RESUMO
Small cell carcinoma of the bladder (SCCB) is a rare cancer that accounts for approximately 1% of primary malignant bladder tumors. It is highly malignant and has a poor prognosis. Similar to small cell lung cancer, platinum-based chemotherapy is recommended as the first-line therapy, and amrubicin (AMR) is recommended as the second-line therapy, but there is no established therapy after the second line. We report a case of SCCB that was refractory to multiple chemotherapies but responded to pembrolizumab. A 77-year-old male, diagnosed with clinical stage T3N0M0 small cell carcinoma and invasive urothelial carcinoma by transurethral resection of bladder tumor (TURBT), underwent robot-assisted radical cystectomy after three cycles of neoadjuvant cisplatin-irinotecan chemotherapy, and pathological examination revealed only small cell carcinoma in his cystectomy specimen. After three courses of adjuvant carboplatin-etoposide chemotherapy, the patient developed liver and bone metastases. Furthermore, after two courses of amrubicin, we started pembrolizumab due to the progression of metastases. Metastases decreased after starting pembrolizumab and continued to decrease after discontinuation because of immunerelated adverse events (irAEs). Therefore, pembrolizumab may be an option for the treatment of refractory SCCB.
Assuntos
Anticorpos Monoclonais Humanizados , Carcinoma de Células Pequenas , Neoplasias da Bexiga Urinária , Humanos , Masculino , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Anticorpos Monoclonais Humanizados/uso terapêutico , Carcinoma de Células Pequenas/tratamento farmacológico , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/diagnóstico por imagem , Resultado do Tratamento , Antineoplásicos Imunológicos/uso terapêutico , CistectomiaRESUMO
ABSTRACT: Postpneumonectomy syndrome (PPS) is a rare, life-threatening complication characterized by dynamic airway obstruction due to mediastinal rotation at any time point following pneumonectomy. This can produce life-threatening respiratory and cardiovascular complications. We report a case who developed PPS following right pneumonectomy in a 55-year-old female patient with small cell carcinoma (SCC) right lung.
Assuntos
Obstrução das Vias Respiratórias , Neoplasias Pulmonares , Pneumonectomia , Complicações Pós-Operatórias , Carcinoma de Pequenas Células do Pulmão , Humanos , Feminino , Pneumonectomia/efeitos adversos , Pessoa de Meia-Idade , Neoplasias Pulmonares/cirurgia , Complicações Pós-Operatórias/etiologia , Síndrome , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/cirurgia , Carcinoma de Pequenas Células do Pulmão/cirurgia , Carcinoma de Pequenas Células do Pulmão/complicações , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/complicações , Tomografia Computadorizada por Raios XAssuntos
Neoplasias da Mama , Carcinoma Neuroendócrino , Humanos , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/diagnóstico por imagem , Carcinoma Neuroendócrino/diagnóstico , Feminino , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/terapia , Carcinoma de Células Pequenas/diagnóstico por imagem , Pessoa de Meia-IdadeAssuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias do Colo do Útero , Humanos , Feminino , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/cirurgia , Neoplasias do Colo do Útero/diagnóstico , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/diagnóstico , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/terapia , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/diagnóstico , Pessoa de Meia-Idade , Adulto , IdosoAssuntos
Carcinoma Neuroendócrino , Neoplasias Nasais , Humanos , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/diagnóstico por imagem , Carcinoma Neuroendócrino/diagnóstico , Neoplasias Nasais/cirurgia , Neoplasias Nasais/patologia , Masculino , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/terapia , Carcinoma de Células Pequenas/cirurgia , Pessoa de Meia-IdadeAssuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias da Bexiga Urinária , Humanos , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/diagnóstico por imagem , Carcinoma Neuroendócrino/diagnóstico , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/terapia , Carcinoma de Células Pequenas/cirurgia , Cistectomia/métodos , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
