Influence of Isolated Tumor Cells in Sentinel Nodes on Outcome in Small, Node-Negative (pT1N0M0) Breast Cancer

Purpose

To evaluate the prognostic significance of isolated tumor cells found on sentinel node biopsy.

Methods

The study is based on a prospectively followed up cohort of 1,865 consecutive patients diagnosed with pT1 (tumor size ≤20 mm) breast cancer in one university breast unit between February 2001 and August 2005. Of the 1,390 patients who received no neoadjuvant therapy and who underwent sentinel node biopsy, 63 had isolated tumor cells in the sentinel nodes (stage pT1N0i + M0, verified by axillary node dissection) and 868 did not (pT1N0i ? M0). Median follow-up time was 55 months.

Results

Patients with pN0i+ disease received systemic adjuvant therapies more often than those with pN0i? disease (87 versus 51%; P < 0.0001). There was no significant difference between the groups in terms of 5-year recurrence-free survival (90.3 versus 93.2%, respectively; P = 0.32) or overall survival, but patients with pN0i+ cancer had less favorable 5-year breast-cancer-specific survival (95.2 versus 98.4%; P = 0.035) than those with pN0i? cancer, and they were more frequently diagnosed with distant metastases from breast cancer during the first 5 years of follow-up (8.1 versus 1.9%, respectively; P = 0.001). Some conventional prognostic factors, such as histological grade, steroid hormone receptor status, and cell proliferation rate, were more strongly associated with outcome than was pN0i status.

Conclusions

The findings suggest that presence of isolated tumor cells in the sentinel nodes is an adverse prognostic factor in early breast cancer, but its prognostic significance in association with standard factors may be limited.     

Long-Term Outcome of Patients with Complete Pathologic Response after Neoadjuvant Chemoradiation for cT3 Rectal Cancer: Implications for Local Excision Surgical Strategies

Background

Neoadjuvant chemoradiotherapy (CRT) followed by radical surgery including total mesorectal excision (TME) is standard treatment in patients with locally advanced rectal cancer. Emerging data indicate that patients with complete pathologic response (ypCR) after CRT have favorable outcome, suggesting the possibility of less invasive surgical treatment. We analyzed long-term outcome of cT3 rectal cancer treated by neoadjuvant CRT in relation to ypCR and type of surgery.

Methods

The study population comprised 139 patients (93 men, 46 women; median age 62 years) with cT3N0–1M0 mid and distal rectal adenocarcinoma treated by CRT and surgery (110 TME and 29 local excision) at our institution between 1996 and 2008. At pathology, ypCR was defined as no residual cancer cells in the primary tumor.

Results

Tumors of 42 patients (30.2%) were classified as ypCR. After a median follow-up of 55.4 months, comparing patients with ypCR to patients with no ypCR, 5-year disease-specific survival was 95.8% versus 78.0% (P = 0.004), and 5-year disease-free survival was 90.1% vs. 64.0% (P = 0.004). In patients with ypCR, no statistically significant outcome difference was observed between TME and local excision. In patients treated by local excision, comparing patients with ypCR to patients with no ypCR, 5-year disease-free survival was 100% vs. 65.5% (P = 0.024), and 5-year local recurrence-free survival was 92.9% vs. 66.7% (P = 0.047).

Conclusions

With retrospective analysis limitations, our data confirm favorable long-term outcome of cT3 rectal cancer with ypCR after CRT and warrant clinical trials exploring local excision surgical strategies.     

Outcomes after neoadjuvant or adjuvant chemotherapy for cT2-4N0-1 non–small cell lung cancer: A propensity-matched analysis

Objective

Comparative survival between neoadjuvant chemotherapy and adjuvant chemotherapy for patients with cT2-4N0-1M0 non–small cell lung cancer has not been extensively studied.

Adequacy of Lymph Node Retrieval for Ampullary Cancer and Its Association with Improved Staging and Survival

Background

The aim of the present study was to determine the optimal number of lymph nodes (LN) examined to stage pN0 tumors after surgery for ampulla of Vater carcinoma (AVC).

Methods

We reviewed retrospectively 127 patients with AVC who underwent pancreaticoduodenectomy (1990–2008). Univariate and multivariate analysis was performed.

