BACKGROUND: The oncologic safety of preoperative controlled ovarian stimulation (COS) for fertility preservation in women with an in situ estrogen receptor positive (ER+) breast cancer is unclear. The purpose of this stu...BACKGROUND: The oncologic safety of preoperative controlled ovarian stimulation (COS) for fertility preservation in women with an in situ estrogen receptor positive (ER+) breast cancer is unclear. The purpose of this study was to compare oncologic outcomes of women with ER+ breast cancer undergoing preoperative COS versus (1) postoperative COS or (2) matched controls not undergoing COS. PATIENTS AND METHODS: This was a single-institution retrospective cohort study of women with ER+ breast cancer receiving oncofertility counseling who pursued COS from 2014-2024. The primary outcome was progression-free survival (PFS). A subcohort of patients who received neoadjuvant systemic therapy was compared with a matched cohort of similar patients with ER+ breast cancer who did not undergo COS. Propensity score matching criteria were age, HER2 receptor status, and clinical stage. RESULTS: Among 51 women with ER+ breast cancer undergoing COS, the median follow-up was 5.5 years. 5-year PFS was similar for preoperative COS (n = 32) versus postoperative COS (n = 19): 94.1% (95% CI 65.0-99.2%) versus 93.3% (95% CI 61.3-99.0%), p = 0.73. Patients undergoing neoadjuvant systemic therapy (NST) and preoperative COS (n = 30) experienced a significantly longer time from diagnosis to NST initiation than propensity-score matches who did not undergo COS (48 versus 29.5 days, p < 0.0001), but disease-free survival was similar: 94.1% (95% CI 65.0-99.2%) versus 93.3% (95% CI 75.9-98.3%), p = 0.15. CONCLUSIONS: In this study of women with ER+ breast cancers, preoperative COS was not associated with increased risks of disease progression or death. While COS was associated with a modest delay in NST initiation, PFS was similar to propensity-score matched patients who did not undergo COS. Results support the oncologic safety of COS in the setting of an in situ ER+ tumor and provide much-needed evidence for young women with breast cancer receiving gonadotoxic NST who desire future childbearing during survivorship.
BACKGROUND: The role of checking the pancreatic neck margin with frozen section (PNM-FS) during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) to secure R0 resection and its impact on long-term ou...BACKGROUND: The role of checking the pancreatic neck margin with frozen section (PNM-FS) during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) to secure R0 resection and its impact on long-term outcomes remains an area of debate. PATIENTS AND METHODS: Patients with PD for PDAC between 2018 and 2023 were included. The primary outcome was pancreatic neck recurrence-free survival (PN-RFS). Secondary outcomes were locoregional recurrence-free survival (LR-RFS), distant recurrence-free survival (D-RFS), and overall survival (OS). RESULTS: There were 403 patients who met inclusion criteria. PNM-FS was checked in 361 patients (89.6.2%) and returned negative at first attempt in 285 (78.9%). A total of 76 patients had positive PNM-FS; 71 were revised and clearance achieved on repeat sampling in 49 (69.0%). Median PN-RFS in patients with PNM-FS cleared with revision was significantly shorter compared with those with negative PNM-FS at first attempt (16.9 versus 23.1 months; p = 0.048) but was not different from patients with PNM-FS not cleared (16.9 versus 16.0 months; p = 0.961). LR-RFS and D-RFS were not different between the groups. OS was marginally longer in patients with negative PNM-FS at first attempt (23.9 versus 19.4 versus 16.0 months; p = 0.049). Six patients underwent completion total pancreatectomy (TP) for margin clearance, four developed distant recurrence, one locoregional recurrence and two died without disease at 1 and 11 months postoperatively. CONCLUSIONS: PNM-FS is only a prognostic marker. Pursuing PNM-FS clearance does not improve PN-RFS, LR-RFS, D-RFS, or OS. Furthermore, pursuing a completion TP may be associated with shorter OS either from disease progression or surgical morbidity.
