgery is unsatisfactory, and preoperative therapy is needed to facilitate complete resection. Neoadjuvant chemotherapy is the most used form of preoperative therapy. But studies on neoadjuvant chemotherapy have included mainly patients with thymoma; its efficacy in patients with thymic carcinoma is less known. Neoadjuvant chemoradiation has also been explored in a few studies. Novel therapies such as immunotherapy and targeted therapy have shown efficacy in patients with recurrent/metastatic TETs as a second-line option; their role as preoperative therapy is still under investigation. In this review, we discuss the existing evidence on preoperative therapy and the insight it provides for current clinical practice and future studies.

Identification of Potential Serum Protein Biomarkers in Thymoma with Myasthenia Gravis After Docetaxel Treatment

INTRODUCTION

Myasthenia gravis (MG) is a devastating acquired autoimmune disease that can seriously affect the patient's quality of life. It is also a common complication of thymoma. Previous studies have shown that docetaxel alleviates myasthenic symptoms in thymoma with MG (TMG). However, little is known about the protein expression profiles and biomarkers for efficacy after docetaxel treatment.

METHODS

We recruited 9 healthy controls and 30 patients with TMG for the serum proteomics study with data-independent acquisition (DIA) technology. We further recruited additional 30 patients for the key protein validation by enzyme-linked immunosorbent assay (ELISA).

RESULTS

We identified 43 proteins by trend analysis and analyzed the interaction between these proteins and MG pathogenic proteins from the DisGNET database and the correlation analysis with clinical data of patients with TMG. Among these, KRAS and SELP were screened out and validated. KRAS and SELP increased in patients with TMG and decreased significantly after docetaxel treatment.

CONCLUSIONS

Our study revealed that the serum proteins were differentially expressed after docetaxel treatment, suggesting their important role in patients with TMG, as well as the critical role of KRAS and SELP as biomarkers in evaluating the efficacy of docetaxel treatment.

Tumor size exceeding 5 cm as a valid prognostic factor in all stages of thymic epithelial tumors

PURPOSE

This study investigated the prognostic factors of thymic epithelial tumors (TETs) to identify patients who require multidisciplinary treatment and improve the TET prognosis.

METHODS

We retrospectively reviewed the data of 268 TET patients. Prognostic variables for the overall survival (OS) were analyzed in all TET stages (n = 268), and the recurrence-free survival (RFS) was analyzed in patients who achieved complete resection (n = 164).

RESULTS

The median follow-up period was 7 years; thymic carcinomas (TCs) and advanced stages of tumor, node, and metastasis (TNM) classification had the worse prognosis according to a Kaplan-Meier analysis. The cut-off value of the tumor size to predict the OS and RFS was determined using modified Harrell's c-index calculated by a Cox regression analysis of the OS. Regarding the OS, a multivariate analysis revealed that age > 70 years old (p = 0.011), tumor size > 5 cm (p < 0.001), and TCs (p = 0.002) were significant prognostic factors aside from the TNM stage (p < 0.001). Regarding the RFS, tumor size > 5 cm was the only significant prognostic factor in the multivariate analysis (p = 0.002) aside from the TNM stage (p = 0.008).

CONCLUSIONS

Tumor size > 5 cm was shown to be a prognostic predictor in addition to the WHO and TNM classifications. Therefore, multidisciplinary treatment should be developed for TET patients with poor prognostic factors, specifically tumor size.

Therapeutic options in thymomas and thymic carcinomas

INTRODUCTION

Radical surgery is the best therapeutic option for thymic malignancies. However, patients with advanced or recurrent thymic malignancies often require chemotherapy or radiotherapy. Since thymic malignancies are rare cancers, the efficacy and safety of treatments have been verified based on small Phase 2 trials or retrospective studies.

AREA COVERED

We comprehensively reviewed the treatment strategies for thymic malignancies, including surgery, radiotherapy, and pharmacotherapy, including cytotoxic chemotherapy, molecular-targeted therapy, and immunotherapy. Additionally, we reviewed specific situations, such as pleural dissemination, central nervous system metastasis, and paraneoplastic syndrome.

