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BRCA2 mutations linked to greater risk for pancreatic cancer
MIAMI BEACH – Although population-wide screening for pancreatic cancer is considered unfeasible and costly, new evidence suggests a benefit to screening a select population: people who test positive for BRCA2 genetic mutations.
Cross-sectional imaging of 117 people with BRCA2 mutations revealed pancreatic abnormalities in 10 patients, including a patient with pancreatic cancer whose only symptom was unexplained weight loss.
Pancreatic cancer is not as common as are some other malignancies, with an incidence estimated between 1% and 3%. However, it is a particularly deadly form of cancer, with only 7.7% of people living to 5 years after diagnosis, according to data from the National Cancer Institute.
A relatively low incidence is a good thing, but it also limits widespread screening. “There is a low predictive value of screening the population at large, and it is not considered cost effective,” said Eugene P. Ceppa, MD, a general surgeon at IU Health University Hospital, Indianapolis. However, patients at high risk for pancreatic adenocarcinoma might be worth targeting for screening, he added.
“This represents a 21% increase in the chance of pancreatic cancer in these patients,” Dr. Ceppa said.
Buoyed by these and other findings, Dr. Ceppa and his colleagues launched a study of their own. “Our hypothesis is that screening all BRCA2s would identify more patients with pancreatic cancer,” he said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Dr. Ceppa and coinvestigators reviewed electronic medical records at their institution from 2005 to 2015. They identified 204 BRCA mutation carriers, and after excluding 87 BRCA1 positive patients, further assessed the 117 with documented BRCA2 mutations. A total 47 people (40%) of this group had undergone cross-sectional imaging. The images were initially reviewed, and then re-reviewed for the study, by radiologists with specific expertise in pancreatology.
The cross-sectional imaging revealed pancreatic abnormalities in 10 people, including 1 patient with a pancreatic ductal adenocarcinoma located in the head of the pancreas. Another nine patients had intraductal papillary mucinous neoplasms (IPMNs). There were no significant demographic or clinical differences between the groups of patients with and without the imaging abnormalities, Dr. Ceppa said.
The investigators also compared the patients with BRCA2 mutations against a historical cohort representing the general population. They found 21% of patients with BRCA2 had a defined pancreatic abnormality, compared with 8% in the general population. The difference was statistically significant (P = .007).
Interestingly, the same comparison also revealed a rate of IPMN of 19%, versus 1%, respectively (P less than .001). “BRCA2 mutation carriers have significantly higher incidence of IPMN than the general population,” Dr. Ceppa said.
The study results support a high-risk screening protocol in asymptomatic BRCA patients regardless of family history, he said. In fact, a high-risk screening protocol implemented at his institution in 2013 led to a 14% detection rate of pancreatic cancer among BRCA2-positive patients, compared with a 3% rate in the general population.
“Your most significant finding might be the more IPMN patients – but how do we follow them, and will it be cost effective?” asked invited discussant Matthew J. Weiss, MD, of Johns Hopkins Medicine in Baltimore.
One of the most notable impacts of instituting the high-risk screening protocol has been an increase in patient referrals from other specialists at Dr. Ceppa’s institution. “I’ve looked at every single breast surgeon in our department, and I know how each of them are referring,” he explained.
Following initial screening of BRCA2 mutation patients, Dr. Ceppa repeats screening at 6 months, 1 year, and then annually. “However, some insurers may balk at our recommendations for frequency of screening,” he noted.
Dr. Ceppa and Dr. Weiss had no relevant financial disclosures.
MIAMI BEACH – Although population-wide screening for pancreatic cancer is considered unfeasible and costly, new evidence suggests a benefit to screening a select population: people who test positive for BRCA2 genetic mutations.
Cross-sectional imaging of 117 people with BRCA2 mutations revealed pancreatic abnormalities in 10 patients, including a patient with pancreatic cancer whose only symptom was unexplained weight loss.
Pancreatic cancer is not as common as are some other malignancies, with an incidence estimated between 1% and 3%. However, it is a particularly deadly form of cancer, with only 7.7% of people living to 5 years after diagnosis, according to data from the National Cancer Institute.
A relatively low incidence is a good thing, but it also limits widespread screening. “There is a low predictive value of screening the population at large, and it is not considered cost effective,” said Eugene P. Ceppa, MD, a general surgeon at IU Health University Hospital, Indianapolis. However, patients at high risk for pancreatic adenocarcinoma might be worth targeting for screening, he added.
“This represents a 21% increase in the chance of pancreatic cancer in these patients,” Dr. Ceppa said.
Buoyed by these and other findings, Dr. Ceppa and his colleagues launched a study of their own. “Our hypothesis is that screening all BRCA2s would identify more patients with pancreatic cancer,” he said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Dr. Ceppa and coinvestigators reviewed electronic medical records at their institution from 2005 to 2015. They identified 204 BRCA mutation carriers, and after excluding 87 BRCA1 positive patients, further assessed the 117 with documented BRCA2 mutations. A total 47 people (40%) of this group had undergone cross-sectional imaging. The images were initially reviewed, and then re-reviewed for the study, by radiologists with specific expertise in pancreatology.
The cross-sectional imaging revealed pancreatic abnormalities in 10 people, including 1 patient with a pancreatic ductal adenocarcinoma located in the head of the pancreas. Another nine patients had intraductal papillary mucinous neoplasms (IPMNs). There were no significant demographic or clinical differences between the groups of patients with and without the imaging abnormalities, Dr. Ceppa said.
The investigators also compared the patients with BRCA2 mutations against a historical cohort representing the general population. They found 21% of patients with BRCA2 had a defined pancreatic abnormality, compared with 8% in the general population. The difference was statistically significant (P = .007).
Interestingly, the same comparison also revealed a rate of IPMN of 19%, versus 1%, respectively (P less than .001). “BRCA2 mutation carriers have significantly higher incidence of IPMN than the general population,” Dr. Ceppa said.
The study results support a high-risk screening protocol in asymptomatic BRCA patients regardless of family history, he said. In fact, a high-risk screening protocol implemented at his institution in 2013 led to a 14% detection rate of pancreatic cancer among BRCA2-positive patients, compared with a 3% rate in the general population.
“Your most significant finding might be the more IPMN patients – but how do we follow them, and will it be cost effective?” asked invited discussant Matthew J. Weiss, MD, of Johns Hopkins Medicine in Baltimore.
One of the most notable impacts of instituting the high-risk screening protocol has been an increase in patient referrals from other specialists at Dr. Ceppa’s institution. “I’ve looked at every single breast surgeon in our department, and I know how each of them are referring,” he explained.
Following initial screening of BRCA2 mutation patients, Dr. Ceppa repeats screening at 6 months, 1 year, and then annually. “However, some insurers may balk at our recommendations for frequency of screening,” he noted.
Dr. Ceppa and Dr. Weiss had no relevant financial disclosures.
MIAMI BEACH – Although population-wide screening for pancreatic cancer is considered unfeasible and costly, new evidence suggests a benefit to screening a select population: people who test positive for BRCA2 genetic mutations.
Cross-sectional imaging of 117 people with BRCA2 mutations revealed pancreatic abnormalities in 10 patients, including a patient with pancreatic cancer whose only symptom was unexplained weight loss.
Pancreatic cancer is not as common as are some other malignancies, with an incidence estimated between 1% and 3%. However, it is a particularly deadly form of cancer, with only 7.7% of people living to 5 years after diagnosis, according to data from the National Cancer Institute.
A relatively low incidence is a good thing, but it also limits widespread screening. “There is a low predictive value of screening the population at large, and it is not considered cost effective,” said Eugene P. Ceppa, MD, a general surgeon at IU Health University Hospital, Indianapolis. However, patients at high risk for pancreatic adenocarcinoma might be worth targeting for screening, he added.
“This represents a 21% increase in the chance of pancreatic cancer in these patients,” Dr. Ceppa said.
Buoyed by these and other findings, Dr. Ceppa and his colleagues launched a study of their own. “Our hypothesis is that screening all BRCA2s would identify more patients with pancreatic cancer,” he said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Dr. Ceppa and coinvestigators reviewed electronic medical records at their institution from 2005 to 2015. They identified 204 BRCA mutation carriers, and after excluding 87 BRCA1 positive patients, further assessed the 117 with documented BRCA2 mutations. A total 47 people (40%) of this group had undergone cross-sectional imaging. The images were initially reviewed, and then re-reviewed for the study, by radiologists with specific expertise in pancreatology.
The cross-sectional imaging revealed pancreatic abnormalities in 10 people, including 1 patient with a pancreatic ductal adenocarcinoma located in the head of the pancreas. Another nine patients had intraductal papillary mucinous neoplasms (IPMNs). There were no significant demographic or clinical differences between the groups of patients with and without the imaging abnormalities, Dr. Ceppa said.
The investigators also compared the patients with BRCA2 mutations against a historical cohort representing the general population. They found 21% of patients with BRCA2 had a defined pancreatic abnormality, compared with 8% in the general population. The difference was statistically significant (P = .007).
Interestingly, the same comparison also revealed a rate of IPMN of 19%, versus 1%, respectively (P less than .001). “BRCA2 mutation carriers have significantly higher incidence of IPMN than the general population,” Dr. Ceppa said.
The study results support a high-risk screening protocol in asymptomatic BRCA patients regardless of family history, he said. In fact, a high-risk screening protocol implemented at his institution in 2013 led to a 14% detection rate of pancreatic cancer among BRCA2-positive patients, compared with a 3% rate in the general population.
“Your most significant finding might be the more IPMN patients – but how do we follow them, and will it be cost effective?” asked invited discussant Matthew J. Weiss, MD, of Johns Hopkins Medicine in Baltimore.
One of the most notable impacts of instituting the high-risk screening protocol has been an increase in patient referrals from other specialists at Dr. Ceppa’s institution. “I’ve looked at every single breast surgeon in our department, and I know how each of them are referring,” he explained.