Results

Fifty-nine patients (46.5 %) were pN0, whereas 68 patients (53.5 %) were pN1. The 5-year disease-specific survival (DSS) was worse for pN1 patients than for pN0 patients (46 vs. 77 %; P < 0.0001). In the pN0 cohort, the optimal cut-off number of LN analyzed was found to be 12. The 5-year DSS for patients with ≤12 LN was 50 %, compared with 89 % in those with >12 LN (P = 0.001). By multivariate analysis, a LN count >12 was the only independent predictor associated with improved survival (HR 0.16, P = 0.003) among pN0 patients. Among pN1 patients, a LN count >12 was associated with a significantly better 5-year DSS (59 vs. 22 %; P = 0.027). Patients with a lymph node ratio (LNR) >0.20 had a 5-year DSS of 24 %, compared with 58 % in those with 0 < LNR ≤ 0.20 (P = 0.038).

Conclusions

Removal of more than 12 LN for examination is associated with improved survival rate after surgery for AVC in both pN0 and pN1 patients.     

Clinical and therapeutic factors associated with adverse pathological outcomes in clinically node-negative patients treated with neoadjuvant cisplatin-based chemotherapy and radical cystectomy

Purpose

Several disease characteristics have been identified as potential predictors for pathological node involvement (pN+) following radical cystectomy (RC). However, these have not been assessed in patients treated with neoadjuvant chemotherapy (NAC). We endeavored to assess factors predicting adverse pathology in clinically node-negative patients treated with NAC and RC.

Methods

Patients from four North American institutions with cT2-4aN0M0 UC who received three or four cycles of NAC followed by RC were selected. Logistic regression was used to predict pN+, <pT2 and pT4 disease.

Results

One hundred and ninety-six patients were included. The clinical stage was cT2 in 115 (61 %), cT3 in 62 (33 %) and cT4 in 12 (6 %) cases. NAC regiments were gemcitabine–cisplatin (GC)-4 cycles 57 (29 %), GC-3 cycles 77 (39 %), methotrexate, vinblastine, adriamycin, cisplatin (MVAC)-3 cycle 22 (11 %) and MVAC-4 cycles 40 (21 %). pN+ was seen in 35 (18 %) patients. In the logistic regression analysis, cT4 stage (OR 7.50; 95 % CI 1.58–33.3) and three compared to four cycles of GC (OR 3.44; 95 % CI 1.09–10.9) were significant predictors of pN+ status. Additionally, when controlling for clinical stage, three cycles of GC, compared to four, were significantly associated with higher rates of pT4 disease and lower rates of downstaging to non-muscle-invasive disease.

Conclusions

The results suggest that four cycles of neoadjuvant GC may be superior to three cycles, and the latter regimen may be associated with adverse pathological findings. Although this would require validation in a prospective trial, it does encourage the completion of the conventional four cycles GC whenever possible.

     

Clinically-Staged T3N0 Rectal Cancer: Is Preoperative Chemoradiotherapy the Optimal Treatment?

Background

Preoperative chemoradiotherapy has been widely adopted as the standard of care for stage II–III rectal cancers. However, patients with T3N0 lesions had been shown to have a better prognosis than other categories of locally advanced tumor. Thus, neoadjuvant chemoradiation is likely to be overtreatment in this subgroup of patients. Nevertheless, the low accuracy rate of preoperative staging techniques for detection of node-negative tumors does not allow to check this hypothesis. We analyzed a group of patients with cT3N0 low rectal cancer who underwent neoadjuvant chemoradiotherapy with the purpose of evaluating the incidence of metastatic nodes in the resected specimens.

Methods

Between January 2002 and February 2008, 100 patients with low rectal cancer underwent clinical staging by means of endorectal ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging. All patients received preoperative 5-fluorouracil-based chemoradiotherapy and surgical resection with curative aim.

Results

Of 100 patients with locally advanced rectal cancer, 32 were clinically staged as T3N0M0. Pathological analysis showed the presence of lymph node metastases in nine patients (28%) (node-positive group). In the remaining 23 cases, clinical N stage was confirmed at pathology (node-negative group). Node-positive and node-negative groups differ only in the number of ypT3 tumors (P < .01).

Conclusions

Our results indicate that immediate surgery for patients with cT3N0 rectal cancer represents an undertreatment risk in at least 28% of cases, making necessary the use of postoperative chemoradiotherapy. Preoperative chemoradiotherapy should be the therapy of choice on the grounds of the principle that overtreatment is less hazardous than undertreatment for cT3N0 rectal cancers.     