BACKGROUND: The number of robotic pancreaticoduodenectomy (R-PD) and robotic distal pancreatectomy (R-DP) procedures has been increasing worldwide. However, there are no reports on clinical cases of robotic remnant total...BACKGROUND: The number of robotic pancreaticoduodenectomy (R-PD) and robotic distal pancreatectomy (R-DP) procedures has been increasing worldwide. However, there are no reports on clinical cases of robotic remnant total pancreatectomy (R-RTP). This report presents a standardized surgical technique for R-RTP after R-PD based on the authors' experience with three clinical cases. The procedure is presented with accompanying surgical videos, and its feasibility and potential advantages are discussed. PURPOSE: This study presents a standardized surgical technique for R-RTP following R-PD, based on our experience with three clinical cases. The procedure is presented with accompanying surgical videos, and its feasibility and potential advantages are discussed. METHODS: The standardized surgical procedure for R-RTP involves patient setting and port placement, intra-abdominal adhesiolysis, dissection of the jejunal loop, encirclement and dissection of the splenic artery and vein, dissection of the dorsal pancreatic border from the retroperitoneum, dissection of the splenocolic ligament and the gastrosplenic ligament, and specimen removal. In this study, the clinicopathologic features and short-term outcomes of the three cases were retrospectively analyzed. RESULTS: The patients had a mean operative time 332 min (range, 277-425 min), an intraoperative blood loss of 168 mL (range, 50-254 mL), and a postoperative hospital stay of 13.3 days (range, 10-20 days). No postoperative complications or mortality were observed. All the patients achieved pathologic R0 resection and at this writing are alive without recurrence. CONCLUSIONS: This study suggests that R-RTP after R-PD may be technically feasible. The minimally invasive approach, standardization of the surgical procedure, and appropriate metabolic management may contribute to favorable perioperative outcomes and postoperative recovery.
BACKGROUND: The current study was performed to analyze the accuracy of imaging in determining the amount of residual tumor after neoadjuvant chemotherapy. The hypothesis was that imaging overestimated the local extent of...BACKGROUND: The current study was performed to analyze the accuracy of imaging in determining the amount of residual tumor after neoadjuvant chemotherapy. The hypothesis was that imaging overestimated the local extent of tumor in breast in a significant proportion of patients, contributing to the selection of mastectomy as the definitive surgical procedure. PATIENTS AND METHODS: A retrospective analysis was performed for patients with newly diagnosed invasive breast cancer treated with NAC from 2015 through 2023. Imaging characteristics after NAC were compared with tumor size on final pathology. Imaging overestimation and underestimation were defined as size on imaging > 1 cm either greater than or less than the final size on pathology, respectively. RESULTS: Of 274 patients receiving NAC, there were 21(17%) patients who had false-positive and 24(28%) with false-negative imaging post-NAC. There were 181 patients who did not have radiographic complete response post-NAC, for whom mean radiographic tumor size post-NAC was 3.2 cm. Comparison of T size on post-NAC imaging versus final pathology yielded a correlation coefficient of 0.579. Radiographic assessment overestimated final pathology tumor size by > 1 cm in 81 (45%) of 181 patients overall. Rates of overestimation were not associated with tumor biomarker status or multi-focality/centricity but were significantly higher on post-NAC imaging for ycT2 (55%, p < 0.001) and ycT3 (67%, p < 0.001) versus ycT1 (25%, Ref.) tumors. CONCLUSIONS: These results cast uncertainty on the reliability of post-NAC imaging to guide selection of the breast surgical procedure, especially when there is ycT3 tumor remaining after neoadjuvant systemic therapy.
BACKGROUND: Studies regarding therapeutic response of invasive lobular carcinoma (ILC) to neoadjuvant systemic therapy (NST) suggest that ILC is less favorable and the prognostic impact of a pathologic complete response...BACKGROUND: Studies regarding therapeutic response of invasive lobular carcinoma (ILC) to neoadjuvant systemic therapy (NST) suggest that ILC is less favorable and the prognostic impact of a pathologic complete response (pCR) is unclear. PATIENTS AND METHODS: This study included 853 (NAC; n = 715 and NET; n = 138) non-metastatic classic ILC cases that received NST followed by surgery. Propensity-score matched analysis (PSMA) was performed to compare clinicopathologic groups. Survival outcomes were compared for patients with and without a pCR. RESULTS: Most had large primary tumors with nodal metastases (89.5% cT2-T4, 64% cN+) and luminal subtype tumors (87.6%). Patients receiving NAC were more likely to be clinically node-positive (69.1% versus 34.3%; p = 0.0005), have grade 3 disease (18.7% versus 8.7%; p = 0.0082), and undergo mastectomy (84.2% versus 69.6%; p < 0.001) and ALND (84.9% versus 57.3%; p < 0.0001) compared with NET. Overall, breast and axillary nodal pCR rates were 4.9% and 9.3%, respectively. Among 155 patients who had SLNB, there was 1 axillary nodal recurrence (0.6%). The 10-year distant recurrence-free survival (DRFS) for patients with a breast pCR was 61% versus 46% for those without (p = 0.267). Patients with a nodal pCR demonstrated higher 10-year DRFS (49% versus 33%; p = 0.026) and OS compared with those without (65% versus 48%; p = 0.068). No survival outcome difference was seen for patients treated with NAC versus NET on PSMA. CONCLUSIONS: Nodal pCR was associated with survival outcomes in ILC and systemic therapy decision-making should be reconsidered. SLNB after NST appears to be safe and effective in ILC.
