Role of surgery in clinical N2 non-small-cell lung cancer: a pro and con debate; the ‘con’ viewpoint

<span class="paragraphSection"><div class="boxTitle">Abstract</div>It has been proven that there is no survival advantage of surgery in clinical N2 non-small-cell lung cancer rather than chemoradiotherapy. Several decades ago, the results of thoracic radiotherapy for Clinical Stage III non-small-cell lung cancer were poor, and long-term survival rate was only 6%. Recent advances in combined therapy (radiotherapy and chemotherapy) have improved median survival to 15–20 months. In the Japanese registry of lung cancer surgery, the number of patients with Clinical Stage IIIA has decreased over the last decade because of the poor results of surgery alone for Clinical Stage III non-small-cell lung cancer. In contrast, survival of patients with Clinical Stage III non-small-cell lung cancer treated with surgery has improved gradually. This can be mainly attributed to the following: first, well-selected patients are treated with surgery; second, improved diagnostic imaging has produced a 'Will Rogers phenomenon'. Similarly, concurrent chemoradiotherapy has also further improved and in recent clinical trials, the median survival time was 28–40 months. Unfortunately, recent randomized trials comparing induction chemotherapy followed by surgery, or induction chemoradiotherapy followed by surgery with chemoradiotherapy showed no significant survival advantage of surgery. Until appropriate patient selection for surgery can be shown in randomized control trials, chemoradiotherapy is the mainstream treatment for clinical N2 non-small-cell lung cancer in clinical practice.</span>

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Incidence rate for prostate cancer in Japanese in Japan and in the United States from the Cancer Incidence in Five Continents

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A prediction model of survival for patients with bone metastasis from uterine corpus cancer

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objective</div>The aim of the study was to establish a predictive model of survival period after bone metastasis from endometrial cancer.<div class="boxTitle">Methods</div>A total of 28 patients with bone metastasis from uterine corpus cancer were included in the study. Data at the time of bone metastasis diagnosis, which included presence of extraskeletal metastasis, performance status, history of any previous radiation/chemotherapy and the number of bone metastases, were collected. Survival data were analyzed using Kaplan–Meier methods and Cox proportional hazard models.<div class="boxTitle">Results</div>The most common site of bone metastasis was the pelvis (50.0%), followed by lumbar spine (32.1%), thoracic spine (25.0%) and rib bone (17.9%). The median survival period after bone metastasis was 25 weeks. The overall rate of survival after bone metastasis of the entire cohort was 75.0% at 13 weeks, 46.4% at 26 weeks and 42.9% at 52 weeks. Performance status of 3–4 was confirmed as an independent prognostic factor (Hazard ratio, 3.5; 95% confidence interval, 1.41–8.70) and multiple bone metastases tended to be associated with poor prognosis (Hazard ratio, 2.4; 95% confidence interval, 0.95–5.97). A prognostic score was calculated by adding up the number of these two factors. The 26-week survival rates after bone metastasis were 88.9% for those with a score of 0, 45.5% for those with a score of 1 and 0% for those with a score of 2 (<span style="font-style:italic;">P </span>= 0.0006).<div class="boxTitle">Conclusions</div>This scoring system can be used to determine the optimal treatment for patients with bone metastasis from endometrial cancer.</span>

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Prognostic significance of vascular invasion in intermediate-grade subtype of lung adenocarcinoma

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objectives</div>Although the recent reclassification of histological subtypes of lung adenocarcinoma reflects disease prognosis better, the prognosis of papillary and acinar-predominant adenocarcinoma, which are highly prevalent, is heterogeneity. The present study aimed to identify the prognostic indicators for papillary and acinar-predominant adenocarcinoma.<div class="boxTitle">Methods</div>This retrospective study included 315 consecutive patients with completely resected pathological N0 lung adenocarcinoma tumors ≤3 cm from two institutions. Tumors were classified according to histologically predominant subtypes as low-grade (adenocarcinoma <span style="font-style:italic;">in situ</span>, minimally invasive adenocarcinoma or lepidic predominant), intermediate-grade (papillary or acinar predominant) or high-grade (solid or micropapillary predominant). Prognostic factors in intermediate-grade group were assessed among clinicopathological factors of age, gender, surgical procedure, tumor size, pleural, lymphatic and vascular invasion using Cox proportion hazards analyses.<div class="boxTitle">Results</div>There were 174 patients in the low-grade group, 109 in the intermediate-grade group and 32 in the high-grade group. The 3-year recurrence-free survival rates were 98.1%, 86.3% and 74.8% for these groups, respectively (<span style="font-style:italic;">P</span> < 0.001). In the intermediate-grade group, the presence of vascular invasion was an independent prognostic factor on multivariate Cox regression analysis of recurrence-free survival (hazard ratio, 3.48; 95% confidence interval, 1.26–9.57, <span style="font-style:italic;">P</span> = 0.01). Classification of intermediate-grade group based on vascular invasion revealed a clear division into favorable and unfavorable prognostic subgroups.<div class="boxTitle">Conclusions</div>Consideration of the vascular invasion status in addition to the predominant subtype could provide a more accurate assessment of malignant aggressiveness and prognosis of patients with early-stage lung adenocarcinoma.</span>

