A Longitudinal Comparison of Arm Morbidity in Stage I–II Breast Cancer Patients Treated with Sentinel Lymph Node Biopsy,Sentinel Lymph Node Biopsy Followed by Completion Lymph Node Dissection,or Axillary Lymph Node Dissection

Background  

Long-term shoulder and arm function following sentinel lymph node biopsy (SLNB) may surpass that following complete axillary lymph node dissection (CLND) or axillary lymph node dissection (ALND). We objectively examined the morbidity and compared outcomes after SLNB, SLNB + CLND, and ALND in stage I/II breast cancer patients.     

Prophylactic Lymph Node Dissection in Papillary Thyroid Carcinoma: Is There a Place for Lateral Neck Dissection?

Background

Cervical lymph node (LN) metastases are common in patients with papillary thyroid carcinoma (PTC), and they have a negative impact on recurrence. The management of preoperatively node-negative (N0) PTC is still controversial. The aim of our study was to describe the results of a prophylactic bilateral lymph node dissection (LND) and to investigate its impact on recurrence.

Methods

From 2003 to 2011, we analyzed 603 consecutive preoperatively N0 PTC patients. For each patient, we reviewed demographics data, tumor characteristics, pattern and risk factors of LN metastasis, and outcome.

Results

Lymph node metastases were found in 23 % of patients: 19 % in the central compartment and 8 % in the lateral compartment, including 1 % in the lateral compartment on the opposite side from the tumor. Multivariate analysis showed that hyperthyroidism and extrathyroidal invasion of the tumor were significantly associated with LN metastasis. Further analysis showed that localization of the tumor in the upper third of the thyroid lobe and metastatic LN in the central compartment were independent risk factors for lateral LN metastasis. During the 4.3-year follow-up, 23 recurrences were observed (4 %), including 5 in the central compartment. Recurrence rates were 2 % in the N0 group, 5 % in N1a patients, and 22 % in N1b patients (p < 0.001).

Conclusions

In preoperatively N0 PTC patients, LN metastases are frequent in central and ipsilateral lateral compartments. Prophylactic LND in the central and ipsilateral lateral compartments should therefore be recommended in the presence of PTC to identify high-risk patients.     

Diagnosis of Renal Cell Carcinoma: A Clinician’s Perspective

Renal cell carcinoma (RCC) is a heterogeneous disease. A rigorous diagnostic assessment by a pathologist with close communication with the clinician provides more accurate prognostication and informed treatment decisions. In the localized setting, an accurate prognostic assessment directs patients to potential adjuvant clinical trials. For patients with advanced disease, the pathologic assessment may have a direct impact on the systemic therapy algorithm. Additionally, it provides the basis for continuous efforts in biomarker development. In rare histologic subtypes, the interaction between clinicians and pathologists provides an opportunity to offer patients specific clinical trials. Molecular characterization platforms may identify targets for therapeutic intervention.     

Immunoguided Lymph Node Dissection in Colorectal Cancer: A New Challenge?

Knowledge of lymphatic involvement in patients with colorectal cancer is important in surgery and in the postoperative decision-making process. Fifty-eight patients with recurrent colorectal cancer underwent operation with the RIGS/(Radioimmunoguided Surgery) technology. Preoperatively, patients were injected with 1 mg monoclonal antibody (MoAb) CC49 (anti-TAG-72-tumor-associated glycoprotein) labeled with 2 mCi of iodine 125. Traditional surgical exploration was followed by survey with a gamma-detecting probe. Localization of MoAb on tumor was noted in 54/58 patients (93%). Traditional exploration identified 117 suspected tumor sites. With RIGS, 177 suspected tumor sites were detected. In 17 of the 58 patients (27.5%), at least one occult tumor site identified by RIGS was confirmed by pathology with hematoxylin & eosin (H & E) staining. This finding resulted in 16 major changes in surgical plan. RIGS performance varied between lymphatic and non-lymphatic tissue, with a positive predictive value (PPV) of 95.6% and negative predictive value (NPV) of 90% in non-lymphoid tissue compared to PPV of 40% and NPV of 100% in lymphoid tissue. In patients with tumors that localize, no RIGS activity in lymph nodes signifies no tumor, while decisions based on RIGS activity in lymph nodes requires H & E confirmation. Using this guideline, additional information acquired by RIGS can help the surgeon in making an informed decision during surgery and in planning postoperative therapy.     

