The IASLC Lung Cancer Staging Project: Proposals for Revision of the Classification of Residual Tumor after Resection for the Forthcoming (9th) Edition of the TNM Classification of Lung Cancer

The goal of surgical resection is to completely remove a cancer; it is useful to have a system to describe how well this was accomplished. This is captured by the residual tumor (R) classification, which is separate from the TNM classification that describes the anatomic extent of a cancer independent of treatment. The traditional R-classification designates as R0 a complete resection, as R1 a macroscopically complete resection but with microscopic tumor at the surgical margin, and as R2 a resection that leaves gross tumor behind. For lung cancer, an additional category encompasses situations in which the presence of residual tumor is uncertain. This paper represents a comprehensive review of evidence regarding these R categories and the descriptors thereof, focusing on studies published after the year 2000 and with adjustment for potential confounders. Consistent discrimination between complete, uncertain, and incomplete resection is demonstrated with respect to overall survival. Evidence regarding specific descriptors is generally somewhat limited and only partially consistent; nevertheless, the data suggests retaining all descriptors but with clarifications to address ambiguities. Based on this review, the R-classification for the 9th edition of stage classification of lung cancer is proposed to retain the same overall framework and descriptors, with more precise definitions of descriptors. These refinements should facilitate application as well as further research.

Pain in axial spondyloarthritis: role of the JAK/STAT pathway

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that is characterized by new bone formation in the axial musculoskeletal system, with X-ray discriminating between radiographic and non-radiographic forms. Current therapeutic options include non-steroidal anti-inflammatory drugs in addition to biological disease-modifying anti-rheumatic drugs that specifically target tumor necrosis factor-alpha (TNFα) or interleukin (IL)-17. Pain is the most critical symptom for axSpA patients, significantly contributing to the burden of disease and impacting daily life. While the inflammatory process exerts a major role in determining pain in the early phases of the disease, the symptom may also result from mechanical and neuromuscular causes that require complex, multi-faceted pharmacologic and non-pharmacologic treatment, especially in the later phases. In clinical practice, pain often persists and does not respond further despite the absence of inflammatory disease activity. Cytokines involved in axSpA pathogenesis interact directly/indirectly with the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling cascade, a fundamental component in the origin and development of spondyloarthropathies. The JAK/STAT pathway also plays an important role in nociception, and new-generation JAK inhibitors have demonstrated rapid pain relief. We provide a comprehensive review of the different pain types observed in axSpA and the potential role of JAK/STAT signaling in this context, with specific focus on data from preclinical studies and data from clinical trials with JAK inhibitors.

Why Is Surgery Still Done after Concurrent Chemoradiotherapy in Locally Advanced Cervical Cancer in Romania?

The incidence and mortality of cervical cancer are high in Romania compared to other European countries, particularly for locally advanced cervical cancer cases, which are predominant at the time of diagnosis. Widely accepted therapeutic guidelines indicate that the treatment for locally advanced cervical cancer consists of concurrent chemoradiotherapy (total dose 85-90 Gy at point A), with surgery not being necessary as it does not lead to improved survival and results in significant additional morbidity. In Romania, the treatment for locally advanced cervical cancer differs, involving lower-dose chemoradiotherapy (total dose 60-65 Gy at point A), followed by surgery, which, under these circumstances, ensures better local control. In this regard, we attempted to evaluate the role and necessity of surgery in Romania, considering that in our study, residual lesions were found in 55.84% of cases on resected specimens, especially in cases with unfavorable histology (adenocarcinoma and adenosquamous carcinoma). This type of surgery was associated with significant morbidity (28.22%) in our study. The recurrence rate was 24.21% for operated-on patients compared to 62% for non-operated-on patients receiving suboptimal concurrent chemotherapy alone. In conclusion, in Romania, surgery will continue to play a predominant role until radiotherapy achieves the desired effectiveness for local control.

Is Unplanned Excision of Soft Tissue Sarcomas Associated with Worse Oncological Outcomes?-A Systematic Review and Meta-Analysis

BACKGROUND

Soft tissue sarcomas are a group of rare neoplasms which can be mistaken for benign masses and be excised in a non-oncologic fashion (unplanned excision). Whether unplanned excision (UE) is associated with worse outcomes is highly debated due to conflicting evidence.

METHODS

We performed a systematic review and meta-analysis following PRISMA guidelines. Main outcomes analyzed were five-year overall survival (OS), five-year local recurrence-free survival (LRFS), amputation rate and plastic reconstruction surgery rate. Risk ratios were used to compare outcomes between patients treated with planned and unplanned excision.

RESULTS

We included 16,946 patients with STS, 6017 (35.5%) with UE. UE was associated with worse five-year LRFS (RR 1.35, p = 0.019). Residual tumor on the tumor bed was associated with lower five-year LRFS (RR = 2.59, p < 0.001). Local recurrence was associated with worse five-year OS (RR = 1.82, p < 0.001). UE was not associated with a worse five-year OS (RR = 0.90, p = 0.16), higher amputation rate (RR = 0.77, p = 0.134), or a worse plastic reconstruction surgery rate (RR = 1.25, p = 0.244).

CONCLUSIONS

Unplanned excision of Soft Tissue Sarcomas and the presence of disease in tumor bed after one were associated with worse five-year LRFS. Tumor bed excision should remain the standard approach, with special consideration to the presence of residual disease.

Survival impact and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer: a systematic review and meta-analysis

Purpose

Achieving no residual disease is essential for increasing overall survival (OS) and progression-free survival (PFS) in ovarian cancer patients. However, the survival benefit of achieving no residual disease during both intrathoracic and abdominopelvic cytoreductive surgery is still unclear. This meta-analysis aimed to assess the survival benefit and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer patients.

Methods

We systematically searched for studies in online databases, including PubMed, Embase, and Web of Science. We used Q statistics and I-squared statistics to evaluate heterogeneity, sensitivity analysis to test the origin of heterogeneity, and Egger's and Begg's tests to evaluate publication bias.

Results

We included 4 retrospective cohort studies, including 490 patients, for analysis; these studies were assessed as high-quality studies. The combined hazard ratio (HR) with 95% confidence interval (CI) for OS was 1.92 (95% CI 1.38-2.68), while the combined HR for PFS was 1.91 (95% CI 1.47-2.49). Only 19 patients in the four studies reported major complications, and 4 of these complications were surgery related.

Conclusion

The maximal extent of cytoreduction in the intrathoracic and abdominopelvic tract improves survival outcomes, including OS and PFS, in advanced ovarian cancer patients with acceptable complications.

Systematic Review Registration

PROSPERO, identifier CRD42023468096.

Pathologic and immunohistochemical prognostic markers in residual triple-negative breast cancer after neoadjuvant chemotherapy

Background

The persistence of residual tumour after neoadjuvant chemotherapy (NAC) in localised triple-negative breast cancer (TNBC) is known to have a negative prognostic value. However, different degrees of expression of some immunohistochemical markers may correlate with different prognoses.

Methods

The expression of biomarkers with a known prognostic value, i.e., cytokeratin 5/6 (CK5/6), androgen receptor (AR), epidermal growth factor receptor (EGFR) proliferation-related nuclear antigen Ki-67, human epidermal growth factor receptor 2 (HER2), protein 53 (p53), forkhead box protein 3 (FOXP3), and cluster differentiation 8 (CD8), was analysed by immunohistochemistry in 111 samples after NAC in non-metastatic TNBC patients addressed to Georges-François Leclerc Cancer Centre Dijon, France. Clinical and pathological variables were retrospectively collected. Cox regression was used to identify immunohistochemical (IHC) and clinicopathological predictors of event-free survival (EFS) (relapse or death).

Results

Median age was 50.4 years (range 25.6-88.3), 55.9% (n = 62) were non-menopausal, 70 (63.1%) had stage IIA-IIB disease. NAC was mostly sequential anthracycline-taxanes (72.1%), and surgical intervention was principally conservative (51.3%). We found 65.7% ypT1, 47.2% lymph node involvement (ypN+), and 29.4% lymphovascular invasion (LVI). Most residual tumours were EGFR >110 (H-score) (60.5%, n = 66), AR ≥4% (53.2%, n = 58), p53-positive mutated (52.7%, n = 58), CD8 ≥26 (58.1%, n = 61), FOXP3 ≥7 (51.4%, n = 54), more than half in the stroma, and 52.3% (n = 58) HER2 score 0. After a median follow-up of 80.8 months, 48.6% had relapsed. Median EFS was 62.3 months (95% CI, 37.2-not reached (NR)). Factors independently associated with poor EFS were AR-low (p = 0.002), ypN+ (p < 0.001), and LVI (p = 0.001). Factors associated with lower overall survival (OS) were EGFR-low (p = 0.041), Ki-67 high (p = 0.024), and ypN+ (p < 0.001).

Conclusion

Post-NAC residual disease in TNBC showed biomarkers specific to a basal-like subtype and markers of lymphocyte infiltration mostly present in the stroma. Prognostic markers for EFS were AR, LVI, and ypN and warrant further validation in a prognostic model.

Treatment of residual disease following neoadjuvant therapy in breast cancer

Substantial advances have been made in the systemic treatment of breast cancer with residual disease following neoadjuvant therapy. We reviewed recent and ongoing studies informing the standard clinical management of residual disease by subtype: HER2+, TNBC, and HR+/HER2-, as well as strategies for BRCA+ disease. We conclude with a discussion of ongoing clinical trials and current controversies regarding the treatment of residual disease in breast cancer.

