Preoperative risk stratification of lymph node metastasis for non-functional pancreatic neuroendocrine neoplasm: An international dual-institutional study

Background/Objectives: Although the presence of lymph node metastasis (LNM) defines malignant potential, preoperative prediction of LNM has not been established for non-functional pancreatic neuroendocrine neoplasm (NF-PNEN). We sought to develop a prediction system using only preoperatively available factors that would stratify the risk of LNM for NF-PNEN.MethodsWe retrospectively reviewed patients who underwent R0/1 resection of NF-PNEN at Kyoto University (2007–2019) and the University of California, San Francisco (2010–2019). Risk stratification of LNM was developed using preoperative factors by the logistic regression analysis. Long-term outcomes were compared across the risk groups.ResultsA total of 131 patients were included in this study. Lymph nodes were pathologically examined in 116 patients, 23 (20%) of whom had LNM. Radiological tumor size [1.5–3.5 cm (odds ratio: 13.5, 95% confidence interval: 1.77–398) and >3.5 cm (72.4, 9.06–2257) against ≤1.5 cm], <50% cystic component (8.46 × 10^6, 1.68 × 10^106-), and dilatation of main pancreatic duct ≥5 mm (31.2, 3.94–702) were independently associated with LNM. When patients were classified as the low-risk (43 patients), intermediate-risk (44 patients), and high-risk groups (29 patients), proportions of LNM differed significantly across the groups (0%, 14%, and 59%, respectively). Recurrence-free survival (RFS) of the low- and intermediate-risk groups were significantly better than that of the high-risk group (5-year RFS rates of 92.2%, 85.4%, and 47.1%, respectively).ConclusionsThe prediction system using preoperative radiological factors stratifies the risk of LNM for NF-PNEN. This stratification helps to predict malignant potential and determine the surgical procedure and necessity of regional lymphadenectomy.     

Extent of gastrectomy and lymphadenectomy for gastric adenocarcinoma

Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well-established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This chapter outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed.     

Metastatic lymph node ratio, 6th or 7th AJCC edition: witch is the best lymph node classification for esophageal cancer? Prognosis factor analysis in 487 patients

Background

The esophageal cancer is one of the most common and aggressive worldwide. Recently, the AJCC changed the staging system, considering, among others, the important role of the lymph node metastasis on the prognosis.

Aim

To discuss the applicability of different forms of lymph node staging in a western surgical center.

Methods

Four hundred eighty seven patients with esophageal cancer were enrolled. Three staging systems were evaluated, the 6^th and the 7^th AJCC editions and the Lymph Node Metastatic Ratio.

Results

The majority of the cases were squamous cell carcinoma. The mean lymph node sample was eight. Considering the survival, there was no significant difference between the patients when they were classified by the 7^th AJCC edition. Analysis of the Lymph Node Metastatic Ratio, just on the group of patients with 0 to 25%, has shown significant difference (p=0,01). The 6^th AJCC edition shows the major significant difference between among the classifications evaluated.

Conclusion

In this specific population, the 7^th AJCC edition for esophageal cancer was not able to find differences in survival when just the lymph node analysis was considered.     

Lymph node pick up by separate stations: Option or necessity

AIM: To evaluate whether lymph node pick up by separate stations could be an indicator of patients submitted to appropriate surgical treatment. METHODS: One thousand two hundred and three consecutive gastric cancer patients submitted to radical resection in 7 general hospitals and for whom no information was available on the extension of lymphatic dissection were included in this retrospective study. RESULTS: Patients were divided into 2 groups: group A, where the stomach specimen was directly formalinfixed and sent to the pathologist, and group B, where lymph nodes were picked up after surgery and fixed for separate stations. Sixty-two point three percent of group A patients showed 16 retrieved lymph nodes compared to 19.4% of group B(P 0.0001). Group B(separate stations) patients had significantly higher survival rates than those in group A [46.1 mo(95%CI: 36.5-56.0) vs 27.7 mo(95%CI: 21.3-31.9); P = 0.0001], independently of T or N stage. In multivariate analysis, group A also showed a higher risk of death than group B(HR = 1.24; 95%CI: 1.05-1.46).CONCLUSION: Separate lymphatic station dissection increases the number of retrieved nodes, leads to better tumor staging, and permits verification of the surgical dissection. The number of dissected stations could potentially be used as an index to evaluate the quality of treatment received.     

Hepatocellular carcinoma in children: Epidemiology and the impact of regional lymphadenectomy on surgical outcomes

Background

Factors influencing survival in children with HCC have not been studied. The objective of this study was to identify prognostic factors in pediatric HCC, and to determine whether regional lymphadenectomy is associated with improved survival.

Methods

We performed a retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER) registry. All patients < 20 years old diagnosed with HCC from 1973–2009 were included. Disease-specific survival was compared using Kaplan-Meier statistics and Cox proportional-hazards regression.

