Validation of the 2021 FIGO staging schema for advanced vulvar cancer

ObjectiveThe International Federation of Gynecology and Obstetrics (FIGO) revised the vulvar cancer staging schema in 2021. Previous stage IIIA–B diseases were reclassified based on nodal size (≤5 mm for stage IIIA compared with >5 mm for stage IIIB), and previous stage IVA1 disease based on non-osseous organ extension was reclassified to stage IIIA whereas osseous extension remained as stage IVA. This study sought to validate the 2021 FIGO vulvar cancer staging schema.MethodsThis retrospective cohort study examined 889 women with stage III–IV vulvar cancer from 2010 to 2015 in the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Stage shift and overall survival were assessed by comparing the 2021 and 2009 FIGO staging schemas.ResultsStage shift occurred in 229 (25.8%) patients (upstaged 17.7% and downstaged 8.1%). When comparing the new and previous staging schemas, 5 year overall survival rates were 45.6% versus 48.9% for stage IIIA, 47.0% versus 44.2% for stage IIIB, and 13.9% versus 25.1% (interval change −11.2%) for stage IVA diseases. According to the revised staging schema, 5 year overall survival rates were similar for stage IVA and IVB diseases (13.9% vs 14.5%) and for stage IIIA and IIIB disease (45.6% vs 47.0%). For new stage IIIA disease, 5 year overall survival rates differed significantly based on the staging factors (nodal involvement vs non-nodal organ involvement, 48.9% vs 38.7%, difference 10.2%, p=0.038).ConclusionThe 2021 FIGO staging schema results in one in four cases of advanced vulvar cancer being reclassified. Survival rates of patients with new stage IVA disease worsened significantly whereas those of patients with new stage IIIA disease were heterogenous based on the staging factors. The discriminatory ability of the revised 2021 FIGO staging schema for 5 year overall survival rate between patients with stage IIIA and IIIB tumors and those with IVA and IVB tumors is limited in this study population.

Accuracy and Reproducibility of Endoscopic Ultrasound B-Mode Features for Observer-Based Lymph Nodal Malignancy Prediction

<b><i>Background:</i></b> Endoscopic ultrasound routinely guides lymph node evaluation for the staging of a known or suspected lung cancer. Characteristics seen on B-mode imaging might help the observer decide on the lymph nodes of risk. The influence of nodal size on the predictivity of these characteristics and the agreement with which operators can combine these for malignancy risk prediction is to be determined. <b><i>Objectives:</i></b> We evaluated (1) if prospectively scored individual B-mode ultrasound features predict malignancy when further divided by size and (2) assessed if observers were able to reproducibly agree on still lymph node image malignancy risk. <b><i>Methods:</i></b> Lymph nodes as visualized by EBUS were prospectively scored for B-mode characteristics. Still B-mode images were furthermore collected. After collection, a repeated scoring of a subset of lymph nodes was retrospectively performed (<i>n</i> = 11 observers). <b><i>Results:</i></b> Analysis of 490 lymph nodes revealed the short axis size is an objective measure for stratifying risk of malignancy (ROC area under the curve 0.78). With ≥8-mm size, 210/237 malignant lymph nodes were correctly identified (89% sensitivity, 46% specificity, 61% PPV, and 81% NPV). Secondary addition of B-mode features in &#x3c;8-mm nodes had limited value. Retrospective analysis of intra- and interobserver scoring furthermore revealed significant disagreement. <b><i>Conclusions:</i></b> Lymph nodes of ≥8-mm size and preferably even smaller should be aspirated regardless of other B-mode features. Observer disagreement in scoring both small and large lymph nodes suggests it is infeasible to include subjective features for stratification. Future research should focus on (integrating) other (semi)quantitative values for improving prediction.

