Significance of pelvic lymphadenectomy for the prognosis after radical cystectomy

OBJECTIVE: In contrast to other carcinomas such as breast or colon cancer, there are no guidelines regarding the number and location of lymph nodes to be removed during radical surgery in patients with invasive bladder carcinoma. The therapeutic effect of pelvic lymphadenectomy and its influence on tumour staging has not been documented yet. METHODS: Here we present an evaluation of pelvic lymph nodes from 484 patients who underwent radical cystectomy with curative intention between 1986 and 1999. The number of lymph nodes was correlated with the depth of invasion of the primary tumour, occurrence of nodal metastases, clinical outcome, the operating surgeon, and the pathologist. RESULTS: There were 484 patients with a mean age of 62.7 years. Clinical follow up was available from 321 patients with a mean follow up period of 35.9 months. The average number of lymph nodes removed was 14.3 (range: 1-46). The number of lymph nodes removed varied significantly between different surgeons and did not correlate with the pathologists. There was a significant correlation between the number of lymph nodes removed and the tumour-free survival in pT2 or pT3 tumours and in patients without lymph node metastases. Multivariate analysis revealed that pT-category (p < 0.01), pN-category (p < 0.01), and the total number of lymph nodes removed (p = 0.04) were the most important factors affecting survival. CONCLUSION: The more extensive lymphadenectomy significantly improved the prognosis of patients with invasive bladder cancer and therefore, represents a potentially curative procedure. The results indicate a need for a standardised lymph node dissection.     

Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum.

OBJECTIVE: In this study, the impact of preoperative chemotherapy and radiation on the histopathology of a subgroup of patients with rectal adenocarcinoma was examined. As well, survival, disease-free survival and pelvic recurrence rates were examined, and compared with a concurrent control group. SUMMARY BACKGROUND DATA: The optimal treatment of large rectal carcinomas remains controversial; current therapy usually involves abdominoperineal resection plus postoperative chemoradiation; the combination can be associated with significant postoperative morbidity. In spite of these measures, local recurrences and distant metastases continue as serious problems. METHODS: Fluorouracil, cisplatin, and 4500 cGy were administered preoperatively over a 5-week period, before definitive surgical resection in 43 patients. In this group of patients, all 43 had biopsy-proven lesions > 3 cm (median diameter), involving the entire rectal wall (as determined by sigmoidoscopy and computed tomography scan), with no evidence of extrapelvic disease. The patients ranged from 31 to 81 years of age (median 61 years), with a male:female ratio of 3:1. A concurrent control group consisting of 56 patients (median: 62 years, male:female ration of 3:2) with T2 and T3 lesions was used to compare survival, disease-free survival, and pelvic recurrence rates. RESULTS: The preoperative chemoradiation therapy was well tolerated, with no major complications. All patients underwent repeat sigmoidoscopy before surgery; none of the lesions progressed while patients underwent therapy, and 22 (51%) were determined to have complete clinical response. At the time of resection, 21 patients (49%) had gross disease, 9 (22%) patients had only residual microscopic disease, and 11 (27%) had sterile specimens. Of the 30 patients with evidence of residual disease, 4 had positive lymph nodes. In follow-up, 39 of the 43 remain alive (median follow-up = 25 months), and only 1 of the 11 patients with complete histologic response developed recurrent disease. Six of the 32 patients with residual disease (2 with positive nodes) have developed metastatic disease in follow-up (median time to diagnosis 10 months, range 3-15 months). Three of these patients with metastases have died (median survival after diagnosis of metastases = 36 months). Local recurrence was seen in only 2 of 43 patients (< 5%). Cox-Mantel analysis of Kaplan-Meier distributions demonstrated increased survival (p = 0.017), increased disease-free survival (p = 0.046), and decreased pelvic recurrence (p = 0.031) for protocol versus control patients. CONCLUSIONS: This therapeutic regimen has provided enhanced local control and decreased metastases. Furthermore, the marked degree of tumor downstaging, as seen by a 27% incidence of sterile pathologic specimens and a low rate of positive lymph nodes in this group with initially advanced lesions, strongly suggest that less radical surgery and sphincter preservation may be used with increasing frequency.     