Comparing Methods to Determine Complete Response to Chemoradiation in Patients with Locally Advanced Cervical Cancer

OBJECTIVES

There is no consensus on the most reliable procedure to determine remission of cervical cancer after chemoradiotherapy (CRT). Therefore, this study aims to assess the diagnostic performance of two different imaging techniques, MRI and 18F[FDG]-PET/CT, in determining the presence of locoregional residual disease after CRT in patients with locally advanced cervical cancer.

METHODS

Patients diagnosed with locally advanced cervical cancer (FIGO 2009) treated with CRT were retrospectively identified from a regional cohort. The accuracy of MRI and 18F[FDG]-PET/CT in detecting locoregional residual disease was assessed with histology as the reference standard.

RESULTS

The negative predictive value (NPV) and positive predictive value (PPV) for locoregional residual disease detection of MRI and 18F[FDG]-PET/CT combined were 84.2% (95% CI 73.2-92.1), and 70.4% (95% CI 51.8-85.2), respectively. The NPV and PPV of MRI alone were 80.2% (95% CI 71.2-87.5) and 47.7% (95% CI 35.8-59.7), respectively, and values of 81.1% (95% CI 72.2-88.3) and 55.8 (95% CI 42.2-68.7), respectively, were obtained for 18F[FDG]-PET/CT alone.

CONCLUSION

In this study, the reliability of MRI and 18F[FDG]-PET/CT in detecting locoregional residual disease was limited. Combining MRI and 18F[FDG]-PET/CT did not improve predictive values. Routine use of both MRI and 18F[FDG]-PET/CT in the follow-up after CRT should be avoided. MRI during follow-up is the advised imaging technique. Pathology confirmation of the presence of locoregional residual disease before performing salvage surgery is warranted.

Next-generation sequencing-based liquid biopsy may be used for detection of residual disease and cancer recurrence monitoring in dogs

OBJECTIVE

The purpose of this study was to evaluate the performance of a next-generation sequencing-based liquid biopsy test for cancer monitoring in dogs.

SAMPLES

Pre- and postoperative blood samples were collected from dogs with confirmed cancer diagnoses originally enrolled in the CANcer Detection in Dogs (CANDiD) study. A subset of dogs also had longitudinal blood samples collected for recurrence monitoring.

METHODS

All cancer-diagnosed patients had a preoperative blood sample in which a cancer signal was detected and had at least 1 postoperative sample collected. Clinical data were used to assign a clinical disease status for each follow-up visit.

RESULTS

Following excisional surgery, in the absence of clinical residual disease at the postoperative visit, patients with Cancer Signal Detected results at that visit were 1.94 times as likely (95% CI, 1.21 to 3.12; P = .013) to have clinical recurrence within 6 months compared to patients with Cancer Signal Not Detected results. In the subset of patients with longitudinal liquid biopsy samples that had clinical recurrence documented during the study period, 82% (9/11; 95% CI, 48% to 97%) had Cancer Signal Detected in blood prior to or concomitant with clinical recurrence; in the 6 patients where molecular recurrence was detected prior to clinical recurrence, the median lead time was 168 days (range, 47 to 238).

CLINICAL RELEVANCE

Next-generation sequencing-based liquid biopsy is a noninvasive tool that may offer utility as an adjunct to current standard-of-care clinical assessment for cancer monitoring; further studies are needed to confirm diagnostic accuracy in a larger population.

Factors Associated With Residual Disease in Axial Spondyloarthritis: Results From a Clinical Practice Registry

OBJECTIVE

To explore residual disease, defined as substantial symptoms and disease burden despite a remission or low disease activity (LDA) state, in patients with axial spondyloarthritis (axSpA), and to determine which factors are associated with residual disease.

METHODS

For this cross-sectional observational study, 1 timepoint per patient was used from SpA-Net, a web-based monitoring registry for SpA. Patients with an Ankylosing Spondylitis Disease Activity Score (ASDAS) < 2.1 (LDA) were included. Indicators of residual disease (outcomes) included fatigue (primary outcome), pain, physical functioning, health-related quality of life (HRQOL), and peripheral symptoms. Sex was the primary explanatory factor for residual disease. Other explanatory factors included demographics and disease-related factors. Associations between these factors and presence and extent of residual disease were explored using logistic and linear regression.

RESULTS

In total, 267 patients in an LDA state were included. Mean age was 50.6 (SD 14.3) years and 100 (37.5%) were female. Residual disease occurred frequently (n = 114 [42.7%] had fatigue scores > 4/10; n = 34 [17.8%] had pain scores > 4/10), including in those in remission (ASDAS < 1.3). Physical HRQOL was reduced in 27% and moderate/poor in 33%. Multivariable regression analyses showed that reported fatigue was more severe and prevalent in female patients (fatigue severity [0-10]: Bfemale = 0.78, 95% CI 0.18-1.38; fatigue > 4/10: ORfemale = 3.29, 95% CI 1.74-6.20). Other indicators of residual disease (ie, pain, peripheral symptoms, physical HRQOL) were also more severe and/or more prevalent in females.

CONCLUSION

Residual disease is frequent in patients with axSpA who are in an LDA state, including remission, and it is particularly prevalent in female patients. Future studies should address how to manage or prevent residual disease in axSpA.

Prognostic indicators for colorectal peritoneal metastases are different for patients with complete versus incomplete cytoreductive surgery

BACKGROUND

In the management of peritoneal metastases in patients with colorectal cancer, the completeness of cytoreduction has consistently been the most prominent prognostic indicator. Other clinical and histologic features have been described that may also have an impact on survival.

METHODS

The colorectal peritoneal metastases patients treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy were divided into two groups. One group had complete CRS and the second group had an incomplete CRS. The prognostic variables in these two groups of patients were statistically analyzed for their impact on survival.

RESULTS

In the complete CRS group of 124 patients lymph node positivity, poorly differentiated histopathology, asymptomatic status following treatment with systemic chemotherapy, incomplete response to systemic chemotherapy, and moderate to high peritoneal cancer index showed a significantly reduced survival. All five of these prognostic variables ceased to show statistical significance in the group of 82 patients with incomplete cytoreduction.

CONCLUSION

The cause for significance of five prognostic indicators identified in patients with complete cytoreduction versus loss of significance of these indicators in patients with incomplete cytoreduction has not been determined. An absence of residual disease in complete CRS patients and a widely variable extent of residual disease in incomplete CRS patients may be important. Prognostic indicators in patients with colorectal peritoneal metastases find their greatest usefulness in patients who have had a complete cytoreduction.

Overexpression of E6/E7 mRNA HPV Is a Prognostic Biomarker for Residual Disease Progression in Women Undergoing LEEP for Cervical Intraepithelial Neoplasia 3

The risk of overtreatment or not treating an occult carcinoma exists in women at risk of residual disease after a LEEP excision for CIN3. Our goal was to discover an efficient method to select patients requiring a second LEEP from those requiring a FU only through an mRNA-detection test. In a population of 686 women undergoing a LEEP excision for CIN 3, we selected 285 women at risk of residual disease and subjected them to a search for E6/E7 mRNA HPV. The women with negative mRNA were subjected to a follow up, while the women with positive mRNA were subjected to a second LEEP. The histological examination of the second cone revealed 120 (85.7%) cases of residual disease in the mRNA-positive women: 40 cases of CIN2, 51 cases of CIN3, 11 cases of squamous microinvasive carcinoma, 7 cases of squamous carcinoma, 9 cases of AIS (adenocarcinoma in situ) and 2 cases of adenocarcinoma. Among the mRNA-negative women undergoing a follow up, there were only five cases of residual disease. During the follow-up period of about 6 years, we witnessed the regression of the residual disease and the elimination of the virus, just as predicted by the negative result of the mRNA test. Testing patients for E6/E7 mRNA allowed us to identify women with residual disease (CIN2+) and treat them appropriately.

Impact of the time interval between primary or interval surgery and adjuvant chemotherapy in ovarian cancer patients

Introduction

Primary debulking surgery (PDS), interval debulking surgery (IDS), and platinum-based chemotherapy are the current standard treatments for advanced ovarian cancer (OC). The time to initiation of adjuvant chemotherapy (TTC) could influence patient outcomes.

Methods

We conducted a multicenter retrospective cohort study of advanced (International Federation of Gynecology and Obstetrics (FIGO) stage III or IV) OC treated between 2014 and 2018 to assess progression-free survival (PFS) and overall survival (OS) in relation to TTC. All patients underwent a germline multigene panel for BRCA1/2 evaluation.

Results

Among the 83 patients who underwent PDS, a TTC ≥ 60 days was associated with a shorter PFS (hazard ratio (HR) 2.02, 95% confidence interval (CI) 1.04-3.93, p = 0.038), although this association lost statistical significance when adjusting for residual disease (HR 1.52, 95% CI 0.75-3.06, p = 0.244, for TTC and HR 2.73, 95% CI 1.50-4.96, p = 0.001, for residual disease). Among 52 IDS patients, we found no evidence of an association between TTC and clinical outcomes. Ascites, type of chemotherapy, or germline BRCA1/2 mutational status did not influence TTC and were not associated with clinical outcomes in PDS or IDS patients.

Discussion

In conclusion, longer TTC seems to negatively affect prognosis in patients undergoing PDS, especially those with residual disease.

The characteristics of the residual disease after cervical conization: A retrospective analysis from a tertiary gynecological cancer center

Background

Patients with a biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 have an increased risk of disease progression to invasive cancer and should be treated with an excisional method. However, after treatment with an excisional method, a high-grade residual lesion may remain in patients with positive surgical margins. We aimed to investigate the risk factors for a residual lesion in patients with a positive surgical margin after cervical cold knife conization.