Small-cell neuroendocrine carcinoma of the cervix (SCNCC) is a rare and aggressive tumor with a poor prognosis. Surgical resection followed by adjuvant therapy is the standard treatment for early-stage disease but the influence of different neo/adjuvant treatment approaches remains unclear. Retrospectively, we collected patients' characteristics and treatments in two medical centers. Disease status and survival outcomes were renewed through follow-up. Statistics analysis mainly included Kaplan-Meier methods for survival curve estimation, log-rank test for survival curve comparison, and Cox proportional hazards models for independent prognostic factors prediction. Finally, 51 patients treated by radical surgery between January 2010 and April 2020 were enrolled with a median age of 50 years (range: 32-68). 12 (23.5%) patients were at stage IIIC1 according to the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging systems and the rest were at the early stage. The mean tumor size was 3.6±1.3 cm. Pathological examination found 24 cases with pure SCNCC and 27 cases with admixed SCCC. 29 (56.9%) patients had deep stromal infiltration and 19 (37.3%) patients had lymphovascular space invasion. 34 (66.7%) patients received neo/adjuvant chemotherapy and pelvic radiation was conducted in 41 (80.39%) patients with a median dose of 46 Gy (range: 40-50.4 Gy). The median follow-up time was 25.0 months. The median disease-free survival (DFS) time was 23.0 months. 27 (52.9%) patients developed distant metastasis and 14 (27.5%) experienced local failure. The median overall survival (OS) was 32.0 months. Univariate and multivariate analysis showed neoadjuvant chemotherapy as negative (HR=2.081, 95% CI 1.030-4.203, p=0.041) and adjuvant chemotherapy (HR=0.409, 95% CI 0.213-0.784, p=0.020) as positive independent prognostic factor for DFS. For OS, only lymph node metastasis was confirmed as an independent prognostic factor in both univariate analysis (HR=1.528, 95% CI 1.011-2.308, p=0.044) and multivariate analysis (HR=1.697, 95% CI 1.041-2.768, p=0.034). In conclusion, for surgically treated SCNCC, adjuvant chemotherapy showed a positive influence on DFS while neoadjuvant chemotherapy harmed DFS. OS was unaffected by either treatment choice.
Assuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias do Colo do Útero , Feminino , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Resultado do Tratamento , Colo do Útero/patologia , Estudos Retrospectivos , Estadiamento de Neoplasias , Prognóstico , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/tratamento farmacológico , Neoplasias do Colo do Útero/cirurgia , Neoplasias do Colo do Útero/tratamento farmacológico , Quimioterapia Adjuvante , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/tratamento farmacológicoAssuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Carcinoma de Células Escamosas , Neoplasias Ovarianas , Teratoma , Feminino , Humanos , Teratoma/cirurgia , Teratoma/patologia , Neoplasias Ovarianas/cirurgia , Neoplasias Ovarianas/patologia , Carcinoma de Células Pequenas/diagnóstico por imagem , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Escamosas/patologia , Carcinoma Neuroendócrino/cirurgiaAssuntos
Carcinoma de Células Pequenas , Colite Ulcerativa , Bolsas Cólicas , Proctocolectomia Restauradora , Humanos , Colite Ulcerativa/complicações , Colite Ulcerativa/cirurgia , Colite Ulcerativa/patologia , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/cirurgia , Proctocolectomia Restauradora/efeitos adversos , Reto/cirurgia , Anastomose Cirúrgica , Bolsas Cólicas/efeitos adversos , Bolsas Cólicas/patologia , Resultado do Tratamento , Canal AnalAssuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Carcinoma de Células de Transição , Neoplasias Renais , Ureter , Sistema Urinário , Humanos , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/patologia , Sistema Urinário/patologia , Carcinoma Neuroendócrino/tratamento farmacológico , Carcinoma Neuroendócrino/cirurgia , Carcinoma Neuroendócrino/patologia , Neoplasias Renais/patologia , Carcinoma de Células de Transição/patologia , Ureter/patologiaRESUMO
BACKGROUND: Previously, only six cases of mixed neuroendocrine-non-neuroendocrine neoplasm (MiNENs) with squamous cell carcinoma (SCC) component have been described in the colorectum, and the molecular landscape of MiNENs is also poorly understood. Herein, we present a unique case in which the SCC developed as a component of a MiNEN in the rectum. CASE PRESENTATION: The patient was firstly diagnosed as rectal small cell neuroendocrine carcinoma (SCNEC) covered by tubulovillous adenoma, and then mixed SCNEC and SCC in the same site 6 months later. Representative samples from the three histologic subtypes were then sent for next-generation sequencing (NGS) separately. Multiple liver metastases occurred in the following month after the last surgery. The patient died of ketoacidosis 1 year after initial diagnosis of the tumor. CONCLUSION: This is the first report of this exceedingly rare tumor type to include NGS of the 3 separate morphological entities. Our findings may expedite the understanding of combined tumors in the colorectum.