Outcomes After Combined Therapy Including Surgical Resection in Patients with Epithelial Ovarian Cancer Recurrence(s) Exclusively in Lymph Nodes

Background: The aim was to study the prognosis for and survival of patients treated with combined therapy (including surgical resection) for nodal recurrences from epithelial ovarian cancer (EOC).Methods: This was a retrospective study of a group of 12 patients with a recurrence from EOC, a priori, exclusively located in lymph node(s). All patients underwent surgical resection of nodal metastases, followed by adjuvant therapy.Results: The median age of patients was 51 (range, 42–71) years. The initial disease stages were as follows: stage IA, n = 5; stage IIA, n = 1; and stage IIIC, n = 6. The median interval between the end of initial treatment and the nodal relapse was 21 (range, 6–72) months. The recurrence was located in the abdominal nodes in 10 patients (pelvic and/or para-aortic area) and was extra-pelvic in one patient, and the last patient had concomitant para-aortic and supraclavicular nodal involvement. Ten patients received postoperative chemotherapy and two had radiation therapy (one patient received both treatments). Eight patients relapsed and four did not. To date, three patients have died of the disease, three are alive with persistent disease, and six are alive and disease-free (including two patients who were treated by surgical resection after relapses twice in abdominal nodes). Five-year overall survival from the time of treatment of recurrent disease is 71% (confidence interval, 41%–90%).Conclusions: The prognosis of patients with an a priori isolated nodal recurrence from EOC was good in this group of treated with surgical resection followed by chemoradiation or radiation therapy. This finding argues in favor of proposing surgical resection in such patients.     

Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder?

PURPOSE: We identified a subset of patients with bladder cancer (transitional cell carcinoma) and regional nodal metastasis to the retroperitoneal lymph nodes without detectable systemic dissemination. While the majority of these patients respond initially to chemotherapy, most have disease relapse at the same site within a year. We report the results of a phase II study exploring the potential benefit of retroperitoneal lymph node dissection in patients with transitional cell carcinoma of the bladder in whom disease has shown a significant response to chemotherapy. MATERIALS AND METHODS: A total of 11 patients with biopsy proven metastatic transitional cell carcinoma in the retroperitoneal lymph nodes and no evidence of visceral metastatic disease in whom disease showed a significant response to chemotherapy underwent complete bilateral retroperitoneal lymph node dissection. The end point of study was disease specific survival, calculated from the time of retroperitoneal lymph node dissection to death from transitional cell carcinoma of the bladder. RESULTS: Four patients underwent delayed retroperitoneal lymph node dissection. Seven patients underwent concurrent cystectomy, and pelvic and retroperitoneal lymph node dissection. There was no perioperative mortality. Nine patients had evidence of residual disease in the retroperitoneal nodes. Seven patients have recurrence outside of the original surgical field with a median time to recurrence of 7 months and 6 died at a median time to death of 8 months (range 5 to 14). One patient with retrocrural recurrence attained a complete response to salvage chemotherapy and remained disease-free 57 months after retroperitoneal lymph node dissection. For all 11 patients median disease specific and recurrence-free survival rates were 14 and 7 months, respectively. Four-year disease specific and recurrence-free survival rates were 36% and 27%, respectively. We stratified the patients based on the number of involved lymph nodes at retroperitoneal lymph node dissection and noted that viable tumor in no more than 2 lymph nodes correlated with greater disease specific and recurrence-free survival (p = 0.006 and 0.01, respectively). CONCLUSIONS: Retroperitoneal lymph node dissection can be safely performed for metastatic transitional cell carcinoma. Retroperitoneal lymph node dissection has curative potential, particularly in patients with viable tumor in no more than 2 lymph nodes after chemotherapy.     

Does the Extent of Operation Influence the Prognosis in Patients With Melanoma Metastatic to Inguinal Nodes?

Background: The role of pelvic lymphadenectomy in melanoma metastatic to the superficial inguinal region remains controversial. Some researchers advocate aggressive surgical management,whereas others feel that outcome depends more on extent of disease rather than extent of treatment.We reviewed our recent experience to investigate possible therapeutic effects of extended surgery.Methods: We performed a retrospective clinical and pathological review of 227 consecutive patients having superficial (SLND) or combined inguinal lymphadenectomy (CLND) for cutaneous melanoma.Results: A total of 174 SLNDs and 53 CLNDs were performed. Overall 5-year survival for node-positive patients was 39%. Survival for patients with positive superficial nodes was 40%; for those with positive deep nodes it was 35% (P = ns). In node-positive patients, number and size of involved lymph nodes and the presence of extranodal spread, failure to receive adjuvant therapy, and tumor ulceration were associated with poorer prognosis. Extent of surgery was not associated with differential survival, although CLND patients had worse pathological features. Subgroup analysis showed no significant survival difference between SLND and CLND.Conclusions: Some patients with deep nodal involvement apparently are cured by CLND. However, it is the biology of the disease and not the extent of surgery that primarily governs outcome. Patients with clinical or radiological evidence of pelvic nodal disease without evidence of systemic disease should have a CLND, but we find no evidence to support CLND if the pelvic nodes are clinically and radiologically negative.     