Factors Associated with Lymph Node Assessment in Ductal Carcinoma in situ: Analysis of 1988–2002 Seer Data

Background  Ductal carcinoma in situ (DCIS) represents 20–30% of mammographically detected breast cancers, but the role of lymph node assessment (LNA) in women with DCIS remains unclear. Methods  Using the 1988–2002 Surveillance, Epidemiology, and End Results (SEER) Program data, we conducted a case–control study to identify variables associated with (1) LNA in DCIS patients and (2) use of axillary lymph node dissection (ALND) compared with sentinel lymph node biopsy (SLNB). Using separate multivariable logistic regression models, we identified patient and tumor-related factors associated with LNA (1988–2002) and with the method used (recorded only in 1998–2002). We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results  Of 23,502 women with DCIS, 37% underwent mastectomy and 63% underwent breast-conservation therapy (BCT); 6,650 cases (28%) underwent LNA. Women younger than 80 years (aOR 1.47; 95% CI 1.24–1.75) or who had mastectomy (aOR 11.06; 95% CI 10.30–11.90), tumor size greater than 9 mm (aORs ranged from 1.27–1.97 for 10-mm increments from 10 to 50 mm or more) or poorly differentiated grade (aOR 1.33; 95% CI 1.11–1.55) were more likely to have had a LNA. From 1998 to 2002, 10,637 women underwent resection for DCIS (21% mastectomy; 79% BCT); of these, 2,219 (21%) had LNA (73% mastectomy; 27% BCT). Mastectomy patients were 3.52 times more likely to receive ALND (95% CI 2.71–4.57) than SLNB, after controlling for other factors. Conclusion  Optimal guidelines for use of LNA in DCIS have not been defined. However, there appeared to be a persistent and excessive utilization of ALND for LNA in women with DCIS (1998–2002).     

Can Retroperitoneal Lymph Node Dissection (RPLND) be feasibly performed to prolong survival in Renal Cell Carcinoma (RCC) with limited lymph node involvement? An Analysis of Recurrence Patterns

IntroductionThe therapeutic benefit of performing a lymph node dissection (LND) in patients with renal cell carcinoma (RCC) has been controversial. In prior studies, it was thought that a low event rate for nodal metastases affected the ability to draw any conclusions. Here, we opted to select patients that had low burden 1 or 2 nodes positive to study survival outcomes and recurrence patterns based on limited LND or extended LND with a template retroperitoneal lymph node dissection (RPLND).MethodsWe used our single institutional database from 2000 and 2019 and identified 45 patients that had only 1 or 2 nodes positive on final pathology without any other systemic disease. These patients all underwent nephrectomy with limited LND or a template RPLND on the ipsilateral side.ResultsWe identified 23 patients in the limited LND and 22 in the template RPLND group. Thirty-one patients included in the study had 1 positive lymph node and 14 patients had 2 positive lymph nodes. For patients undergoing a limited LND, a median 4 (IQR 1–11) lymph nodes were resected and for those undergoing template RPLND, 18 (IQR: 13–23) lymph nodes were resected. On Kaplan-Meier analysis, a difference was noted in overall survival (P = 0.04) when comparing limited LND to template RPLND. We also mapped out patterns of recurrence and found that 6 patients had retroperitoneal lymph node recurrences after a limited LND in the ipsilateral node packet. On univariate analysis, pathologic stage was a major factor for survival, but did not remain as significant with the inclusion of template RPLND status and Charlson Comorbidity Index in multivariate analysis.ConclusionWe identified specific patients that had RCC with limited lymph node involvement. We found that a select number of patients had durable improvement in survival outcomes with template RPLND. In examining the recurrence patterns, a greater number of patients may have derived benefit for an initial template RPLND.     