Following initial screening of BRCA2 mutation patients, Dr. Ceppa repeats screening at 6 months, 1 year, and then annually. “However, some insurers may balk at our recommendations for frequency of screening,” he noted.
Dr. Ceppa and Dr. Weiss had no relevant financial disclosures.
Key clinical point: Although general population screening for pancreatic cancer is considered costly, with a low predictive value, targeting screening to patients with BRCA2 mutations could detect more cases of this deadly disease.
Major finding: People with BRCA2 mutations had a significantly greater incidence of intraductal papillary mucinous neoplasms, 19%, versus 1% in the general population (P less than .001).
Data source: Retrospective study of electronic medical records of 117 patients with BRCA2 mutations at a single academic institution.
Disclosures: Dr. Ceppa and Dr. Weiss had no relevant financial disclosures.
Coming soon!
Watch for our on-site coverage of the 18th annual meeting of the American Society of Breast Surgeons, which will take place in Las Vegas April 26-30.
Watch for our on-site coverage of the 18th annual meeting of the American Society of Breast Surgeons, which will take place in Las Vegas April 26-30.
Watch for our on-site coverage of the 18th annual meeting of the American Society of Breast Surgeons, which will take place in Las Vegas April 26-30.
U.S. thyroid cancer incidence, mortality on the upswing
ORLANDO – with incidence-based mortality increasing by 1.1% annually from 1994 to 2013, according to a study conducted by the National Cancer Institute.
In a study of 77,726 patients diagnosed with thyroid cancer between 1974 and 2013, incidence rates increased from 4.56 per 100,000 person-years during 1974-1977 to 14.42 per 100,000 person-years during 2010-2013, according to Hyeyeun Lim, PhD, a postdoctoral fellow at National Cancer Institute, and colleagues (JAMA. 2017;317[13]:1338-48).
A majority of patients in the sample were female (75%) and white (82%); average age was 48 years.
A notable trend was the increase in papillary thyroid cancer (PTC). PTC was the most common thyroid cancer at 83.6% of diagnoses, followed by follicular, medullary, anaplastic, and other at 10.8%, 2.2%, 1.3%, and 2.1%, respectively. PTC was associated with the highest annual percent change (4.4%) and the only positive incidence-based mortality annual percent change (1.7%) among all histologic types, according to the researchers.
Regional and distant tumors accounted for 53.2% and 29% of deaths, respectively, compared to 13.5% for local tumors.
Dr. Lim and colleagues interpret the increase in incidence to contradict a common idea among researchers that attributes rising rates to new methods of detection such as ultrasound imaging and fine-needle aspiration biopsies.
“Such changes could account for the rapid increases in the incidence rates for localized and small PTCs that have been previously observed,” the researchers reported. “However, the significant, albeit less-rapid increase in advanced-stage and larger PTC incidence rates and increasing thyroid cancer mortality rates among patients diagnosed with advanced-stage PTC is not consistent with the notion that over-diagnosis is solely responsible for the changing trends in PTC incidence.”
While the researchers reported increased mortality rates among all PTC demographics, statistical significance was found solely in patients with distant disease (annual percentage changes, 2.9% [95% confidence interval, 1.1%-4.7%]), stage IV disease (APC, 12.9%[95%CI, 7.2%-19.0%]), or both, according to researchers.
Researchers speculate increased rates of obesity, childhood ionizing radiation exposure, and increased exposure to pesticides may be possible sources for increased rates of PTC, however Dr. Lim and peers assert further research must be conducted.
Based on these findings, researchers suggest “renewed focus on aggressive transdisciplinary management that includes surgery, adjuvant radioactive iodine, and, when indicated for the 5%-10% of patients who develop progressive disease, systemic therapy,” for patients with advanced-stage PTC.
Due to the nature of the study, researchers were limited to speculating potential reasons for increase in thyroid cancer incidence. Information of tumor size and stage was limited to the years when this information began to be recorded, after the initial years included in the study.
[email protected]
On Twitter @EAZTweets
ORLANDO – with incidence-based mortality increasing by 1.1% annually from 1994 to 2013, according to a study conducted by the National Cancer Institute.
In a study of 77,726 patients diagnosed with thyroid cancer between 1974 and 2013, incidence rates increased from 4.56 per 100,000 person-years during 1974-1977 to 14.42 per 100,000 person-years during 2010-2013, according to Hyeyeun Lim, PhD, a postdoctoral fellow at National Cancer Institute, and colleagues (JAMA. 2017;317[13]:1338-48).
A majority of patients in the sample were female (75%) and white (82%); average age was 48 years.
A notable trend was the increase in papillary thyroid cancer (PTC). PTC was the most common thyroid cancer at 83.6% of diagnoses, followed by follicular, medullary, anaplastic, and other at 10.8%, 2.2%, 1.3%, and 2.1%, respectively. PTC was associated with the highest annual percent change (4.4%) and the only positive incidence-based mortality annual percent change (1.7%) among all histologic types, according to the researchers.
Regional and distant tumors accounted for 53.2% and 29% of deaths, respectively, compared to 13.5% for local tumors.
Dr. Lim and colleagues interpret the increase in incidence to contradict a common idea among researchers that attributes rising rates to new methods of detection such as ultrasound imaging and fine-needle aspiration biopsies.
“Such changes could account for the rapid increases in the incidence rates for localized and small PTCs that have been previously observed,” the researchers reported. “However, the significant, albeit less-rapid increase in advanced-stage and larger PTC incidence rates and increasing thyroid cancer mortality rates among patients diagnosed with advanced-stage PTC is not consistent with the notion that over-diagnosis is solely responsible for the changing trends in PTC incidence.”
While the researchers reported increased mortality rates among all PTC demographics, statistical significance was found solely in patients with distant disease (annual percentage changes, 2.9% [95% confidence interval, 1.1%-4.7%]), stage IV disease (APC, 12.9%[95%CI, 7.2%-19.0%]), or both, according to researchers.
Researchers speculate increased rates of obesity, childhood ionizing radiation exposure, and increased exposure to pesticides may be possible sources for increased rates of PTC, however Dr. Lim and peers assert further research must be conducted.
Based on these findings, researchers suggest “renewed focus on aggressive transdisciplinary management that includes surgery, adjuvant radioactive iodine, and, when indicated for the 5%-10% of patients who develop progressive disease, systemic therapy,” for patients with advanced-stage PTC.
Due to the nature of the study, researchers were limited to speculating potential reasons for increase in thyroid cancer incidence. Information of tumor size and stage was limited to the years when this information began to be recorded, after the initial years included in the study.
[email protected]
On Twitter @EAZTweets
ORLANDO – with incidence-based mortality increasing by 1.1% annually from 1994 to 2013, according to a study conducted by the National Cancer Institute.
In a study of 77,726 patients diagnosed with thyroid cancer between 1974 and 2013, incidence rates increased from 4.56 per 100,000 person-years during 1974-1977 to 14.42 per 100,000 person-years during 2010-2013, according to Hyeyeun Lim, PhD, a postdoctoral fellow at National Cancer Institute, and colleagues (JAMA. 2017;317[13]:1338-48).
A majority of patients in the sample were female (75%) and white (82%); average age was 48 years.
A notable trend was the increase in papillary thyroid cancer (PTC). PTC was the most common thyroid cancer at 83.6% of diagnoses, followed by follicular, medullary, anaplastic, and other at 10.8%, 2.2%, 1.3%, and 2.1%, respectively. PTC was associated with the highest annual percent change (4.4%) and the only positive incidence-based mortality annual percent change (1.7%) among all histologic types, according to the researchers.
Regional and distant tumors accounted for 53.2% and 29% of deaths, respectively, compared to 13.5% for local tumors.
Dr. Lim and colleagues interpret the increase in incidence to contradict a common idea among researchers that attributes rising rates to new methods of detection such as ultrasound imaging and fine-needle aspiration biopsies.
“Such changes could account for the rapid increases in the incidence rates for localized and small PTCs that have been previously observed,” the researchers reported. “However, the significant, albeit less-rapid increase in advanced-stage and larger PTC incidence rates and increasing thyroid cancer mortality rates among patients diagnosed with advanced-stage PTC is not consistent with the notion that over-diagnosis is solely responsible for the changing trends in PTC incidence.”
While the researchers reported increased mortality rates among all PTC demographics, statistical significance was found solely in patients with distant disease (annual percentage changes, 2.9% [95% confidence interval, 1.1%-4.7%]), stage IV disease (APC, 12.9%[95%CI, 7.2%-19.0%]), or both, according to researchers.
Researchers speculate increased rates of obesity, childhood ionizing radiation exposure, and increased exposure to pesticides may be possible sources for increased rates of PTC, however Dr. Lim and peers assert further research must be conducted.
Based on these findings, researchers suggest “renewed focus on aggressive transdisciplinary management that includes surgery, adjuvant radioactive iodine, and, when indicated for the 5%-10% of patients who develop progressive disease, systemic therapy,” for patients with advanced-stage PTC.
Due to the nature of the study, researchers were limited to speculating potential reasons for increase in thyroid cancer incidence. Information of tumor size and stage was limited to the years when this information began to be recorded, after the initial years included in the study.
[email protected]
On Twitter @EAZTweets
AT ENDO 2017
Key clinical point:
Major finding: Thyroid cancer incidence increased 3.6% from 1974 to 2013 and incidence-based mortality increased by 1.1% per year from 1994 to 2013.
Data source: A retrospective study of 77,726 patient records attained from Surveillance, Epidemiology, and End Results–9 cancer registry database, analyzed via log-linear regression.
Disclosures: Dr. Julie Sosa reported being on the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry, which is sponsored by AstraZeneca, Eli Lilly, GlaxoSmithKline, and Novo Nordisk.