Methods

Records of 1008 patients who underwent conization at a tertiary gynecological cancer center were retrospectively reviewed. One hundred and thirteen patients with a positive surgical margin after cold knife conization were included in the study. We have retrospectively analyzed the characteristics of the patients treated with re-conization or hysterectomy.

Results

Residual disease was identified in 57 (50.4%) patients. The mean age of the patients with residual disease was 42.47 ± 8.75 years. Age greater than 35 years (P = 0.002; OR, 4.926; 95%CI [Confidence Interval] - 1.681-14.441), more than one involved quadrant (P = 0.003; OR, 3.200; 95% CI - 1.466-6.987), and glandular involvement (P = 0.002; OR, 3.348; 95% CI - 1.544-7.263) were risk factors for residual disease. The rate of high-grade lesion positivity in post-conization endocervical biopsy at initial conization was similar between patients with and without residual disease (P = 0.16). The final pathology of the residual disease was microinvasive cancer in four patients (3.5%) and invasive cancer in one patient (0.9%).

Conclusion

In conclusion, residual disease is found in about half of the patients with a positive surgical margin. In particular, we found that age greater than 35 years, glandular involvement, and more than 1 involved quadrant were associated with the residual disease.

Optimal adjuvant treatment strategies for TNBC patients with residual disease after neoadjuvant treatment

INTRODUCTION

The therapeutic armamentarium for the neoadjuvant treatment of triple-negative breast cancer (TNBC) has significantly expanded with the hopes of improving pathological complete response (pCR) rates and the possibility of a cure. However, the data on optimal adjuvant treatment strategies for patients with residual disease after neoadjuvant treatment is limited.

AREAS COVERED

We discuss the available data on adjuvant treatment for residual TNBC after neoadjuvant treatment considering clinical trials. Additionally, we discuss ongoing trials to give perspectives on how the field may evolve in the next decade.

EXPERT OPINION

The available data support the use of adjuvant capecitabine for all patients and either adjuvant capecitabine or olaparib for patients with germline BRCA1 and BRCA2 mutations, according to availability. The CREATE-X study of capecitabine and OlympiA study of olaparib demonstrated disease-free and overall survival benefits. There is an unmet need for studies comparing these two options for patients with germline BRCA mutations. Further research is needed to delineate the use of immunotherapy in the adjuvant setting, molecular targeted therapy for patients with molecular alterations other than germline BRCA mutation, combinations, and antibody-drug conjugates to further improve outcomes.

The meaning of R1 resection after endoscopic removal of gastric, duodenal and rectal neuroendocrine tumors

INTRODUCTION

Well-differentiated gastric, duodenal, and rectal neuroendocrine neoplasms (NETs) are rare diseases usually managed by endoscopic treatment. Although several endoscopic techniques are available, the number of patients with incomplete (R1) resection is significant.

AREAS COVERED

This review focuses on the meaning of incomplete R1 findings after endoscopic resection in type I gastric NETs; nonfunctioning, non-ampullary duodenal NETs; and small rectal NETs. Data were identified by MEDLINE database search without publication date limitation.

EXPERT OPINION

An incomplete R1 finding may have no significant impact on a patient's clinical outcome, particularly in small G1 type I gastric NETs, which have an indolent course. A 'stepwise approach,' which uses more advanced endoscopic techniques, or minimally invasive surgery may be justified to achieve complete margin-free resection. This approach must balance the tumor features and the procedure-related risk of complications, particularly in the duodenum, where the role of deep endoscopic resections is limited due to the thin duodenal wall. Gastric and rectal NETs that are incompletely removed after initial resection are more easily amenable to deep endoscopic techniques. However, this might not be necessary for patients with comorbidities, elderly, or both due to the uncertainty of how R1 finding impacts a patient's clinical outcome.

Immune cells in residual disease and recurrence

Tumor recurrence following potentially curative therapy constitutes a major obstacle to achieving cures in patients with cancer. Recurrent tumors frequently arise from a population of residual cancer cells - also referred to as minimal residual disease (RD) or persister cells - that survive therapy and persist for prolonged periods prior to tumor relapse. While there has been significant recent progress in deciphering tumor-cell-intrinsic pathways that regulate residual cancer cell survival and recurrence, much less is known about how the tumor microenvironment (TME) of residual tumors impacts persister cancer cells or tumor recurrence. In this review, we highlight recent studies exploring the regulation and function of immune cells in RD and discuss therapeutic opportunities to target immune cells in residual tumors.

[Prognostic value of residual disease detection in acute myeloid leukemia with normal karyotype and negative FLT3-ITD]

INTRODUCTION

Complete remission (CR) in patients with acute myeloid leukemia (AML) is still morphologicaly defined, thus corresponding to a wide range of tumor burden.

OBJECTIVES

we aimed to evaluate the residual disease (MRD) status in patients with AML, as well as perform a molecular analysis of the FLT3/ITD gene in patients with normal karyotype.

MATERIAL AND METHODS

adult patients with AML, diagnosed according to the WHO 2016 criteria, were included. MRD was detected using flow cytometric techniques after induction treatment resulting in CR.

RESULTS

thirty patients met our inclusion criteria. 83 % of them had an intermediate risk status, 67 % of which (20/30) having a normal karyotype. MRD and leukemic stem cell (LSC) positivity in this group was predominant with considerable decrease in benign progenitor count. The relapse-free survival (RFS) in the group of MRD negative patients with normal cytogenetics and non-mutated FLT3 gene was better than the RFS in all of our patients studied.

CONCLUSION

MRD and LSC are powerful prognostic factors for relapse. They should be routinely integrated to guide better management of AML.

Radiologically enlarged cardiophrenic lymph nodes and CA-125 in relation to diaphragmatic carcinomatosis, surgical outcome, and overall survival in advanced ovarian cancer

BACKGROUND

We primarily aimed to determine whether the presence of enlarged cardiophrenic lymph nodes (CPLNs), visualized by computed tomography (CT), and CA-125 can be used to assess diaphragmatic carcinomatosis and residual disease (RD) in advanced ovarian cancer (AOC) patients treated with upfront surgery. The secondary aim was to determine the prognostic role of CT-CPLNs in overall survival (OS).

MATERIAL AND METHODS

A single-center, retrospective, population-based study was conducted of patients who underwent surgery for AOC from January 1, 2014-December 31, 2018. Suspicious CT-CPLNs were defined as having a short axis ≥5 mm. The median survival and rate of survival were calculated with the Kaplan-Meier method using multivariate Cox regression analyses, including comparisons of complete cytoreductive surgery (CCS; defined as the complete removal of all intra-abdominal tumor) versus noncomplete cytoreductive surgery (non-CCS) and analyses related to CT-CPLN status and preoperative CA-125 values.

RESULTS

We included 208 patients. CT-CPLNs correlated with both diaphragmatic carcinomatosis (OR 3.59, 95% CI 1.81-7.16, p < 0.01) and RD (OR 2.54, 95% CI 1.38-4.6, p = 0.003). When CCS was achieved, no differences in survival between patients with suspicious or nonsuspicious CT-CPLNs were found. The relationships between CA-125 ≥ 500 U/ml and diaphragmatic carcinomatosis (OR 3.51, 95% CI 1.86-6.64, p < 0.01) and RD (OR 2.41, 95% CI 1.33-4.38, p = 0.004) were positive. All data were adjusted for age and ECOG performance status. Survival analyses were also adjusted for RD.

CONCLUSION

Enlarged CPLNs on CT scans and CA-125 levels correlate with diaphragmatic carcinomatosis and RD at the end of the surgery. The strongest prognostic factor for OS remains CCS, regardless of the CT-CPLN status.

Validation of models in predicting residual disease in ovarian cancer: comparing CT urography with PET/CT

BACKGROUND

Many ovarian cancer (OC) residual-disease prediction models were not externally validated after being constructed, the clinical applicability needs to be evaluated.

PURPOSE

To compare computed tomography urography (CTU) with PET/CT in validating models for predicting residual disease in OC.

MATERIAL AND METHODS

A total of 250 patients were included during 2018-2021. The CTU and PET/CT scans were analyzed, generating CT-Suidan, PET-Suidan, CT-Peking Union Medical College Hospital (PUMC), and PET-PUMC models. All imagings were evaluated by two readers independently, then compared to pathology. According to surgical outcomes, all patients were divided into the R0 group, with no visible residual disease, and the R1 group, with any visible residual disease. Logistic regression was used to assess the discrimination and calibration abilities of each model.

RESULTS

CTU and PET/CT showed good diagnostic performance in predicting OC peritoneal metastases based on the Suidan and PUMC model (all the accuracies >0.8). As for model evaluation, the value of correct classification of the CT-Suidan, PET-Suidan, CT-PUMC, and PET-PUMC models was 0.89, 0.84, 0.88, and 0.83, respectively, representing stable calibration. The areas under the curve (AUC) of these models were 0.95, 0.90, 0.91, and 0.90, respectively. Furthermore, the accuracy of these models at the optimal threshold value (score 3) was 0.75, 0.78, 0.80, and 0.80, respectively. All two-paired comparisons of the AUCs and accuracies did not show a significant difference (all P > 0.05).

CONCLUSION

CT-Suidan, CT-PUMC, PET-Suidan, and PET-PUMC models had equal abilities in predicting the residual disease of OC. The CT-PUMC model was recommended for its economic and user-friendly characteristics.