BACKGROUND: Squamous cell carcinoma (SCC) has historically been associated with worse outcomes than adenocarcinoma (AD) in non-small cell lung cancer (NSCLC). However, the prognostic significance of histology in resectab...BACKGROUND: Squamous cell carcinoma (SCC) has historically been associated with worse outcomes than adenocarcinoma (AD) in non-small cell lung cancer (NSCLC). However, the prognostic significance of histology in resectable disease remains incompletely defined and warrants re-evaluation in large contemporary cohorts. METHODS: The National Cancer Database was queried for adults with resected stage I-III NSCLC diagnosed between 2004 and 2021. Histology was limited to AD and SCC using ICD-O-3 codes. Patients with in situ or occult disease, multiple primaries, death within 30 days of surgery, missing survival data, tumor size or pathologic stage, and ablative procedures were excluded. The primary outcome was 10-year overall survival. Adjusted Cox proportional hazards models were used to evaluate the association between histology and survival in the overall cohort and within pathologic stages I-III, with histology × stage interaction testing. RESULTS: Among 130,731 patients, 92,598 (71%) had AD and 38,133 (29%) had SCC. Kaplan-Meier analysis demonstrated worse 10-year survival for SCC compared with AD (log-rank p < 0.001). On multivariable analysis, SCC remained associated with worse 10-year survival (aHR 1.14, 95% CI 1.12-1.17; p < 0.001). Stage-stratified models showed worse survival for SCC in stage I disease (aHR 1.24, 95% CI 1.21-1.28, p < 0.001) but not in stage II or III disease. Histology × stage interaction terms confirmed significant effect modification by stage (p < 0.001). CONCLUSIONS: In resected stage I-III NSCLC, SCC remains associated with worse 10-year survival. SCC remained independently associated with worse survival in stage I disease, whereas this association was substantially attenuated in stage II and III disease.
INTRODUCTION: Women aged ≤40 years with breast cancer have historically undergone overtreatment with extensive surgery. This study compares trends in breast and axillary operations in young patients with breast cancer ov...INTRODUCTION: Women aged ≤40 years with breast cancer have historically undergone overtreatment with extensive surgery. This study compares trends in breast and axillary operations in young patients with breast cancer over time and assesses for surgical de-escalation. METHODS: Women aged ≤40 years with stage I-III breast cancer who underwent surgery from January 2005 to December 2019 were identified from the National Cancer Database. Patients were divided into two groups to capture trends over time: the 2005-2009 cohort and the 2015-2019 cohort. RESULTS: In total, 96,722 evaluable patients with a median age of 36.5 years (range 18-40) were identified. Compared with the 2005-2009 cohort (n = 44,497), the 2015-2019 cohort (n = 52,225) had a higher proportion of early-stage cancers and an increase in hormone receptor-positive breast cancer (p < 0.001). For breast operations, partial mastectomies decreased significantly over time, from 40.8% to 30.2% (p < 0.001). The rate of nipple-sparing mastectomies increased from 0.3% to 9.5%, along with an increased use of reconstruction (p < 0.001). Axillary lymph node dissections (ALNDs) decreased over time, from 37.5% to 19.4% (p < 0.001), with a corresponding increase in the use of radiation (56.3% vs 57.4%, p < 0.001). This trend was pronounced in the node-positive cohort of 29,062 patients who underwent a mastectomy (ALND: 9392 [72.4%] vs 5967 [37.1%]; radiation: 7255 [59.0%] vs 11,757 [75.5%]; p < 0.001). The use of ALND decreased over time, regardless of timing of chemotherapy and type of breast operation (p < 0.001). CONCLUSIONS: In young patients with stage I-III operable breast cancer, de-escalation of axillary surgery and increased use of radiation is demonstrated.