PELVIC LYMPH NODE METASTASES FROM BLADDER CANCER: OUTCOME IN 83 PATIENTS AFTER RADICAL CYSTECTOMY AND PELVIC LYMPHADENECTOMY

PURPOSE: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy. MATERIALS AND METHODS: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study. RESULTS: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer. CONCLUSIONS: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.     

Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis

OBJECTIVE: To determine the need to standardize the number and location of lymph nodes to be removed during radical cystectomy in patients with invasive bladder carcinoma. PATIENTS AND METHODS: The pelvic lymph nodes from 447 patients (mean age 62.8 years) who underwent radical cystectomy between 1986 and 1997 were evaluated. The number of lymph nodes was correlated with the depth of invasion of the primary tumour (pT), occurrence of nodal metastases, clinical outcome, the operating surgeons and the pathologists dissecting the nodes. RESULTS: The clinical follow-up was available for 302 patients (mean follow-up 38.7 months). The mean (range) number of lymph nodes removed was 14.7 (1-46). The number of lymph nodes removed varied significantly among different surgeons but not among pathologists. In pT3 and pT4 tumours, a more extended lymphadenectomy (>/= 16 lymph nodes) correlated with a higher percentage of patients with documented nodal metastases. There was a significant correlation between the number of lymph nodes removed and the tumour-free 5-year survival in patients with pT1, pT2 or pT3 tumours, and in patients with 1-5 positive lymph nodes (P < 0.01). CONCLUSION: Extensive lymphadenectomy significantly improves the prognosis of patients with invasive bladder cancer and represents a potentially curative procedure in patients with nodal metastases, including micrometastases that may escape detection during routine histopathological evaluation. The results indicate the need for a standardized lymph node dissection.     

The role of lateral lymph node dissection in the management of lower rectal cancer

Introduction  

Lateral lymph node involvement is a problem encountered in patients with low rectal cancers. This has been documented in both anatomical and pathological studies. Currently, the vast majority of centers have concentrated on the use of chemoradiation to obtain better local control and manage these nodes indirectly. In Japan, extended nodal dissection for the control of pelvic nodal disease has seen further advancement. This paper discusses the key issues involved in the management of pelvic lateral nodes in low rectal cancers.     

Prognostic significance of lymph node involvement in middle and distal bile duct cancer

BACKGROUND: Although lymph node involvement is considered an important prognostic factor, a detailed analysis has not been conducted in middle (Bm) and distal (Bi) bile duct cancer. METHODS: The histopathology of resections taken from 59 patients with Bm and Bi disease (Bm, 33 patients; Bi, 26 patients) was examined. The prevalence of lymph node involvement and its relationship to recurrence and prognosis were investigated. Survival rates were investigated according to the number of metastatic lymph nodes found, the TNM nodal stages, and the nodal stage classifications of The General Rules of the Japanese Society of Biliary Surgery. RESULTS: The frequency of nodal involvement in Bm and Bi was 45.5% and 30.8%, respectively. A significant correlation existed between a patient's prognosis and his TNM nodal stage, Japanese Society of Biliary Surgery nodal stage, and the number of metastatic lymph nodes found (P <.0001, respectively). Among 8 sites of postoperative recurrence, metastasis occurred most frequently in the liver (16/23). Patients with nodal involvement had a significantly higher rate of liver metastasis (10/23) than those without it (6/36) (P =.024). CONCLUSIONS: The number of metastatic lymph nodes found in patients with Bm or Bi cancer, and the nodal stage of their nodes, are significant prognostic indicators. Patients with nodal involvement are at high risk for liver metastasis in Bm and Bi disease.     