Recurrence in cholesteatoma surgery: what have we learnt and where are we going? A narrative review

Treatment of cholesteatoma is surgical and has historically encompassed two main techniques: canal wall up (CWU) and canal wall down (CWD) tympanoplasty. Follow-up for cholesteatoma is still debated and can be either radiological or with second-look surgery. MRI with diffusion weighted sequences has proved to have high sensitivity and specificity in detecting recurrent or residual disease. Specifically, non-echo planar imaging DWI (non-EPI DWI) has been shown to be superior to other imaging techniques, allowing, in some cases, to avoid second-look surgery. Both residual and recurrence rates are higher in CWU compared to CWD procedures. Endoscopic ear surgery (EES) has become popular with the advantage of “looking around corners”. The endoscope is used in addition to a microscope or exclusively to reduce cholesteatoma recurrence. In addition, it has been demonstrated that mastoid obliteration and the use of potassium titanyl phosphate laser (KTP) can reduce cholesteatoma recurrence, with better functional outcomes. A synthetic sulphur compound (MESNA) may have an interesting role in the overall improvement in recurrence and residual cholesteatoma disease. This narrative review critically appraises the factors associated with the risk of recurrent cholesteatoma.

Impact of residual disease biomarkers on the prognosis of HER2-positive breast cancer following neoadjuvant therapy

BACKGROUND

The changes in prognostic factors and clinicopathological characteristics of residual disease following neoadjuvant therapy (NAT) for breast cancer are important references for postoperative adjuvant therapy. The analyses of the relationship between the clinicopathological characteristics of residual diseases and the prognosis were not comprehensive in most previous studies. This study aimed to determine how prognostic factors changed following NAT and the impact of clinicopathological characteristics of residual disease on the prognosis of human epidermal growth factor receptor 2 (HER2)-positive breast cancer.

METHODS

The study comprised 350 consecutive patients with HER2-positive breast cancer who had residual disease after surgery following NAT. The independent risk factors affecting the prognosis of HER2-positive breast cancer were analyzed using univariate and multivariate Cox regression analyses. Chi-square test and binary logistic regression were used to analyze the influencing factors of HER2 loss following NAT.

RESULTS

The expression of prognostic factors changed significantly following NAT. A total of 44 patients (12.6%) had HER2 loss. HER2 status (immunohistochemistry (IHC) 3+ vs. IHC 2+/FISH+, p < 0.001) at baseline was associated with HER2 loss. In this investigation, the HER2 loss did not affect the prognosis. In univariate analysis, the decrease in Ki-67 (p < 0.001) after NAT was associated with improved prognosis, but this influence was lost in the Cox proportional hazards model. The ypN stage (p < 0.001), postoperative ER status (p = 0.020), Miller-Payne grade (p = 0.007), and targeted therapy (p = 0.003) were all independent prognostic factors.

CONCLUSIONS

ER, PR, HER2, and Ki-67 changed significantly after NAT, but no impact of these changes on DFS was observed in this study. Postoperative N stage, postoperative ER status, MP grade, and targeted therapy were independent prognostic factors in patients with HER2-positive breast cancer after NAT.

Long-term effects of COVID-19 on lungs and the clinical relevance: a 6-month prospective cohort study

Background: We aimed to explore the prevalence of prolonged symptoms, pulmonary impairments and residual disease on chest tomography (CT) in COVID-19 patients at 6 months after acute illness. Methods: In this prospective, single-center study, hospitalized patients with radiologically and laboratory-confirmed COVID-19 were included. Results: A high proportion of the 116 patients reported persistent symptoms (n = 54; 46.6%). On follow-up CT, 33 patients (28.4%) demonstrated residual disease. Multivariate analyses revealed that only neutrophil-to-lymphocyte ratio was an independent predictor for residual disease. Conclusion: Hospitalized patients with mild/moderate COVID-19 still had persistent symptoms and were prone to develop long-term pulmonary sequelae on chest CT. However, it did not have a significant effect on long-term pulmonary functions.

May Women with a Negative Co-Test at First Follow-Up Visit Return to 3-Year Screening after Treatment for Cervical Intraepithelial Neoplasia?

BACKGROUND

The Norwegian Cervical Cancer Screening Programme recommends that women treated for cervical intraepithelial neoplasia (CIN) only be returned to 3-year screening after receiving two consecutive negative co-tests, 6 months apart. Here we evaluate adherence to these guidelines and assessed the residual disease, using CIN3+ as the outcome.

METHODS

This cross-sectional study comprised 1397 women, treated for CIN between 2014 and 2017, who had their cytology, HPV, and histology samples analyzed by a single university department of pathology. Women who had their first and second follow-up at 4-8 and 9-18 months after treatment were considered adherent to the guidelines. The follow-up ended on 31 December 2021. We used survival analysis to assess the residual and recurrent CIN3 or worse among women with one and two negative co-tests, respectively.

RESULTS

71.8% (1003/1397) of women attended the first follow-up 4-8 months after treatment, and 38.3% were considered adherent at the second follow-up. Nearly 30% of the women had incomplete follow-up at the study end. None of the 808 women who returned to 3-year screening after two negative co-tests were diagnosed with CIN3+, whereas two such cases were diagnosed among the 887 women who had normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up (5-year risk of CIN3+: 0.24, 95%, CI: 0.00-0.57 per 100 woman-years).

CONCLUSIONS

The high proportion of women with incomplete follow-up at the end of the study period requires action. The risk of CIN3+ among women with normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up is indicative of a return to 3-year screening.

Predictors of residual disease after debulking surgery in advanced stage ovarian cancer

Objective

Optimal debulking with no macroscopic residual disease strongly predicts ovarian cancer survival. The ability to predict likelihood of optimal debulking, which may be partially dependent on tumor biology, could inform clinical decision-making regarding use of neoadjuvant chemotherapy. Thus, we developed a prediction model including epidemiological factors and tumor markers of residual disease after primary debulking surgery.

Methods

Univariate analyses examined associations of 11 pre-diagnosis epidemiologic factors (n=593) and 24 tumor markers (n=204) with debulking status among incident, high-stage, epithelial ovarian cancer cases from the Nurses' Health Studies and New England Case Control study. We used Bayesian model averaging (BMA) to develop prediction models of optimal debulking with 5x5-fold cross-validation and calculated the area under the curve (AUC).

Results

Current aspirin use was associated with lower odds of optimal debulking compared to never use (OR=0.52, 95%CI=0.31-0.86) and two tissue markers, ADRB2 (OR=2.21, 95%CI=1.23-4.41) and FAP (OR=1.91, 95%CI=1.24-3.05) were associated with increased odds of optimal debulking. The BMA selected aspirin, parity, and menopausal status as the epidemiologic/clinical predictors with the posterior effect probability ≥20%. While the prediction model with epidemiologic/clinical predictors had low performance (average AUC=0.49), the model adding tissue biomarkers showed improved, but weak, performance (average AUC=0.62).

Conclusions

Addition of ovarian tumor tissue markers to our multivariable prediction models based on epidemiologic/clinical data slightly improved the model performance, suggesting debulking status may be in part driven by tumor characteristics. Larger studies are warranted to identify those at high risk of poor surgical outcomes informing personalized treatment.

Chemotherapeutic Activity of Pitavastatin in Vincristine Resistant B-Cell Acute Lymphoblastic Leukemia

B-cell acute lymphoblastic leukemia (ALL) is derived from an accumulation of malignant, immature B cells in the bone marrow and blood. Relapse due, in part, to the emergence of tumor cells that are resistant to front line standard chemotherapy is associated with poor patient outcomes. This challenge highlights the need for new treatment strategies to eliminate residual chemoresistant tumor cells. Based on the use of pitavastatin in acute myeloid leukemia (AML), we evaluated its efficacy in an REH ALL cell line derived to be resistant to vincristine. We found that pitavastatin inhibited the proliferation of both parental and vincristine-resistant REH tumor cells at an IC50 of 449 nM and 217 nM, respectively. Mitochondrial bioenergetic assays demonstrated that neither vincristine resistance nor pitavastatin treatment affected cellular oxidative phosphorylation, beta-oxidation, or glycolytic metabolism in ALL cells. In a co-culture model of ALL cells with bone marrow stromal cells, pitavastatin significantly decreased cell viability more robustly in the vincristine-resistant ALL cells compared with their parental controls. Subsequently, NSG mice were used to develop an in vivo model of B-cell ALL using both parental and vincristine-resistant ALL cells. Pitavastatin (10 mg/kg i.p.) significantly reduced the number of human CD45+ REH ALL cells in the bone marrow of mice after 4 weeks of treatment. Mechanistic studies showed that pitavastatin treatment in the vincristine-resistant cells led to apoptosis, with increased levels of cleaved PARP and protein-signaling changes for AMP-activated protein kinase/FoxO3a/Puma. Our data suggest the possible repurposing of pitavastatin as a chemotherapeutic agent in a model of vincristine-resistant B-cell ALL.

Positron emission tomography derived metrics in relapsed or refractory large B-cell lymphoma with residual disease before autologous stem cell transplant

Salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT) is a potentially curative treatment for patients with relapsed or refractory large B-cell lymphoma (rrLBCL) with chemosensitive disease. A18 F-fluorodeoxyglucose positron emission tomography (PET) scan after salvage chemotherapy is used to assess response and eligibility for ASCT, but metrics for chemosensitivity in patients with residual disease are not well defined. We performed a single-centre retrospective analysis of 92 patients with a partial response or stable disease after salvage chemotherapy for rrLBCL who received ASCT to investigate PET-derived parameters and their prognostic utility. The Deauville 5-point Scale (D-5PS) score, maximum standardised uptake value (SUVmax ), total metabolic tumour volume (TMTV), and total lesion glycolysis (TLG) were calculated from the post-salvage/pre-ASCT PET scan. The 5-year progression-free survival (PFS) and overall survival (OS) rates were 40% and 54% respectively. A D-5PS score of 5 (p = 0.0082, hazard ratio [HR] 2.09), high SUVmax (p = 0.0015, HR 2.48), TMTV (p = 0.035, HR 1.83) and TLG (p = 0.0036, HR 2.27) were associated with inferior PFS. A D-5PS score of 5 (p = 0.030, HR 1.98) and high SUVmax (p = 0.0025, HR 2.55) were associated with inferior OS. PET-derived parameters may help prognosticate outcomes after ASCT in patients with rrLBCL with residual disease after salvage chemotherapy.