EXPERT OPINION

Cytotoxic chemotherapy remains the standard option in pharmacotherapy. However, multikinase inhibitors, such as sunitinib and lenvatinib, and immune checkpoint inhibitors including pembrolizumab have been developed to treat thymic carcinomas. Now, a Phase 2 study is evaluating whether lenvatinib plus pembrolizumab benefits patients with type B3 thymoma or thymic carcinoma. Phosphatidylinositol 3-kinase/AKT/ mammalian target of rapamycin inhibitors may contribute to disease control and octreotide scan is only applicable to somatostatin analogues. Although the genomic characteristics of thymic malignancies have been analyzed, few actionable mutations have been detected in general. The development of a treatment strategy using combination pharmacotherapy is anticipated.

Salvage Chemotherapy in Patients with Previously Treated Thymic Carcinoma

Thymic carcinoma is a rare neoplasm, and it is difficult to achieve complete remission with systemic chemotherapy. In advanced or recurrent thymic carcinoma, platinum-based chemotherapy is chosen as the first-line setting; however, it remains unclear which regimen is better to improve its outcome. It remains unknown whether salvage chemotherapy should be administered to patients with platinum-based chemotherapy-refractory thymic carcinoma. Currently, several clinical studies have investigated the efficacy of second-line settings for advanced thymic carcinoma. As cytotoxic agents, S-1, amrubicin, pemetrexed, docetaxel, paclitaxel, and gemcitabine have been reported as prospective phase II studies or retrospective studies. The overall response rates (ORRs) of S-1, amrubicin, and pemetrexed were 25-50%, 11-44.4%, and 9-10%, respectively. Molecular targeting drugs, such as sunitinib, everolimus, and lenvatinib, also provide clinical effectiveness with tolerability after the failure of platinum-based regimens. Based on the results of the prospective phase II study, the ORR, median progression-free survival, and median overall survival were 16.6% and 5.6 months, respectively, in everolimus, 26% and 7.2 months, respectively, in sunitinib, and 38% and 9.3 months, respectively, in lenvatinib. Although it is difficult to compare each study, lenvatinib appears to be better in increasing efficacy as a second-line setting. However, each study had a small sample size, which may have biased the results of their studies. Further investigation is warranted to elucidate the therapeutic significance of salvage chemotherapy in advanced thymic carcinoma in a large-scale study.

Induction Strategy for Locally Advanced Thymoma

Surgery remains cornerstone for the management of thymoma. Complete surgical resection (R0), is recognized as the constant and significant factor for prognosis. However, in locally advanced (Masaoka-Koga stages III-IVa) thymomas, achieving R0 resection remains challenging due to local-regional invasion of the disease. Induction treatment, with the aim of reducing bulky tumor mass, offers new strategy to facilitate totally surgical resection. Herein, we reviewed recent progress and provided a comprehensive overview of induction strategy in locally advance thymoma.

Programmed cell death, redox imbalance, and cancer therapeutics

Cancer cells are disordered by nature and thus featured by higher internal redox level than healthy cells. Redox imbalance could trigger programmed cell death if exceeded a certain threshold, rendering therapeutic strategies relying on redox control a possible cancer management solution. Yet, various programmed cell death events have been consecutively discovered, complicating our understandings on their associations with redox imbalance and clinical implications especially therapeutic design. Thus, it is imperative to understand differences and similarities among programmed cell death events regarding their associations with redox imbalance for improved control over these events in malignant cells as well as appropriate design on therapeutic approaches relying on redox control. This review addresses these issues and concludes by bringing affront cold atmospheric plasma as an emerging redox controller with translational potential in clinics.

S-1 salvage chemotherapy for stage IV thymic carcinoma: a study of 44 cases

Background

Thymic carcinoma (TC) is a rare mediastinal tumor, and patients with stage IV TC have a poor prognosis. No optimal chemotherapeutic regimen has yet been established. In this study, we evaluated the efficacy and safety of S-1 as a salvage mono-therapy in stage IV TC.

Methods

Patients with histologically confirmed stage IV TC were enrolled in this study when front-lined chemotherapy failed. S-1 capsules were orally taken twice a day. The daily dose was prescribed in three levels (80, 100, 120 mg) based on body surface area (BSA). One cycle of treatment consists of 4 weeks of drug use and 2 weeks of rest. The cycle was repeated until tumor progressed or intolerable toxicity occurred. The response rate, progression-free survival (PFS), overall survival (OS), and toxicity were evaluated.