The additive role of diffusion-weighted magnetic resonance imaging to axillary nodal status evaluation in cases of newly diagnosed breast cancer

Background Axillary nodal status is crucial for the management of cases with recently diagnosed breast cancer; usually addressed via axillary ultrasonography (US) along with tissue sampling in case of suspicion. Axillary nodal dissection and sentinel biopsy may be done, but are rather invasive, carrying a potential complication risk, which raises the need for non-invasive, reliable, pre-operative axillary imaging. We aimed at evaluating the performance of diffusion-weighted imaging (DWI) regarding preoperative axillary evaluation, using functional information derived from diffusion capacity differences between benign and malignant tissue. We included 77 axillary nodes from 77 patients (age range 20–78 years, mean 50 ± 12.6 SD) in our prospective study, presenting with variable clinical breast complaints, all scoring BIRADS 4/5 on sonomammography (SM). They underwent axillary evaluation by both US and DW-MRI where US classified nodes into benign, indeterminate, or malignant by evaluating nodal size, shape, cortical thickness, and hilar fat. Qualitative DWI classified them into either restricted or not and a cut-off apparent diffusion coefficient (ADC) value was calculated to differentiate benign and malignant nodal involvement. Results for each modality were correlated to those of final histopathology, which served as the standard of reference. Results The calculated sensitivity, specificity, accuracy, PPV, and NPV for US was 100%, 36.6%, 75.3%, 71.2%, and 100%, respectively. Statistical indices for qualitative DWI were 76.6%, 63.3%, 76.6%, 63.3%, and 71.4%, respectively (P value < 0.001). The calculated cut off value for ADC between infiltrated and non-infiltrated nodes was 0.95 × 10−3 mm2/s concluding statistical indices of 76.6%, 63.3%, 76.6%, 63.3%, and 71.4%, respectively (P value < 0.001). Conclusion Combining DW-MRI to conventional US improves diagnostic specificity and overall accuracy of preoperative axillary evaluation of patients with recently discovered breast cancer.

Imaging of metastatic cervical nodes: is CT helpful in differentiation of squamous cell carcinoma (SCC) from non-SCC groups?

Background Cervical node metastasis is frequently encountered in CT neck of patients with squamous cell carcinoma (SCC) and non-(SCC). Differentiation between both entities carries its value on prognosis and choice of treatment plans. The purpose of the study was to compare between the SCC and non-SCC metastatic cervical adenopathies according to different imaging parameters with the use of comparative statistical analysis of any of these criteria. This was made by retrospectively studying 157 patients. Imaging analyzed the following parameters: nodal size, laterality, nodal levels, “grouping” of nodes, nodal shape, and “periphery,” as well as the presence or absence of nodal “necrosis.” Statistics are made to show significant differences between both groups. Results The criterion of necrosis had statistical significance, being more prevalent among the SCC groups. Involvement of levels I, II, and supra clavicular was more prevalent among SCC patients. Age and sex had also some statistical significance. Conclusions The combination of different imaging parameters could distinguish SCC from non-SCC. Nodal “necrosis”—(excluding “cystic”)—combined with involvement of nodal levels II and being in older-aged men were statistically significant in the SCC compared to non-SCC.

A Nomogram to Predict the Outcome of Fine Needle Aspiration Cytology in Head and Neck Masses

Fine needle aspiration cytology (FNAC) is an important diagnostic tool for tumors of the head and neck. However, non-diagnostic or inconclusive results may occur and lead to delay in treatment. The aim of this study was to evaluate the factors that predict a successful FNAC. A retrospective search was performed to identify all patients who received an FNAC at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna. The variables were patients’ age and sex, localization and size of the punctured structure, previous radiotherapy, experience of the head and neck surgeon, experience of the pathologist and the FNAC result. Based on these parameters, a nomogram was subsequently created to predict the probability of accurate diagnosis. After performing 1221 FNACs, the size of the punctured lesion (p = 0.0010), the experience of the surgeon and the pathologist (p = 0.00003) were important factors for a successfully procedure and reliable result. FNACs performed in nodes smaller than 20 mm had a significantly worse diagnostic outcome compared to larger nodes (p = 0.0004). In conclusion, the key factors for a successful FNAC are nodal size and the experience of the head and neck surgeon and the pathologist.

A nomogram constructed using intraoperative ex vivo shear-wave elastography precisely predicts metastasis of sentinel lymph nodes in breast cancer