Assuntos
Adenoma , Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Carcinoma de Células Escamosas , Neoplasias Gastrointestinais , Humanos , Reto , Pelve , Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Pequenas/genética , Carcinoma de Células Pequenas/cirurgia , Carcinoma Neuroendócrino/genética , Carcinoma Neuroendócrino/cirurgiaRESUMO
Small cell carcinoma of the ovary (SCCO) is a rare type of ovarian cancer with high aggressiveness. The optimal treatment modality remains elusive. This study aims to comprehensively investigate the survival impact of clinical characteristics and treatments including lymphadenectomy in SCCO. A retrospective cohort study was performed and included patients from the Surveillance, Epidemiology, and End Results (SEER) database. Data collected included demographics, therapeutic details, and pathologic characteristics. Propensity-score matching analysis (PSM) was carried out to balance baseline variables between SCCO and non-SCCO. Cox regression, Kaplan-Meier, and stratified analyses were conducted before and after PSM. After filtering, 80 records on SCCO and 39,662 records on non-SSCO were obtained. Patients with SCCO were more prone to present unilateral tumor (57.6% and 85.0%, p < 0.001), larger tumor size (>15 cm: 9.5% and 32.5%; 10-15 cm: 13.2% vs. 22.5%, p < 0.001), younger age (59.1 ± 14.91 vs. 37.2 ± 19.05; p < 0.001), single status (17.0% vs. 45.0%; p < 0.001), single malignant tumor in a lifetime (76.1% vs. 87.5%; p = 0.0244), and pathologic grade IV diseases (14.5% vs. 40.0%; p < 0.001) compared with non-SCCO. After balancing the baseline clinical characteristics with a 1:4 ratio PSM, a total of matched 72 patients with SCCO and 254 patients with non-SCCO were identified. The survival rate of SCCO was distinctly inferior to non-SCCO, particularly in FIGO I, II, and III stages. Lymphadenectomy was performed in 37 (51.39%) SCCO patients, of whom 12 (32.43%) were found to have pathologically positive lymph nodes. Lymphadenectomy was linked to favorable overall survival in SCCO, particularly in the advanced stage, and was also an independent prognostic factor, whereas lymphadenectomy did not reveal an edge in matched non-SCCO. There was a pronounced survival benefit for SCCO when at least 10 or more nodes were resected. Lymphadenectomy in a non-stage-dependent way should be considered and deserves further clinical validation to promote the overall survival in SCCO.
Assuntos
Carcinoma de Células Pequenas , Neoplasias Pulmonares , Carcinoma de Pequenas Células do Pulmão , Feminino , Humanos , Carcinoma de Células Pequenas/cirurgia , Ovário , Estudos Retrospectivos , Estadiamento de Neoplasias , Prognóstico , Excisão de Linfonodo/métodosRESUMO
BACKGROUND: This study aimed to investigate the efficacy of surgery in the treatment of small cell carcinoma of the esophagus (SCCE) and explore potential prognostic factors. METHODS: We screened patients with SCCE who underwent esophagectomy from 2010 to 2018 at three institutes. Differences in survival were analyzed using the Kaplan-Meier method and log-rank test. The prognostic factors were identified using univariate and multivariate analyses. RESULTS: A total of 69 patients were included. Multivariate analysis showed that TNM stage (hazard ratio [HR]: 4.10, 95% confidence interval [CI]: 1.57-10.75, p = 0.004) and adjuvant therapy (HR: 0.28, 95% CI: 0.16-0.51, p < 0.001) were independent prognostic factors. Stage I, stage IIA, and stage IIB disease were merged into the surgery response disease (SRD), whereas stage III disease into the surgery nonresponse disease (SNRD). The SRD group had significantly improved survival compared to the SNRD group (HR: 0.33, 95% CI: 0.19-0.58, p < 0.001). In addition, adjuvant therapy increased survival benefit in the SNRD group (p < 0.001) but not in the SRD group (p = 0.061). CONCLUSIONS: Surgery alone appears to be adequate for disease control in the SRD group, whereas multimodality therapy was associated with improved survival in the SNRD group.