Safe to avoid sentinel node biopsy in some breast cancer patients
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
Are there patients older than 70 years of age who have a low risk of nodal metastasis and/or even if they had nodal metastasis, could be adequately treated with anti-hormones?
If the answer is “yes,” then sentinel node sampling can be avoided in these patients. This study identified a group with a low risk for nodal metastasis. Even though it may be difficult to estimate tumor size preoperatively for lobular cancers, this is less of a problem for ductal cancers. Another approach is to use molecular profiling to determine which patients may “skip” sentinel node biopsy. Molecular profiling can identify patients who will have an excellent outcome with adjuvant anti-hormones even in the presence of nodal metastases.
Maureen Chung, MD, FACS, is medical director of the breast care program at Southcoast Health, North Dartmouth, Mass.
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.
In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.
The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.
“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”
She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”
Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.
They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).
The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.
The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.
Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.
“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.
In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.
When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).
Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).
“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”
But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.
The investigator had no disclosures.
Key clinical point: Sentinel node biopsy can be safely avoided in certain populations of breast cancer patients.
Major finding: In women 70 years and older with hormone receptor (HR)–positive invasive breast cancer who are at low risk, sentinel node surgery can safely be avoided.
Data source: Two large databases of more than 150,000 women, from the Mayo Clinic and the National Cancer Database.
Disclosures: There was no funding source disclosed. The author had no disclosures.
Preoperative variables can predict prolonged air leak
Prolonged air leak is a well-known complication after lung cancer surgery that can worsen patient outcomes and drive up costs, and while international authors have developed tools to calculate the risk of PAL, their use has been limited in the United States for various reasons. Researchers at the University of Pittsburgh have reported on a predictive model that uses easy-to-obtain patient factors, such as forced expiratory volume and smoking history, to help surgeons identify patients at greatest risk for complications and implement preventative measures.
Adam Attaar and his coauthors reported that their nomogram had an accuracy rate of 76%, with a 95% confidence interval, for predicting PAL after surgery (J Thorac Cardiovasc Surg. 2017 March;153[3]:690-9). “Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability,” noted Mr. Attaar, a student at University of Pittsburgh, and his coauthors.
Previously published reports put the incidence of PAL complications at 6%-18%, they noted. In the University of Pittsburgh series of 2,317 patients who had pulmonary resection for lung cancer or nodules from January 2009 to June 2014, the incidence was 8.6%.
In this series, patients with PAL were more likely to be older, men, and smokers, and to have a lower body mass index, peripheral vascular disease, chronic obstructive pulmonary disease, a history of steroid use, a high Zubrod score and lower forced expiratory volume.“They were less likely to have diabetes or to be hospitalized before surgery,” the researchers said. Surgical factors that characterized patients with PAL were resection for primary lung cancer rather than benign or metastatic tumors; lobectomy/segmentectomy or bilobectomy rather than wedge resection; a right-sided resection; thoracotomy; and a surgeon with higher annual caseloads.
Not all those factors made it into the nomogram, however. The nomogram scores each of these 10 variables to calculate the risk of PAL, in order of their weighting: lower forced expiratory volume, procedure type, BMI, right-sided thoracotomy, preoperative hospitalization, annual surgeon caseload, wedge resection by thoracotomy, reoperation, smoking history, and Zubrod score. A second nomogram drops out surgeon volume to make it more generalizable to other institutions.
In explaining higher surgeon volume as a risk factor for PAL, the researchers said that high-volume surgeons may be operating on patients with variables not accounted for in the Society of Thoracic Surgeons General Thoracic Surgery Database. “These unmeasured variables … could reveal modifiable technical factors to reduce the incidence of PAL and require further study,” the researchers said.
Fast-track discharge has gained acceptance in recent years as a way to spare patients a prolonged hospital stay and cut costs, but in this series the median hospital stay for patients with PAL was 10 days vs. 4 days for non-PAL patients (P less than 0.001).
“An accurate and generalizable PAL risk stratification tool could facilitate surgical decision making and patient-specific care” and aid in the design of trials to evaluate air-leak reduction methods such as sealants, buttressed staple lines, and pneumoperitoneum the researchers wrote.
Going forward, further development of the model would involve a multicenter study and inclusion of risk factors not accounted for in the thoracic surgery database, they noted.
The researchers had no relevant financial relationships to disclose.
The authors of this study “have performed a rigorous set of analyses to create this model,” Chi-Fu Jeffrey Yang, MD, of Duke University, Durham, N.C., noted in his invited commentary (J Thorac Cardiovasc Surg. 2017 March;53[3]:700-1). “The strengths of this study include its sound statistical analysis and study design,” Dr. Yang wrote. He gave the authors credit for using bootstrapping to internally validate the model.
However, Dr. Yang said that the database used by the researchers did not account for “numerous important variables,” including presence of pleural adhesions and emphysema status. The analysis also grouped lobectomy and segmentectomy together, and did not consider intraoperative variables such as sealant use, or postoperative management.
While Dr. Yang commended the study authors for developing a “reliable nomogram,” getting it implemented in the clinic is another hurdle. “It is commonly cited that it takes approximately 17 years for research evidence to translate into daily practice,” he said. To shorten that time line, he suggested the authors take a cue from various tech groups: Develop an app that surgeons can use.
Dr. Yang had no relevant financial relationships to disclose.
The authors of this study “have performed a rigorous set of analyses to create this model,” Chi-Fu Jeffrey Yang, MD, of Duke University, Durham, N.C., noted in his invited commentary (J Thorac Cardiovasc Surg. 2017 March;53[3]:700-1). “The strengths of this study include its sound statistical analysis and study design,” Dr. Yang wrote. He gave the authors credit for using bootstrapping to internally validate the model.
However, Dr. Yang said that the database used by the researchers did not account for “numerous important variables,” including presence of pleural adhesions and emphysema status. The analysis also grouped lobectomy and segmentectomy together, and did not consider intraoperative variables such as sealant use, or postoperative management.
While Dr. Yang commended the study authors for developing a “reliable nomogram,” getting it implemented in the clinic is another hurdle. “It is commonly cited that it takes approximately 17 years for research evidence to translate into daily practice,” he said. To shorten that time line, he suggested the authors take a cue from various tech groups: Develop an app that surgeons can use.
Dr. Yang had no relevant financial relationships to disclose.
The authors of this study “have performed a rigorous set of analyses to create this model,” Chi-Fu Jeffrey Yang, MD, of Duke University, Durham, N.C., noted in his invited commentary (J Thorac Cardiovasc Surg. 2017 March;53[3]:700-1). “The strengths of this study include its sound statistical analysis and study design,” Dr. Yang wrote. He gave the authors credit for using bootstrapping to internally validate the model.
However, Dr. Yang said that the database used by the researchers did not account for “numerous important variables,” including presence of pleural adhesions and emphysema status. The analysis also grouped lobectomy and segmentectomy together, and did not consider intraoperative variables such as sealant use, or postoperative management.
While Dr. Yang commended the study authors for developing a “reliable nomogram,” getting it implemented in the clinic is another hurdle. “It is commonly cited that it takes approximately 17 years for research evidence to translate into daily practice,” he said. To shorten that time line, he suggested the authors take a cue from various tech groups: Develop an app that surgeons can use.
Dr. Yang had no relevant financial relationships to disclose.
Prolonged air leak is a well-known complication after lung cancer surgery that can worsen patient outcomes and drive up costs, and while international authors have developed tools to calculate the risk of PAL, their use has been limited in the United States for various reasons. Researchers at the University of Pittsburgh have reported on a predictive model that uses easy-to-obtain patient factors, such as forced expiratory volume and smoking history, to help surgeons identify patients at greatest risk for complications and implement preventative measures.
Adam Attaar and his coauthors reported that their nomogram had an accuracy rate of 76%, with a 95% confidence interval, for predicting PAL after surgery (J Thorac Cardiovasc Surg. 2017 March;153[3]:690-9). “Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability,” noted Mr. Attaar, a student at University of Pittsburgh, and his coauthors.
Previously published reports put the incidence of PAL complications at 6%-18%, they noted. In the University of Pittsburgh series of 2,317 patients who had pulmonary resection for lung cancer or nodules from January 2009 to June 2014, the incidence was 8.6%.
In this series, patients with PAL were more likely to be older, men, and smokers, and to have a lower body mass index, peripheral vascular disease, chronic obstructive pulmonary disease, a history of steroid use, a high Zubrod score and lower forced expiratory volume.“They were less likely to have diabetes or to be hospitalized before surgery,” the researchers said. Surgical factors that characterized patients with PAL were resection for primary lung cancer rather than benign or metastatic tumors; lobectomy/segmentectomy or bilobectomy rather than wedge resection; a right-sided resection; thoracotomy; and a surgeon with higher annual caseloads.
Not all those factors made it into the nomogram, however. The nomogram scores each of these 10 variables to calculate the risk of PAL, in order of their weighting: lower forced expiratory volume, procedure type, BMI, right-sided thoracotomy, preoperative hospitalization, annual surgeon caseload, wedge resection by thoracotomy, reoperation, smoking history, and Zubrod score. A second nomogram drops out surgeon volume to make it more generalizable to other institutions.
In explaining higher surgeon volume as a risk factor for PAL, the researchers said that high-volume surgeons may be operating on patients with variables not accounted for in the Society of Thoracic Surgeons General Thoracic Surgery Database. “These unmeasured variables … could reveal modifiable technical factors to reduce the incidence of PAL and require further study,” the researchers said.
Fast-track discharge has gained acceptance in recent years as a way to spare patients a prolonged hospital stay and cut costs, but in this series the median hospital stay for patients with PAL was 10 days vs. 4 days for non-PAL patients (P less than 0.001).