The Prognostic Role of True Radical Resection in Perihilar Cholangiocarcinoma after Improved Evaluation of Radial Margin Status

BACKGROUND

The evaluation of surgical margins in resected perihilar cholangiocarcinoma (PHCC) remains a challenging issue. Both ductal (DM) and radial margin (RM) should be considered to define true radical resections (R0). Although DM status is routinely described in pathological reports, RM status is often overlooked. Therefore, the frequency of true R0 and its impact on survival might be biased.

OBJECTIVE

To improve the evaluation of RM status and investigate the impact of true R0 on survival.

METHODS

From 2014 to 2020, 90 patients underwent curative surgery for PHCC at Verona University Hospital, Verona, Italy. Both DM (proximal and distal biliary margin) and RM (hepatic, periductal, and vascular margin) status were evaluated by expert hepatobiliary pathologists. Patients with lymph-node metastases or positive surgical margins (R1) were candidates for adjuvant treatment. Clinicopathological and survival data were retrieved from an institutional database.

RESULTS

True R0 were 46% (41) and overall R1 were 54% (49). RM positivity resulted in being higher than DM positivity (48% versus 27%). Overall survival was better in patients with true R0 than in patients with R1 (median survival time: 53 vs. 28 months; p = 0.016). Likewise, the best recurrence-free survival was observed in R0 compared with R1 (median survival time: 32 vs. 15 months; p = 0.006). Multivariable analysis identified residual disease status as an independent prognostic factor of both OS (p = 0.009, HR = 2.68, 95% CI = 1.27-5.63) and RFS (p = 0.009, HR = 2.14, 95% CI = 1.20-3.83).

CONCLUSION

Excellent survival was observed in true R0 patients. The improved evaluation of RM status is mandatory to properly stratify prognosis and select patients for adjuvant treatment.

Association of Surgical Margin Status with Oncologic Outcome in Patients Treated with Breast-Conserving Surgery

We aimed to compare the prognosis of patients with close resection margins after breast-conserving surgery (BCS) with that of patients with negative margins and identified predictors of residual disease. A total of 542 patients with breast cancer who underwent BCS between 2003 and 2019 were selected and divided into the close margin (114 patients) and negative margin (428 patients) groups. The median follow-up period was 72 (interquartile range, 42-113) months. Most patients received radiation therapy (RTx) and systemic therapy according to their stage and molecular subtype. The 10-year locoregional recurrence-free survival rates of the close and negative margin groups were 88.2% and 95.5%, respectively (p = 0.001). Multivariable analysis showed that adjuvant RTx and margin status after definitive surgery were significantly associated with locoregional recurrence. Of the 57 patients who underwent re-excision, 34 (59.6%) had residual disease. Multivariable analysis revealed that a histological type of positive or close margins and multifocality were independent predictive factors for residual disease. Although the current guidelines suggest that no ink on tumor is an adequate margin after BCS, a close resection margin may be associated with locoregional failure. The treatment strategy for close resection margins after BCS should be based on individual clinicopathological features.

Short-term efficacy and long-term survival of nasopharyngeal carcinoma patients with radiographically visible residual disease following observation or additional intervention: A real-world study in China

Background

To explore the short- and long-term outcomes in patients with nasopharyngeal carcinoma (NPC) with magnetic resonance imaging (MRI)-detected residual disease at 3 months post-treatment who received intervention either promptly (0 month) or following observation (after an additional 3 months).

Methods

A total of 272 patients with residual disease at 3 months post-treatment (observation [observation for additional 3 months]: 122, intervention [prompt intervention]: 150) were analyzed. Univariate and multivariate analyses were performed to examine the survival. Adverse events were analyzed in all patients.

Results

Patients in the observation group had a lower 3-year overall survival (77.1% vs. 85.2%), progression-free survival (10.2% vs. 18.1%), and locoregional relapse-free survival (10.2% vs. 20.6%) (all p < .05), but not distant metastasis-free survival (83.8% vs. 78.4%, p = .189), whereas patients in the intervention group achieved higher complete remission (CR) rates (43.3% vs. 21.2%, p = .003). Patients who achieved CR after prompt intervention had a better survival rate than those who achieved observation-CR or non-CR (p < .001). Multivariate analyses revealed that a wait-and-see policy was an independent prognostic factor for impaired survival (p < .001). No significant differences of acute or late toxicities were observed between the two groups.

Conclusions

Patients with NPC with MRI-detected residual disease 3 months post-radiotherapy should be encouraged to undergo prompt intervention rather than adopting a passive wait-and-see policy.

Residual Disease After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 2: Network Meta-analysis Incorporating Expert Elicitation to Adjust for Publication Bias

BACKGROUND

Previous work has identified a strong association between the achievements of macroscopic cytoreduction and improved overall survival (OS) after primary surgical treatment of advanced epithelial ovarian cancer. Despite the use of contemporary methodology, resulting in the most comprehensive currently available evidence to date in this area, opponents remain skeptical.

AREAS OF UNCERTAINTY

We aimed to conduct sensitivity analyses to adjust for potential publication bias, to confirm or refute existing conclusions and recommendations, leveraging elicitation to incorporate expert opinion. We recommend our approach as an exemplar that should be adopted in other areas of research.

DATA SOURCES

We conducted random-effects network meta-analyses in frequentist and Bayesian (using Markov Chain Montel Carlo simulation) frameworks comparing OS across residual disease thresholds in women with advanced epithelial ovarian cancer after primary cytoreductive surgery. Elicitation methods among experts in gynecology were used to derive priors for an extension to a previously reported Copas selection model and a novel approach using effect estimates calculated from the elicitation exercise, to attempt to adjust for publication bias and increase confidence in the certainty of the evidence.

THERAPEUTIC ADVANCES

Analyses using data from 25 studies (n = 20,927 women) all showed the prognostic importance of complete cytoreduction (0 cm) in both frameworks. Experts accepted publication bias was likely, but after adjustment for their opinions, published results overpowered the informative priors incorporated into the Bayesian sensitivity analyses. Effect estimates were attenuated but conclusions were robust in all analyses.

CONCLUSIONS

There remains a strong association between the achievement of complete cytoreduction and improved OS even after adjustment for publication bias using strong informative priors formed from an expert elicitation exercise. The concepts of the elicitation survey should be strongly considered for utilization in other meta-analyses.

Long-Term Anatomical and Hearing Outcomes of Canal Wall down Tympanoplasty for Tympano-Mastoid Cholesteatoma: A 20-Year Retrospective Study

Background: to evaluate the residual rate and the functional results after ten years from canal wall down tympanoplasty (CWD) for tympano-mastoid cholesteatoma. Methods: All the patients undergoing CWD for chronic otitis media with cholesteatoma at our ENT University Department between January 2002 and December 2022 were initially assessed. We performed clinical and diagnostic evaluation at baseline, 6 months, and then every year until an average follow-up of 10 years was obtained. Patients were consequently divided into two groups according to the presence (group A) or absence (group B) of the stapes superstructure. Results: After the selection process, 176 ears were included. The presence of the stapes superstructure was associated with better hearing outcomes (rate of patients < 30 dB) at 6 months (91.42% vs. 74.46%; p = 0.001) and 10 years (74.46% vs. 24.11%; p < 0.001). Residual cholesteatoma was reported in 10 ears, which included 2/35 ears in group A (5.71 %) and 8/141 in group B (5.67 %) (p = 0.993). The recurrent cholesteatoma rate was respectively 1/35 (2.85%) vs. 3/141 (2.18%) (p = 0.516). Conclusions: the CWD approach to cholesteatoma allows for effective long-term anatomical disease control and good hearing results when the stapes superstructure is preserved.

Identification of a Gene Panel Predictive of Triple-Negative Breast Cancer Response to Neoadjuvant Chemotherapy Employing Transcriptomic and Functional Validation

Triple-negative breast cancer (TNBC) patients exhibiting pathological complete response (pCR) have better clinical outcomes compared to those with residual disease (RD). Therefore, robust biomarkers that can predict pCR may help with triage and resource prioritization in patients with TNBC. Herein, we identified a gene panel predictive of RD and pCR in TNBC from the discovery (n = 90) treatment-naive tumor transcriptomic data. Eight RD-derived genes were identified as TNBC-essential genes, which were highly predicative of overall survival (OS) and relapse-free survival (RFS) in an additional cohort of basal breast cancer (n = 442). Mechanistically, targeted depletion of the eight genes reduced the proliferation potential of TNBC cell models, while most remarkable effects were for combined SLC39A7, TIMM13, BANF1, and MVD knockdown in conjunction with doxorubicin. Orthogonal partial least squares-discriminant analysis (OPLS-DA) and receiver operating characteristic curve (ROC) analyses revealed significant predictive power for the identified gene panels with an area under the curve (AUC) of 0.75 for the validation cohort (n = 50) to discriminate RD from pCR. Protein–Protein Interaction (PPI) network analysis of the pCR-derived gene signature identified an 87-immune gene signature highly predictive of pCR, which correlated with better OS, RFS, and distant-metastasis-free survival (DMFS) in an independent cohort of basal and, to a lesser extent, HER2+ breast cancer. Our data have identified gene signatures predicative of RD and pCR in TNBC with potential clinical implications.

