Clinical significance of stereological estimation of mean nuclear volume in human bladder carcinoma--further analysis of nuclear morphometric variables]

Recently, nuclear morphometry methods have been used to quantitatively analyze the malignant potential of cancer cells. We have previously shown that the malignant potential of human bladder carcinoma can be analyzed quantitatively through mean nuclear volume measurements. In the present study, we examined other measurements obtained from nuclear morphometry and evaluated their usefulness as indicators of the outcome of bladder carcinoma. Our subject group consisted of 161 patients with untreated bladder carcinoma. Four nuclear morphometric values were measured on each subject: the mean nuclear volume (MNV), the mean nuclear area (MNA), the nuclear roundness factor (NRF) and the variation of nuclear area (VNA). MNV, MNA and VNA values increased as the tumors progressed to a more advanced stage and grade of malignancy. Patients were then divided into two subgroups based on each morphometric value: small MNV (< 186.9 microns3) and large MNV (> or = 186.9 microns3); small MNA (< 33.6 microns2) and large MNA (> or = 33.6 microns2); low NRF (< 81.1) and high NRF (> or = 81.1); and low VNA (< 33.0) and high VNA (> or = 33.0). Survival rates were significantly higher among patients with a small MNV, a small MNA and a low NRF (5-year survival rate; 93.0, 84.9 and 84.6%), compared to patients exhibiting high values (5-year survival rate; 59.7, 61.3 and 61.9%). For patients with grade 2 tumors, those with a small MNV had a high survival rate (5-year survival rate; 95.2%), similar to that of patients with grade 1 tumors (5-year survival rate; 95.2%)(ABSTRACT TRUNCATED AT 250 WORDS)     

Estimation of nuclear volume of nontumorous bladder mucosa in patients with bladder tumor--measurement by vertical section

The mean nuclear volume (MNV) of non-tumorous bladder mucosa in 27 patients with a bladder tumor was estimated by using a new stereological method, "vertical section". Eighty four specimens were obtained by punch biopsy from preselected sites of urinary bladder. Thirteen specimens (10 patients) out of 84 were histologically diagnosed as carcinoma in situ (CIS). Bladder mucosa of 24 patients with various benign diseases were also measured as normal controls. The MNV of the normal control group was 127.1 +/- 19.6 microns 3 (mean +/- standard error) and that of the specimens diagnosed with CIS was 279.6 +/- 69.0 microns 3. There was no overlap between the two groups. Out of 71 specimens diagnosed as having no malignancy, 30 (42.3%) exhibited significantly increased MNV. Estimation of the MNV of non-tumorous bladder mucosa may be useful for standardization of CIS. Further studies are needed to investigate the role of the increased MNV in histologically normal mucosa in the course of a bladder tumor.     

Superficial bladder cancer: survival and prognostic factors.

Two hundred and seventeen consecutive patients with superficial bladder cancer stages Ta-T1 were analyzed for survival and prognostic factors. The overall 5-year survival was 88 +/- 5.3%. Factors that impacted significantly on survival were: grade of anaplasia (GI 92 +/- 5.9% vs. GII 87 +/- 7.5% vs. GIII 68 +/- 20.7%; p = 0.01); increasing grade of anaplasia (98 +/- 1.9% vs. 55 +/- 15.6%; p less than 0.0001); progression in tumor stage (100% vs. 58 +/- 12.5%; p less than 0.0001); index of recurrences greater than 0.7 (100% vs. 71 +/- 10%; p less than 0.0001); the presence of urothelial dysplasia (98 +/- 1.7% vs. 77 +/- 9.8%; p less than 0.05); inflammatory infiltrate (90 +/- 7% vs. 83 +/- 7.3%; p less than 0.01), and residual tumor post-TUR (89 +/- 5.5% vs. 68 +/- 18.6%; p less than 0.001). Tumor stage did not impact on survival (p greater than 0.05). Using multivariate statistical analysis only the grade of anaplasia (p less than 0.0001) and increasing grade of anaplasia (p = 0.001) demonstrated significant prognostic value. Eight percent of patients died because of tumor progression. Of these patients, 87% were T1 and had concomitant urothelial dysplasia. Twenty-five percent had carcinoma in situ and the mean index of recurrence was 1.59. Seventy-five percent of patients dying because of tumor progression developed muscle-infiltrating cancer (greater than or equal to T2GIII) and 25% developed previously metastatic spread without evidence of local progression (T1GIII).(ABSTRACT TRUNCATED AT 250 WORDS)     

