Can Lymph Node Ratio Take the Place of pN Categories in the UICC/AJCC TNM Classification System for Colorectal Cancer?

Background  

Lymph node ratio (LNR) has been reported to represent a powerful independent prognostic value in some malignancies. The significance of LNR in colorectal cancer is still under debate.     

Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma?

Introduction  

The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival.     

Prognostic Significance of the Number of Metastatic Lymph Nodes: Is UICC/TNM Node Classification Perfectly Suitable for Early Gastric Cancer?

Metastatic lymph node (MLN) is less frequently involved in early gastric cancer (EGC) and barely exceeds six in number. The prognostic value of the 5th edition of the UICC tumor–node–metastasis (TNM) node classification appears to be less accurate when applied to patients with EGC and needs to be further stratified. Three hundred twenty-three EGC patients were enrolled into this study. Prognoses of these patients were first assessed based on the 5th edition UICC TNM classification, followed by a reevaluation in which the prognoses of patients were further stratified according to the number of MLNs involved with an increment of one node at a time. A new node classification was proposed based on the correlation between prognoses and the number of positive nodes. According to the prognostic value, a new node classification was categorized as new N0 (0 MLN), new N1 (1–3 MLNs), new N2 (4–6 MLNs), and new N3 (>6 MLNs). While the survival of N0 and N1 groups based on the 5th edition UICC TNM classification appeared to be homogeneous (p = 0.0947), significant difference was unmasked between the new N2 and new N0/N1 groups (p < 0.001). In addition, differentiation status, vessel involvement, and new node classification were identified as independent prognostic factors by multivariate analysis for EGC. We conclude that subsets exist in patients with EGC at stage IB by UICC classification; patients with ≥4 MLNs are at higher risk of recurrence and surgical outcome in this population is relatively poor. Supported by grants from the National 973 Program (no. G1998051203) and the National Natural Science Foundation of China (no. 30672050).     

Definition of T3/4 and Regional Lymph Nodes in Gallbladder Cancer: Which Is More Valid, the UICC or the Japanese Staging System?

Background

The Union for International Cancer Control (UICC) and Japanese Society of Biliary Surgery (JSBS) staging systems differ in their staging of gallbladder cancer: they define hepatic invasion with or without invasion of another organ as T3 and either T3 or T4, respectively, and posterosuperior pancreatic lymph node (PSPLN) metastases as M1 and N2, respectively.

Methods

We retrospectively evaluated the survival of 224 patients who had undergone macroscopically curative resection for gallbladder cancer and assessed the influence of the differences between the two staging systems on survival.

Results

JSBS staging stratified the survival curves better for stages III or IV. Fifty-seven patients were classified as UICC-T3 but JSBS-T4. These patients had better survival than did 43 patients with UICC-T4/JSBS-T4 and comparable survival to 17 patients with UICC-T3/JSBS-T3. UICC stage IIIB is composed of two subgroups: U-T2N1 (18 patients) and U-T3N1 (21 patients). Their 5-year survivals were 85 and 41?%, respectively (P?=?0.01). The latter was comparable to that of 28 T3N0 patients (35?%, P?=?0.93). The survival of the UICC-M1 patients with disease restricted to PSPLNs was significantly better than that of those with involvement beyond PSPLNs (5-year survival 35 vs. 17?%; P?=?0.04).

Conclusions

Although UICC staging more accurately defines the T category, JSBS staging better stratifies the prognosis of patients with gallbladder cancer, mainly because UICC stage IIIB includes T1/2N1M0, which is associated with significantly better survival than T3N0M0. It would be appropriate to classify PSPLNs as regional lymph nodes.     

Hypo- and Hypernatraemia in Surgical Patients: Is There Room for Improvement?

Background  

Up to 30% of surgical inpatients develop complications related to fluid and electrolyte therapy. We sought to study the occurrence of hypo- and hypernatraemia in these patients to inform current standards of care.     

Impact of Preoperative Risk Factors on Morbidity after Esophagectomy: Is There Room for Improvement?

Background

Despite progress in multidisciplinary treatment of esophageal cancer, oncologic esophagectomy is still the cornerstone of therapeutic strategies. Several scoring systems are used to predict postoperative morbidity, but in most cases they identify nonmodifiable parameters. The aim of this study was to identify potentially modifiable risk factors associated with complications after oncologic esophagectomy.

Methods

All consecutive patients with complete data sets undergoing oncologic esophagectomy in our department during 2001–2011 were included in this study. As potentially modifiable risk factors we assessed nutritional status depicted by body mass index (BMI) and preoperative serum albumin levels, excessive alcohol consumption, and active smoking. Postoperative complications were graded according to a validated 5-grade system. Univariate and multivariate analyses were used to identify preoperative risk factors associated with the occurrence and severity of complications.