Top advances of the year: Pediatric oncology

Accelerated discovery and collaborative research continue to highlight the remarkable progress that has been made in the diagnosis and treatment of pediatric cancers. This manuscript highlights important discoveries on how precision oncology is being incorporated into the diagnosis and treatment of childhood cancer at the national level to identify promising new therapies using a tumor-agnostic approach. In addition, we have highlighted three articles that incorporate genomics and cell-free DNA to better classify, monitor and incorporate risk-based therapies for children with medulloblastoma. Finally, we highlighted the important role of monclonal antiobody therapy in the treatment of recurrent B-cell leukemia and newly diagnosed high-risk neuroblastoma.

Diffusion-Weighted Magnetic Resonance Imaging and Morphological Characteristics Evaluation for Outcome Prediction of Primary Debulking Surgery for Advanced High-Grade Serous Ovarian Carcinoma

BACKGROUND

Preoperative assessment of whether a successful primary debulking surgery (PDS) can be performed in patients with advanced high-grade serous ovarian carcinoma (HGSOC) remains a challenge. A reliable model to precisely predict resectability is highly demanded.

PURPOSE

To investigate the value of diffusion-weighted MRI (DW-MRI) combined with morphological characteristics to predict the PDS outcome in advanced HGSOC patients.

STUDY TYPE

Prospective.

SUBJECTS

A total of 95 consecutive patients with histopathologically confirmed advanced HGSOC (ranged from 39 to 77 years).

FIELDS STRENGTH/SEQUENCE

A 3.0 T, readout-segmented echo-planar DWI.

ASSESSMENT

The MRI morphological characteristics of the primary ovarian tumor, a peritoneal carcinomatosis index (PCI) derived from DWI (DWI-PCI) and histogram analysis of the primary ovarian tumor and the largest peritoneal carcinomatosis were assessed by three radiologists. Three different models were developed to predict the resectability, including a clinicoradiologic model combing MRI morphological characteristic with ascites and CA125 level; DWI-PCI alone; and a fusion model combining the clinical-morphological information and DWI-PCI.

STATISTICAL TESTS

Multivariate logistic regression analyses, receiver operating characteristic (ROC) curve, net reclassification index (NRI) and integrated discrimination improvement (IDI) were used. A P < 0.05 was considered to be statistically significant.

RESULTS

Sixty-seven cases appeared as a definite mass, whereas 28 cases as an infiltrative mass. The morphological characteristics and DWI-PCI were independent factors for predicting the resectability, with an AUC of 0.724 and 0.824, respectively. The multivariable predictive model consisted of morphological characteristics, CA-125, and the amount of ascites, with an incremental AUC of 0.818. Combining the application of a clinicoradiologic model and DWI-PCI showed significantly higher AUC of 0.863 than the ones of each of them implemented alone, with a positive NRI and IDI.

DATA CONCLUSIONS

The combination of two clinical factors, MRI morphological characteristics and DWI-PCI provide a reliable and valuable paradigm for the noninvasive prediction of the outcome of PDS.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Complications after advanced ovarian cancer surgery-A population-based cohort study

INTRODUCTION

Surgical complications after primary or interval debulking surgery in advanced ovarian cancer were investigated and associations with patient characteristics and surgical outcomes were explored.

MATERIAL AND METHODS

A population-based cohort study including all women with ovarian cancer, FIGO III-IV, treated with primary or interval debulking surgery, 2013-2017. Patient characteristics, surgical outcomes and complications according to the Clavien-Dindo (CD) classification system ≤30 days postoperatively, were registered. Uni- and multivariable regression analyses were performed with severe complications (CD ≥ III) as endpoint. PFS in relation was analyzed using the Kaplan-Meier method.

RESULTS

The cohort included 384 women, where 304 (79%) were treated with primary and 80 (21%) with interval debulking surgery. Complications CD I-V were registered in 112 (29%) patients and CD ≥ III in 42 (11%). Preoperative albumin was significantly lower in the CD ≥ III cohort compared with CD 0-II (P = 0.018). For every increase per unit in albumin, the risk of complications decreased by a factor of 0.93. There was no significant difference in completed chemotherapy between the cohorts CD 0-II 90.1% and CD ≥ III 83.3% (P = 0.236). In the univariable analysis; albumin <30 g/L, primary debulking surgery, complete cytoreduction and intermediate/high surgical complexity score (SCS) were associated with CD ≥ III. In the following multivariable analysis, only intermediate/high SCS was found to be an independent significant prognostic factor. Low (n = 180) vs intermediate/high SCS (n = 204) showed a median PFS of 17.2 months (95% confidence interval [CI] 15.2-20.7) vs 21.5 months (95% CI 18.2-25.7), respectively, with a significant log-rank; P = 0.038.

CONCLUSIONS

Advanced ovarian cancer surgery is associated with complications but no significant difference was seen in completion of adjuvant chemotherapy when severe complications occur. Importantly, our study shows that intermediate/high SCS is an independent prognostic risk factor for complications. Low albumin, residual disease and primary debulking surgery were found to be associated with severe complications. These results may facilitate forming algorithms in the decision-making procedure of surgical treatment protocols.

An immunological signature to predict outcome in patients with triple-negative breast cancer with residual disease after neoadjuvant chemotherapy

Background

When triple-negative breast cancer (TNBC) patients have residual disease after neoadjuvant chemotherapy (NACT), they have a high risk of metastatic relapse. With immune infiltrate in TNBC being prognostic and predictive of response to treatment, our aim was to develop an immunologic transcriptomic signature using post-NACT samples to predict relapse.

Materials and methods

We identified 115 samples of residual tumors from post-NACT TNBC patients. We profiled the expression of 770 genes related to cancer microenvironment using the NanoString PanCancer IO360 panel to develop a prognostic transcriptomic signature, and we describe the immune microenvironments of the residual tumors.

Results

Thirty-eight (33%) patients experienced metastatic relapse. Hierarchical clustering separated patients into five clusters with distinct prognosis based on pathways linked to immune activation, epithelial-to-mesenchymal transition and cell cycle. The immune microenvironment of the residual disease was significantly different between patients who experienced relapse compared to those who did not, the latter having significantly more effector antitumoral immune cells, with significant differences in lymphoid subpopulations. We selected eight genes linked to immunity (BLK, GZMM, CXCR6, LILRA1, SPIB, CCL4, CXCR4, SLAMF7) to develop a transcriptomic signature which could predict relapse in our cohort. This signature was validated in two external cohorts (KMplot and METABRIC).

Conclusions

Lack of immune activation after NACT is associated with a high risk of distant relapse. We propose a prognostic signature based on immune infiltrate that could lead to targeted therapeutic strategies to improve patient prognosis.

•

Infiltrate of cytotoxic cells is higher in the residual disease of TNBC patients who will not experience metastatic relapse.

•

Underexpression of immune-related pathways is associated with metastatic relapse in residual disease of TNBC patients.

•

An immune gene-based signature can predict metastatic relapse in TNBC patients after NACT.

Residual Disease in Patients with Axial Spondyloarthritis: A Post-Hoc Analysis of the QUASAR Study

In this study, we evaluated the presence of residual disease in patients with axial spondyloarthritis (axSpA) in remission/low disease activity (LDA) status. This cross-sectional post-hoc analysis of the QUASAR study involving 23 rheumatology centres across Italy included adults with axSpA classified according to the Assessment of SpondyloArthritis International Society criteria. Patients with inactive disease (score < 1.3) or at least LDA status (score < 2.1) at baseline visit according to Ankylosing Spondylitis Disease Activity Score were investigated to evaluate how residual disease activity impacts patients’ quality of life. They were assessed using the Ankylosing Spondylitis Quality of Life (ASQoL) and EuroQoL 5-Dimension 5-Level (EQ-5D-5L) questionnaires. This study included 480 patients with axSpA (mean age, 47.5 ± 12.9 years, 64% male). In total, 123 patients (25.6%) had inactive disease and 262 (54.6%) had at least LDA. Using the ASQoL, ranges of 10−25% and 20−40% of patients with inactive disease and with LDA status, respectively, experienced tiredness/fatigue. Despite being classified with inactive disease, 48.8% of patients reported light pain/discomfort according to the EQ-5D-5L, with 4.1% reporting moderate pain/discomfort, whereas 55.7% of patients with LDA reported light pain/discomfort and 13% had moderate pain/discomfort. Using the ASQoL questionnaire, in patients with at least LDA, a higher proportion of women compared with males and a higher proportion of patients > 48 years of age (vs. patients ≤ 48 years) experienced tiredness. In this post-hoc analysis, ≥25% of axSpA patients in remission/LDA status were still burdened by residual disease, mainly characterised by pain and fatigue.

Exosomal Metabolic Signatures Are Associated with Differential Response to Neoadjuvant Chemotherapy in Patients with Breast Cancer

Neoadjuvant chemotherapy (NAC) is commonly used in breast cancer (BC) patients to increase eligibility for breast-conserving surgery. Only 30% of patients with BC show pathologic complete response (pCR) after NAC, and residual disease (RD) is associated with poor long-term prognosis. A critical barrier to improving NAC outcomes in patients with BC is the limited understanding of the mechanisms underlying differential treatment outcomes. In this study, we evaluated the ability of exosomal metabolic profiles to predict NAC response in patients with BC. Exosomes isolated from the plasma of patients after NAC were used for metabolomic analyses to identify exosomal metabolic signatures associated with the NAC response. Among the 16 BC patients who received NAC, eight had a pCR, and eight had RD. Patients with RD had 2.52-fold higher exosome concentration in their plasma than those with pCR and showed significant enrichment of various metabolic pathways, including citrate cycle, urea cycle, porphyrin metabolism, glycolysis, and gluconeogenesis. Additionally, the relative exosomal levels of succinate and lactate were significantly higher in patients with RD than in those with pCR. These data suggest that plasma exosomal metabolic signatures could be associated with differential NAC outcomes in BC patients and provide insight into the metabolic determinants of NAC response in patients with BC.