Therapeutic node dissections in malignant melanoma

Background: Therapeutic lymphadenectomies involve the dissection and removal of clinically enlarged, histologically positive nodes at the regional nodal basin, in the absence of detectable distant disease. Methods: The literature dealing with therapeutic lymphadenectomies in malignant melanoma was reviewed. Results: The rate of wound complications varies with the particular nodal basin. The 5-year survival varies from 19% to 38%, with an average of 26%. Survival is affected primarily by the number of histologically positive nodes and extracapsular spread, and secondarily by the extent of disease at the various levels of the nodal basin, fixation of the nodes, and, probably, the preceding disease-free interval. Prognostic parameters of the primary lesion, e.g., thickness, ulceration, and location, also may have an effect on survival. The rate of local recurrence at the nodal basin after lymphadenectomy has varied from 0.8% to 52%. Adjuvant therapy with interferon alfa-2b has improved the 5-year disease-free survival from 26% to 37%. Conclusions: Therapeutic node dissections in melanoma provide an appreciable 5-year survival rate, which is further augmented by adjuvant therapy. Many series report a significant rate of local recurrence at the nodal basin following therapeutic dissection. Complete lymphadenectomy reduces the rate of local failure with its attendant morbidity.     

The prognostic significance of the metastatic lymph node ratio in Dukes stage C colorectal cancer in a district general hospital

Aim Our aim was to determine if the lymph node ratio would predict overall survival and disease‐free survival in Dukes C colorectal cancer in a district general hospital setting in the UK. Method Fifty‐six patients were analysed from a prospectively maintained colorectal cancer database. The lymph node ratio was defined as the number of positive lymph nodes divided by the total number of nodes harvested. Comparison was made between the lymph node ratio,TNM nodal status and number of positive lymph nodes by the Kaplan–Meier method. An analysis of covariates was performed by a Cox proportional hazard regression analysis. Results A lymph node ratio of > 0.25 is prognostically significant for overall survival (P = 0.03) and disease‐free survival (P = 0.0003). The lymph node ratio was the strongest covariate in the multivariate regression analysis for recurrence (P = 0.003). Conclusion The lymph node ratio may help clinicians determine which patients have a more aggressive tumour biology and direct appropriate more aggressive chemotherapy regimes towards these patients.     

Pelvic Lymph Node Dissection Is Beneficial in Subsets of Patients with Node-positive Melanoma

BACKGROUND: The benefits of deep pelvic lymph node dissection (DLND) for patients with node-positive melanoma continue to be debated. The objective of our analysis was to identify factors associated with involvement of pelvic nodes and to determine survival outcomes following DLND. METHODS: We retrospectively reviewed the records of 804 patients who had undergone any type of lymph node dissection between 1990 and 2001. Logistic regression was performed to identify factors associated with tumor metastasis to pelvic nodes. Associations between clinicopathological factors and survival outcomes were estimated using the Cox proportional hazards model. RESULTS: Of the 804 patients, 235 underwent superficial lymph node dissection (SLND) and 97 underwent combined SLND and DLND (combined LND). Age >or=50 years, number of positive superficial nodes, and positive radiological imaging findings were found to be predictors of metastasis to deep nodes. With a median follow-up of 7.5 years, 5-year overall survival (OS) was 42% for patients with positive deep nodes and 51% for those with negative deep nodes (P = 0.11). OS in patients with melanoma that metastasized to three or fewer deep pelvic lymph nodes is comparable to that in patients with no deep nodal involvement. Multivariate analysis identified number of positive deep nodes, male gender, and extra-capsular extension as independent adverse prognostic factors for OS. CONCLUSIONS: These relatively favorable survival outcomes support current surgical practice and the classification of metastatic pelvic nodal disease as stage-III rather than stage-IV (distant) disease.     

Ilioinguinal lymph node dissection for palpable metastatic melanoma to the groin

Background: Block dissection of the inguinal lymph nodes is the routine management for palpable metastatic melanoma confined to this node basin. Involvement of the next tier external iliac and obturator lymph nodes in the pelvis is common, and untreated pelvic nodal disease can become advanced before becoming clinically apparent. We have routinely performed combined inguinal and pelvic (ilioinguinal) lymph node block dissection to avoid this morbid outcome. Methods: A retrospective analysis of all patients undergoing ilioinguinal lymph node dissection for melanoma between January 1998 and January 2006 was carried out. Results: There were 72 patients with a median age of 52.7 years (19.7–75.2 years) who were followed up for a median of 28.9 months (1.0–115.0 months) after ilioinguinal lymph node dissection. There were 22 (30.6%) of 72 patients with histologically involved pelvic lymph nodes. Preoperative computed tomography (CT) scanning accuracy for pelvic lymph node involvement was as follows: sensitivity 60.0%, specificity 100.0%, positive predictive value 100.0% and negative predictive value 86.2%. Lymphoedema was reported in 32 (44.4%) of 72 patients. Median time to first recurrence was 8.7 months (0.8–69.7 months). Regional recurrence occurred in 6 (8.3%) of 72 patients at a median of 4.9 months (0.9–32.0 months). Extranodal spread was the only factor adversely associated with disease‐free survival. In all patients, 5‐year disease‐free survival was 38% (95% confidence interval (CI) 26–50) and overall survival 47% (95% CI 33–60). Conclusion: Palpable metastatic melanoma in the groin is commonly associated with pelvic lymph node involvement, is not well predicted by CT scanning and is appropriately managed by ilioinguinal lymph node block dissection.     

