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.

Comparison of the quality of total mesorectal excision after robotic and laparoscopic surgery for rectal cancer: a multicenter, propensity score-matched study

Purpose: This study aimed to evaluate and compare the quality of total mesorectal excision (TME) and disease-free and overall survival rates between robotic and laparoscopic surgeries for rectal cancer.Methods: From January 2015 to December 2018, 234 patients underwent curative robotic or laparoscopic surgery for rectal cancer at two centers. Ultimately, 201 patients were enrolled. To control for different demographic factors in the two groups, propensity score matching was used at a 1:1 ratio. Propensity scores were generated with the baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, tumor location, preoperative chemotherapy, and preoperative radiation. Finally, 134 patients were matched with 67 patients in the robotic surgery group and 67 patients in the laparoscopic surgery group.Results: There was no significant difference in the pathologic stages between the robotic and laparoscopic surgery groups. Distal margin involvement was only observed in the robotic surgery group (1/67, 1.5%). Circumferential resection margin involvement was not different between the robotic surgery and laparoscopic surgery groups (3/67 [4.5%] and 4/67 [6.0%], respectively, P = 1.000). The quality of TME (complete, nearly complete, and incomplete) was similar between the robotic surgery and laparoscopic surgery groups (88.0%, 6.0%, 6.0% and 79.1%, 9.0%, 11.9%, respectively, P = 0.358). The disease-free and overall survival rates were not significantly different between the groups.Conclusion: The quality of TME and disease-free and overall survival rates between the two surgeries were similar. There was no oncologic advantage of robotic surgery for rectal cancer compared to laparoscopic surgery.

Surgical Margins Status and Prognosis after Resection of Oral Cavity Squamous Cell Carcinoma: Results from a Taiwanese Nationwide Registry-Based Study

(1) Background: The optimal cutoff value that maximizes the prognostic value of surgical margins in patients with resected oral cavity squamous cell carcinoma has not yet been identified. (2) Methods: Data for this study were retrieved from the Taiwan Cancer Registry Database. A total of 13,768 Taiwanese patients with oral cavity squamous cell carcinoma were identified and stratified according to different margin statuses (0, 0.1–4 and > 4 mm). The five-year local control, disease-specific survival and overall survival rates were the main outcome measures. (3) Results: The 5-year local control, disease-specific survival and overall survival rates of patients with close margins (0 and 0.1–4 mm) were significantly lower than those observed in patients with clear margins (> 4 mm; all p values < 0.001). In multivariate analysis, margin status, depth of invasion and extra-nodal extension were identified as independent adverse prognostic factors for 5-year local control. (4) Conclusions: A thorough assessment of surgical margins can provide a reliable prognostic prediction in patients with OCSCC. This has potential implications for treatment approaches tailored to the individual level. The achievement of clear margins (>4 mm) should be considered a key surgical goal to improve outcomes in this patient group.

Temporal Trends in Characteristics and Outcomes Associated With In‐Hospital Cardiac Arrest: A 20‐Year Analysis (1999–2018)

Background Despite advances in resuscitation medicine, the burden of in‐hospital cardiac arrest (IHCA) remains substantial. The impact of these advances and changes in resuscitation guidelines on IHCA survival remains poorly defined. To better characterize evolving patient characteristics and temporal trends in the nature and outcomes of IHCA, we undertook a 20‐year analysis of a national database. Methods and Results We analyzed the National Inpatient Sample (1999–2018) using International Classification of Diseases , Ninth Revision and Tenth Revision, Clinical Modification ( ICD‐9‐CM and ICD‐10‐CM ) codes to identify all adult patients suffering IHCA. Subgroup analysis was performed based on the type of cardiac arrest (ie, ventricular tachycardia/ventricular fibrillation or pulseless electrical activity‐asystole). An age‐ and sex‐adjusted model and a multivariable risk‐adjusted model were used to adjust for potential confounders. Over the 20‐year study period, a steady increase in rates of IHCA was observed, predominantly driven by pulseless electrical activity‐asystole arrest. Overall, survival rates increased by over 10% after adjusting for risk factors. In recent years (2014–2018), a similar trend toward improved survival is noted, though this only achieved statistical significance in the pulseless electrical activity‐asystole cohort. Conclusions Though the ideal quality metric in IHCA is meaningful neurological recovery, survival is the first step toward this. As overall IHCA rates rise, overall survival rates are improving in tandem. However, in more recent years, these improvements have plateaued, especially in the realm of ventricular tachycardia/ventricular fibrillation‐related survival. Future work is needed to better identify characteristics of IHCA nonsurvivors to improve resource allocation and health care policy in this area.