Assuntos
Carcinoma de Células Pequenas , Neoplasias Esofágicas , Humanos , Esofagectomia/métodos , Carcinoma de Células Pequenas/cirurgia , Carcinoma de Células Pequenas/patologia , Estudos Retrospectivos , Estadiamento de Neoplasias , Neoplasias Esofágicas/cirurgia , Prognóstico , Resultado do TratamentoRESUMO
Thymic neuroendocrine tumours are rare anterior mediastinal neoplasms often associated with paraneoplastic syndromes. A patient presented with intractable hyponatraemia and a DOTATATE-avid mediastinal mass. Following medical optimization, she underwent thoracoscopic thymectomy with en bloc thymic small-cell carcinoma resection. Her symptoms resolved and her sodium levels normalized. In localized disease, curative-intent, minimally invasive thymic neuroendocrine tumour resection is safe and effective following preoperative staging and paraneoplastic syndrome management.
Assuntos
Carcinoma de Células Pequenas , Síndromes Paraneoplásicas , Neoplasias do Timo , Carcinoma de Células Pequenas/complicações , Carcinoma de Células Pequenas/diagnóstico por imagem , Carcinoma de Células Pequenas/cirurgia , Feminino , Humanos , Síndromes Paraneoplásicas/etiologia , Síndromes Paraneoplásicas/cirurgia , Tomografia por Emissão de Pósitrons , Cintilografia , Timoma , Neoplasias do Timo/complicações , Neoplasias do Timo/diagnóstico por imagem , Neoplasias do Timo/cirurgia , VasopressinasAssuntos
Carcinoma Endometrioide , Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias do Endométrio , Neoplasias Ovarianas , Carcinoma Endometrioide/patologia , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma de Células Pequenas/cirurgia , Neoplasias do Endométrio/patologia , Feminino , Humanos , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgia , Útero/patologiaRESUMO
A 60-year-old woman was not accompanied by any symptom. She had a gallstone which was identified 20 years prior. Ultrasonography performed by a local doctor revealed that the gallbladder was filled with small stones, and the patient was referred to our department for further examination and treatment for gallbladder stone. Tumor markers are elevated. Contrast- enhanced CT revealed gallbladder stones and thickening in the gallbladder body. PET-CT showed abnormal accumulation of FDG-PET with SUVmax 3.6 in the body of the gallbladder. With a diagnosis of gallbladder cancer, extended cholecystectomy and gallbladder bed resection with regional lymph node dissection were performed. The tumor was diagnosed histologically as small cell type neuroendocrine carcinoma of the gallbladder(pT2a[SS], pN0, pStage â ¡A; Japanese society of hepato-biliary-pancreatic surgery, the 7th edition). The postoperative course was uneventful. This patient has been followed up for 8 years without obvious signs of recurrence. R0 resection and lack of lymph node metastasis can allow long- term survival.
Assuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias da Vesícula Biliar , Carcinoma Neuroendócrino/cirurgia , Carcinoma de Células Pequenas/cirurgia , Feminino , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/cirurgia , Humanos , Excisão de Linfonodo , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , PrognósticoRESUMO
OBJECTIVE: To compare the prognostic value of International Federation of Gynecology and Obstetrics (FIGO) 2009 and 2018 staging systems in surgical patients with small cell neuroendocrine carcinoma of the cervix (SCNEC). METHODS: We re-staged 64 surgical IB-IIA (FIGO 2009) SCNEC patients according to the FIGO 2018 system and refined stage IIIC of FIGO 2018 based on tumor local invasion. The prognostic factors were analyzed, and the advantages of FIGO 2018 were compared with 2009. RESULTS: The 5-year overall survival rate (OS) was 78.5% for stage I and 22.2% for stage II (FIGO 2009). In FIGO 2018, there was no difference between stage I and II, and the 5-year OS was 74.1%, 60.2%, and 0% for stage I/II, IIIC1, and IIIC2. After combining stage IIIC with the local invasion stage (T1 was limited to the cervix and vagina; T2 involved the parametrium; T3 involved the pelvic or abdominal cavity), the 5-year OS for stage IIICT1, IIICT2, and IIICT3 was 83.3%, 30.0%, and 0%, respectively. CONCLUSIONS: For stage II SCNEC patients, FIGO 2009 underestimated the prognosis, while FIGO 2018 was more accurate. For stage IIIC, FIGO 2018 might be more individualized and accurate after combining stage IIIC with tumor local invasion.
