cT1N0M0 Esophageal Squamous Cell Carcinoma Invades the Muscularis Mucosa or Submucosa: Comparison of the Results of Endoscopic Submucosal Dissection and Esophagectomy

Background: Endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy may be a new treatment option for cT1N0M0 esophageal squamous cell carcinoma (ESCC) invading muscularis mucosa or submucosa (pT1a-M3/pT1b). We aim to report the effectiveness of this treatment by comparing the results of esophagectomy. Methods: This retrospective single-center study included 72 patients with pT1a-M3/pT1b ESCC who received ESD combined with selective adjuvant chemoradiotherapy (n = 40) and esophagectomy (n = 32). The main outcome comparison was overall survival (OS). The secondary outcomes were treatment-related events, including operation time, complication rate, and length of hospital stay. Disease-specific survival (DSS) and progression-free survival (PFS) were also evaluated. Results: There were no significant differences in the rates of OS, DSS, and PFS between the two groups (median follow-up time: 49.2 months vs. 50.9 months); these were also the same in the subgroup analysis of pT1b ESCC patients. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced. However, the metachronous recurrence rate was significantly higher. In a multivariate analysis, tumor depth and R0 resection were the independent factors associated with OS. Conclusions: ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for cT1N0M0 ESCC invading muscularis mucosa or submucosa.

Immune Score Predicts Outcomes of Gastric Cancer Patients Treated with Adjuvant Chemoradiotherapy

Background. Substantial evidence has demonstrated that tumor-infiltrating lymphocytes (TILs) are correlated with patient prognosis. The TIL-based immune score (IS) affects prognosis in various cancers, but its prognostic impact in gastric cancer (GC) patients treated with adjuvant chemoradiotherapy remains unclear. Methods. A total of 101 GC patients who received chemoradiotherapy after gastrectomy were retrospectively analyzed in this study. Immunohistochemistry staining for CD3+ and CD8+ T-cell counts in both tumor center (CT) and invasive margin (IM) regions was built into the IS. Patients were then divided into three groups based on their differential IS levels. The correlation between IS and clinical parameters was analyzed. The prognostic impact of IS and clinical parameters was evaluated using Kaplan–Meier analysis and Cox proportional hazard regression analysis. Receiver operating characteristic (ROC) curves were plotted to compare the area under the curve (AUC) of IS with other clinical parameters. Nomograms for disease-free survival (DFS) and overall survival (OS) prediction were constructed based on the identified parameters. Results. Finally, 20 (19.8%), 57 (56.4%), and 24 (23.8%) GC patients were identified with low, intermediate, and high IS levels, respectively. GC patients with higher IS levels exhibited better DFS ( p < 0.001) and OS ( p < 0.001). IS was an independent prognostic factor for both DFS ( p < 0.001) and OS ( p < 0.001) in multivariate analysis. IS presented a better predictive ability than the traditional pathological tumor-node-metastasis (pTNM) staging system (AUC: 0.801 vs. 0.677 and 0.800 vs. 0.660, respectively) with respect to both DFS and OS. The C-index of the nomograms for DFS and OS prediction was 0.737 and 0.774, respectively. Conclusions. IS is a strong predictive factor for both DFS and OS in GC patients treated with adjuvant chemoradiotherapy, which may complement the traditional pTNM staging system.

Locally Advanced Rectal Cancer Patients Got PCR After Chemoradiotherapy May Have Better Survival Outcomes: A Retrospective Analysis of 246 Patients.