Assessing the Prognostic Value of the ChOLE Classification in Predicting the Severity of Acquired Cholesteatoma

OBJECTIVE

To assess the prognostic value of the ChOLE classification in predicting the severity of acquired cholesteatoma.

METHOD

A retrospective chart review of patients undergoing primary cholesteatoma surgery in our tertiary referral center. The primary outcome measures were analyzed in three groups of follow up (FU): residual cholesteatoma in group A, FU > 52 weeks after last-look surgery or MRI-DWI; recurrent cholesteatoma in group B, FU > 52 weeks after last outpatient visit; and adverse events (AE) in group C, FU > 12 weeks after surgery. Cholesteatomata were staged according to the ChOLE classification. Kaplan-Meier curves were used to determine the prognostic value of the classification in predicting cholesteatoma severity, while correcting for FU.

RESULTS

No significant differences were observed between the various stages of the ChOLE classification and residual or recurrent cholesteatoma rate, nor the occurrence of AE. Cholesteatoma extension to the sinus tympani or widespread in the mastoid, as well as absence of the stapes superstructure were predictive of residual disease. Sclerotic mastoids had a lower risk of residual disease than mastoids with good or poor pneumatization and ventilation. Poorly ventilated and poorly pneumatized mastoids were associated with increased risk of recurrence. Widespread cholesteatoma in the mastoid as well as presence of preoperative extracranial complications were correlated with an increased risk of AE.

CONCLUSION

The ChOLE classification does not predict residual nor recurrent disease, nor the occurrence of AE, in our study population. Risk factors for severe cholesteatoma were identified, potentially useful for the development of future classifications.

Clinical Validity of Circulating Tumor DNA as Prognostic and Predictive Marker for Personalized Colorectal Cancer Patient Management

Simple Summary

CtDNA analysis is a promising tool in liquid biopsy for the detection of tumor recurrence and progression, and is increasingly adopted into clinical practice. Still, guidelines for the accurate clinical interpretation of ctDNA analysis results are largely lacking, especially for tumor mutant variants detected at very low frequencies. Here, we show that cutoff determination for the detection and quantification of low-frequency mutant variants enables the accurate prediction of residual disease, tumor recurrence and progression, even before clinical evidence. CtDNA analysis using these cutoffs outperformed cfDNA and CEA level measurements. With these findings, we highlight the need to thoroughly validate each liquid biopsy assay and define the assay-specific limit of blanks (LOB) and limit of quantifications (LOQ) of BRAF p.V600E and KRAS p.G12/p.G13 assays for clinical interpretation. Our approach enables accurate clinical interpretation to support clinical decision making.

Abstract

Circulating tumor DNA (ctDNA) is a promising liquid biopsy (LB) marker to support clinical decisions in precision medicine. For implementation into routine clinical practice, clinicians need precise ctDNA level cutoffs for reporting residual disease and monitoring tumor burden changes during therapy. We clinically validated the limit of blank (LOB) and the limit of quantification (LOQ) of assays for the clinically most relevant somatic variants BRAF p.V600E and KRAS p.G12/p.G13 in colorectal cancer (CRC) in a study cohort encompassing a total of 212 plasma samples. We prove that residual disease detection using the LOB as a clinically verified cutoff for ctDNA positivity is in concordance with clinical evidence of metastasis or recurrence. We further show that tumor burden changes during chemotherapy and the course of disease are correctly predicted using the LOQ as a cutoff for quantitative ctDNA changes. The high potential of LB using ctDNA for accurately predicting the course of disease was proven by direct comparison to the routinely used carcinoembryonic antigen (CEA) as well as the circulating free DNA (cfDNA) concentration. Our results show that LB using validated ctDNA assays outperforms CEA and cfDNA for residual disease detection and the prediction of tumor burden changes.

What is the best treatment recommendation for HER2+ IBC with residual disease?-a narrative review

OBJECTIVE

The purpose of this article review is to discuss the current adjuvant approach for human epidermal growth factor receptor 2 (HER2) gene amplification or overexpression inflammatory breast cancer (IBC), as well as promising therapies to improve the prognosis of these patients, with the main focus on the high risk setting of patients with residual disease after neoadjuvant therapy.

BACKGROUND

IBC is a rare and very aggressive form of breast cancer. HER2+ is more frequent in IBC than in non-IBC. A combined multimodality therapy is essential for better outcomes in non-metastatic HER2+ IBC patients, including neoadjuvant chemotherapy, with dual HER2 blockade, local therapy with surgery and radiotherapy, and adjuvant systemic therapy, which is defined on the basis of pathological response and hormone receptor (HR) status. Dual HER2 blockade with trastuzumab and pertuzumab combined to neoadjuvant chemotherapy improved the pathological complete response (pCR) rate. However, HER+ IBC patients with residual disease at surgery have a high risk of recurrence and death.

METHODS

A comprehensive review was conducted through Medline/PubMed database, ClinicalTrials.gov, and conference abstracts.

CONCLUSIONS

Escalation of adjuvant therapy for patients with HER2+ IBC with residual invasive disease after neoadjuvant therapy is recommended. Adjuvant ado-trastuzumab emtansine and neratinib, for HR+ disease, are the most recent advances in this setting, with a clinically meaningful improvement in invasive disease-free survival (iDFS). Despite the clinical advances, reducing the risk of central nervous system recurrence remains an unmet need. Several promising clinical trials are ongoing to improve patients' prognosis in this high-risk of recurrence setting.

Role of MRI in predicting response to neo-adjuvant systemic therapy (NAST) in breast cancer

BACKGROUND AND OBJECTIVES

MRI is generally performed to assess response to Neo-adjuvant systemic therapy (NAST) in breast cancer.

OBJECTIVE

To assess role of MRI in determining the probability of having residual disease in patients undergoing NAST. We also evaluated synchronous cancers diagnosed following MRI.

METHODS

This is a retrospective study which included all patients who had pre-and post-NAST MRI between June 2014 and December 2019. Data on demographics, tumour characteristics and pathology were collected and analysed. Pre- and post-MRI probability were calculated and depicted on nomograms.

RESULTS

The study included 205 patients. Overall pre-MRI probability of having residual disease was 55% (OR:1.2). The post-MRI probability was 78% (95% CI 72-83%; OR:3.5) if MRI showed residual disease and 23% (95% CI 16-31%, OR:0.3) if imaging showed complete response. The absolute benefit was higher in TNBC and HR-HER2. Additional cancers were identified in 8.78% of patients.

CONCLUSION

MRI is beneficial in evaluating response to NAST specifically in TNBC and HR-HER2 cancers. Pre- and post-MRI probabilities of residual disease depicted on nomograms are a useful tool for clinicians. MRI can potentially impact the treatment decisions by identification of synchronous cancers.

Efficacy and Safety of Local Radiotherapy to All Oligometastatic Sites in Elderly Patients with Metachronous Oligometastatic Cancers After Initial Treatment for the Primary Tumor

Background and Purpose

This study aimed to investigate the efficacy and safety of maintenance therapy combined with local radiotherapy at all oligometastatic sites (LRTOS) in elderly patients with metachronous oligometastatic cancers (MOC).

Patients and Methods

A total of 242 elderly patients with MOC (≤5 metastases) and primary tumor well controlled after definitive treatment was retrospectively analyzed between August 2014 and February 2020 at Beijing Geriatric Hospital and Air Force General Hospital. Patients were divided into maintenance therapy group (maintenance therapy alone) and local radiotherapy group (maintenance therapy combined with LRTOS).

Results

There were 86 patients in the local radiotherapy group and 156 patients in the maintenance therapy group. The median length of follow-up was 36 months (range, 8.0–62 months). Median overall survival (mOS) was 25 months (95% CI: 21.1–28.9) in the local radiotherapy group and 16 months (95% CI: 14.5–17.6) in the maintenance therapy group (p < 0.001). Multivariate analyses demonstrated that LRTOS (hazard ratio (HR) = 0.49, 95% confidence interval (CI): 0.35–0.67, p < 0.001), good Eastern Cooperative Oncology Group Performance Status (ECOG PS, HR = 0.69, 95% CI: 0.49–0.97, p = 0.032), longer duration between diagnosis of primary tumor and occurrence of progression (HR = 0.87, 95% CI: 0.78–0.97, p = 0.015), and subsequent systemic treatment (HR = 0.52, 95% CI: 0.38–0.72, p < 0.001) were independent predictors of good OS. In patients who did not receive subsequent systemic treatment, their mOS was 21 months (95% CI: 12.8–29.2) for those treated with LRTOS and 14 months (95% CI: 11.4–16.6) for those who did not receive local radiotherapy (p = 0.001). Further multivariate analysis showed that LRTOS was the only independent factor for predicting good OS (HR = 0.47, 95% CI: 0.26–0.83, p = 0.010). Patients with metachronous oligometastatic lung cancer, colorectal cancer, prostate cancer, and breast cancer had higher survival benefits following LRTOS. Most patients suffered from grade 1–2 toxicities, but no treatment-related death was recorded.