Differences in gene expression in muscle-invasive bladder cancer: a comparison of Italian and American patients

OBJECTIVE: To seek differences in gene expression in the primary muscle-invasive bladder cancers of two cohorts of patients having different survival rates. An Italian group treated by transurethral resection of the bladder tumor (TURBT) and neo-adjuvant chemotherapy using methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) followed by TURBT, partial cystectomy or radical cystectomy (75% 3-year survival) was compared to an American cohort treated by radical cystectomy (51% 3-year survival). METHODS: Immunohistochemistry was used to examine the protein expression levels of three genes that act at the G1/S cell cycle checkpoint, p53, p21/waf-1/cip1 (a downstream effector gene in the p53 pathway) and Rb, plus a major inhibitor of apoptosis, Bcl-2. RESULTS: For the bladder cancers of the Italian patient cohort, there was a significantly higher rate of p53 immunopositivity (93 vs. 63%, p = 0.002) and a significantly lower rate of Rb loss (25 vs. 54%, p = 0.009). In bivariate analysis, 72% of Italian tumors were immunopositive for both p53 and p21 (p53+/p21+) vs. 49% for the American tumors. The subset of Italian patients with p53+/p21+ tumors were more frequently disease-free (stage pT0) following chemotherapy and were less likely to fail therapy than those with p53+/p21- tumors (p = 0.0357). Loss of Rb staining was associated with a decreased 5-year survival in the Italian, but not in the American patients. CONCLUSIONS: (1) Significant differences in the expression of the p53, p21 and Rb genes were found between the 2 groups of patients. (2) Italian patients with p53+/p21+ tumors had significantly lower recurrence rates after TURBT and chemotherapy than those having p53+/p21- tumors. (3) Absence of p21 immunopositivity in the Italian tumors may identify alterations in the p53 pathway that predict poor outcome.     

Long-term survival after resection of pulmonary metastases from carcinoma of the breast.

Resection of isolated pulmonary metastases may yield improved survival in select patients. Between 1981 and 1991, 44 women (median age, 55 years) with a history of breast cancer underwent 47 thoracotomies with no operative deaths and only three minor postoperative complications (3/47, 6.4%). Confirmation of the metastatic origin of the lung lesion was made by direct histological comparison with the primary. Three patients had benign nodules and were excluded, and 4 patients had less than complete resection at thoracotomy. The median survival after thoracotomy of the remaining 37 patients with completely resected metastases was 47 +/- 5.5 months, and their actuarial 5-year survival was 49.5%. Patients with a disease-free interval of longer than 12 months had a longer survival (median survival, 82 +/- 6 months; 5-year survival, 57%) than patients with a disease-free interval of 12 months or less (median survival, 15 +/- 3.6 months; 5-year survival, 0%) (p = 0.004). Patients with estrogen receptor-positive status (n = 14) tended to have longer survival after resection than patients with estrogen receptor-negative status (n = 15) (median survival, 81 +/- 9 months versus 23 +/- 6 months, respectively; p = 0.098). Other clinical variables analyzed did not predict survival after thoracotomy. We conclude that resection of pulmonary metastases in patients with breast cancer can be done safely and may result in long-term survival for a substantial number of patients. Patients with a disease-free interval of longer than 12 months have an excellent prognosis after complete resection.     