Utility and pitfalls of sentinel node identification using indocyanine green during segmentectomy for cT1N0M0 non-small cell lung cancer

Purposes

Sentinel node identification using indocyanine green (ICG) is not only simpler, but also more cost-effective, than using radioisotope tracers. We herein examined the utility and pitfalls of sentinel node (SN) identification using ICG during segmentectomy in patients with cT1N0M0 non-small cell lung cancer (NSCLC).

Methods

ICG was injected around the tumor after thoracotomy, followed by segmentectomy and lymph node dissection, in 135 patients with cT1N0M0 NSCLC. The dissected nodes were examined using an ICG fluorescence imaging system.

Results

SNs could be identified in 113 patients (84 %). The mean number of SNs was 2.3 ± 1.3. The percentages of being an SN were 57 % for both stations #12 and #13, which was significantly higher than the 18 % for #10 and 22 % for #11 (p < 0.001). Fourteen patients had N1 or N2 disease. Of these, the SNs were true positive (i.e., SNs contained metastasis) in 11 patients (79 %) and false negative (i.e., SNs did not contain metastasis, while non-SNs contained metastasis) in three patients (21 %). Of the three patients with false-negative results, all non-SNs containing metastases were at station #12 or #13.

Conclusion

While ICG makes it simple to identify SNs during segmentectomy for cT1N0M0 NSCLC, stations #12 and #13 should be submitted for frozen sections along with the identified SNs to avoid missing true SNs.

     

Long-term outcomes of laparoscopy-assisted distal gastrectomy for early gastric cancer: result of a randomized controlled trial (COACT 0301)

Background

The purpose of this study was to evaluate laparoscopy-assisted distal gastrectomy (LADG) compared to open distal gastrectomy (ODG) in the treatment of early gastric cancer with respect to survival, surgical outcomes, complications, and quality of life (QOL).

Methods

One hundred sixty-four patients with cT1N0M0 and cT1N1M0 distal gastric cancer were randomly assigned to either the LADG group or the ODG group. The primary end point was the 5-year disease-free survival (DFS) rate. Complications were classified using the accordion severity classification of postoperative complications scheme. QOL was measured using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 preoperatively and postoperatively during regular follow-up visits. This trial is registered at ClinicalTrials.gov (NCT00546468).

Results

The median (range) follow-up period was 74.3 (24.8–90.8) months. The LADG and ODG groups showed similar survival [5-year DFS rate: 98.8 % vs. 97.6 %, respectively (P = 0.514), 5-year overall survival (OS) rate: 97.6 vs. 96.3 %, respectively (P = 0.721)] or overall complication rate (29.3 vs. 42.7 %, respectively; P = 0.073). Mild complications were significantly less frequent in the LADG group than in the ODG group (23.2 vs. 41.5 %; P = 0.012). The rates of moderate, severe, and long-term complications (i.e., 31 days to 5 years after surgery) did not differ significantly between groups. No clinically meaningful differences were detected between the two groups in long-term QOL.

Conclusion

LADG showed similar DFS and OS compared to ODG in treating early gastric cancer. Marginal benefits in mild complications were observed with LADG. LADG did not show advantages over ODG regarding other complications and long-term QOL.     

Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis

Objectives

We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation.

Aggressive Surgical Approach for Patients with T4 Gastric Carcinoma: Promise or Myth?

Background

Surgical outcomes of multiorgan resection (MOR) for T4 gastric carcinoma reported in the literature are widely variable. We herein report a large surgical series of T4 gastric carcinoma.

Methods

One hundred seventy-nine patients with cT4 gastric carcinoma were recruited onto the study. Patient characteristics, surgical strategy and related complications, long-term survival, and prognostic factors of T4 gastric carcinoma were analyzed.

Results

Of 179 cT4 gastric carcinoma, there were 57 cT4 (pT3) with MOR, 91 pT4 with MOR, and 31 cT4 without MOR. pT4 with MOR were more likely to be associated with nodal metastasis, cellular dedifferentiation, and lymphoperineural infiltration compared to those of pT0–3 (P < 0.01 for all). For 91 pT4 with MOR, their surgical mortality and morbidity rates were 4.4 and 28.6%, respectively; their 1-, 3-, and 5-year overall survival rates were 55.2, 22.4, and 12.2%, respectively. The long-term survival of cT4 (pT3) with MOR was superior to pT4 with MOR (P = 0.006) and cT4 without MOR (P = 0.004). There was a striking difference between pT4 with MOR, R0 and pT4 with MOR, and R1 or R2 (P = 0.007). By means of multivariate analysis, lymph node status, liver invasion, and positive surgical margin were independent prognostic factors.