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Clinical significance of adding 3 Tesla MRI to the algorithm for decision making on neurovascular bundle preservation in radical prostatectomy

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objectives</div>The aim of this study was to evaluate the additional benefit of 3 Tesla magnetic resonance imaging for neurovascular bundle preservation in radical prostatectomy.<div class="boxTitle">Methods</div>We retrospectively evaluated patients who underwent 3 T magnetic resonance imaging followed by radical prostatectomy from April 2010 through February 2014 in our university. A total of 50 patients (100 prostate sides) were included in the study. The algorithm previously we described and magnetic resonance imaging findings were considered for the decision on neurovascular bundle preservation. A tumor adjacent to the neurovascular bundle or with extracapsular extension of a posterolateral lesion of the prostate on magnetic resonance imaging was considered a contraindication for nerve-sparing radical prostatectomy. Two experienced radiologists evaluated the magnetic resonance imaging findings. Patients who received neoadjuvant hormonal therapy were excluded. All patients underwent ultrasound-guided prostate biopsy with at least 10 cores.<div class="boxTitle">Results</div>Overall, 60 of the 100 neurovascular bundles were preserved according to an algorithm that consisted of the clinical stage, prostate specific antigen, Gleason score and a positive biopsy core in the apex of the prostate. Considering magnetic resonance imaging findings together with the algorithm, six neurovascular bundles were not preserved. The accuracy of predicting a positive surgical margin only by the algorithm was 56 of 60 neurovascular bundle (93.3%). When adding magnetic resonance imaging, the accuracy was 50 of 54 neurovascular bundle (92.3%).<div class="boxTitle">Conclusions</div>3 T magnetic resonance imaging provided no additional benefit to our algorithm for neurovascular bundle preservation.</span>

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The clinical presentation and favorable prognosis of patients with isolated metachronous brain metastasis from germ cell tumors

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objective</div>We conducted the present study to elucidate the clinical presentation, treatment outcomes and risk factors for the development of metachronous brain metastasis at a single progressive disease site, the so-called isolated brain metastasis, in patients with testicular germ cell tumors.<div class="boxTitle">Methods</div>To identify metachronous brain metastasis in a timely manner, brain imaging was performed when the re-elevation of tumor markers was observed during chemotherapy, even in patients who were free from central nervous system symptoms. The medical records of 147 patients with metastatic germ cell tumors who were treated between 1991 and 2015 were retrospectively reviewed.<div class="boxTitle">Results</div>Eight (5.4%) of the 147 patients presented synchronous brain metastasis. Of these, five patients suffered from metachronous brain metastasis relapse. An additional nine patients developed metachronous brain metastasis during or after chemotherapy. Ten of the 14 patients with metachronous brain metastasis did not have central nervous system symptoms. Eight (57%) patients had isolated brain metastasis. Ten patients underwent multimodal treatments, predominantly chemotherapy and radiotherapy. The 3-year overall survival of all 14 patients was 34.6%, but that of the patients with isolated brain metastasis was high as 66.7%. The development of metachronous brain metastasis was associated with a choriocarcinoma element at the primary site and an human chorionic gonadotropin level of >50 000 IU/L and brain metastasis at the initial diagnosis.<div class="boxTitle">Conclusions</div>In our series, we identified isolated brain metastasis in 57% of the metachronous brain metastasis patients. The monitoring of tumor markers and appropriate brain imaging are mandatory for the diagnosis of isolated brain relapse, which is associated with a higher rate of long-term survival.</span>

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Guidelines for parenteral fluid management for terminal cancer patients

<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Japan's first guidelines for parenteral fluid management for terminal cancer patients were issued in 2006. These guidelines focused on the fluid levels to administer to patients with a remaining life expectancy of 1–2 months. However, recent refinement of the concept of cachexia is prompting caregivers worldwide to rethink parenteral fluid management for terminal cancer patients.<div class="boxTitle">Objective</div>Our objective was to develop guidelines for parenteral fluid management for terminal cancer patients with a remaining life expectancy of 1 month, a point when cachexia generally begins to severely adversely affect the body.<div class="boxTitle">Methods</div>The Japanese Society for Palliative Medicine appointed a Guidelines Working Practitioner Group consisting of a multidisciplinary team of specialists. In response to 26 clinical questions on parenteral fluid management for terminal cancer patients, the Working Group used the Delphi method to reach consensus on the recommendability and evidence level of 89 relevant manuscripts identified through a systematic literature review. The Working Group then had an outside committee reviews the draft guidelines validity before authoring the final version.<div class="boxTitle">Results</div>The resulting clinically aligned guidelines contain specific recommendations (25 recommendations on physical suffering/remaining life expectancy, 10 nursing-related recommendations and 4 ethical recommendations) assessed using the Delphi method and by an outside committee.<div class="boxTitle">Conclusions</div>Japanese Society for Palliative Medicine released a revised edition of the Guidelines for Parenteral Fluid Management for Terminal Cancer Patients, which are based on medical evidence and consider the pathologic features of cachexia. We recommend that caregivers carefully evaluate the clinical usefulness of the guidelines.</span>

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