Risk Factors for Nodal Recurrence After Lymphadenectomy for Melanoma

Background:The risk and outcome of regional failure after elective and therapeutic lymph node dissection (ELND/TLND) for microscopically and macroscopically involved lymph nodes without adjuvant radiotherapy were evaluated.Methods:Retrospective melanoma database review of 338 patients (ELND 85, TLND 253) from 1970 to 1996 with pathologically involved lymph nodes.Results:Regional recurrence occurred in 14% of patients treated with ELND (n = 12) and 28% of patients treated with TLND (n = 72; P = .009). Risk factors associated with nodal recurrence were advanced age, primary lesion in the head and neck region, depth of the primary lesion, number of involved lymph nodes, and extracapsular extension (ECE). For each nodal basin, the ELND group had a lower incidence of recurrence than the TLND group. The TLND group had larger lymph nodes, greater number of involved lymph nodes, and a higher incidence of ECE. The 10-year disease-specific survival was 51% vs. 30% for ELND and TLND, respectively (P = .0005). Nodal basin failure was predictive of distant metastasis, with 87% developing distant disease compared with 54% of patients without nodal recurrence (P < .0001). Of six patients who underwent a second dissection after isolated nodal recurrence, five patients have had a median disease-free interval of 79 months.Conclusions:After ELND or TLND, patients who have a large tumor burden (thick primary melanoma, multiply involved lymph nodes, ECE), advanced age, and a primary lesion located in the head and neck have a significantly increased likelihood of relapse and a decreased survival. Few patients present with an isolated nodal recurrence, but the majority can be salvaged by a second dissection.Presented at the Society of Surgical Oncology Cancer Symposium, New Orleans, Louisiana, March 16–19, 2000     

Results of Hysterectomy in Patients With Bulky Residual Disease at the End of Chemoradiotherapy for Stage IB2/II Cervical Carcinoma

Background We assessed the clinical outcome after hysterectomy in patients with bulky residual disease after chemoradiotherapy for stage IB2/II cervical carcinoma.Methods Subjects were 10 patients who had bulky (>2 cm) residual disease in the cervix after external radiotherapy (45 Gy) combined with concomitant chemotherapy (cisplatin 40 mg/m²/week) and uterovaginal brachytherapy (15 Gy).Results Extrafascial hysterectomy was performed in three patients, type II radical hysterectomy was performed in six patients, and pelvic exenteration was performed in one patient. Pelvic lymphadenectomy was performed in eight patients, and para-aortic lymphadenectomy was performed in eight. Five patients had nodal involvement (pelvic nodes in four and para-aortic nodes in four), and six had lymphovascular space involvement. Surgical margins were free in nine patients. Seven patients developed grade 2 (n = 3) and/or grade 3 (n = 4) complications. The median duration of follow-up after surgery was 22 months (range, 1–37 months). With follow-up available in nine patients, seven relapsed, and only two remained disease free.Conclusions This series confirms the high rate of nodal spread in patients with bulky residual cervical disease after chemoradiotherapy. Furthermore, patients who underwent hysterectomy had a high complication rate. Only two patients are alive and disease free. The results of surgery are disappointing; surgery does not seem to improve the survival of these patients.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

Mortality Risk After Preoperative Versus Postoperative Chemotherapy and Radiotherapy in Lymph Node-Positive Rectal Cancer

Introduction

Persistent lymph node-positive disease after preoperative radiotherapy for rectal cancer is associated with adverse outcomes. We quantified mortality risks of persistent pathologic lymph nodes in lymph node-positive rectal cancer patients treated with preoperative versus postoperative chemoradiation.