Conclusions

Aggressive surgical management of pT4 gastric carcinoma should be limited to patients without adverse prognostic factors such as advanced nodal involvement and pancreatic invasion.     

The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy

Purpose

Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU.

Methods

In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis.

Results

Median age was 70 years [interquartile range (IQR), 60–75] with median follow-up of 27 months (IQR, 10–50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73–88 %] for pN0 patients, 85 % (95 % CI, 80–90 %) for pNx patients and 47 % (95 % CI, 24–69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation.

Conclusion

LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.     

Pneumonectomy for node-positive non-small cell lung cancer: can it be a treatment option for N2 disease?

Objective

The feasibility of multimodality therapy in patients with node-positive non-small cell lung cancer (NSCLC) requiring pneumonectomy and the role of pneumonectomy in N2 disease remain controversial. This study evaluated outcomes in patients with node-positive NSCLC undergoing pneumonectomy in a community hospital.

Methods

Perioperative and long-term outcomes of 37 patients with node-positive (pN1–2) NSCLC undergoing pneumonectomy from September 1994 to April 2010 as a clinical practice were retrospectively analyzed.

Results

Twenty patients received induction therapy, and 17 received preoperative chemoradiation (30–40 Gy). Fifteen patients and 22 patients underwent right and left pneumonectomy, respectively. A postoperative complication occurred in 8 patients. In-hospital mortality occurred in 1 patient. Induction therapy did not increase the operative risk including operative time, blood loss and postoperative complications. Nineteen patients were given a diagnosis of pN2. Although 7 bulky N2 patients and 10 multi-station N2 patients were included, 5-year overall survival was 34.3 % in pN1 and 28.0 % in pN2 (p = 0.998), respectively. Twenty-three patients received additional postoperative therapy. Five patients died within 3 months postoperatively due to distant metastases. Induction therapy and laterality did not influence survival. Extended resection, such as vagus nerve or chest wall resection, predicted an unfavorable outcome in multivariate analysis (Hazard ratio 2.81, p = 0.032).

Conclusions

The safety and acceptable long-term outcome of pneumonectomy as a general clinical practice were shown for both pN1 and pN2 patients with various preoperative or postoperative therapies. Extended resection due to the extrapleural or extranodal involvement of tumor was an unfavorable prognostic factor.     

Homozygous GNAS 393C-Allele Carriers with Locally Advanced Esophageal Cancer Fail to Benefit from Platinum-Based Preoperative Chemoradiotherapy

Background

Currently, patients with locally advanced esophageal cancer receive neoadjuvant chemoradiotherapy but only about half of these patients benefit from this treatment. GNAS T393C has been shown to predict the postoperative course in solid tumors and may therefore be useful for treatment stratification. The aim of the present study was to determine if the single-nucleotide polymorphism GNAS T393C can be used for treatment stratification in esophageal cancer patients.

Methods

A total of 596 patients underwent surgical resection for esophageal carcinoma from 1996 to 2008; 279 patients received chemoradiotherapy prior to surgery (RTX-SURG group). All patients and a reference group of 820 healthy White individuals were genotyped for GNAS T393C.

Results

The 5-year-survival rate for the 317 patients who underwent esophagectomy as initial treatment (SURG group) was 57 % for homozygous C-allele carriers (n = 99) and 43 % for T-allele carriers (n = 218; log- rank test p = 0.025). Multivariate analysis revealed the GNAS T393C genotype (p = 0.034), pT (p < 0.001), pN (p < 0.001) and age (p < 0.001) as prognostic of survival. Homozygous C-allele carriers with a locally advanced tumor stage (cT3/T4, n = 129) in the SURG group had a 5-year survival rate of 37 %, which, remarkably, exceeded the 5-year survival rate of 30 % for the entire RTX-SURG group (n = 279). In the RTX-SURG group, the GNAS T393C genotype did not show any prognostic significance.