Prognostic Value of Perinodal Lymphovascular Invasion Following Radical Cystectomy for Lymph Node–positive Urothelial Carcinoma

Background

Metastasis of urothelial carcinoma of the bladder (UCB) into regional lymph nodes (LNs) is a key prognosticator for cancer-specific survival (CSS) after radical cystectomy (RC). Perinodal lymphovascular invasion (pnLVI) has not yet been defined.

Objective

To assess the prognostic value of histopathologic prognostic factors, especially pnLVI, on survival.

Design, setting, and participants

A total of 598 patients were included in a prospective multicentre study after RC for UCB without distant metastasis and neoadjuvant and/or adjuvant chemotherapy. En bloc resection and histopathologic evaluation of regional LNs were performed based on a prospective protocol. The final study group comprised 158 patients with positive LNs (26.4%).

Intervention

Histopathologic analysis was performed based on prospectively defined morphologic criteria of LN metastases.

Outcome measurements and statistical analysis

Multivariable Cox proportional hazard regression models determined prognostic impact of clinical and histopathologic variables (age, gender, tumour stage, surgical margin status, pN, diameter of LN metastasis, LN density [LND], extranodal extension [ENE], pnLVI) on CSS. The median follow-up was 20 mo (interquartile range: 11–38).

Results and limitations

Thirty-one percent of patients were staged pN1, and 69% were staged pN2/3. ENE and pnLVI was present in 52% and 39%, respectively. CSS rates after 1 yr, 3 yr, and 5 yr were 77%, 44%, and 27%, respectively. Five-year CSS rates in patients with and without pnLVI were 16% and 34% (p < 0.001), respectively. PN stage, maximum diameter of LN metastasis, LND, and ENE had no independent influence on CSS. In the multivariable Cox model, the only parameters that were significant for CSS were pnLVI (hazard ratio: 2.47; p = 0.003) and pT stage. However, pnLVI demonstrated only a minimal gain in predictive accuracy (0.1%; p = 0.856), and the incremental accuracy of prediction is of uncertain clinical value.

Conclusions

We present the first explorative study on the prognostic impact of pnLVI. In contrast to other parameters that show the extent of LN metastasis, pnLVI is an independent prognosticator for CSS.     

The Role of Radical Prostatectomy and Lymph Node Dissection in Lymph Node–Positive Prostate Cancer: A Systematic Review of the Literature

Context

Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined.

Objective

To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa.

Evidence acquisition

A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed.

Evidence synthesis

RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (<60 yr) with high-risk PCa and should be an impetus to treat as thoroughly as possible.

Conclusions

Increasing evidence suggests that RP and extended PLND improve survival in LN-positive PCa. Our understanding of surgery of the primary tumor in LN-positive PCa needs a conceptual change from a palliative option to the first step in a multimodal approach with a significant improvement of long-term survival and cure in selected patients.     

Therapeutic Value of Lymph Node Dissection in Advanced Gastric Cancer with Macroscopic Duodenum Invasion: Is the Posterior Pancreatic Head Lymph Node Dissection Beneficial?