Renal cell carcinoma: vena caval invasion and prognostic factors

Ninety-one consecutive patients with renal cell carcinoma stages pT1-4/N0-3/V0-2/M0 were analyzed for survival rates. The overall 5-year survival was 57%. Factors which made an impact on 5-year survival rates were: (1) grade of anaplasia (GI: 72%, GII: 42%, GIII: 22%; p = 0.0001); (2) pathological stage (pT1-2: 86%, pT3: 30%; p = 0.0000); (3) perinephric fat invasion (pT1-2: 86%, pT3a: 61%; p = 0.01); (4) nodal involvement (N0: 69%, N1: 11%; p = 0.0000), and (5) venous invasion (V0: 72%, V1-2: 30%; p less than 0.01). There were no differences in survival rates between V1 and V2 tumors (p greater than 0.05). Using multivariate statistical analysis we found that grade of anaplasia and venous invasion contained dire prognostic information (p = 0.0000). Among patients with stage pT3b, those without perinephric fat invasion or nodal involvement had a better survival rate than those with capsular infiltration (p less than 0.01) and a significantly better rate than those with perinephric fat invasion and nodal involvement (p less than 0.01). Moreover, there were no differences between stages pT3b with venous invasion only and stages pT1-2 (p greater than 0.05). Patients with venous invasion developed distant metastases with a significantly higher frequency than those without (p = 0.01). The prognostic impact of venous invasion is unclear yet, but is probably related to perinephric fat invasion and nodal involvement. Until further data are collected, the radical approach with complete removal of the thrombus remains the treatment of choice for localized renal cell carcinoma with vena caval extension.(ABSTRACT TRUNCATED AT 250 WORDS)     

Growth fractions of transitional cell carcinomas of the bladder defined by the monoclonal antibody Ki-67

We used an immunohistochemical technique with the monoclonal antibody Ki-67, which recognizes nuclear antigen expressed in proliferating cells to determine the growth fractions of 5 normal mucosa specimens and 55 transitional cell carcinomas of the bladder. Normal mucosa had a mean value of 0.37 +/- 0.35% cells positive for Ki-67, whereas 9 histological grade 1 tumors showed 2.2 +/- 1.5%, 31 grade 2 tumors averaged 10.1 +/- 7.5% and 15 grade 3 tumors yielded 19.5 +/- 9.0%. These values were significantly different from each other (p less than 0.01), with Ki-67 indexes for grade 2 varying from 0.3 to 24.6%. Nonpapillary tumors had significantly higher indexes than papillary tumors (20.1 +/- 8.0 versus 6.7 +/- 5.9, p less than 0.01). The Ki-67 indexes were 4.6 +/- 4.5% for stage Ta (20 cases), 7.8 +/- 4.7% for stage T1 (14) and 20.2 +/- 7.8% for stages equal to or higher than T2 (21). Significant differences were noted between stages Ta and T1 (p less than 0.05) and between stages T1 and T2 or greater (p less than 0.01). Tumors with muscle layer invasion often showed more than 15% Ki-67 positive cells. Our results imply that Ki-67 indexes not only provide objective information to determine a malignant potential but also help to select the treatment.     

Soft-Tissue sarcomas of the shoulder girdle: Factors influencing local recurrence,distant metastases,and survival

Background: Prognostic factors and the role of radiotherapy have not been well characterized for soft-tissue sarcomas (STS) of the shoulder girdle. Methods: The cases of 70 patients with primary shoulder STS were reviewed for the following information: size, grade and histology of tumors, extent of resection, and use of adjuvant radiotherapy. The influence of these factors on local disease-free survival (LDFS), distant disease-free survival (DDFS), and overall survival (OS) rates was analyzed using univariate analysis. Results: With a median follow-up of 108 months, the overall 5- and 10-year survival rates for patients with shoulder girdle STS were 82% and 80%, respectively, whereas the 5-year disease-free survival rate was 63%. There were 25 (35%) tumor recurrences: 12 (17%) distant and 13 (18%) local regional. Tumors >5 cm in size were associated with a significantly decreased 5-year OS rate compared with lesions <5 cm, and high-grade tumors were associated with significantly decreased DDFS and OS rates. Because most of the patients who underwent amputation had large, high-grade tumors, they had significantly decreased 5-year DDFS and OS rates compared with wide local excision. Radiotherapy produced a significant improvement in LDFS rates, particularly in patients with tumors >5 cm in size. Conclusions: The results indicate that both tumor size and grade are important prognostic factors in shoulder girdle STS. Adjuvant radiotherapy should be considered in large tumors to improve the LDFS and to decrease the need for radical ablative surgery. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Prognostic value of sarcomatoid histology and volume-weighted mean nuclear volume in renal cell carcinoma