Conclusions

Patients with a locally advanced esophageal cancer and an homozygous GNAS 393C genotype do not benefit from platinum-based neoadjuvant chemoradiotherapy, indicating that these patients should be treated by alternative treatment strategies.     

Disease-Related Mortality within the First Year after Subtotal Esophagectomy for Cancer

Background

Esophageal carcinoma has poor prognosis. Surgery is still considered to be the mainstay of treatment. The mortality rate within the first year after surgery is unknown, but identifying risk factors for early mortality would increase our ability to predict the outcome of these patients and might improve patient selection.

Methods

All patients who had undergone subtotal esophagectomy for cancer between 2003 and 2008 were included in this retrospective series. Patients with less than 12 months follow-up, perioperative mortality, and death from unrelated causes were excluded. Patients were divided into two groups. Group A included all oncological mortality cases within 12 months of surgery. Group B included all patients who survived longer than 12 months following surgery.

Results

Of 81 patients who met the inclusion criteria, group A included 18 patients and group B included 63 (median survival 10 and 25 months, respectively). A higher proportion of patients were operated for pN1 disease in group A (72% versus 33%, p = 0.0004). R₀ esophagectomy rate was lower in group A (39% versus 76%, p = 0.03). Metastatic lymph node ratio (LNR) was higher in group A (mean: 46% versus 10%, p = 0.0003). Multivariate analysis identified LNR as an independent risk factor for first-year oncological mortality [odds ratio (OR) = 1.04, p = 0.0001; 95% confidence interval (CI): 1.02–1.06]. No differences were found in preoperative variables including age, gender, tumor histology, type of operation, and administration of or response to neoadjuvant therapy. Response to neoadjuvant therapy was associated with R₀ resection.

Conclusions

pN1 disease, resection margin involvement, and high LNR were found to be risk factors for first-year oncological mortality after esophagectomy for cancer.     

Predictors for Locoregional Recurrence for Clinical Stage III-N2 Non-small Cell Lung Cancer with Nodal Downstaging After Induction Chemotherapy and Surgery

Purpose

Pathologic downstaging following chemotherapy for stage III-N2 NSCLC is a well-known positive prognostic indicator. However, the predictive factors for locoregional recurrence (LRR) in these patients are largely unknown.

Methods

Between 1998 and 2008, 153 patients with clinically or pathologically staged III-N2 NSCLC from two cancer centers in the United States were treated with induction chemotherapy and surgery. All had pathologic N0-1 disease, and none received postoperative radiotherapy. LRR were defined as recurrence at the surgical site, lymph nodes (levels 1–14 including supraclavicular), or both.

Results

Median follow-up was 39.3 months. Pretreatment N2 status was confirmed pathologically (18.2 %) or by PET/CT (81.8 %). Overall, the 5-year LRR rate was 30.8 % (n = 38), with LRR being the first site of failure in 51 % (22/+99877943). Five-year overall survival for patients with LRR compared with those without was 21 versus 60.1 % (p < 0.001). Using multivariate analysis, significant predictors for LRR were pN1 disease at time of surgery (p < 0.001, HR 3.43, 95 % CI 1.80–6.56) and a trend for squamous histology (p = 0.072, HR 1.93, 95 % CI 0.94–3.98). Five-year LRR rate for pN1 versus pN0 disease was 62 versus 20 %. Neither single versus multistation N2 disease (p = 0.291) nor initial staging technique (p = 0.306) were predictors for LRR. N1 status also was predictive for higher distant recurrence (p = 0.021, HR 1.91, 95 % CI 1.1–3.3) but only trended for poorer survival (p = 0.123, HR 1.48, 95 % CI 0.9–2.44).

Conclusions

LRR remains high in resected stage III-N2 NSCLC patients after induction chemotherapy and nodal downstaging, particularly in patients with persistent N1 disease.     

Impact of Circumferential Resection Margin Distance on Locoregional Recurrence and Survival after Chemoradiotherapy in Esophageal Squamous Cell Carcinoma

Background

Close circumferential resection margin (CRM) is an established predictor for locoregional recurrence (LR) in rectal cancer but remains controversial in esophageal malignancy. As yet, little is known about the significance of CRM after chemoradiotherapy (CRT), especially in squamous cell carcinoma (SCC). This study investigated the relationship between CRM distance and recurrence after neoadjuvant CRT in esophageal SCC patients.