Results

We identified 238 patients (139 Male: 99 Female). Overall, 112 (47%) received an operation (resection/transplantation). Observed mortality and adjusted hazard of disease-specific death was greater for females (HR = 2.07, p = 0.013) and older children. Among operative patients, 44% were documented to have a regional lymphadenectomy. Although demographic factors did not differ between lymphadenectomy and non-lymphadenectomy groups, patients who underwent lymphadenectomy had a greater proportion of metastatic disease (24% vs. 15%) and fibrolamellar HCC (53% vs. 31%). Five-year survival for lymphadenectomy patients was superior to non-lymphadenectomy (70% vs. 57%). Adjusted mortality for lymphadenectomy was also improved relative to non-lymphadenectomy (HR = 0.26, p = 0.013).

Conclusions

HCC in children is associated with poor survival, especially among children older than 4 years and girls. In surgical candidates, regional lymphadenectomy may be associated with improved survival.     

Systematic Review of Adrenalectomy and Lymph Node Dissection in Locally Advanced Renal Cell Carcinoma

Context

Controversy remains over whether adrenalectomy and lymph node dissection (LND) should be performed concomitantly with radical nephrectomy (RN) for locally advanced renal cell carcinoma (RCC) cT3–T4N0M0.

Objective

To systematically review all relevant literature comparing oncologic, perioperative, and quality-of-life (QoL) outcomes for locally advanced RCC managed with RN with or without concomitant adrenalectomy or LND.

Evidence acquisition

Relevant databases were searched up to August 2012. Randomised controlled trials (RCTs) and comparative studies were included. Outcome measures were overall survival, QoL, and perioperative adverse effects. Risks of bias (RoB) were assessed using Cochrane RoB tools. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

Evidence synthesis

A total of 3658 abstracts and 252 full-text articles were screened. Eight studies met the inclusion criteria: six LNDs (one RCT and five nonrandomised studies [NRSs]) and two adrenalectomies (two NRSs). RoB was high across the evidence base, and the quality of evidence from outcomes ranged from moderate to very low. Meta-analyses were not undertaken because of diverse study designs and data heterogeneity. There was no significant difference in survival between the groups, even though 5-yr overall survival appears better for the RN plus LND group compared with the no-LND group in one randomised study. There was no evidence of a difference in adverse events between the RN plus LND and no-LND groups. No studies reported QoL outcomes. There was no evidence of an oncologic difference between the RN with adrenalectomy and RN without adrenalectomy groups. No studies reported adverse events or QoL outcomes.

Conclusions

There is insufficient evidence to draw any conclusions on oncologic outcomes for patients having concomitant LND or ipsilateral adrenalectomy compared with patients having RN alone for cT3–T4N0M0 RCC. The quality of evidence is generally low and the results potentially biased. Further research in adequately powered trials is needed to answer these questions.     

胰腺癌外科治疗新进展

胰腺癌的诊断和治疗问题仍极具挑战性。虽无前瞻性的研究结果报道,仍提倡对“可切除”及“可能切除”的胰腺癌患者进行新辅助治疗,以提高R0切除率。近年来针对腹膜后切缘问题不断有术式改进的报告,如动脉优先入路、提拉悬吊技术、钩突优先入路等,丰富了传统的切除方式。鉴于病理学对R0及R1切除判断标准的再评价,应重新审视R1切除对改善患者预后的价值和意义。在淋巴结清扫范围方面,基于若干临床随机对照研究结果,以日本胰腺学会淋巴结分组为基础,目前研究者们普遍认为应清扫至第二站淋巴结。由解剖学层面对胰腺系膜的探讨及临床应用有助于提高腹膜后切缘的阴性率。     

Sixth and seventh tumor-node-metastasis staging system compared in gastric cancer patients

AIM: To investigate the clinical relevance and prognosis regarding survival according to the changes of the tumor-node-metastasis (TNM) in gastric cancer patients.METHODS: We retrospectively studied 347 consecutive subjects who underwent surgery for gastric adenocarcinoma at the Division of General Surgery, Hospital of Busto Arsizio, Busto Arsizio, Italy between June 1998 and December 2009. Patients who underwent surgery without curative intent, patients with tumors of the gastric stump and patients with tumors involving the esophagus were excluded for survival analysis. Patients were staged according to the 6^th and 7^th edition TNM criteria; 5-year overall survival rates were investigated, and the event was defined as death from any cause.RESULTS: After exclusion, our study population included 241 resected patients with curative intent for gastric adenocarcinoma. The 5-year overall survival (5-year OS) rate of all the patients was 52.8%. The diagnosed stage differed in 32% of 241 patients based on the TNM edition used for the diagnosis. The patients in stage II according to the 6^th edition who were reclassified as stage III had significantly worse prognosis than patients classified as stage II (5-year OS, 39% vs 71%). According to the 6^th edition, 135 patients were classifed as T2, and 75% of these patients migrated to T3 and exhibited a significantly worse prognosis than those who remained T2, regardless of lymph node involvement (37% vs 71%). The new N1 patients exhibited a better prognosis than the previous N1 patients (67% vs 43%).CONCLUSION: 7^th TNM allows new T2 and N1 patients to be selected with better prognosis, which leads to different staging. New stratification is important in multimodal therapy.