Exploring the Clinical Characteristics of the Lymph Nodal Metastatic Regions in Patients with Endometrial Cancer

Objective To evaluate clinical factors that can help determine the extent of lymphadenectomy required in endometrial cancer patients and confirm the differences of metastatic lymph node regions based on the risk factors for endometrial cancer patients. Methods The medical records of 468 endometrial cancer patients were retrospectively reviewed between January 2006 and December 2018. Patients were categorized into pelvic lymph node dissection (PLND) and pelvic plus para-aortic lymph nodes dissection (PPALND) groups. Demographics, recurrence-free survival, and 5-year overall survival rates were compared, and the clinical factors affecting survival were evaluated using Cox proportional hazards model. Results The median follow-up period was 55 months (range, 6–142 months). The mean age was higher in the PPALND group than in the PLND group (51.0 vs. 54.5 years; P < 0.001). The PPALND group had a higher International Federation of Gynecology and Obstetrics (FIGO) stage, lymphovascular invasion, endocervical invasion, and FIGO grade (P = 0.001) than the PLND group. The PPALND group had higher 5-year recurrence-free and overall survival rates than the PLND group. While comparing lymph node (LN) metastasis confirmed pathologically, the group with confirmed metastasis showed a higher number of high-risk group patients than lymph node-negative patients. However, no difference was observed in pelvic LN metastasis, pelvic plus para-aortic LN metastasis, and isolated para-aortic LN metastasis groups. Conclusions When treating patients with endometrial cancer, risk group evaluation is an important factor for determining LN dissection. Our study found no differences in clinical factors of metastatic LN regions.

Late Toxicities, Failure Patterns, Local Tumor Control, and Survival of Esophageal Squamous Cell Carcinoma Patients After Chemoradiotherapy With a Simultaneous Integrated Boost: A 5-Year Phase II Study

PurposeWe aimed to evaluate the long-term outcomes of concurrent chemoradiotherapy (CCRT) with a simultaneous integrated boost (SIB) of radiotherapy for esophageal squamous cell carcinoma (ESCC).Methods and MaterialsEighty-seven patients with primary ESCC enrolled in this phase II trial. The majority (92.0%) had locoregionally advanced disease. They underwent definitive chemoradiotherapy. The radiotherapy doses were 66 Gy for the gross tumor and 54 Gy for the subclinical disease. Doses were simultaneously administered in 30 fractions over 6 weeks. The patients also underwent concurrent and adjuvant chemotherapy, which comprised cisplatin and fluorouracil. The study end points were acute and late toxicities, first site of failure, locoregional tumor control, and overall survival rates.ResultsThe median follow-up time was 65.7 (range, 2.2-97.5) months for all patients and 81.5 (range, 19.4-97.5) months for those alive. There were 17 cases (19.5%) of severe late toxicities, including four cases (4.6%) of grade 5 and seven (8.0%) of grade 3 esophageal ulceration, four (4.6%) of grade 3 esophageal stricture, and two (2.3%) of grade 3 radiation-induced pneumonia. Twenty-three (26.4%) patients had locoregional disease progression. Most (86.7%) locally progressive lesions were within the dose-escalation region in the initial radiation plan, while majority of the recurrent lymph nodes were found out-of-field (83.3%) and in the supraclavicular region (75.0%). The 1-, 2-, 3-, and 5-year locoregional tumor control and overall survival rates were 79.2%, 72.4%, 72.4%, 70.8%, and 82.8%, 66.6%, 61.9%, 58.4%, respectively. Incomplete tumor response, which was assessed immediately after CCRT was an independent risk predictor of disease progression and death in ESCC patients.ConclusionsCCRT with SIB was well tolerated in ESCC patients during treatment and long-term follow-up. Moreover, patients who underwent CCRT with SIB exhibited improved local tumor control and had better survival outcomes compared to historical data of those who had standard-dose radiotherapy.