Assuntos
Carcinoma Neuroendócrino , Carcinoma de Células Pequenas , Neoplasias do Colo do Útero , Carcinoma Neuroendócrino/diagnóstico , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/cirurgia , Colo do Útero/patologia , Colo do Útero/cirurgia , Feminino , Humanos , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/cirurgiaRESUMO
BACKGROUND: The optimal treatment approach for limited-stage small cell carcinoma of the esophagus remains uncertain. This study aimed to evaluate the efficacy and safety of preoperative chemotherapy in combination with surgery vs upfront surgery in those patients. METHODS: From June 2001 to June 2015, a total of 280 patients with limited-stage small cell carcinoma of the esophagus were screened from 60 131 patients with esophageal cancer. Outcome analysis of those patients who underwent preoperative chemotherapy in combination with surgery or upfront surgery was conducted. The primary end point was overall survival, and secondary end points included progression-free survival and safety. RESULTS: Of the 280 patients, 200 were men (71.4%), the median age was 64 years (range, 42-75 years), 171 patients (61.1%) patients had preoperative chemotherapy in combination with surgery, and 109 patients (38.9%) underwent upfront surgery. A pathologic complete response rate of 8.8% was noted in patients who received preoperative chemotherapy. Compared with the upfront surgery group, the preoperative chemotherapy group had a better median overall survival (26.0 months vs 19.5 months, respectively; hazard ratio, 0.69; 95% CI, 0.51 to 0.92; P = .011) and a prolonged progression-free survival (16.0 months vs 13.0 months, respectively; hazard ratio, 0.75; 95% CI, 0.57 to 0.99; P = .039). Postoperative complications and peritreatment mortality were comparable between both groups. CONCLUSIONS: Compared with upfront surgery, preoperative chemotherapy in combination with surgery improves overall survival in patients with limited-stage small cell carcinoma of the esophagus.
Assuntos
Carcinoma de Células Pequenas , Neoplasias Esofágicas , Neoplasias Pulmonares , Carcinoma de Pequenas Células do Pulmão , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células Pequenas/tratamento farmacológico , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Pequenas/cirurgia , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Carcinoma de Pequenas Células do Pulmão/patologiaRESUMO
BACKGROUND: Primary small cell carcinoma of the esophagus (SCCE) is a rare and extremely fatal disease. We aim to evaluate the efficacy of radical surgery for resectable SCCE and to explore potential prognostic factors. METHODS: We retrospectively reviewed 52 consecutive SCCE patients who underwent radical surgery from February 1993 to November 2014 at a single institution. The Kaplan-Meier estimator with log-rank test was used to assess overall survival (OS), disease-free survival (DFS) and median survival time. Univariate and multivariable analyses were used to evaluate prognostic factors through Cox proportional hazard regression model. RESULTS: Twenty-five (48.1%) patients were treated with surgery alone, whereas 27 (51.9%) patients underwent adjuvant therapy after surgery. The median OS time was 17.4 months (95% CI: 13.5-21.3). The median DFS time was 13.4 months (95% CI: 7.7-19.0). Patients whose tumors were located in the lower part of thoracic esophagus and the esophagogastric junction showed significantly better OS (27.0 vs. 13.2 months, P = 0.016) and DFS (27.0 vs. 11.3 months, P = 0.017) than those located in the upper and middle parts. Patients with N0 status experienced significantly better OS (21.4 vs. 11.6 months, P = 0.012) and DFS (21.4 vs. 8.6 months, P = 0.012) than those with N+ status. Patients whose tumor lengths were shorter than 5 cm had a better OS (17.4 vs. 5.7 months, P = 0.035) than those longer than 5 cm. Patients who underwent chemotherapy experienced a significantly improved OS (21.0 vs. 14.1 months, P = 0.032) compared to surgery alone. Multivariable analysis showed that lower tumor location, shorter tumor length, pN0 status and chemotherapy independently predicted better OS; lower tumor location and pN0 status independently predicted better DFS. CONCLUSIONS: Radical surgery in combination with chemotherapy has better outcomes than surgery alone for resectable SCCE. Higher tumor location, longer tumor length, lymph node metastasis and not undergoing chemotherapy independently predict worse prognoses.