Objective: To investigate whether the locally advanced rectal cancer patients who got a pathological complete response after neo-adjuvant chemoradiotherapy have a better survival. Methods: From January 1 2014 to January 1 2018, the clinical information of locally advanced rectal cancer patients who underwent neo-adjuvant chemoradiotherapy were collected for a retrospective analysis. Then a telephone follow-up visit was done to get the patients’ survival information of progression-free survival and overall survival. At last the information was analyzed by Kaplan-Meier analysis, log-rank test and cox-regression analysis. Results: The clinical information of 246 locally advanced rectal cancer patients were collected and analyzed, which shows that the PCR rate after chemoradiotherapy was 20.3% in these patients. There were correlations between pathological grade(grade III-IV Vs. I-II, P=0.001), CRM invasion(positive Vs. negative, P=0.001), clinical T stage(T4 Vs. T1-3, P=0.000), PCR status(PCR Vs. Non-PCR, P=0.027), downstage after preoperative therapy(yes Vs. not, P=0.009) and PFS. Similarly, age(≤60 Vs. >60, P=0.000), pathological grade(grade III-IV Vs. I-II, P=0.016), EMVI status(positive Vs. negative, P=0.005), CRM invasion(positive Vs. negative, P=0.000), clinical T stage(T4 Vs. T1-3, P=0.000), clinical N stage(N0-1 Vs. N2, P=0.013), PCR status(PCR Vs. Non-PCR, P=0.010), downstage after preoperative therapy(yes Vs. not, P=0.002) were associated with the OS. After the Cox-regression analyses, the responses after preoperative therapy or T4 tumors were identified as the prognostic factors that affected PFS and OS. Conclusions: The PCR rate after chemoradiotherapy was 20.3% in locally advanced rectal patients. Stage T1-3, better response after chemoradiotherapy tumors (PCR or downstage) might have a better survival outcome.

Rare Orbital Metastasis Originating from Ampullary Adenocarcinoma

Background: Orbital metastasis from ampullary carcinoma is rare, with no previously reported cases. Case presentation: We report the case of a 60-year-old man who complained of a right-sided headache, blurred vision, progressive proptosis, ptosis, and right eye pain for 3 months. His past medical history included an ampullary adenocarcinoma stage IIIA treated via the Whipple procedure and adjuvant chemoradiotherapy 1 year ago. However, he was lost to follow-up. Computed tomography of the orbit showed a soft tissue lesion in the right orbital fossa measuring 3.3 × 2 × 2 cm. An orbital mass biopsy demonstrated an intestinal-type adenocarcinoma that tested positive for cytokeratins 7 and 20 and CDX2 on immunohistochemical staining. The pathologic diagnosis was metastatic adenocarcinoma from the ampulla of Vater. Despite oncological treatment, the patient’s illness progressed. He received palliative treatment and died 1 month later. Conclusions: We presented a rare case of orbital metastasis from ampullary adenocarcinoma. This should be considered in the differential diagnosis of patients with a history of ampullary adenocarcinoma who present with symptoms referring to the relevant locations.

Primary Extraskeletal Osteosarcoma of Liver: Case of Report

BackgroundExtraskeletal osteosarcoma (ESOS) is a highly malignant osteosarcoma that occurs in extraskeletal tissues. It often affects the soft tissues of the limbs. ESOS is classified as primary or secondary ESOS. Case presentationwe report a case of primary hepatic osteosarcoma in a 76-year-old male patient. The patient had a giant cystic-solid mass in the right liver that was evident on ultrasound and computed tomography. Postoperative pathology and immunohistochemistry of the mass, which was surgically removed, suggested fibroblastic osteosarcoma. No other abnormal lesions were found. Therefore, the patient was diagnosed with primary hepatic osteosarcoma. The hepatic osteosarcoma reoccurred 48 days after surgery, resulting in significant compression and narrowing of the hepatic segment of the inferior vena cava. Consequently, the patient underwent stent implantation in the inferior vena cava and transcatheter arterial chemoembolization. Unfortunately, the patient died of postoperative multiple organ failure.ConclusionsHepatic osteosarcoma is a rare mesenchymal tumor with a short course and a high likelihood of metastasis and recurrence. If a biopsy were to return osteoid in a large liver tumor, ESOS would be suspected. However, there is no evidence-based treatment plan to date. Surgical resection combined with adjuvant chemoradiotherapy seems to be the best treatment option.