Methods

This was a retrospective population-based analysis of 2,038 patients with stage III rectal cancer diagnosed 1994–2005 with follow-up through 2007 using data from the California Cancer Registry. Survival estimates were generated using the Kaplan–Meier method. Multivariate cancer-specific and overall mortality analyses were performed using Cox proportional hazard ratios with adjustment for age, gender, race/ethnicity, tumor grade, T stage, N stage, socioeconomic status, and time period (1994–1997, 1998–2001, and 2002–2005).

Results

Overall survival was higher among lymph node-positive patients receiving postoperative chemoradiation compared to lymph node-positive patients receiving preoperative chemoradiation (median overall survival?=?87 versus 62 months, P?=?0.0002). In adjusted analyses, patients with persistent lymph node-positive disease after preoperative chemoradiation treatment had increased overall (HR?=?1.69; 95 % CI, 1.42–2.01) and CRC-specific (HR?=?1.78; 95 % CI, 1.44–2.19) mortality risk compared to lymph node-positive disease after postoperative chemoradiation treatment.

Conclusions

Stage III rectal cancer patients with persistent pathologic lymph nodes after preoperative chemoradiation represent a high-risk group, with higher mortality than those treated with postoperative chemoradiation.     

The prognostic value of lymph node staging with prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and extended pelvic lymph node dissection in node-positive patients with prostate cancer

Objectives

To investigate whether patients with suspected pelvic lymph node metastases (molecular imaging [mi] N1) on staging prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) had a different oncological outcome compared to those in whom the PSMA PET/CT did not reveal any pelvic lymph node metastases (miN0).

Patients and Methods

All patients with pelvic lymph node metastatic (pN1) disease after robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) between January 2017 and December 2020 were included. To assess predictors of biochemical progression of disease after RARP, a multivariable Cox regression analysis was performed, including number of tumour-positive lymph nodes, diameter of the largest nodal metastasis, and extranodal extension.

Results

In total, 145 patients were diagnosed with pN1 disease after ePLND. The median biochemical progression-free survival in patients with miN0 on PSMA PET/CT was 13.7 months, compared to 7.9 months in patients with miN1 disease (P = 0.006). On multivariable Cox regression analysis, both number of tumour-positive lymph nodes (>2 vs 1–2: hazard ratio [HR] 1.97; P = 0.005) and diameter of the largest nodal metastasis (HR 1.12; P < 0.001) were significant independent predictors of biochemical progression of disease.

Conclusion

Patients in whom pelvic lymph node metastases were suspected on preoperative PSMA imaging (miN1), patients diagnosed with >2 tumour-positive lymph nodes, and patients with a larger diameter of the largest nodal metastasis had a significantly increased risk of biochemical disease progression after surgery.     

Outcomes of persistent lymph node involvement after neoadjuvant therapy for stage III rectal cancer

Introduction

Lymph node involvement is a well-known predictor of recurrent rectal cancer in patient who did not undergo neoadjuvant therapy patients. The role of persistent lymph node disease after neoadjuvant treatment, however, is debatable. This study compares outcomes of patients with clinical, stage III rectal cancer who had nodal disease on surgical pathology after neoadjuvant treatment to patients with negative nodes.

Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma

Background: Rectal carcinoma tends to recur locally, with invasion of adjacent organs and significant pelvic pain. Both radiation therapy alone and combined chemoradiation have been used in an attempt to decrease the local recurrence rate and thereby improve survival. Although preoperative chemoradiation can clinically downstage rectal tumors, the pathologic extent of the residual disease has not been studied. Methods: Thirty-seven patients with T3 rectal cancer diagnosed by transrectal ultrasonography (uT3) received 45 Gy with continuous infusion 5-fluorouracil (300 mg/m²/day). Proctoscopy with mucosal/submucosal biopsy was performed in patients (16 of 37) posttreatment and before definitive surgery. Results: Microscopic evaluation of the 37 resected specimens showed a 30% (11 patients) pathologic complete remission rate. The pattern of residual disease in the remaining 26 patients showed that nine (25%) had microscopic residual tumor without evidence of mucosal involvement. Of the 14 patients with a negative proctoscopic evaluation and biopsy only, five (36%) had no residual tumor on final pathology. Conclusions: After chemoradiation, the pathologic presentation of rectal cancer may be altered, making endoscopic procedures and mucosal/submucosal biopsies unreliable in detection of residual disease. Despite the relatively good pathologic complete remission rate noted in this study, all patients undergoing chemoradiation for uT3 rectal carcinomas need definitive surgical resection to confirm a complete clinical remission. Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.