Results

Forty-four patients with stage IV TC were included between January 2013 and July 2017. Squamous cell carcinoma accounted for 84% of cases (37/44). There were 22 males and 22 females with a median age of 57 years (27-78 years). S-1 was prescribed at a dose of 80 mg for 18 (41%) patients, 100 mg for 17 patients (38%), and 120 mg for 9 patients (21%). The median number of cycles of administrated per patient was 3 [1-32]. Among 44 patients, 13 (30%) achieved a partial response, 22 (50%) remained stable disease, and 9 (20%) showed a rapid progression. With a median follow-up time of 14 months, the median PFS and OS of the whole group were 6 (95% CI, 7.0-13.9) months and 15 (95% CI, 13.2-21.6) months, respectively. For the 13 patients who showed response to S-1, the median PFS was 22 (95% CI, 15.5-30) months. Anorexia was the most common side effect, but all cases were mild. Other toxicities of grade ≥3 were bone marrow suppression (n=6) and rash (n=1). No drug-related deaths occurred.

Conclusions

S-1 is a safe and effective treatment for stage IV TC as a salvage monotherapy. It is especially effective in disease control when the tumor shows response to S-1.

Systemic treatments for thymoma and thymic carcinoma: A systematic review

Thymic tumours are rare diseases that for most of the cases are cured with surgery and eventually adjuvant radiotherapy. However, about 30% of patients present with advanced stage or relapsing tumours, which require administration of chemotherapy. While cisplatin-adriamycin-cyclophosphamide combination is regularly prescribed, other drugs have been assessed in the literature. Our aim is to evaluate the effectiveness (response rate) of systemic treatments, whatever the therapeutic line, including chemotherapy, targeted therapies and immunotherapies, in thymoma and thymic carcinoma, using the principles of evidence-based medicine. A systematic review was designed using the PICO system, by an experienced librarian and clinicians' experts in thoracic oncology, through the Ovid Medline system. Only phase II-IV trials and retrospective studies including at least 14 patients treated with the same regimen were considered. Articles were independently selected by at least two investigators. Fifty-five eligible articles were retrieved. Sixty% were dealing with platinum-based regimens, mainly cisplatin, and showed overall similar activity (mostly response rate above 50%) independently of the line of treatment or histological type (thymoma versus thymic carcinoma). Non-platinum based regimens included octreotide-prednisone and capecitabine-gemcitabine. Promising data of immunotherapy with antiPDL1 antibody (pembrolizumab) requires confirmation. Based on available data, the most popular and active regimens are cisplatin-anthracycline (CAP or ADOC) or cisplatin-etoposide combinations that should be recommended when considering first-line chemotherapy in thymoma or thymic carcinoma.

Comparison of Neoadjuvant Chemotherapy Followed by Surgery to Upfront Surgery for Thymic Malignancy

BACKGROUND

The oncologic benefit of neoadjuvant chemotherapy in thymic malignancies remains unclear. Postoperative oncologic outcomes of curative resection after neoadjuvant chemotherapy were compared with those of upfront surgery.

METHODS

Based on records from a multicenter database, 1,486 patients with surgically resected thymic malignancies between 2000 and 2013 were included in the final study cohort. Of these, 110 patients (7.4%) underwent surgical resection after neoadjuvant chemotherapy, and 1,376 patients (92.6%) underwent upfront surgery. A propensity score-matched analysis was performed to minimize differences in preoperative and intraoperative variables. Postoperative outcomes and survivals were compared between the two groups.

RESULTS

In the matched cohort, there were no significant differences in postoperative mortality (p value not calculated), postoperative complications (p = 0.405), and hospital length of stay (p = 0.821) between the two groups. However, the neoadjuvant chemotherapy group showed significantly higher transfusion rates (p = 0.003) and longer operation times (p < 0.001) than the upfront surgery group. Pathologically complete resection rates (p = 0.382) and tumor sizes (p = 0.286) were similar between the two groups. The 5-year overall survival rates were 77.4% and 76.7%, respectively (p = 0.596). The 3-year recurrence-free survival rates were 62.9% and 71.5%, respectively (p = 0.070).