“An accurate and generalizable PAL risk stratification tool could facilitate surgical decision making and patient-specific care” and aid in the design of trials to evaluate air-leak reduction methods such as sealants, buttressed staple lines, and pneumoperitoneum the researchers wrote.
Going forward, further development of the model would involve a multicenter study and inclusion of risk factors not accounted for in the thoracic surgery database, they noted.
The researchers had no relevant financial relationships to disclose.
Prolonged air leak is a well-known complication after lung cancer surgery that can worsen patient outcomes and drive up costs, and while international authors have developed tools to calculate the risk of PAL, their use has been limited in the United States for various reasons. Researchers at the University of Pittsburgh have reported on a predictive model that uses easy-to-obtain patient factors, such as forced expiratory volume and smoking history, to help surgeons identify patients at greatest risk for complications and implement preventative measures.
Adam Attaar and his coauthors reported that their nomogram had an accuracy rate of 76%, with a 95% confidence interval, for predicting PAL after surgery (J Thorac Cardiovasc Surg. 2017 March;153[3]:690-9). “Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability,” noted Mr. Attaar, a student at University of Pittsburgh, and his coauthors.
Previously published reports put the incidence of PAL complications at 6%-18%, they noted. In the University of Pittsburgh series of 2,317 patients who had pulmonary resection for lung cancer or nodules from January 2009 to June 2014, the incidence was 8.6%.
In this series, patients with PAL were more likely to be older, men, and smokers, and to have a lower body mass index, peripheral vascular disease, chronic obstructive pulmonary disease, a history of steroid use, a high Zubrod score and lower forced expiratory volume.“They were less likely to have diabetes or to be hospitalized before surgery,” the researchers said. Surgical factors that characterized patients with PAL were resection for primary lung cancer rather than benign or metastatic tumors; lobectomy/segmentectomy or bilobectomy rather than wedge resection; a right-sided resection; thoracotomy; and a surgeon with higher annual caseloads.
Not all those factors made it into the nomogram, however. The nomogram scores each of these 10 variables to calculate the risk of PAL, in order of their weighting: lower forced expiratory volume, procedure type, BMI, right-sided thoracotomy, preoperative hospitalization, annual surgeon caseload, wedge resection by thoracotomy, reoperation, smoking history, and Zubrod score. A second nomogram drops out surgeon volume to make it more generalizable to other institutions.
In explaining higher surgeon volume as a risk factor for PAL, the researchers said that high-volume surgeons may be operating on patients with variables not accounted for in the Society of Thoracic Surgeons General Thoracic Surgery Database. “These unmeasured variables … could reveal modifiable technical factors to reduce the incidence of PAL and require further study,” the researchers said.
Fast-track discharge has gained acceptance in recent years as a way to spare patients a prolonged hospital stay and cut costs, but in this series the median hospital stay for patients with PAL was 10 days vs. 4 days for non-PAL patients (P less than 0.001).
“An accurate and generalizable PAL risk stratification tool could facilitate surgical decision making and patient-specific care” and aid in the design of trials to evaluate air-leak reduction methods such as sealants, buttressed staple lines, and pneumoperitoneum the researchers wrote.
Going forward, further development of the model would involve a multicenter study and inclusion of risk factors not accounted for in the thoracic surgery database, they noted.
The researchers had no relevant financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Preoperative variables can be evaluated to determine patient risk for prolonged air leak (PAL) in lung resection for cancer.
Major finding: A nomogram demonstrated 76% discriminatory accuracy in predicting PAL after lung resection.
Data source: Analysis of 2,522 pulmonary resections performed at eight hospitals within the University of Pittsburgh health system from January 2009 to June 2014.
Disclosures: The researchers had no conflicts of interest to disclose.
Isolated tumor cells did not predict progression in endometrial cancer
NATIONAL HARBOR, MD. – Patients with endometrial cancer should not receive adjuvant chemotherapy or radiotherapy solely because they have isolated tumor cells in their sentinel lymph nodes, Marie Plante, MD, said during an oral presentation at the annual meeting of the Society of Gynecologic Oncology.
In a single-center prospective cohort study, about 96% of patients with endometrial cancer were alive and progression free at 3 years, a rate which resembles those reported for node-negative patients, said Dr. Plante of Laval University, Quebec City. Moreover, all 10 patients who did not receive adjuvant therapy remained alive and progression free during follow-up, she said. “Patients with isolated tumor cells carry an excellent prognosis,” she added. “Adjuvant treatment should be tailored based on uterine factors and histology and not solely on the presence of isolated tumor cells in sentinel lymph nodes.”
Pathologic ultrastaging has boosted the detection of low-volume metastases, which comprise anywhere from 35% to 63% of nodal metastases in patients with endometrial cancer. Clinicians continue to debate management when this low-volume disease consists of isolated tumor cells (ITC), defined as fewer than 200 carcinoma cells found singly or in small clusters. Finding ITC in endometrial cancer is uncommon, and few studies have examined this subgroup, Dr. Plante noted.
She and her associates evaluated 519 patients who underwent hysterectomy, salpingo-oophorectomy, lymphadenectomy, or sentinel lymph node mapping for endometrial cancer at their center between 2010 and 2015. Pathologic ultrastaging identified 31 patients with ITC (6%), of whom 11 patients received adjuvant chemotherapy, 14 received pelvic radiation therapy, and 10 underwent only brachytherapy or observation, with some patients receiving more than one treatment. Another 54 patients in the cohort had metastatic disease, including 43 patients with macrometastasis and 11 with micrometastasis.
Stage, not treatment, predicted progression-free survival (PFS), Dr. Plante emphasized. After a median follow-up period of 29 months, the estimated 3-year rate of PFS was significantly better among patients with ITC (96%), node-negative disease (88%), or micrometastasis (86%) than among those with macrometastasis (59%; P = .001), even though macrometastasis patients received significantly more chemotherapy (P = .0001).
Rates of PFS did not statistically differ between the ITC and node-negative groups, Dr. Plante noted. The single recurrence in an ITC patient involved a 7 cm carcinosarcoma that recurred despite adjuvant chemotherapy and radiation therapy. There were no recurrences among patients with endometrioid histology.
Among ITC patients who received no adjuvant treatment, half had stage IA endometrial cancer and half were stage IB, half were grade 1 and half were grade 2, all had endometrioid histology, and seven (70%) had evidence of lymphovascular space invasion, Dr. Plante said. All remained alive and progression free at follow-up.
Ultrastaging should only be performed if a sentinel lymph node is negative on initial hematoxylin and eosin stain and if there is myoinvasion, commented Nadeem R. Abu-Rustum, MD, chief of the gynecology service at Memorial Sloan Kettering Cancer Center, New York, who was not involved in the study. “Ultrastaging increases positive-node detection by about 8%,” he said during the scientific plenary session at the conference. “Finding positive nodes can change management, and we have to be careful not to overtreat.”
Ongoing research is examining the topography and anatomic location of ITC in sentinel lymph nodes, Dr. Abu-Rustum said. In the meantime, he advised clinicians to consider any ultrastaging result of ITC in context. “When modeling the risk of ITCs, don’t look at them in isolation. Don’t be ‘node-centric,’ ” he advised. “Look at the uterine factors and the overall bigger picture.”
Dr. Plante did not acknowledge external funding sources. Dr. Plante and Dr. Abu-Rustum reported having no conflicts of interest.
NATIONAL HARBOR, MD. – Patients with endometrial cancer should not receive adjuvant chemotherapy or radiotherapy solely because they have isolated tumor cells in their sentinel lymph nodes, Marie Plante, MD, said during an oral presentation at the annual meeting of the Society of Gynecologic Oncology.
In a single-center prospective cohort study, about 96% of patients with endometrial cancer were alive and progression free at 3 years, a rate which resembles those reported for node-negative patients, said Dr. Plante of Laval University, Quebec City. Moreover, all 10 patients who did not receive adjuvant therapy remained alive and progression free during follow-up, she said. “Patients with isolated tumor cells carry an excellent prognosis,” she added. “Adjuvant treatment should be tailored based on uterine factors and histology and not solely on the presence of isolated tumor cells in sentinel lymph nodes.”
Pathologic ultrastaging has boosted the detection of low-volume metastases, which comprise anywhere from 35% to 63% of nodal metastases in patients with endometrial cancer. Clinicians continue to debate management when this low-volume disease consists of isolated tumor cells (ITC), defined as fewer than 200 carcinoma cells found singly or in small clusters. Finding ITC in endometrial cancer is uncommon, and few studies have examined this subgroup, Dr. Plante noted.
She and her associates evaluated 519 patients who underwent hysterectomy, salpingo-oophorectomy, lymphadenectomy, or sentinel lymph node mapping for endometrial cancer at their center between 2010 and 2015. Pathologic ultrastaging identified 31 patients with ITC (6%), of whom 11 patients received adjuvant chemotherapy, 14 received pelvic radiation therapy, and 10 underwent only brachytherapy or observation, with some patients receiving more than one treatment. Another 54 patients in the cohort had metastatic disease, including 43 patients with macrometastasis and 11 with micrometastasis.
Stage, not treatment, predicted progression-free survival (PFS), Dr. Plante emphasized. After a median follow-up period of 29 months, the estimated 3-year rate of PFS was significantly better among patients with ITC (96%), node-negative disease (88%), or micrometastasis (86%) than among those with macrometastasis (59%; P = .001), even though macrometastasis patients received significantly more chemotherapy (P = .0001).
Rates of PFS did not statistically differ between the ITC and node-negative groups, Dr. Plante noted. The single recurrence in an ITC patient involved a 7 cm carcinosarcoma that recurred despite adjuvant chemotherapy and radiation therapy. There were no recurrences among patients with endometrioid histology.
Among ITC patients who received no adjuvant treatment, half had stage IA endometrial cancer and half were stage IB, half were grade 1 and half were grade 2, all had endometrioid histology, and seven (70%) had evidence of lymphovascular space invasion, Dr. Plante said. All remained alive and progression free at follow-up.