Long-term analysis of bilateral versus unilateral neck dissection in the treatment of early-stage supraglottic laryngeal cancer

OBJECTIVE: This study aimed to investigate the effect of routine bilateral neck dissection on the survival outcomes of supraglottic laryngeal cancer patients with lateralized tumors and clinically negative necks. METHODS: The data of 234 patients surgically treated for supraglottic squamous cell carcinoma between January 2000 and September 2014 were retrospectively collected. Patients treated previously for head and neck cancer, patients who could not be contacted, and those with missing data were excluded. Of the remaining 187 patients, 124 patients with early-stage primaries (T1-T2) (116 males, 8 females; mean age: 55.5±9.5 years; range, 33 to 82 years) were included. Age and sex of the patients, site of the primary tumor, TNM stage, type of the neck dissection, length of follow-up, and survival rates were evaluated. The tumors were classified into three groups according to their relationship with the median line of the larynx, and the neck dissections were recorded as unilateral or bilateral. Recurrences and survival outcomes were evaluated. RESULTS: There was no statistically significant difference in the recurrences according to tumor site groups (p=0.39). Similarly, there was no statistically significant difference in 10-year overall survival rates in patient groups according to the tumor site (p=0.072). We found no statistically significant difference in 10-year overall survival rates between the patients who underwent unilateral and bilateral neck dissection (p=0.580). CONCLUSION: Long-term survival analysis of 124 patients with supraglottic carcinoma did not show a survival benefit of elective contralateral neck dissection in lateralized supraglottic cancer with contralateral clinically negative neck.

Non-Ablative Chemotherapy Followed by HLA-Mismatched Allogeneic CD3+ T-Cells Infusion Causes An Augment of T-Cells With Mild CRS: A Multi-Centers Single-Arm Prospective Study on Elderly Acute Myeloid Leukemia and int-2/High Risk Myelodysplastic Syndrome Patients

ObjectiveTo evaluate the efficacy and safety of standard or low-dose chemotherapy followed by HLA-mismatched allogeneic T-cell infusion (allo-TLI) for the treatment of elderly patients with acute myeloid leukemia (AML) and patients with intermediate-2 to high-risk myelodysplastic syndrome (MDS).MethodsWe carried out a prospective, multicenter, single-arm clinical trial. Totally of 25 patients were enrolled, including 17 AML patients and 8 MDS patients. Each patient received four courses of non-ablative chemotherapy, with HLA-mismatched donor CD3+ allo-TLI 24 h after each course. AML patients received chemotherapy with decitabine, idarubicin, and cytarabine, and MDS patients received decitabine, cytarabine, aclarubicin, and granulocyte colony-stimulating factor.ResultsA total of 79 procedures were performed. The overall response rates of the AML and MDS patients were 94% and 75% and the 1-year overall survival rates were 88% (61–97%) and 60% (13–88%), respectively. The overall 60-day treatment-related mortality was 8%. Compared with a historical control cohort that received idarubicin plus cytarabine (3 + 7), the study group showed significantly better overall response (94% vs. 50%, P=0.002) and overall survival rates (the 1-year OS rate was 88% vs. 27%, P=0.014). Post-TLI cytokine-release syndrome (CRS) occurred after 79% of allo-TLI operations, and 96% of CRS reactions were grade 1.ConclusionElderly AML patients and intermediate-2 to high-risk MDS patients are usually insensitive to or cannot tolerate regular chemotherapies, and may not have the opportunity to undergo allogeneic stem cell transplantation. Our study showed that non-ablative chemotherapy followed by HLA-mismatched allo-TLI is safe and effective, and may thus be used as a first-line treatment for these patients.Clinical Trial Registrationhttps://www.chictr.org.cn/showproj.aspx?proj=20112.

Neuroprognostication after Cardiac Arrest: Who Recovers? Who Progresses to Brain Death?

Approximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since the advent of targeted temperature management, neurologic recovery has improved substantially, but the majority of patients are left with neurologic deficits ranging from minor cognitive impairment to persistent coma. Of those who survive cardiac arrest, but die during their hospitalization, some progress to brain death and others die after withdrawal of life-sustaining treatment due to anticipated poor neurologic prognosis. Here, we discuss considerations neurologists must make when asked, “Given their recent cardiac arrest, how much neurologic improvement do we expect for this patient?”