OBJECTIVE: To determine the prognostic value of two histopathological factors, sarcomatoid histology and volume-weighted mean nuclear volume (MNV) in renal cell carcinoma (RCC). PATIENTS AND METHODS: The study included 106 patients (72 men and 34 women, mean age 63 years, range 32-83) with RCC, all of whom were surgically treated between 1985 and 1995. The presence of any sarcomatoid component was determined and MNV estimated using a stereological method in histological slides of tumour specimens from these patients. The prognostic significance of the two variables was evaluated by univariate and multivariate analyses in comparison with other histopathological variables (T, N and M categories, nuclear grade, tumour size, tumour type), using the cause-specific and progression-free survival of the patients as the endpoints. RESULTS: Among the 106 RCC cases examined, a sarcomatoid component was detected in 34 (32%); the MNV was 90-627 micro3 (mean 225). By univariate and multivariate analysis, both variables were significant prognostic factors for cause-specific survival in all patients. In addition, multivariate analysis of the 74 patients with localized RCCs (T1-3, N0 M0) showed that sarcomatoid histology was a significant prognostic factor for disease progression. CONCLUSION: The presence of sarcomatoid histology and the MNV, both of which can be examined with no specialized laboratory procedures, seem to be useful tumour-related prognostic factors in RCC.     

T2期胃癌术后复发因素分析

目的　探讨T2 期胃癌的临床病理学特性和影响术后复发的因素。　方法　将 12 4例接受了根治性手术的T2 期胃癌患者分为复发组和未复发组 ,对其临床资料、手术方式、病理结果以及术后累积生存率等进行对比分析。　结果　 2组患者年龄、性别、血型、手术方式、肿瘤大小及部位和组织学分化程度等情况 ,差异无显著性意义 (P >0 0 5 )。未复发组局限性溃疡型肿瘤占 45 1%、浅肌层肿瘤占 30 5 %、透肌层肿瘤占 2 5 6 % ,复发组分别占 2 6 2 %、4 8%、6 1 8% ,2组相比差异有显著性意义 (分别P <0 0 5、P <0 0 1)。复发组淋巴结转移率为 88 1% ,阳性淋巴结数为 (7 0 2± 6 5 0 )枚 ,未复发组分别为 5 7 3%、(2 16± 2 0 4)枚 ;复发组中位生存时间为 2 6 5个月 ,未复发组为 5 7 0个月 ;复发组 1、3、5年累积生存率分别为 6 1 4%、18 7%、8 3% ,未复发组分别为 97 6 %、95 9%、95 9% ,两者差异均有显著性意义 (P <0 0 1)。复发组局部复发占 5 4 8% ,远处转移占 46 2 %。　结论　T2 期胃癌患者一旦术后复发预后极差。肿瘤浸润程度、淋巴结转移状况是影响复发的重要因素。     

Surgical resection versus percutaneous radiofrequency ablation in the treatment of hepatocellular carcinoma on cirrhotic liver