Ultrastaging should only be performed if a sentinel lymph node is negative on initial hematoxylin and eosin stain and if there is myoinvasion, commented Nadeem R. Abu-Rustum, MD, chief of the gynecology service at Memorial Sloan Kettering Cancer Center, New York, who was not involved in the study. “Ultrastaging increases positive-node detection by about 8%,” he said during the scientific plenary session at the conference. “Finding positive nodes can change management, and we have to be careful not to overtreat.”
Ongoing research is examining the topography and anatomic location of ITC in sentinel lymph nodes, Dr. Abu-Rustum said. In the meantime, he advised clinicians to consider any ultrastaging result of ITC in context. “When modeling the risk of ITCs, don’t look at them in isolation. Don’t be ‘node-centric,’ ” he advised. “Look at the uterine factors and the overall bigger picture.”
Dr. Plante did not acknowledge external funding sources. Dr. Plante and Dr. Abu-Rustum reported having no conflicts of interest.
NATIONAL HARBOR, MD. – Patients with endometrial cancer should not receive adjuvant chemotherapy or radiotherapy solely because they have isolated tumor cells in their sentinel lymph nodes, Marie Plante, MD, said during an oral presentation at the annual meeting of the Society of Gynecologic Oncology.
In a single-center prospective cohort study, about 96% of patients with endometrial cancer were alive and progression free at 3 years, a rate which resembles those reported for node-negative patients, said Dr. Plante of Laval University, Quebec City. Moreover, all 10 patients who did not receive adjuvant therapy remained alive and progression free during follow-up, she said. “Patients with isolated tumor cells carry an excellent prognosis,” she added. “Adjuvant treatment should be tailored based on uterine factors and histology and not solely on the presence of isolated tumor cells in sentinel lymph nodes.”
Pathologic ultrastaging has boosted the detection of low-volume metastases, which comprise anywhere from 35% to 63% of nodal metastases in patients with endometrial cancer. Clinicians continue to debate management when this low-volume disease consists of isolated tumor cells (ITC), defined as fewer than 200 carcinoma cells found singly or in small clusters. Finding ITC in endometrial cancer is uncommon, and few studies have examined this subgroup, Dr. Plante noted.
She and her associates evaluated 519 patients who underwent hysterectomy, salpingo-oophorectomy, lymphadenectomy, or sentinel lymph node mapping for endometrial cancer at their center between 2010 and 2015. Pathologic ultrastaging identified 31 patients with ITC (6%), of whom 11 patients received adjuvant chemotherapy, 14 received pelvic radiation therapy, and 10 underwent only brachytherapy or observation, with some patients receiving more than one treatment. Another 54 patients in the cohort had metastatic disease, including 43 patients with macrometastasis and 11 with micrometastasis.
Stage, not treatment, predicted progression-free survival (PFS), Dr. Plante emphasized. After a median follow-up period of 29 months, the estimated 3-year rate of PFS was significantly better among patients with ITC (96%), node-negative disease (88%), or micrometastasis (86%) than among those with macrometastasis (59%; P = .001), even though macrometastasis patients received significantly more chemotherapy (P = .0001).
Rates of PFS did not statistically differ between the ITC and node-negative groups, Dr. Plante noted. The single recurrence in an ITC patient involved a 7 cm carcinosarcoma that recurred despite adjuvant chemotherapy and radiation therapy. There were no recurrences among patients with endometrioid histology.
Among ITC patients who received no adjuvant treatment, half had stage IA endometrial cancer and half were stage IB, half were grade 1 and half were grade 2, all had endometrioid histology, and seven (70%) had evidence of lymphovascular space invasion, Dr. Plante said. All remained alive and progression free at follow-up.
Ultrastaging should only be performed if a sentinel lymph node is negative on initial hematoxylin and eosin stain and if there is myoinvasion, commented Nadeem R. Abu-Rustum, MD, chief of the gynecology service at Memorial Sloan Kettering Cancer Center, New York, who was not involved in the study. “Ultrastaging increases positive-node detection by about 8%,” he said during the scientific plenary session at the conference. “Finding positive nodes can change management, and we have to be careful not to overtreat.”
Ongoing research is examining the topography and anatomic location of ITC in sentinel lymph nodes, Dr. Abu-Rustum said. In the meantime, he advised clinicians to consider any ultrastaging result of ITC in context. “When modeling the risk of ITCs, don’t look at them in isolation. Don’t be ‘node-centric,’ ” he advised. “Look at the uterine factors and the overall bigger picture.”
Dr. Plante did not acknowledge external funding sources. Dr. Plante and Dr. Abu-Rustum reported having no conflicts of interest.
AT THE ANNUAL MEETING ON WOMEN’S CANCER
Key clinical point: For patients with endometrial cancer, isolated tumor cells in sentinel lymph nodes did not lead to disease progression and were not an indication for adjuvant treatments.
Major finding: At 3 years, the estimated rate of progression-free survival was 100% among patients who underwent only pelvic brachytherapy or observation.
Data source: A single-center prospective study of 519 patients undergoing hysterectomy, salpingo-oophorectomy, lymphadenectomy, and sentinel lymph node mapping for endometrial cancer, including 31 patients with isolated tumor cells identified in sentinel lymph nodes.
Disclosures: Dr. Plante did not report having external funding sources. Dr. Plante and Dr. Abu-Rustum had no disclosures.
VIDEO: HER2+ patients may do fine with local therapies alone
MIAMI BEACH – Unquestionably, the advent of human epidermal growth factor receptor-2 (HER2) inhibitors has dramatically improved long-term outcomes in patients with HER2-positive breast cancer.
But the benefits of therapy with the HER2-inhibitor trastuzumab (Herceptin) must be weighed against its potential for causing or exacerbating cardiomyopathy, especially when combined with anthracyclines such as doxorubicin that are associated with increased risk for late cardiotoxicity, said Sara Hurvitz, MD, director of the Breast Cancer Clinical Research Program at the David Geffen School of Medicine at UCLA in Santa Monica, Calif.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Many patients with HER2-positive disease can be safely and effectively treated with local therapy alone, but clinicians at present have no reliable way of knowing which patients are likely to have excellent outcomes without adjuvant systemic therapies or which are at high risk for recurrence and might benefit from HER2 with or without an anthracycline, leading to overtreatment of some patients out of an abundance of caution, she said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
In a video interview, Dr. Hurvitz discussed strategies under development for identifying and evaluating biomarkers and cardiac imaging studies that could help to identify patients at highest risk for long-term cardiotoxicity, as well as alternative therapeutic regimens that eliminate the need for anthracyclines.
Dr. Hurvitz disclosed grants/research support from Amgen, Bayer, Boehringer Ingelheim, Genentech, GlaxoSmithKline, Pfizer, Roche, Biomarin, Merrimack, OBI Pharma, Puma Biotechnology, Dignitana, Medivation, Lilly and Novartis, and travel reimbursement from Lilly, Novartis, and OBI Pharma.
MIAMI BEACH – Unquestionably, the advent of human epidermal growth factor receptor-2 (HER2) inhibitors has dramatically improved long-term outcomes in patients with HER2-positive breast cancer.
But the benefits of therapy with the HER2-inhibitor trastuzumab (Herceptin) must be weighed against its potential for causing or exacerbating cardiomyopathy, especially when combined with anthracyclines such as doxorubicin that are associated with increased risk for late cardiotoxicity, said Sara Hurvitz, MD, director of the Breast Cancer Clinical Research Program at the David Geffen School of Medicine at UCLA in Santa Monica, Calif.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Many patients with HER2-positive disease can be safely and effectively treated with local therapy alone, but clinicians at present have no reliable way of knowing which patients are likely to have excellent outcomes without adjuvant systemic therapies or which are at high risk for recurrence and might benefit from HER2 with or without an anthracycline, leading to overtreatment of some patients out of an abundance of caution, she said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
In a video interview, Dr. Hurvitz discussed strategies under development for identifying and evaluating biomarkers and cardiac imaging studies that could help to identify patients at highest risk for long-term cardiotoxicity, as well as alternative therapeutic regimens that eliminate the need for anthracyclines.
Dr. Hurvitz disclosed grants/research support from Amgen, Bayer, Boehringer Ingelheim, Genentech, GlaxoSmithKline, Pfizer, Roche, Biomarin, Merrimack, OBI Pharma, Puma Biotechnology, Dignitana, Medivation, Lilly and Novartis, and travel reimbursement from Lilly, Novartis, and OBI Pharma.
MIAMI BEACH – Unquestionably, the advent of human epidermal growth factor receptor-2 (HER2) inhibitors has dramatically improved long-term outcomes in patients with HER2-positive breast cancer.
But the benefits of therapy with the HER2-inhibitor trastuzumab (Herceptin) must be weighed against its potential for causing or exacerbating cardiomyopathy, especially when combined with anthracyclines such as doxorubicin that are associated with increased risk for late cardiotoxicity, said Sara Hurvitz, MD, director of the Breast Cancer Clinical Research Program at the David Geffen School of Medicine at UCLA in Santa Monica, Calif.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Many patients with HER2-positive disease can be safely and effectively treated with local therapy alone, but clinicians at present have no reliable way of knowing which patients are likely to have excellent outcomes without adjuvant systemic therapies or which are at high risk for recurrence and might benefit from HER2 with or without an anthracycline, leading to overtreatment of some patients out of an abundance of caution, she said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
In a video interview, Dr. Hurvitz discussed strategies under development for identifying and evaluating biomarkers and cardiac imaging studies that could help to identify patients at highest risk for long-term cardiotoxicity, as well as alternative therapeutic regimens that eliminate the need for anthracyclines.