Conclusion

This retrospective study shows that elderly patients with MOC treated with LRTOS may have better survival outcomes.

Alliance A011801 (compassHER2 RD): postneoadjuvant T-DM1 + tucatinib/placebo in patients with residual HER2-positive invasive breast cancer

This report describes the rationale, purpose and design of A011801 (CompassHER2 RD), an ongoing prospective, multicenter, Phase III randomized trial. Eligible patients in the United States (US) and Canada with high-risk (defined as ER-negative and/or node-positive) HER2-positive (HER2+) residual disease (RD) after a predefined course of neoadjuvant chemotherapy and HER2-directed treatment are randomized 1:1 to adjuvant T-DM1 and placebo, versus T-DM1 and tucatinib. Patients have also received adjuvant radiotherapy and/or endocrine therapy, if indicated per standard of care guidelines. The primary objective of the trial is to determine if the invasive disease-free survival (iDFS) with T-DM1 plus tucatinib is superior to iDFS with T-DM1 plus placebo; other outcomes of interest include overall survival (OS), breast cancer-free survival (BCFS), distant recurrence-free survival (DRFS), brain metastases-free survival (BMFS) and disease-free survival (DFS). Correlative biomarker, quality of life (QoL) and pharmacokinetic (PK) end points are also evaluated.

Secondary cytoreductive surgery for recurrent low-grade serous ovarian carcinoma: A systematic review and meta-analysis

OBJECTIVES

Low-grade serous ovarian cancer (LGSC) is a relatively chemo-resistant disease with limited effective treatment options for patients with recurrence. Secondary cytoreductive surgery (SCS) is commonly offered at recurrence, although any benefit this has on survival is not fully determined. This review evaluates the impact of SCS, including residual disease, on progression-free survival (PFS) and overall survival (OS) in recurrent LGSC.

METHODS

A comprehensive search of Medline ALL, Embase Classic + Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science was conducted to obtain studies evaluating optimal or complete SCS versus suboptimal SCS and the amount of residual disease in recurrent LGSC. Meta-analysis was performed and PFS and OS outcomes were calculated.

RESULTS

1Of 5296 studies screened, 350 progressed to full-text review, with 9 ultimately selected for inclusion in the systematic review. Two studies met criteria for meta-analysis of PFS and of OS. The presence of visible residual disease at the conclusion of SCS negatively impacted PFS (HR = 3.51, 95% CI = 1.72-7.14), whereas SCS with no residual disease significantly improved OS (HR = 0.4, 95% CI = 0.23-0.7) in patients with recurrent LGSC. Diffuse and extensive disease distribution was inversely linked to survival. In addition, SCS as an initial treatment for recurrent LGSC was associated with superior survival in comparison to chemotherapy. A short platinum-free interval was not associated with worse survival in this cohort.

CONCLUSIONS

Complete SCS, and to a lesser extent optimal SCS, are associated with improved PFS and OS in patients with recurrent LGSC. SCS may be a better initial treatment strategy than systemic chemotherapy for recurrent disease. Patients with recurrent LGSC should be evaluated for the role of SCS based on disease distribution and functional status, irrespective of the platinum-free interval. Prospective studies are needed to further study the role of SCS in patients with recurrent LGSC.

Accuracy of Pretreatment Ultrasonography Assessment of Intra-Abdominal Spread in Epithelial Ovarian Cancer: A Prospective Study

The aim of this study was to test the accuracy of ultrasonography performed by gynecological oncologists for the preoperative assessment of epithelial ovarian cancer (EOC) spread in the pelvis and abdominal cavity. A prospective, observational cohort study was performed at a single tertiary cancer care unit. Patients with suspected EOC were recruited and underwent comprehensive transvaginal and abdominal ultrasonography performed by a gynecological oncologist. Sixteen intra-abdominal localizations and parameters were assessed using ultrasonography and compared with surgical-pathological status (reference standard). Sensitivity, specificity, positive and negative predictive values, and overall accuracy were calculated. Differences were analyzed using Fisher’s exact and chi-square tests. Ultimately, we included 132 patients (median age 62 years), of whom 67% were in stage IIIC–IVB and 72% had serous cancer. Overall prediction accuracies for the involvement of the omentum, small bowel mesentery root, and frozen pelvis, and detecting ascites were >90%. Detecting the involvement of the pelvis peritoneum, liver and spleen hilum, and rectosigmoid colon, and predictions of disease stage and residual disease had overall accuracies of 80–90%. The lowest accuracy was for involvement of the abdominal peritoneum (69%) and diaphragm peritoneum (right 71%; left 75%) and surgical complexity prediction (77%). Stratification of results by presence or absence of ascites revealed significantly higher specificity of ultrasonography (clinically meaningful) for assessments of the abdominal/pelvic peritoneum, spleen hilum, and rectum wall, if there were ascites. A gynecological oncologist, experienced in surgery and sonology, performing comprehensive ultrasonography on patients with EOC can accurately detect intraperitoneal lesions and recognize critical disease manifestations and predict stage, surgical complexity, and residual disease, which allow accurate qualification of patients for primary debulking surgery or neoadjuvant chemotherapy.

Occurrence of residual disease in specimens of re-excision surgery in patients with positive margins of primary quadrantectomy

Performing a re-intervention following a positive margin after primary lumpectomy in patients with breast cancer entails several disadvantages such as additional costs and postponing the follow-up treatments. In the present study, we sought to measure the incidence rate of residual disease in specimens taken from breast cancer patients who had positive margins after quadrantectomy and also compare the clinical and pathological factors between patients with and without a residual disease after the secondary surgery. All of the medical records of patients undergoing quadrantectomy from December 1994 to December 2019 were collected from Shiraz Breast Cancer Registry (SBCR). Patients were divided into two subgroups of patients with and without residual disease from the secondary surgery and also with and without positive margin from the first operation. Two groups were compared in terms of all clinicopathological factors. The records of 4843 patients undergoing quadrantectomy were reviewed, of which 132 (2.3%) had involved margins. Of these, 112 patients underwent a secondary surgery and 28 had residual disease (25%). No clinicopathological factor was correlated with presence of residual cancer. Also, bigger tumor size (p < 0.001) and the presence of in situ component (p < 0.001) were associated with positive margin and hence the need for a re-excision surgery. These results revealed that the significant rate of residual disease in the specimens of the secondary surgery indicates that a re-operation (either re-excision or simple mastectomy) cannot be omitted after obtaining a positive margin from the primary quadrantectomy.

Liquid Biopsy Hotspot Variant Assays: Analytical Validation for Application in Residual Disease Detection and Treatment Monitoring

BACKGROUND

Analysis of circulating tumor DNA (ctDNA) in plasma is a powerful approach to guide decisions in personalized cancer treatment. Given the low concentration of ctDNA in plasma, highly sensitive methods are required to reliably identify clinically relevant variants.

METHODS

We evaluated the suitability of 5 droplet digital PCR (ddPCR) assays targeting KRAS, BRAF, and EGFR variants for ctDNA analysis in clinical use.

RESULTS

We investigated assay performance characteristics for very low amounts of variants, showing that the assays had very low limits of blank (0% to 0.11% variant allele frequency, VAF) and limits of quantification (0.41% to 0.7% VAF). Nevertheless, striking differences in detection and quantification of low mutant VAFs between the 5 tested assays were observed, highlighting the need for assay-specific analytical validation. Besides in-depth evaluation, a guide for clinical interpretation of obtained VAFs in plasma was developed, depending on the limits of blank and limits of quantification values.

CONCLUSION

It is possible to provide comprehensive clinical reports on actionable variants, allowing minimal residual disease detection and treatment monitoring in liquid biopsy.

Implementation of immunotherapy into the treatment of neuroblastoma - single center experience with the administration of dinutuximab and management of its adverse effects

BACKGROUND

Neuroblastoma is the most common extracranial solid tumour of childhood with extremely heterogeneous bio-logical and clinical behaviour. Despite advances in its treatment, the long-term prognosis of patients with a high-risk and relapsed neuroblastoma remains poor. The implementation of immunotherapy into the treatment protocols has the potential to improve it. Dinutuximab, a chimeric monoclonal antibody, leads to the apoptosis of tumour cells through binding to the GD2 receptor. The article aim is to present the first experience of our centre with dinutuximab treatment.

PATIENTS AND METHODS

In 2018-2019, we administered 31 cycles of dinutuximab to seven patients. Five patients with high-risk neuroblastoma received dinutuximab in the first line, in two patients with relapse, dinutuximab was administered in the second line of treatment. To evaluate the toxicity of the treatment, the nursing records of patients during immunotherapy were retrospectively analysed.

RESULTS

Two patients treated with dinutuximab in the first line are in complete remission, three patients achieved a partial response. Both patients with relapsed neuroblastoma were dia-gnosed with a second relapse after immunotherapy and died of disease progression. The treatment tolerance was acceptable in most patients - in six patients adverse events were managed with adequate supportive care. These were mainly symptoms of capillary leak syndrome, pain and hypersensitivity reactions. In one patient, the treatment was discontinued due to severe neurotoxicity.

CONCLUSION

Dinutuximab has a proven benefit in the eradication of the minimal residual disease in the treatment of neuroblastoma. Immunotherapy is currently the standard for first-line treatment of high-risk neuroblastoma. Its role in the treatment of relapsed neuroblastoma is a subject of several ongoing studies as well as the optimization of therapeutic regimens. Dinutuximab administration is associated with a considerable risk of severe adverse reactions, so the treatment belongs to the hands of an experienced paediatric oncology centre.