CONCLUSIONS

Neoadjuvant chemotherapy, followed by resection, obtained similar resectability and long-term survival rates to those of upfront surgery. Therefore, the role of neoadjuvant chemotherapy should be refined in randomized controlled trials.

Docetaxel/cisplatin Therapy in Myasthenia Gravis with Hypertension/diabetes

Background

Therapeutic options for thymoma-associated myasthenia gravis (MG) patients complicated with hypertension and/or diabetes post thymectomy are often conventional steroids. As the prevalence of diabetes and hypertension globally increases, other therapeutic options for these patients are of great importance.

Material/methods

9 patients with thymoma-associated MG complicated with hypertension and/or diabetes after thymectomy were administered 75 mg/m2 of docetaxel and 70 mg/m2 of cisplatin on day 1. The treatment could be repeated at 3-week intervals, ranging from 1 to 4 cycles according to the status of the patients. Therapeutic efficacy and side effects were evaluated.

Results

2 patients were complicated with type 2 diabetes, 6 with hypertension, and 1 with both diabetes and hypertension. After docetaxel/cisplain therapy, the MG symptoms were markedly improved in all patients (2, complete remission; 3, basic remission; 3, marked improvement; 1, improvement). Acetylcholine receptor (AchR) antibody levels were decreased in 8 patients. Minor adverse effects were observed in 2 patients, 1 with Grade II gastrointestinal reaction, and the other with pulmonary infection.

Conclusion

Docetaxel plus cisplatin might be an effective therapeutic option for thymoma-associated MG patients complicated with hypertension /diabetes post thymectomy without worsening thymoma and hypertension / diabetes.

Chemoradiotherapy for unresectable cases of thymic epithelial tumors: a retrospective study

BACKGROUND

Because of the rarity of thymic epithelial tumors (TETs), there is no treatment for managing unresectable tumors that is supported by a high level of evidence. We present here the clinical outcomes of concurrent or sequential chemoradiotherapy for patients with unresectable TETs.

METHODS

We collated records for 215 patients with TETs who were treated at our institution and focused on the 20 patients who underwent chemoradiotherapy without curative-intent surgical resection.

RESULTS

Six patients with thymoma (4%) and 14 patients with thymic carcinoma (19%) were treated with chemoradiotherapy. Six received concurrent therapy, and platinum-containing regimens were administered to 16 patients. The survival of patients with thymic carcinoma was poorer than that of patients with thymoma [median overall survival (OS), 64.1 and 31.4 months, respectively; P=0.059]. No significant difference in survival was observed between patients treated concurrently and sequentially (48.5 vs. 38.2 months, respectively, P=0.83) or between patients treated with platinum-containing regimens and other regimens (43.5 and 53.8 months, respectively, P=0.25).

CONCLUSIONS

Chemoradiotherapy for unresectable TETs can be beneficial, especially when administrated concurrently. Patients for concurrent chemoradiotherapy should be chosen carefully because of its effectiveness and toxicity.

Expression of PD-L1 and other immunotherapeutic targets in thymic epithelial tumors

Introduction

The thymus is a critical organ for the development of the adaptive immune system and thymic epithelial tumors (TETs; thymomas and thymic carcinomas) are often associated with auto-immune paraneoplastic conditions. However, the immunobiology of TETs is not well described. An evaluation of the tumor microenvironment, with particular focus on expression of immunotherapeutic targets, may facilitate and prioritize development of immunotherapy strategies for patients with TETs.

Methods

Tumor tissues from 23 patients with WHO Type B2/B3 thymoma (n = 12) and thymic carcinoma (n = 11) were identified and clinical outcomes were annotated. The expression of membranous PD-L1 on tumor cells, CD3+ and CD8+ tumor infiltrating lymphocytes (TILs), co-stimulatory (CD137, GITR, ICOS), and co-inhibitory immune checkpoint molecules (PD-1, CTLA-4, TIM-3) were assessed semi-quantitatively using immunohistochemistry.

Results

PD-L1 positivity (≥ 25% of tumor membrane expression) was frequent in TETs (15/23, 65%), more common in thymomas compared to thymic carcinomas (p<0.01), and was associated with longer overall survival (p = 0.02). TIM-3 and GITR were expressed in all TETs, including 18/23 and 12/23 with at least moderate/high expression, respectively. Moderate/high CD137 expression correlated with CD8+ (p = 0.01) and moderate/high GITR expression co-associated with PD-1 (p = 0.043).