Dr. Hurvitz disclosed grants/research support from Amgen, Bayer, Boehringer Ingelheim, Genentech, GlaxoSmithKline, Pfizer, Roche, Biomarin, Merrimack, OBI Pharma, Puma Biotechnology, Dignitana, Medivation, Lilly and Novartis, and travel reimbursement from Lilly, Novartis, and OBI Pharma.
AT MBCC
VIDEO: Breast surgeons can and do provide genetic counseling to cancer patients
MIAMI BEACH – Breast surgeons can help relieve a “medical education crisis” by advising breast cancer patients about the implications of genetic testing results. The crisis continues to worsen given the remarkable rise in precision medicine and the limited number of genetic counselors in the United States, Patrick W. Whitworth, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
Breast surgeons are qualified to help counsel patients, and, in fact, already order more than half of breast cancer genetic sequencing, a specialist survey reveals, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, in a video interview.
At the same time, the one genotype–one phenotype paradigm for cancer genetics is rapidly shifting to testing patients for a whole panel of mutations simultaneously. Breast surgeons can partner with genetic counselors to support and expand the reach of this vital medical testing and counseling to more patients, he added.
Dr. Whitworth receives research grant support from and is a shareholder in Targeted Medical Education. He is also a shareholder in Advantage Consulting and Education.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
MIAMI BEACH – Breast surgeons can help relieve a “medical education crisis” by advising breast cancer patients about the implications of genetic testing results. The crisis continues to worsen given the remarkable rise in precision medicine and the limited number of genetic counselors in the United States, Patrick W. Whitworth, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
Breast surgeons are qualified to help counsel patients, and, in fact, already order more than half of breast cancer genetic sequencing, a specialist survey reveals, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, in a video interview.
At the same time, the one genotype–one phenotype paradigm for cancer genetics is rapidly shifting to testing patients for a whole panel of mutations simultaneously. Breast surgeons can partner with genetic counselors to support and expand the reach of this vital medical testing and counseling to more patients, he added.
Dr. Whitworth receives research grant support from and is a shareholder in Targeted Medical Education. He is also a shareholder in Advantage Consulting and Education.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
MIAMI BEACH – Breast surgeons can help relieve a “medical education crisis” by advising breast cancer patients about the implications of genetic testing results. The crisis continues to worsen given the remarkable rise in precision medicine and the limited number of genetic counselors in the United States, Patrick W. Whitworth, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.
Breast surgeons are qualified to help counsel patients, and, in fact, already order more than half of breast cancer genetic sequencing, a specialist survey reveals, said Dr. Whitworth, director of the Nashville (Tenn.) Breast Center, in a video interview.
At the same time, the one genotype–one phenotype paradigm for cancer genetics is rapidly shifting to testing patients for a whole panel of mutations simultaneously. Breast surgeons can partner with genetic counselors to support and expand the reach of this vital medical testing and counseling to more patients, he added.
Dr. Whitworth receives research grant support from and is a shareholder in Targeted Medical Education. He is also a shareholder in Advantage Consulting and Education.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT MBCC
Standardize opioid prescribing after endocrine neck surgery, researchers say
Twenty oral morphine equivalents is the best option for pain relief medication with which to discharge outpatients after thyroidectomy or parathyroidectomy surgery, according to researchers. The report was published online in Annals of Surgical Oncology.
Irene Lou, MD, of the department of surgery at the University of Wisconsin–Madison, and her coauthors conducted a prospective observational cohort study collecting data on pain scores and the oral morphine equivalents used by 313 adult patients undergoing thyroidectomy or parathyroidectomy at two large endocrine surgery centers.
While patients were prescribed a median of 30 oral morphine equivalents at discharge – with a range from 0 to 120 – the median number of equivalents taken was 3 (with a range of 0-60).
Overall, 68.4% of patients took at least one oral morphine equivalent. The majority of patients (83%) took 10 or fewer oral morphine equivalents, and only 7% of patients took more than 20 oral morphine equivalents (Ann Surg Oncol. 2017 Feb 3. doi: 10.1245/s10434-017-5781-y).
Among the patients who took more than 10 oral morphine equivalents, 85% said it was for incisional pain, 4% said it was for sore throat, and 11% said it was for some other pain.
While the overall mean pain score after surgery was 2, the study found that mean pain scores in the patients who took more than 10 oral morphine equivalents were significantly higher than in patients who took 10 or fewer. Among patients who used narcotic pain relief, 1% said they did so because they were instructed to despite having reported no pain.
Other factors predicting higher oral morphine equivalent use were age – patients tended to be younger than 45 years – total thyroidectomy, or a history of previous narcotic use.
“Based on our results, we have changed our practices to discharge all patients undergoing parathyroid or thyroid surgery and to request an oral narcotic prescription with no more than 20 equivalents, which translates to 20 tablets of hydrocodone/acetaminophen 5/325” the authors wrote.
Noting that the abuse and misuse of prescription opioids is the leading cause of overdose deaths in the United States, they argued that standardized prescribing practices are a way to not only reduce waste but also to improve patient safety.
“We also discovered that even between our two institutions, there was no standard prescribing pattern, with a wide range of prescriptions and number of equivalents dispensed.”
The authors also examined alternative and adjunctive methods of pain relief, pointing to previous studies suggesting benefits from preoperative gabapentin, postoperative music therapy, postoperative ice packs, and nonopioid analgesics.
They noted that because their study covered the breadth of endocrine neck operations, it did include patients who had minimally invasive surgery through to those who underwent total thyroidectomy with neck dissections. They also pointed out that the data pain scores and oral morphine equivalent use was based on patient recollection.
“Notwithstanding these limitations, our study is the first to examine outpatient narcotic pain medication use after thyroid and parathyroid surgery,” they said. “A standardized practice of prescribing stands to increase patient safety and minimize the risks of dependence and overdose.”
Two authors were supported by National Institutes of Health grants. No other conflicts of interest were declared.
Twenty oral morphine equivalents is the best option for pain relief medication with which to discharge outpatients after thyroidectomy or parathyroidectomy surgery, according to researchers. The report was published online in Annals of Surgical Oncology.
Irene Lou, MD, of the department of surgery at the University of Wisconsin–Madison, and her coauthors conducted a prospective observational cohort study collecting data on pain scores and the oral morphine equivalents used by 313 adult patients undergoing thyroidectomy or parathyroidectomy at two large endocrine surgery centers.
While patients were prescribed a median of 30 oral morphine equivalents at discharge – with a range from 0 to 120 – the median number of equivalents taken was 3 (with a range of 0-60).
Overall, 68.4% of patients took at least one oral morphine equivalent. The majority of patients (83%) took 10 or fewer oral morphine equivalents, and only 7% of patients took more than 20 oral morphine equivalents (Ann Surg Oncol. 2017 Feb 3. doi: 10.1245/s10434-017-5781-y).
Among the patients who took more than 10 oral morphine equivalents, 85% said it was for incisional pain, 4% said it was for sore throat, and 11% said it was for some other pain.
While the overall mean pain score after surgery was 2, the study found that mean pain scores in the patients who took more than 10 oral morphine equivalents were significantly higher than in patients who took 10 or fewer. Among patients who used narcotic pain relief, 1% said they did so because they were instructed to despite having reported no pain.
Other factors predicting higher oral morphine equivalent use were age – patients tended to be younger than 45 years – total thyroidectomy, or a history of previous narcotic use.
“Based on our results, we have changed our practices to discharge all patients undergoing parathyroid or thyroid surgery and to request an oral narcotic prescription with no more than 20 equivalents, which translates to 20 tablets of hydrocodone/acetaminophen 5/325” the authors wrote.
Noting that the abuse and misuse of prescription opioids is the leading cause of overdose deaths in the United States, they argued that standardized prescribing practices are a way to not only reduce waste but also to improve patient safety.
“We also discovered that even between our two institutions, there was no standard prescribing pattern, with a wide range of prescriptions and number of equivalents dispensed.”
The authors also examined alternative and adjunctive methods of pain relief, pointing to previous studies suggesting benefits from preoperative gabapentin, postoperative music therapy, postoperative ice packs, and nonopioid analgesics.
They noted that because their study covered the breadth of endocrine neck operations, it did include patients who had minimally invasive surgery through to those who underwent total thyroidectomy with neck dissections. They also pointed out that the data pain scores and oral morphine equivalent use was based on patient recollection.
“Notwithstanding these limitations, our study is the first to examine outpatient narcotic pain medication use after thyroid and parathyroid surgery,” they said. “A standardized practice of prescribing stands to increase patient safety and minimize the risks of dependence and overdose.”
Two authors were supported by National Institutes of Health grants. No other conflicts of interest were declared.
Twenty oral morphine equivalents is the best option for pain relief medication with which to discharge outpatients after thyroidectomy or parathyroidectomy surgery, according to researchers. The report was published online in Annals of Surgical Oncology.
Irene Lou, MD, of the department of surgery at the University of Wisconsin–Madison, and her coauthors conducted a prospective observational cohort study collecting data on pain scores and the oral morphine equivalents used by 313 adult patients undergoing thyroidectomy or parathyroidectomy at two large endocrine surgery centers.
While patients were prescribed a median of 30 oral morphine equivalents at discharge – with a range from 0 to 120 – the median number of equivalents taken was 3 (with a range of 0-60).
Overall, 68.4% of patients took at least one oral morphine equivalent. The majority of patients (83%) took 10 or fewer oral morphine equivalents, and only 7% of patients took more than 20 oral morphine equivalents (Ann Surg Oncol. 2017 Feb 3. doi: 10.1245/s10434-017-5781-y).
Among the patients who took more than 10 oral morphine equivalents, 85% said it was for incisional pain, 4% said it was for sore throat, and 11% said it was for some other pain.
While the overall mean pain score after surgery was 2, the study found that mean pain scores in the patients who took more than 10 oral morphine equivalents were significantly higher than in patients who took 10 or fewer. Among patients who used narcotic pain relief, 1% said they did so because they were instructed to despite having reported no pain.