OBJECTIVE: We sought to compare the experience of 2 different surgical units in the treatment of hepatocellular carcinoma (HCC) on cirrhosis with resection or percutaneous radiofrequency ablation (RFA), respectively. SUMMARY BACKGROUND DATA: When allowed by the hepatic functional reserve, surgery is the therapy for HCC on cirrhosis; alternative treatments are proposed because of the high tumor recurrence rate after resection. RFA is being widely adopted to treat HCC. METHODS: Over a 4-year period, 79 cirrhotics with HCC underwent resection in 1 surgical unit (group A) and another 79 had RFA at a different unit (group B). Patient selection, operative mortality, hospital stay, and 1- and 3-year overall and disease-free survival were analyzed. RESULTS: Group A (surgery): mean follow-up was 28.9 +/- 17.9 months; operative mortality was 3.8%, mean hospital stay 9 days; 1- and 3-year survival were, respectively, 83 and 65%. One- and 3-year disease-free survival were 79 and 50%. Group B (RFA): mean follow-up was 15.6 +/- 11.7 months. Mean hospital stay was 1 day (range 1-8). One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free survival were 60 and 20%. Overall and disease-free survival were significantly higher in group A (P = 0.002 and 0.001). The advantage of surgery was more evident for Child-Pugh class A patients and for single tumors of more than 3 cm in diameter. Results were similar in 2 groups for Child-Pugh class B patients CONCLUSIONS: RFA has still to be confirmed as an alternative to surgery for potentially-resectable HCCs.     

CD44+/CD24-/low在乳腺癌中表达及其临床意义

目的 观察乳腺癌中CD44+/CD24-/low的表达与临床病理特征的关系及其对预后的影响.方法 应用双染免疫组织化学检测144例乳腺癌与30例乳腺良性肿瘤或正常乳腺组织中CD44+/CD24-/low的表达,收集并分析患者的临床病理和随访资料.结果 CD44+/CD24-/low在乳腺良性肿瘤或正常乳腺中表达率为0%～8%,乳腺癌中表达率为0%～75%.67例(46.5%)乳腺癌患者CD44+/CD24-/low表型的细胞>10%,余77例(53.5%)≤10%.CD44+/CD24-/low的表达高低在淋巴结转移(P<0.01)、病理分期(P<0.01)、HER-2表达(P<0.01)以及复发(P<0.01)上差异有统计学意义.CD44+/CD24-/low高表达的肿瘤复发时主要表现为远处转移,尤其是骨转移.CD44+/CD24-/low高表达和低表达的5年无病生存率为65%和82%(P<0.01),5年总生存率为68%和86%(P<0.05),差异有统计学意义.结论 CD44+/CD24-/low的表达可能与乳腺癌的转移有关,有可能作为评估乳腺癌患者预后的参考指标.     

TUR and adjuvant intravesical chemotherapy in T1G3 bladder tumors: recurrence, progression and survival in 137 selected patients followed up to 20 years

OBJECTIVES: To evaluate a highly selected population of patients affected by T1G3 bladder transitional cell carcinoma (TCCB) treated by transurethral resection (TUR) and adjuvant intravesical chemotherapy. MATERIALS AND METHODS: Between January 1976 and April 1999, 137 patients with T1G3 TCCB were treated by TUR plus intravesical chemotherapy. Particularly, a sequential combination of mitomycin C (MMC) and epirubicin (EPI) was adopted in 91 patients (66.4%). The main exclusion criteria were concomitant or previous Tis, previous T1G3 TCCB, tumor size greater than 3 centimeters and number of tumors more than 3. TUR was repeated if a superficial tumor recurred. Patients went off study if Tis, recurrent T1G3 or invasive tumor were detected during treatment or thereafter. Adjuvant therapy, recurrence and progression were considered in multivariate analysis regarding recurrence, progression and survival respectively. RESULTS: Observation period was up to 240 months with a minimum of 2 years in 112 patients (82%). Seventy patients (51%) recurred. The recurring tumor was again a T1G3 in 22 (16%) patients. Thirteen patients (9.5%) progressed. The 5-year progression-free survival rate was 90%. Median progression-free survival was 149 months. Twenty-two patients (16%) died, 9 (6.6%) of whom due to bladder cancer. Median overall survival was 155 months. The 3- and 5-year disease-free overall survival rates were 89% and 80% respectively. Ten cystectomies (7.3%) were performed. In conclusion, 123 patients (90%) maintained their intact bladder with a mean disease-free overall survival of 104 months. The sequential combination of MMC and EPI adjuvant therapy resulted more effective to be than single drug chemotherapy on recurrence rate (p=0.0021) but had no impact upon progression (p=0.127) and specific survival (p=0.163). Progression (p<0.001) after conservative treatment was the main prognostic factor for survival. CONCLUSION: A conservative approach is an appropriate therapeutic option for the initial management of selected T1G3 bladder tumors.     