Objective To develop a nomogram and validate its use for the intraoperative evaluation of nodal metastasis using shear-wave elastography (SWE) elasticity values and nodal size Methods We constructed a nomogram to predict metastasis using ex vivo SWE values and ultrasound features of 228 axillary LNs from fifty-five patients. We validated its use in an independent cohort comprising 80 patients. In the validation cohort, a total of 217 sentinel LNs were included. Results We developed the nomogram using the nodal size and elasticity values of the development cohort to predict LN metastasis; the area under the curve (AUC) was 0.856 (95% confidence interval (CI), 0.783–0.929). In the validation cohort, 15 (7%) LNs were metastatic, and 202 (93%) were non-metastatic. The mean stiffness (23.54 and 10.41 kPa, p = 0.005) and elasticity ratio (3.24 and 1.49, p = 0.028) were significantly higher in the metastatic LNs than those in the non-metastatic LNs. However, the mean size of the metastatic LNs was not significantly larger than that of the non-metastatic LNs (8.70 mm vs 7.20 mm, respectively; p = 0.123). The AUC was 0.791 (95% CI, 0.668–0.915) in the validation cohort, and the calibration plots of the nomogram showed good agreement. Conclusions We developed a well-validated nomogram to predict LN metastasis. This nomogram, mainly based on ex vivo SWE values, can help evaluate nodal metastasis during surgery. Key Points • A nomogram was developed based on axillary LN size and ex vivo SWE values such as mean stiffness and elasticity ratio to easily predict axillary LN metastasis during breast cancer surgery. • The constructed nomogram presented high predictive performance of sentinel LN metastasis with an independent cohort. • This nomogram can reduce unnecessary intraoperative frozen section which increases the surgical time and costs in breast cancer patients.

Outcome if Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer: A Tertiary Care 11 Center Experience

Background: Breast cancer is the most common cancer of Bangladeshi women. Almost allpresent with palpable lump and 40% of them are with locally advanced breast cancer.Neoadjuvant chemotherapy is the standard choice of treatment for the patients. Objective: To observe the clinical and pathological response of locally advanced breastcancer after four cycles of chemotherapy and surgery. Methods: This prospective study was carred over the newly diagnosed locally advancedbreast cancer (LABC) patients from January 2010 to December 2014. Before going toneoadjuvant chemotherapy each patient was evaluated clinically, radiologically and withother relevant investigations. The size of primary tumor and axillary node was measured andrecorded. Chemotherapy schedule with Cyclophosphamide 600mg/m2 and Doxorubicin60mg/m2 (AC) and compared with the previous record. After 3-4 weeks of completion ofchemotherapy, the patients was prescribed and carried out three weekly for four cycles.Primary tumor size and axillary nodal size was measured who were undergone mastectomyand axillary dissection. Histopathology was done to see then the pathological response ofprimary tumor and axillary node. Other biological marker such as estrogen receptor (ER),progesterone receptor (PR) and Human epidermal growth receptor (HER-2) was done. Aftercompletion of study the data was compiled and analyzed. Results: Total 220 cases of LABC were enrolled in this study. After four cycles of chemotherapywith AC, 194 patients (88%) responded clinically, 29 patients (13%) showedcomplete clinical response (cCr)-and 165 patients (75%) partial response (pCr). Surgicalspecimen showed complete pathological response (cPr) in 22 patients (10%). Conclusion: Neoadjuvant chemotherapy with AC is the standard chemotherapy schedule forlocally advanced breast cancer and radical surgery was possible in 75% of the patients. Journal of Surgical Sciences (2016) Vol. 20 (1) : 13-17

Clinically, Radiologically and Biochemically Metastatic Cancer Prostate: Could be Treated without Biopsy? A Clinical Case Study and Review of Literature

Diagnosis of prostate cancer is suspected if there are abnormalities during digital rectal examination (DRE) and/or steady rising in levels of prostate specific antigen (PSA) and the confirmative diagnosis is established by histopathological confirmation of malignancy by biopsy from the prostate. A 87 years old male not diabetic nor hypertensive or other co-morbidities was well apart from mild lower back pain associated with mild irritative urinary symptoms, diagnosed clinically (DRE), radiologically and biochemically (markedly elevated PSA level) as a case of advanced prostate cancer and started treatment without biopsy by androgen deprivation therapy with other symptomatic support. After one month of treatment and then after, general conditions of the patient started to be significantly improved, the first follow-up CT showed considerable decrease of the mass size, then total non visualization of the previous prostatic mass, with marked decrease of the lymph nodal size in subsequent follow-up, PSA level decreased markedly, dropped from ≥700 ng/mL to 6.867 ng/mL, and then continued to decrease in subsequent monthly evaluations to reach 0.212 ng/mL at the last measurement after 8 months of treatment, that mean near complete radiologic and biochemical response. Treatment of advanced prostate cancer might be started without biopsy if there is high probabilities malignancy by DRE, imaging studies and significant rising in PSA levelin exceptional cases.