Conclusions

TETs are characterized by frequent PD-L1 expression and PD-L1 is associated with improved survival, suggesting PD-L1 signaling may be biologically important in TETs. Robust expression of markers of immune activation and immunotherapeutic target molecules in TETs emphasizes the potential for development of anti-PD-1/PD-L1 therapies.

Therapeutic Potential of Docetaxel plus Cisplatin Chemotherapy for Myasthenia Gravis Patients with Metastatic Thymoma

The prognosis of myasthenia gravis (MG) in association with invasive or metastatic thymoma is usually worse, and therapeutic options are quite limited. Here, we retrospectively reported the therapeutic effect of docetaxel plus cisplatin (docetaxel/cisplatin) chemotherapy in 7 MG patients with metastatic thymoma. Previously, all patients underwent thymectomy at the first onset of thymoma. After the metastasis of thymoma, none of the patients received thymectomy due to unresectable conditions after surgeon's evaluation for great risk of myasthenic crisis (n = 5) or patients' refusal (n = 2). All patients received docetaxel (75 mg/m²) and cisplatin (70 mg/m²) on day 1 (d1) every 21 days, with the cycle ranging from 1 to 4. After docetaxel/cisplatin chemotherapy, one patient achieved partial response, and 6 with stable disease of the tumors. The clinical symptoms of MG were alleviated in all patients, 2 with complete remission and the other 5 with marked improvement. Myelosuppression was the major adverse event, occurring in 2 patients (grade II and IV). MG relapse occurred in one patient during the follow-up. Our study presented a series of MG patients with metastatic thymoma who underwent docetaxel/cisplatin chemotherapy. Besides the improved/stabilized thymoma, markedly improvement of MG with the tolerable adverse events was achieved. Docetaxel/cisplatin chemotherapy appears to be an effective treatment for selected patients with MG in association with unresectable metastatic thymoma. Further follow-up of these patients and additional subjects will be needed to determine whether the therapeutic benefits are durable.

Assessment of objective responses in thymic epithelial tumors using ITMIG modified criteria

OBJECTIVES

Pleural metastases of thymic epithelial tumors (TETs) are relatively common, and this unique growth pattern makes the use of RECIST (response evaluation criteria in solid tumors) response criteria difficult. To standardize tumor measurement in TETs, the International Thymic Malignancy Interest Group (ITMIG) has proposed newly developed criteria. We compared evaluation of objective response between ITMIG modified criteria and RECIST 1.1 in patients with TET treated with systemic chemotherapy.

PATIENTS AND METHODS

We retrospectively evaluated the tumor response of 40 patients with unresectable TET who were enrolled in a phase II clinical trial using ITMIG modified criteria, and compared the findings with prospectively evaluated tumor response assessed by RECIST 1.1. Agreement analyses for the response at each time point, including overall response and declaring progression, were performed and the time to progression (TTP) was also assessed using the two different measurements.

RESULTS

The overall response rate assessed by the two methods did not differ significantly, with kappa value of 0.897. Agreement analysis for declaring progression of disease (PD) at the date of RECIST 1.1-designated PD showed 95% concordance rate with ITMIG modified criteria (p=1.000, kappa index=0.875). The median TTP according to RECIST 1.1 and ITMIG modified criteria was 8.4 and 7.9 months (p=0.983), respectively. Validation with another cohort of 27 TET patients treated with neoadjuvant chemotherapy also showed a 96% concordance rate in overall response between the two different criteria.

CONCLUSIONS

ITMIG modified criteria showed a high concordance rate with RECIST 1.1 criteria in response assessment of TETs. Given the rarity of TETs, further evaluation of ITMIG modified criteria in a larger number of patients will be required before their implementation in clinical trials.