Other factors predicting higher oral morphine equivalent use were age – patients tended to be younger than 45 years – total thyroidectomy, or a history of previous narcotic use.
“Based on our results, we have changed our practices to discharge all patients undergoing parathyroid or thyroid surgery and to request an oral narcotic prescription with no more than 20 equivalents, which translates to 20 tablets of hydrocodone/acetaminophen 5/325” the authors wrote.
Noting that the abuse and misuse of prescription opioids is the leading cause of overdose deaths in the United States, they argued that standardized prescribing practices are a way to not only reduce waste but also to improve patient safety.
“We also discovered that even between our two institutions, there was no standard prescribing pattern, with a wide range of prescriptions and number of equivalents dispensed.”
The authors also examined alternative and adjunctive methods of pain relief, pointing to previous studies suggesting benefits from preoperative gabapentin, postoperative music therapy, postoperative ice packs, and nonopioid analgesics.
They noted that because their study covered the breadth of endocrine neck operations, it did include patients who had minimally invasive surgery through to those who underwent total thyroidectomy with neck dissections. They also pointed out that the data pain scores and oral morphine equivalent use was based on patient recollection.
“Notwithstanding these limitations, our study is the first to examine outpatient narcotic pain medication use after thyroid and parathyroid surgery,” they said. “A standardized practice of prescribing stands to increase patient safety and minimize the risks of dependence and overdose.”
Two authors were supported by National Institutes of Health grants. No other conflicts of interest were declared.
FROM ANNALS OF SURGICAL ONCOLOGY
Key clinical point: Twenty oral morphine equivalents is the ideal amount of pain relief medication with which to discharge outpatients after thyroidectomy or parathyroidectomy surgery.
Major finding: Only 7% of patients who undergo thyroidectomy or parathyroidectomy use more than 20 oral morphine equivalents for postoperative pain relief.
Data source: Observational cohort study of 313 adult patients undergoing thyroidectomy or parathyroidectomy.
Disclosures: Two authors were supported by National Institutes of Health grants. No other conflicts of interest were declared.
Watch and wait often better than resecting in ground-glass opacities
Three years of follow-up is adequate for partially solid ground-glass opacity lesions that do not progress, while pure ground-glass opacity lesions that show no progression may require further follow-up care, a study suggests.
The results of the study strengthen the argument for taking a “watch and wait” approach, and raise the question of whether patient outcomes can be improved without more precise diagnostic criteria, said study author Shigei Sawada, MD, PhD, a researcher at the Shikoku Cancer Center in Matsuyama, Japan, and his colleagues. They drew these conclusions from performing a long-term outcome investigation of 226 patients with pure or mixed ground-glass opacity lesions shown by CT imaging to be 3 cm or less in diameter.
Once established that the disease has stabilized in a pure or mixed ground-glass opacity lesion, “the frequency of CT examinations could probably be reduced or ... discontinued,” the investigators wrote. The study is published online in Chest (2017;151[2]:308-15).
Because ground-glass opacities often can remain unchanged for years, reflexively choosing resection can result in a patient’s being overtreated. Meanwhile, the use of increasingly accurate imaging technology likely means detection rates of such lesions will continue to increase, leaving clinicians to wonder about optimal management protocols, particularly since several guidance documents include differing recommendations on the timing of surveillance CTs for patients with stable disease.
The study includes 10-15 years of follow-up data on the 226 patients, registered between 2000 and 2005. Across the study, there were nearly twice as many women as men, all with an average age of 61 years. About a quarter had multiple ground-glass opacities; about a quarter also had partially consolidated lesions. Of the 124 patients who’d had resections, all but one was stage IA. The most prominent histologic subtype was adenocarcinoma in situ in 63 patients, followed by 39 patients with minimally invasive adenocarcinomas, and 19 with lepidic predominant adenocarcinomas. Five patients had papillary-predominant adenocarcinomas.
Roughly one-quarter of the cohort did not receive follow-up examinations after 68 months, as their lesions either remained stable or were shown to have reduced in size. Another 45 continued to undergo follow-up examinations.
After initial detection of a pure ground-glass opacity, the CT examination schedule was every 3, 6, and 12 months, and then annually. After detection of a mixed ground-glass opacity, a CT examination was given every 3 months for the first year, then reduced to every 6 months thereafter. In patients with stable disease, the individual clinicians determined whether to obtain additional CT follow-up imaging.
A ground-glass lesion was determined to have progressed if the diameter increased, as it did in about a third of patients; or, if there was new or increased consolidation, as there was in about two-thirds of patients. The table of consolidation/tumor ratios (CTR) used included CTR zero, also referred to as a pure ground-glass lesion; CTR 1-25; CTR 26-50; and CTR equal to or greater than 51. When there were multiple lesions, the largest one detected was the target.
All cases of patients with a CTR of more than zero were identified within 3 years, while 13.6% of patients with a CTR of zero required more than 3 years to identify tumor growth. Aggressive cancer was detected in 4% of patients with a CTR of zero and in 70% of those with a CTR greater than 25% (P less than .001). Aggressive cancer was seen in 46% of those with consolidation/tumor ratios that increased during follow-up and in 8% of those whose tumors increased in diameter (P less than .007). After about 10 years of follow-up after resection, 1.6% of cancers recurred.
There were two deaths from lung cancer among the study’s patients. The first, a 54-year-old man, had an acinar-predominant adenocarcinoma, 5 mm in diameter with a consolidation/tumor ratio of 0.75 that increased during follow-up. The recurrence developed in the mediastinal lymph nodes 51 months after resection surgery. The second patient had a papillary-predominant adenocarcinoma appearing as a pure ground-glass opacity 27 mm in diameter. The consolidation/tumor ratio also increased during follow-up, with recurrences in the bone and mediastinal lymph nodes at 30 months post resectioning.
Neither patient was re-biopsied, and both were diagnosed according to CT imaging alone. There were 13 other patient deaths from non–lung cancer related causes.
Given the 3-year timespan necessary to detect tumor growth in all but the CTR zero group, and the study’s size and long-term nature, the investigators concluded that a follow-up period of 3 years for patients with part-solid lesions “should be adequate.”
By contrast, CHEST recommends CT scans be done for at least 3 years in patients with pure ground-glass lesions and between 3 and 5 years in the other CTR groups with nodules measuring 8 mm or less. The National Comprehensive Cancer Network guideline advises low-dose CT scanning until a patient is no longer eligible for definitive treatment.
Dr. Sawada and his colleagues did not use an exact criterion for tumor growth in their study, such as a precise ratio of increase in size or consolidation, in part because at the time of the study the most common form of CT evaluation was visual inspection; they reported that tumors exhibiting growth most commonly increased between 2 and 3 mm in either size or consolidation. “Evaluations based on visual inspections can be imprecise, and different physicians may arrive at different judgments,” the investigators wrote. “However, [the use of] computer-aided diagnosis systems are not yet commonly applied in clinical practice.”
Although imaging should have guided the decision to resect, according to Dr. Sawada and his coauthors, two-thirds of patients in the study were given the procedure even though their lesions were not shown by CT scans to have progressed. This was done either at the patient’s request, or per the clinical judgment of a physician.
Also becoming more specific about changing CTRs would be helpful in developing management protocols, according to Dr. Detterbeck. “In my opinion, we need to start factoring in the rate of change. A gradual 2 mm increase in size over a period of 5 years may not be an appropriate trigger for resection.”
Neither the investigators nor the editorial writer had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Eric Gartman, MD, FCCP, comments: This study provides further support that the biology of ground-glass and part-solid nodules is different than fully solid nodules – and we should not be in a rush to resect these lesions. While the recommendations are likely to evolve over time as more information becomes available, this conservative approach toward nonsolid nodules is currently adopted in the Lung-RADS guidelines.
Eric Gartman, MD, FCCP, comments: This study provides further support that the biology of ground-glass and part-solid nodules is different than fully solid nodules – and we should not be in a rush to resect these lesions. While the recommendations are likely to evolve over time as more information becomes available, this conservative approach toward nonsolid nodules is currently adopted in the Lung-RADS guidelines.
Eric Gartman, MD, FCCP, comments: This study provides further support that the biology of ground-glass and part-solid nodules is different than fully solid nodules – and we should not be in a rush to resect these lesions. While the recommendations are likely to evolve over time as more information becomes available, this conservative approach toward nonsolid nodules is currently adopted in the Lung-RADS guidelines.
Three years of follow-up is adequate for partially solid ground-glass opacity lesions that do not progress, while pure ground-glass opacity lesions that show no progression may require further follow-up care, a study suggests.
The results of the study strengthen the argument for taking a “watch and wait” approach, and raise the question of whether patient outcomes can be improved without more precise diagnostic criteria, said study author Shigei Sawada, MD, PhD, a researcher at the Shikoku Cancer Center in Matsuyama, Japan, and his colleagues. They drew these conclusions from performing a long-term outcome investigation of 226 patients with pure or mixed ground-glass opacity lesions shown by CT imaging to be 3 cm or less in diameter.
Once established that the disease has stabilized in a pure or mixed ground-glass opacity lesion, “the frequency of CT examinations could probably be reduced or ... discontinued,” the investigators wrote. The study is published online in Chest (2017;151[2]:308-15).
Because ground-glass opacities often can remain unchanged for years, reflexively choosing resection can result in a patient’s being overtreated. Meanwhile, the use of increasingly accurate imaging technology likely means detection rates of such lesions will continue to increase, leaving clinicians to wonder about optimal management protocols, particularly since several guidance documents include differing recommendations on the timing of surveillance CTs for patients with stable disease.