Results

Our series included 93 patients. Overall morbidity rate was 81 % (n = 75), with 56 % (n = 52) minor complications and 18 % (n = 17) major complications. Active smoking and excessive alcohol consumption were associated with the occurrence of severe complications, whereas BMI and low preoperative albumin levels were not. The simultaneous presence of two or more of these risk factors significantly increased the risk of postoperative complications.

Conclusions

A combination of malnutrition, active smoking and alcohol consumption were found to have a negative impact on postoperative morbidity rates. Therefore, preoperative smoking and alcohol cessation counseling and monitoring and improving the nutritional status are strongly recommended.     

Staging Laparoscopy for Advanced Gastric Cancer: Is It Also Useful for the Group Which has an Aggressive Surgical Strategy?

Background Staging laparoscopy has been shown to be useful for increasing the accuracy of preoperative staging. However, controversy still exists regarding patient selection and subsequent treatment. The aim of this study was to determine the role of staging laparoscopy for a group that has a policy to perform aggressive surgery for advanced gastric cancer. Methods Twenty-four patients with clinical T3 or T4 gastric cancer expected to undergo curative resection, based on conventional preoperative diagnostic methods underwent staging laparoscopy. We examined the accuracy and the impact of staging laparoscopy on the further treatment options. Results The mean running time for the staging laparoscopy was 40.7 min (range: 25–75 min), and one complication was noted (4.2%). In regard to the tumor depth, 11 of 24 (45.8%) cases had a discrepancy after staging laparoscopy. In addition, 15 of 24 patients (62.5%) were found to have unsuspected peritoneal metastases, and 8 patients (33.3%) were excluded from laparotomy. The remaining 16 patients (66.7%), including 9 patients with localized peritoneal metastases (P1), underwent resection. The diagnostic accuracy for T factor was 81.3% in 16 laparotomy cases and overall accuracy of P factor was 91.7%. Conclusions Staging laparoscopy had a significant impact on decisions regarding the treatment plan in patients with advanced gastric cancer for a group that has an aggressive treatment strategy. This paper was supported in part by the Catholic Cancer Center.     

Preoperative staging of cancer of the pancreatic head: Is there room for improvement?

Background

Despite advances in preoperative staging, cancer of the pancreatic head is frequently found to be unresectable at laparotomy. We sought to identify potential areas of improvement in preoperative staging.

Methods

We performed a retrospective institutional review of patients referred for resection of cancer of the pancreatic head over a 2-year period. The primary outcome was the rate of metastasis or unresectable disease found at laparotomy in patients who were booked for pancreaticoduodenectomy with curative intent.

Results

During the study period, 133 patients were referred with suspected cancer of the pancreatic head. All underwent preoperative computed tomography scanning. Twenty-four also underwent preoperative endoscopic ultrasonography (EUS) and 23 also underwent magnetic resonance imaging (MRI). In total, 78 patients were deemed not to be candidates for surgery, leaving 55 patients with potentially resectable cancer who were scheduled for pancreaticoduodenectomy. Of these, 32 patients (58%) underwent successful resection with curative intent, and 23 patients (42%) were found to have metastatic or locally advanced disease not identified by preoperative staging. Reasons for nonresectability were metastases (9 patients, 16%), vascular involvement (12 patients, 22%) and mesentery involvement (2 patients, 4%). One patient had a diagnostic laparoscopy immediately before planned open exploration and was found to have peritoneal seeding precluding curative resection. Of the patients who underwent EUS, 14 were not surgical candidates because of locally advanced tumours. Ten patients were offered surgery with curative intent, and 5 patients (50%) were found have unresectable tumours (4 metastatic, 1 locally advanced). Of the patients who underwent MRI, 11 were offered surgery, and 5 (45%) had unresectable tumours (2 metastatic, 3 locally advanced disease).

Conclusion

In our institution, preoperative staging for cancer of the pancreatic head misses a substantial number of metastatic and unresectable disease. There is clearly room for improvement, and newer technologies should be evaluated to enhance the detection of metastatic and locally advanced disease to prevent unnecessary laparotomy.     

Log Odds of Positive Lymph Nodes (LODDS): What Are Their Role in the Prognostic Assessment of Gastric Adenocarcinoma?

Background

Nodal status is an important prognostic factor for patients with gastric cancer. Log odds of positive nodes (LODDS) (log of the ratio between the number of positive nodes and the number of negative nodes) are a new effective indicator of prognosis. The aim of the study is to evaluate if LODDS are superior to N stage and lymph nodal ratio (LNR).