Detection of volatile organic compounds (VOCs) from exhaled breath as noninvasive methods for cancer diagnosis

The detection of cancer at an early stage is often significant in the successful treatment of the disease. Tumor cells have been reported to generate unique cancer volatile organic compound (VOC) profiles which can reflect the disease conditions. The detection and analysis of VOC biomarkers from exhaled breath has been recognized as a new frontier in cancer diagnostics and health inspections owing to its potential in developing rapid, noninvasive, and inexpensive cancer screening tools. To detect specific VOCs of low concentrations from exhaled breath, and to enhance the accuracy of early diagnosis, many breath collection and analysis approaches have been developed. This paper will summarize and critically review the exhaled-breath VOC-related sampling, collection, detection, and analytical methods, especially the recent development in VOC sensors. VOC sensors are commonly inexpensive, portable, programmable, easy to use, and can obtain data in real time with high sensitivities. Therefore, many sensor-based VOC detection techniques have huge potential in clinical point-of-care use.

Key components of chemotherapy for thymic malignancies: a systematic review and pooled analysis for anthracycline-, carboplatin- or cisplatin-based chemotherapy

Purpose

Thymic malignancies, comprising thymoma and thymic carcinoma, are rare. Consequently, optimal chemotherapy for advanced thymic malignancies remains controversial. Platinum-based chemotherapy is currently the consensus treatment based on the results of single-arm phase II trials and retrospective investigations. However, comparison of cisplatin-based and carboplatin-based chemotherapy has yet to be undertaken; the effectiveness of the addition of anthracycline also remains uncertain.

Methods

In the present study, clinical trials and retrospective data regarding platinum-based chemotherapy were analyzed. The endpoint was the response rate to each chemotherapy. For advanced thymoma, we compared platinum with anthracycline-based chemotherapy and platinum with non-anthracycline-based chemotherapy. For advanced thymic carcinoma, anthracycline-based versus non-anthracycline-based chemotherapy and carboplatin-based versus cisplatin-based chemotherapy were compared. This analysis included a retrospective study of response of advanced thymic carcinoma to irinotecan and cisplatin in our institution.

Results

The response rate for the 314 patients from 15 studies with advanced thymoma, including both prospective and retrospective data, was 69.4 % [95 % confidence interval (CI) 63.1–75.0 %] for platinum with anthracycline-based chemotherapy and 37.8 % (95 % CI 28.1–48.6 %; p < 0.0001) for platinum with non-anthracycline-based chemotherapy. The response rates after anthracycline-based and non-anthracycline-based chemotherapy for advanced thymic carcinoma were similar (41.8 vs. 40.9 %; p < 0.91), whereas the response rates after cisplatin-based and carboplatin-based chemotherapy for advanced thymic carcinoma differed significantly (53.6 vs. 32.8 %; p = 0.0029) in 206 patients from 10 studies.

Conclusions

Platinum with anthracycline-based chemotherapy is an optimal combination for advanced thymoma. For advanced thymic carcinoma, cisplatin-based chemotherapy may be superior to carboplatin-based chemotherapy.

Invasion of the great vessels or atrium predicts worse prognosis in thymic carcinoma

Purpose

We evaluated treatment outcomes of thymic carcinomas to determine prognostic factors for survival.

Materials and Methods

Between May 1988 and May 2009, 41 patients had pathologic diagnosis of thymic carcinoma in Seoul National University Hospital, Seoul, Korea. Of these, 40 patients were followed up to 188 months after treatment. The mean age of all patients was 58.3 years and male to female ratio was 23 to 17.

Results

Among 30 patients who underwent surgical resection, 26 achieved R0 resection and postoperative radiotherapy (PORT) was performed in 22 patients (73%). Various chemotherapeutic regimens were given with local treatment modalities, surgery and/or radiotherapy, in 12 patients. The 5-year locoregional control (LRC), distant metastasis-free survival, progression-free survival (PFS), and overall survival were 79.4%, 53.0%, 42.6%, and 63.6%, respectively. Patients with Masaoka stage I or II showed excellent prognosis of 5-year PFS around 90%. In advanced stages, invasion of the great vessels or atrium by thymic carcinomas was negative prognostic factor for PFS in univariate analysis. Lymph node involvement was statistically significant factor for LRC and PFS. Local or regional recurrence was infrequent after surgical resection followed by PORT, while distant metastasis was the major component of treatment failure.

Conclusion

Complete resection followed by PORT provided remarkable local control without severe acute toxicities in patients with stage II and favorable stage III thymic carcinoma. Invasion of the great vessels or atrium was statistically significant prognostic factor for PFS.