Methods

Between 1997 and 2005, esophageal SCC patients who underwent surgery after neoadjuvant CRT and with pathology stage T3N0M0 and T3N1M0 (metastatic lymph nodes <2) were selected. CRM distance was reassessed and divided into three groups (group 1: CRM >1 mm, group 2: uninvolved CRM but <1 mm, group 3: CRM involved).

Results

The cohort comprised 145 male and 6 female patients with mean age of 57 years. There were 74, 51, and 26 patients in group 1, 2, and 3, respectively. With median follow-up period of 50 months, LR developed in 30.5% of patients. Both group 2 and group 3 had significantly higher LR than group 1 (37 and 42% vs. 21%, P < 0.05). Meanwhile, mean time from operation to recurrence was also significantly shorter in group 2 and group 3 than in group 1 (267 and 269 days versus 402 days, P < 0.05). Five-year disease-specific survival (DSS) was highest in group 1 (40%). Despite the similarity in LR, 5-year DSS significantly differed between group 2 and group 3 (22 vs. 7%, P < 0.05). The higher rate of distant recurrence (DR) and concomitant LR + DR in group 3 accounted for the survival difference.

Conclusion

In ypT3 esophageal SCC patients, CRM distance provides useful information for risk stratification in cancer recurrence and survival.     

Is Lymph-node Ratio a Superior Predictor than Lymph Node Status for Recurrence-free and Overall Survival in Patients with Head and Neck Squamous Cell Carcinoma?

Introduction

TNM status is questioned as an exact predictor of survival in different tumour entities. Recently, lymph node ratio (LNR) has been described as a predictor of survival in patients with HNSCC. The purpose of this study was to evaluate to which degree LNR could be used as a more accurate predictor than TNM staging?

Methods

A total of 291 patients, with a follow-up of at least 3 years, were analyzed using log-rank statistic, univariate and multivariate data analyzes, and p values, for prediction of lymph node ratio on overall and recurrence-free survival.

Results

Survival differed significantly if patients were stratified for LNR. Impact of LNR on survival was significantly different even in patients with extracapsular spread. Patients with pN0 had no survival benefit compared with patients with pN1 or higher with a LNR lower than 6 %.

Conclusions

LNR is a prognostic tool in patients with a lymph node status pN0–pN2b. LNR remained significant even in patients with extracapsular spread, contrary to TNM status. With LNR, stratification for high-risk patients (higher than 6 % LNR) can be evaluated easily. We would suggest using LNR in the clinical routine.     

Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival

Background

Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery.

Methods

Patients aged ≥70 years in the National Cancer Database (2004–2014) with cT1-3, cN0 breast cancer were divided into two cohorts—those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson–Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS.

Results

Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61–1.70).

Conclusions

For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.

     

Close Association of Metastasis-Associated Protein 1 Overexpression with Increased Angiogenesis and Poor Survival in Patients with Histologically Node-Negative Gastric Cancer

Background

Although metastasis-associated protein 1 (MTA1) has been recently demonstrated as a potent angiogenesis-promoting factor in various malignant tumors, its angiogenic property in gastric cancer (GC) remains unclear. This study has detected the expression of MTA1 protein in surgically resected tissues of pathologic N0 (pN0) GC and further investigated its relation with other clinicopathologic factors and tumor angiogenesis and prognosis.

Methods

MTA1 protein expression was detected immunohistochemically in 111 pN0 GC specimens. Its correlations with clinicopathologic factors and tumor prognosis were evaluated. The intratumoral microvessel density (MVD) was assessed based on CD105 antigen immunoreactivity and analyzed for correlation with MTA1 protein expression.

Results

Overexpression of MTA1 was detected in 36.04 % of patients and exhibited a significant association with tumor size and MVD. Survival analysis demonstrated that both overall (OS) and disease-free (DFS) survivals in patients overexpressing MTA1 were significantly poorer than those without MTA1 overexpression 5 years after the operation (both p < 0.001). Multivariate survival analysis demonstrated that MTA1 overexpression was an independent prognosticator for unfavorable OS and DFS (p < 0.001, respectively).

Conclusions

MTA1 overexpression is frequently observed in pN0 GC patients and is significantly associated with increased angiogenesis and poor prognosis. Detection of MTA1 protein expression may help predict the relapse and prognosis of pN0 GC. Also, MTA1 protein may form a novel target for antiangiogenic therapy.