Background  In advanced gastric cancer (AGC) with duodenum invasion, the posterior pancreatic lymph nodes are susceptible to metastasis because of their proximity to the duodenum. The therapeutic value of lymph node dissection in this area for AGC with macroscopic duodenum invasion remains unclear. Methods  Patients who had undergone curative gastrectomy for lower-third AGC from 1970 to 2004 at the Cancer Institute Hospital were recruited for this study. Clinicopathological data were collected retrospectively, and compared between cases of AGC with duodenum invasion (AGC-DI group) and AGC without duodenum invasion (AGC-nDI group). In the AGC-DI group, the therapeutic value of lymph node dissection was evaluated using a therapeutic index (multiplication of the frequency of metastasis to the station by the 5-year survival rate of patients with metastasis to that station). Results  The AGC-DI group generally had tumors of higher pathological stage, which might account for the poorer 5-year survival rate compared with that of the AGC-nDI group (50.1% versus 68.5%; P = 0.0002). The incidence of lymph node metastasis was higher in the AGC-DI group than that in the AGC-nDI group, including nodes in the posterior pancreatic head (23.9% versus 7.0%, P < 0.0001). In the AGC-DI group, posterior pancreatic head lymph node dissection was of therapeutic value (4.19) equivalent to dissection of second-tier lymph nodes. Conclusions  The dissection of posterior pancreatic head lymph nodes might be effective in AGC with macroscopic duodenum invasion since this has therapeutic value equivalent to that of second-tier lymph node dissection and might improve patients’ long-term outcomes.     

Opioid-Free Anesthesia in Bariatric Surgery: a Propensity Score–Matched Analysis

Obesity Surgery - Patients undergoing bariatric surgery are at particular high risk of postoperative nausea and vomiting (PONV). Few studies have shown the superiority of opioid-free anesthesia...     

A Phase 2 Trial of Sunitinib in Patients with Advanced Non–clear Cell Renal Cell Carcinoma

Background

Sunitinib is a standard-of-care treatment in advanced clear cell renal cell carcinoma (ccRCC). Retrospective and expanded access data suggest sunitinib has activity in advanced non–clear cell renal cell carcinoma (nccRCC).

Objective

To prospectively determine the clinical efficacy and safety of sunitinib in patients with advanced nccRCC.

Design, setting, and participants

This is a single-arm phase 2 trial with a two-stage design. Eligibility criteria included pathologically confirmed nccRCC or ccRCC with ≥20% sarcomatoid histology, performance status 0–2, measurable disease, a maximum of two prior systemic therapies, and no prior treatment with tyrosine kinase inhibitors directed against the vascular endothelial growth factor receptors.

Intervention

Patients received sunitinib 50 mg daily on a 4-wk on, 2-wk off schedule.

Outcome measurements and statistical analysis

Primary end points were objective response rate (ORR) and progression-free survival (PFS). Secondary end points were safety and overall survival (OS).

Results and limitations

Fifty-seven patients were eligible (nccRCC histology: papillary, 27; chromophobe, 5; unclassified, 8; collecting duct or medullary carcinoma, 6; sarcomatoid, 7; and others, 4). Median PFS for 55 evaluable patients was 2.7 mo (95% confidence interval [CI], 1.4–5.4). Two patients with chromophobe and one patient with unclassified histology had a confirmed partial response (5% ORR). Median PFS for patients with papillary histology was 1.6 mo (95% CI, 1.4–5.4). Median PFS for patients with chromophobe histology was 12.7 mo (95% CI, 8.5–NA). Median OS for all patients was 16.8 mo (95% CI, 10.7–26.3). Treatment-emergent adverse events were consistent with sunitinib's mechanism of action. The nonrandomized design and small number of patients are limitations of this study.

Conclusions

The differential response of chromophobe histology to sunitinib suggests a therapeutically relevant biological heterogeneity exists within nccRCC. The low ORR and short PFS with sunitinib in the other nccRCC subtypes underscore the need to enroll patients with these diverse tumors in clinical trials.     

A 10-Year Trend Analysis of Sentinel Lymph Node Frozen Section and Completion Axillary Dissection for Breast Cancer: Are These Procedures Becoming Obsolete?

Background  

Recent results from the ACOSOG Z0011 trial question the use of intraoperative frozen section (FS) during sentinel lymph node (SLN) biopsy and the role of axillary dissection (ALND) for SLN-positive breast cancer patients. Here we present a 10-year trend analysis of SLN-FS and ALND in our practice.     