The study includes 10-15 years of follow-up data on the 226 patients, registered between 2000 and 2005. Across the study, there were nearly twice as many women as men, all with an average age of 61 years. About a quarter had multiple ground-glass opacities; about a quarter also had partially consolidated lesions. Of the 124 patients who’d had resections, all but one was stage IA. The most prominent histologic subtype was adenocarcinoma in situ in 63 patients, followed by 39 patients with minimally invasive adenocarcinomas, and 19 with lepidic predominant adenocarcinomas. Five patients had papillary-predominant adenocarcinomas.
Roughly one-quarter of the cohort did not receive follow-up examinations after 68 months, as their lesions either remained stable or were shown to have reduced in size. Another 45 continued to undergo follow-up examinations.
After initial detection of a pure ground-glass opacity, the CT examination schedule was every 3, 6, and 12 months, and then annually. After detection of a mixed ground-glass opacity, a CT examination was given every 3 months for the first year, then reduced to every 6 months thereafter. In patients with stable disease, the individual clinicians determined whether to obtain additional CT follow-up imaging.
A ground-glass lesion was determined to have progressed if the diameter increased, as it did in about a third of patients; or, if there was new or increased consolidation, as there was in about two-thirds of patients. The table of consolidation/tumor ratios (CTR) used included CTR zero, also referred to as a pure ground-glass lesion; CTR 1-25; CTR 26-50; and CTR equal to or greater than 51. When there were multiple lesions, the largest one detected was the target.
All cases of patients with a CTR of more than zero were identified within 3 years, while 13.6% of patients with a CTR of zero required more than 3 years to identify tumor growth. Aggressive cancer was detected in 4% of patients with a CTR of zero and in 70% of those with a CTR greater than 25% (P less than .001). Aggressive cancer was seen in 46% of those with consolidation/tumor ratios that increased during follow-up and in 8% of those whose tumors increased in diameter (P less than .007). After about 10 years of follow-up after resection, 1.6% of cancers recurred.
There were two deaths from lung cancer among the study’s patients. The first, a 54-year-old man, had an acinar-predominant adenocarcinoma, 5 mm in diameter with a consolidation/tumor ratio of 0.75 that increased during follow-up. The recurrence developed in the mediastinal lymph nodes 51 months after resection surgery. The second patient had a papillary-predominant adenocarcinoma appearing as a pure ground-glass opacity 27 mm in diameter. The consolidation/tumor ratio also increased during follow-up, with recurrences in the bone and mediastinal lymph nodes at 30 months post resectioning.
Neither patient was re-biopsied, and both were diagnosed according to CT imaging alone. There were 13 other patient deaths from non–lung cancer related causes.
Given the 3-year timespan necessary to detect tumor growth in all but the CTR zero group, and the study’s size and long-term nature, the investigators concluded that a follow-up period of 3 years for patients with part-solid lesions “should be adequate.”
By contrast, CHEST recommends CT scans be done for at least 3 years in patients with pure ground-glass lesions and between 3 and 5 years in the other CTR groups with nodules measuring 8 mm or less. The National Comprehensive Cancer Network guideline advises low-dose CT scanning until a patient is no longer eligible for definitive treatment.
Dr. Sawada and his colleagues did not use an exact criterion for tumor growth in their study, such as a precise ratio of increase in size or consolidation, in part because at the time of the study the most common form of CT evaluation was visual inspection; they reported that tumors exhibiting growth most commonly increased between 2 and 3 mm in either size or consolidation. “Evaluations based on visual inspections can be imprecise, and different physicians may arrive at different judgments,” the investigators wrote. “However, [the use of] computer-aided diagnosis systems are not yet commonly applied in clinical practice.”
Although imaging should have guided the decision to resect, according to Dr. Sawada and his coauthors, two-thirds of patients in the study were given the procedure even though their lesions were not shown by CT scans to have progressed. This was done either at the patient’s request, or per the clinical judgment of a physician.
Also becoming more specific about changing CTRs would be helpful in developing management protocols, according to Dr. Detterbeck. “In my opinion, we need to start factoring in the rate of change. A gradual 2 mm increase in size over a period of 5 years may not be an appropriate trigger for resection.”
Neither the investigators nor the editorial writer had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
Three years of follow-up is adequate for partially solid ground-glass opacity lesions that do not progress, while pure ground-glass opacity lesions that show no progression may require further follow-up care, a study suggests.
The results of the study strengthen the argument for taking a “watch and wait” approach, and raise the question of whether patient outcomes can be improved without more precise diagnostic criteria, said study author Shigei Sawada, MD, PhD, a researcher at the Shikoku Cancer Center in Matsuyama, Japan, and his colleagues. They drew these conclusions from performing a long-term outcome investigation of 226 patients with pure or mixed ground-glass opacity lesions shown by CT imaging to be 3 cm or less in diameter.
Once established that the disease has stabilized in a pure or mixed ground-glass opacity lesion, “the frequency of CT examinations could probably be reduced or ... discontinued,” the investigators wrote. The study is published online in Chest (2017;151[2]:308-15).
Because ground-glass opacities often can remain unchanged for years, reflexively choosing resection can result in a patient’s being overtreated. Meanwhile, the use of increasingly accurate imaging technology likely means detection rates of such lesions will continue to increase, leaving clinicians to wonder about optimal management protocols, particularly since several guidance documents include differing recommendations on the timing of surveillance CTs for patients with stable disease.
The study includes 10-15 years of follow-up data on the 226 patients, registered between 2000 and 2005. Across the study, there were nearly twice as many women as men, all with an average age of 61 years. About a quarter had multiple ground-glass opacities; about a quarter also had partially consolidated lesions. Of the 124 patients who’d had resections, all but one was stage IA. The most prominent histologic subtype was adenocarcinoma in situ in 63 patients, followed by 39 patients with minimally invasive adenocarcinomas, and 19 with lepidic predominant adenocarcinomas. Five patients had papillary-predominant adenocarcinomas.
Roughly one-quarter of the cohort did not receive follow-up examinations after 68 months, as their lesions either remained stable or were shown to have reduced in size. Another 45 continued to undergo follow-up examinations.
After initial detection of a pure ground-glass opacity, the CT examination schedule was every 3, 6, and 12 months, and then annually. After detection of a mixed ground-glass opacity, a CT examination was given every 3 months for the first year, then reduced to every 6 months thereafter. In patients with stable disease, the individual clinicians determined whether to obtain additional CT follow-up imaging.
A ground-glass lesion was determined to have progressed if the diameter increased, as it did in about a third of patients; or, if there was new or increased consolidation, as there was in about two-thirds of patients. The table of consolidation/tumor ratios (CTR) used included CTR zero, also referred to as a pure ground-glass lesion; CTR 1-25; CTR 26-50; and CTR equal to or greater than 51. When there were multiple lesions, the largest one detected was the target.
All cases of patients with a CTR of more than zero were identified within 3 years, while 13.6% of patients with a CTR of zero required more than 3 years to identify tumor growth. Aggressive cancer was detected in 4% of patients with a CTR of zero and in 70% of those with a CTR greater than 25% (P less than .001). Aggressive cancer was seen in 46% of those with consolidation/tumor ratios that increased during follow-up and in 8% of those whose tumors increased in diameter (P less than .007). After about 10 years of follow-up after resection, 1.6% of cancers recurred.
There were two deaths from lung cancer among the study’s patients. The first, a 54-year-old man, had an acinar-predominant adenocarcinoma, 5 mm in diameter with a consolidation/tumor ratio of 0.75 that increased during follow-up. The recurrence developed in the mediastinal lymph nodes 51 months after resection surgery. The second patient had a papillary-predominant adenocarcinoma appearing as a pure ground-glass opacity 27 mm in diameter. The consolidation/tumor ratio also increased during follow-up, with recurrences in the bone and mediastinal lymph nodes at 30 months post resectioning.
Neither patient was re-biopsied, and both were diagnosed according to CT imaging alone. There were 13 other patient deaths from non–lung cancer related causes.
Given the 3-year timespan necessary to detect tumor growth in all but the CTR zero group, and the study’s size and long-term nature, the investigators concluded that a follow-up period of 3 years for patients with part-solid lesions “should be adequate.”
By contrast, CHEST recommends CT scans be done for at least 3 years in patients with pure ground-glass lesions and between 3 and 5 years in the other CTR groups with nodules measuring 8 mm or less. The National Comprehensive Cancer Network guideline advises low-dose CT scanning until a patient is no longer eligible for definitive treatment.
Dr. Sawada and his colleagues did not use an exact criterion for tumor growth in their study, such as a precise ratio of increase in size or consolidation, in part because at the time of the study the most common form of CT evaluation was visual inspection; they reported that tumors exhibiting growth most commonly increased between 2 and 3 mm in either size or consolidation. “Evaluations based on visual inspections can be imprecise, and different physicians may arrive at different judgments,” the investigators wrote. “However, [the use of] computer-aided diagnosis systems are not yet commonly applied in clinical practice.”
Although imaging should have guided the decision to resect, according to Dr. Sawada and his coauthors, two-thirds of patients in the study were given the procedure even though their lesions were not shown by CT scans to have progressed. This was done either at the patient’s request, or per the clinical judgment of a physician.
Also becoming more specific about changing CTRs would be helpful in developing management protocols, according to Dr. Detterbeck. “In my opinion, we need to start factoring in the rate of change. A gradual 2 mm increase in size over a period of 5 years may not be an appropriate trigger for resection.”
Neither the investigators nor the editorial writer had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
FROM CHEST
Key clinical point:
Major finding: Of 226 patients with ground-glass opacity lesions 3 cm or less in size, 124 had resection, 57 required no further follow-up, and 45 continue to receive follow-up.
Data source: Long-term study of 226 patients with pure or mixed ground-glass opacities of 3 cm or less given regular CT imaging between 2000 and 2005.
Disclosures: Neither the investigators nor the editorial writer had any relevant disclosures.