EPID-25. DISTANCE TRAVELED FOR BRAIN TUMOR CARE IN PAKISTAN: AN LMIC PERSPECTIVE

INTRODUCTION Global oncology development within LMICs (low- and middle-income countries) requires bridging gaps in healthcare systems. Brain tumor care in Pakistan is currently sparse and concentrated in urban centers. Distance traveled to a hospital dictates a patient’s access to care, neurosurgical access, and continuity of care through adjuvant chemoradiotherapy and primary care providers can be disrupted if patients cannot overcome the barriers due to extensive distances traveled. METHODS Data was collected as part of the Pakistan Brain Tumor Epidemiology Study (PBTES) regarding patients with brain tumors who underwent surgical procedures in 2019 at private and public major neurosurgical centers across Pakistan. Using patient addresses, we used a mapping software to calculate the distance traveled by each patient to the primary hospital. Analysis was done using appropriate statistical methods. RESULTS Out of 2403 patients, the mean distance traveled across the country was 240 km. The longest distance traveled within Pakistan was from Skardu to Karachi (2002 km) for resection of a pituitary adenoma (28 hours via car). Only 48% of patients were able to reach their primary hospital within 50 km. 52% of patients had to travel more than 50 km, and 18% had to travel upwards of 500 km to reach their primary hospital. Additionally, 101 patients traveled to Pakistan from other countries for brain tumor surgery (98 patients from Afghanistan [mean distance traveled: 723.6 km], 3 patients from Syria, Oman, and Sudan). CONCLUSION Prior studies have described a cut-off of 50 km as an acceptable limit for distance from the primary hospital in cancer patients for optimal follow-up and outcomes, which is achieved by only 48% of brain tumor patients in Pakistan. Most patients have poor access to surgical care for brain tumors, further compounded by repeat traveling for follow-ups and chemoradiotherapy.

Prospective comparative study of intraoperative balloon electronic brachytherapy versus resection with multidisciplinary adjuvant therapy for recurrent glioblastoma

Background: Intraoperative balloon electronic brachytherapy (IBEB) may provide potential benefit for local control of recurrent cerebral glioblastomas (GBMs). Methods: This is a preliminary report of an open-label, prospective, comparative cohort study conducted in two neurosurgical centers with ongoing follow-up. At recurrence, patients at one center (n = 15) underwent reresection with IBEB while, at the second center (n = 15), control subjects underwent re-resection with various accepted second-line adjuvant chemoradiotherapy options. A comparative analysis of overall survival (OS) and local progression-free survival (LPFS) following re-resection was performed. Exploratory subgroup analysis based on postoperative residual contrast-enhanced volume status was also done. Results: In the IBEB group, median LPFS after re-resection was significantly longer than in the control group (8.0 vs. 6.0 months; log rank χ2 = 4.93, P = 0.026, P < 0.05). In addition, the median OS after second resection in the IBEB group was also significantly longer than in the control group (11.0 vs. 8.0 months; log rank χ2 = 4.23, P = 0.04, P < 0.05). Conclusion: These hypothesis-generating results from a small cohort of subjects suggest putative clinical benefit in OS and LPFS associated with maximal safe re-resection of recurrent GBM with IBEB versus re-resection and standard adjuvant therapy, a hypothesis that deserves further testing in an appropriately powered clinical trial.

Sinonasal Inverted Papilloma Associated with Adenoid Cystic Carcinoma

Inverted papilloma is the most common benign tumor of the paranasal sinuses with the possibility of malignant transformation. On the one hand, adenoid cystic carcinoma (ACC) is a rare malignant neoplasm that arises from the secretory glands. Sinonasal ACC accounts for 10%–25% of all head and neck ACC. This neoplasm is defined by its distinctive histologic appearance. Surgical resection, whenever possible, is the mainstay therapy. An association between inverted papilloma and malignancy is controversial. A synchronous carcinoma has been established at diagnosis in 3.3%–11% of cases, and the risk of metachronous carcinoma is &#x3c;3%. We report a case of an 84-year-old female affected with sinonasal inverted papilloma associated with synchronous ACC. She had right nasal obstruction due to the rapid growth of the tumor. She was referred to our department for further workup. A frozen biopsy revealed part of the tumor as ACC. The tumor was consistent with preoperative imaging, and surgical findings also showed infiltration into the orbit. There was no consent for radical surgery with orbital exenteration and adjuvant chemoradiotherapy in consideration of her advanced age. This is the first case report of the association between sinonasal inverted papilloma and ACC within our retrieval capability.