Therapeutic Lymph Node Dissection in Melanoma: Different Prognosis for Different Macrometastasis Sites?

Background

The prognostic significance of primary tumor location, especially the poor prognosis for melanomas in the scalp and neck region, is well established. However, the prognosis for different sites of nodal macrometastasis has never been studied. This study investigated the prognostic value of the location of macrometastasis in terms of recurrence and survival rates after therapeutic lymph node dissection (TLND).

Methods

All consecutive FDG-PET-staged melanoma patients with palpable and cytologically proven lymph node metastases operated at our clinic between 2003 and 2011 were included. Disease-free survival and disease-specific survival (DSS) were compared for nodal metastases in the groin, axilla, and neck regions by multivariable analysis.

Results

A total of 149 patients underwent TLND; there were 70 groin (47?%), 57 axillary (38?%), and 22 neck (15?%) dissections. During a median follow-up of 18 (range 1?C98) months, 102 patients (68?%) developed recurrent disease. Distant recurrence was the first sign of progressive disease in 78, 76, and 55?% of the groin, axilla, and neck groups, respectively (p?=?0.26). Low involved/total lymph nodes (L/N) ratio (p?<?0.001) and absence of extranodal growth pattern (p?=?0.05) were independent predictors of a longer disease-free survival. For DSS, neck site of nodal metastasis (p?=?0.02) and low L/N ratio (p?<?0.001) were independent predictors of long survival. The estimated 5-year DSS for the groin, axilla, and neck sites was 28, 34, and 66?%, respectively.

Conclusions

There seems significantly longer DSS after TLND for nodal macrometastases in the neck compared to axillary and groin sites, although larger series should confirm this finding.     

Sentinel Lymph Node Biopsy for T1/T2 Oral Cavity Squamous Cell Carcinoma—A Prospective Case Series

Background

Sentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution??s experience of SLNB between 2006 and 2010.

Methods

Prospective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS).

Results

A total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06.

Conclusions

SLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.     

Association of Lymph Node Sampling and Clinical Volume in Lobectomy for Non–Small Cell Lung Cancer

BackgroundSampling of ≥10 lymph nodes during lobectomy for non–small cell lung cancer (NSCLC) was a previous surveillance metric and potential quality metric of the American College of Surgeons Commission on Cancer. We sought to determine guideline adherence and its relationship to hospital lobectomy volume within The Society of Thoracic Surgeons General Thoracic Surgery Database.MethodsParticipant centers providing elective lobectomy for NSCLC within The Society of Thoracic Surgeons General Thoracic Surgery Database (2012-2019) were divided into tertiles according to annual volume. Average hospital nodal harvest of ≥10 nodes per lobectomy defined the primary outcome. Univariable analysis compared average patient and operative characteristics between the participant centers. Multivariable logistic regression was used to determine independent factors associated with average clinical center nodal harvest of ≥10 nodes.ResultsMedian annual lobectomy volume was 6.2, 19.9, and 42.7 for low-, medium-, and high-volume participant centers. Among 305 centers and 43 597 patients, 5.6% of lobectomies occurred in low-volume centers, 24.0% in medium-volume centers, and 70.4% in high-volume centers. Average rates of ≥10 nodes per lobectomy were excised in 44.0% of low-volume centers, 70.6% of medium-volume centers, and 75.2% of high-volume centers (P < .001). On multivariable analysis, average nodal excision of ≥10 nodes was strongly associated with medium-volume (odds ratio, 2.94; CI, 1.57-5.50, P < .01) and high-volume (odds ratio, 3.82; CI, 1.95-7.46; P < .001) participant centers.ConclusionsAlthough higher center volume and increased nodal harvest are associated, 25% of high-volume centers average a rate of <10 lymph nodes per lobectomy for NSCLC. Low nodal yield may underestimate stage, with implications for adjuvant therapy and long-term survival.