PURPOSE: This study was designed to clarify the impact of tumor size on risk stratification in UTUC and to evaluate the feasibility and effectiveness of using 2 cm as a cutoff value for risk stratification. METHODS: Usin...PURPOSE: This study was designed to clarify the impact of tumor size on risk stratification in UTUC and to evaluate the feasibility and effectiveness of using 2 cm as a cutoff value for risk stratification. METHODS: Using data from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2021), we identified patients with nonmetastatic UTUC who underwent radical nephroureterectomy (RNU). Overall survival (OS) and cancer-specific survival (CSS) curves were generated by using the Kaplan-Meier method and compared with the log-rank test. Univariate and multivariate Cox proportional hazards regression models were used to identify predictors of OS and CSS. Univariate and multivariate logistic regression models were applied to assess predictors of adverse pathological features. RESULTS: A total of 10,607 UTUC patients treated with RNU were included, comprising 7503 (70.7%) with renal pelvic UC and 3104 (29.3%) with ureteral UC. Tumor size ≥2.0 cm was independently associated with muscle-invasive disease (P < 0.001) and nonorgan-confined tumors (P < 0.001), but not with lymph node metastasis (P = 0.181). Tumor size ≥ 2.0 cm was independently associated with OS (P = 0.007) but not with CSS (P = 0.236). No significant difference in risk stratification ability was observed between a tumor size cutoff of 2.0 cm and those of 1.5 cm or 3.0 cm. CONCLUSIONS: A 2-cm cutoff is a reasonable threshold for risk stratification in UTUC. Tumors larger than 2 cm are associated with a significantly increased risk of muscle layer invasion, extraorgan extension, and lymph node metastasis.
BACKGROUND: The aspartate aminotransferase-to-platelet ratio index + albumin-bilirubin (APRI+ALBI) score reflects hepatic functional reserve and is widely used for risk stratification of posthepatectomy liver failure (PH...BACKGROUND: The aspartate aminotransferase-to-platelet ratio index + albumin-bilirubin (APRI+ALBI) score reflects hepatic functional reserve and is widely used for risk stratification of posthepatectomy liver failure (PHLF). However, whether baseline hepatic function also predicts long-term survival in biliary tract cancer (BTC) remains unclear. PATIENTS AND METHODS: Patients undergoing curative-intent liver resection for BTC (perihilar cholangiocarcinoma [pCCA], intrahepatic cholangiocarcinoma [iCCA], gallbladder cancer [GBC]) at Mayo Clinic Rochester between 2000 and 2024 were analyzed. Patients were stratified into APRI+ALBI high and low groups using the previously published cutoff (- 2.46). To minimize baseline imbalances, 1:1 direct matching based on tumor type, age, sex, and Eastern Cooperative Oncology Group (ECOG) status was performed. OS and RFS were analyzed using Kaplan-Meier methods with log-rank testing and multivariable Cox proportional hazards regression analysis. RESULTS: Among 683 eligible patients, 616 with available APRI+ALBI scores were included in the analysis. High (poor) APRI+ALBI scores were associated with male sex, pCCA, more frequent major hepatectomy and vascular resection, and higher rates of lymph node positivity and advanced tumor stage. This group also experienced increased rates of major postoperative complications, PHLF grade B/C, and 90-day mortality. Correspondingly, median OS and RFS were significantly worse in the high APRI+ALBI group (OS: 39.8 versus 62.9 months, p = 0.004; RFS: 22.2 versus 27.4 months, p = 0.019). These significant differences persisted after direct matching, and APRI+ALBI remained an independent predictor of both outcomes on multivariable Cox regression. CONCLUSIONS: Preoperative APRI+ALBI score independently predicts survival after curative-intent resection for BTC, supporting a clinically relevant link between baseline hepatic functional reserve and oncologic outcomes beyond perioperative risk.