Methods

Prognostic efficacy of pN, nodal ratio, and LODDS was analyzed and compared in a group of 177 patients with gastric adenocarcinoma who underwent curative gastrectomy.

Results

pT, pN, LNR, and LODDS were all significantly correlated with 5-year survival. Multivariate analyses showed significant values as prognostic factor for pN, LNR, and LODDS. A Pearson test demonstrated no significant correlation between LODDS and retrieved nodes. In patients with less than 15 examined nodes, LODDS classification and pN were significantly correlated with survival, whereas LNR classification was not significantly related.

Conclusions

LODDS are not correlated with the extension of the lymphadenectomy and are able to predict survival even if less than 15 nodes are examined. They permit an effective prognostic stratification of patients with a nodal ratio approaching 0 and 1. Further studies are needed to clarify their role and if they are capable of guaranteeing some advantages over pN and LNR.     

Is there a role for surgery in the treatment of mastalgia?

Breast pain is a common condition affecting most women at some stage in their reproductive life. Mastalgia is resistant to treatment in 6% of cyclical and 26% non-cyclical patients. Surgery is not widely used to treat this condition and only considered in patients with severe mastalgia resistant to medication. The aims of this study were to audit the efficacy of surgery in severe treatment resistant mastalgia and to assess patient satisfaction following surgery. This is a retrospective review of the medical records of all patients seen in mastalgia clinic in the University Hospital of Wales, Cardiff since 1973. A postal questionnaire was distributed to all patients who had undergone surgery. Results showed that of the 1054 patients seen in mastalgia clinic, 12 (1.2%) had undergone surgery. Surgery included 8 subcutaneous mastectomies with implants (3 bilateral, 5 unilateral), 1 bilateral simple mastectomy and 3 quadrantectomies (1 having a further simple mastectomy). The median duration of symptoms was 6.5 years (range 2-16 years). Five patients (50%) were pain free following surgery, 3 developed capsular contractures and 2 wound infections with dehiscence. Pain persisted in both patients undergoing quadrantectomy. We conclude that surgery for mastalgia should only be considered in a minority of patients. Patients should be informed of possible complications inherent of reconstructive surgery and warned that in 50% cases their pain will not be improved.     

Is there still a place for the use of nerve stimulation?

The introduction of nerve stimulation as a method of nerve localization sparked a new beginning in regional anesthesia. It was an epochal development akin to the utilization of ultrasound in more recent times. Many experts now consider ultrasound-guided peripheral nerve blockade to be more efficient, less painful, and more successful than landmark and nerve stimulation techniques. However, inadvertent intraneural injection continues to occur despite the widespread use of ultrasound and nerve stimulation. Both of these technologies allow for only limited elucidation of needle position relative to the target nerve and are unable to reliably identify intraneural position of the needle. This article will review the role of nerve stimulation in modern regional anesthesia techniques in light of the introduction of ultrasound technology.     

Surgery for small-bowel neuroendocrine tumors: Is there any benefit of the laparoscopic approach?

Background

Surgery of small-bowel neuroendocrine (SBNE) tumors is demanding because of the need for associated extensive node dissection and assessment of possible synchronous lesions. For this reason, possible benefit of laparoscopy in SBNE tumors has not been reported to date.

Methods

From 1996, all patients operated on in Beaujon Hospital for SBNE tumors were retrospectively extracted from a prospectively maintained database of intestinal resections.

Results

Overall, 73 patients [55 % males, median age 55 years (range 27–79)] underwent small bowel resection (n = 38; 54 %), ileocolectomy (n = 25; 36 %), or both (n = 7; 10 %). In 18 patients, resection of synchronous liver metastasis was performed simultaneously. Resection was performed laparoscopically in 12 patients (16 %). Resection was R0 in 40 patients (55 %), R1 in 1 patient (1 %), and R2 in 32 patients (44 %) because of unresectable liver metastases (n = 29), nodal involvement (n = 1), or both (n = 2). Laparoscopy was associated with similar R0 (p = 0.06) and morbidity (p = 0.95) rates, but a shorter hospital stay (p = 0.003) compared with laparotomy. Median follow-up was 39 months. Progression-free survival (PFS) at 1, 3, and 5 years were 95, 83 and 75 %, respectively, for R0 patients without liver metastasis; 92, 83, and 57 %, respectively, for R0 patients with resected liver metastasis; and 82, 58 and 30 %, respectively, for R2 patients (p = 0.045). Overall survival and PFS did not show any difference when comparing the laparoscopic and open groups.

Conclusion

Complete resection of primary SBNE tumors with or without liver metastasis is associated with good long-term survival. In selected patients, laparoscopy for SBNE tumors is feasible and associated with a shorter hospital stay than laparotomy.