Radical extensive surgery for renal cell carcinoma: long-term results and prognostic factors

We studied 200 consecutive patients with renal cell carcinoma who underwent radical nephrectomy and extensive lymphadenectomy. Of the patients 25% already had distant metastasis at operation. Higher T stages tended to be associated with positive nodes (p less than 0.01) and distant metastasis (p less than 0.001). However, in patients with stage N0M0V0 tumors we found no statistically significant difference in survival in relationship to the T stage of the disease (5-year survival: stage T1 80%, stage T2 68% and stage T3 70%). Of all patients 10% had positive nodes without distant metastases and no venous spread of the tumor, and the 5-year survival rate was 52%. The 5-year survival rate of patients with distant metastases was 7%. Patient survival in the presence of a vena caval tumor thrombus is similar to that of patients with distant metastases. Based on our results the different stages in disease progression may be classified as having a good prognosis--intracapsular tumors (stages T1 to T2, N0M0V0) and tumors with involvement of perirenal fat (stage T3N0M0V0), an intermediate prognosis--tumors with nodal metastases alone (stages T1 to T3, N1 to 2, M0V0) and a poor prognosis--tumors with venous invasion and/or distant metastases. Histological grading and size of tumor can be used to assess prognosis but are not more accurate than pathological staging.     

Transitional cell carcinoma of the upper urinary tract new concepts in management

Transitional cell carcinomas of the upper urinary tract (UUT-TCCs) are rare: they account for approximately 5% of all urothelial carcinomas. 30% of patients with UUT-TCC have a history of bladder TCC, but fewer than 2% of patients with bladder TCC have UUT-TCC. Tumor microsatellite instability (MSI) is an indicator of the clonal expansion of neoplasms; it was first identified in tumors from patients with hereditary non-polyposis colorectal carcinoma (HNPCC). UUT-TCC occurs in 5% of patients with HNPCC. High-frequency microsatellite instability is present in almost 20% of cases of sporadic UUT-TCC. In cases of UUT-TCC with high-frequency MSI, hereditary cancer must be sought, especially if the patient is younger than 60 years or has a personal or family history of an HNPCC-related cancer: such patients should undergo DNA sequencing for the MSH2 gene germline mutation. Invasive UUT-TCC has a poor prognosis. 5-year survival is less than 50% for stage T2-T3 tumors and less than 10% for T4 or N+/M+ tumors. The main prognostic factors are age and tumor stage and grade. High-frequency MSI is a positive prognostic factor, especially in patients younger than 70 years with T2/T3/N0-M0 tumors.     

Long-term results of primary adenocarcinoma of the urinary bladder: a report on 192 patients

OBJECTIVES: To evaluate the clinical presentation and treatment end results of primary adenocarcinoma of the urinary bladder, and to determine the significant independent prognostic factors that determine this outcome. PATIENTS AND METHODS: Of 3659 patients who underwent cystectomy, 192 had adenocarcinoma of the urinary bladder, with a relative frequency of 5.2%. Most of these patients (68.2%) presented in late stages (P3 + P4). The incidence of pelvic lymph nodes involvement was 25.5%. Mucinous adenocarcinoma was reported in 28 patients (14.6%), papillary in 20 (10.4%), signet ring in 14 (7.3%), while not otherwise specified was reported in 130 (67.7%) in the cystectomy specimens. RESULTS: Mucinous and signet-ring histologic subtypes showed increased frequency of high stages and high grades, and more nodal involvement than the papillary and not otherwise specified. All patients were treated with radical cystectomy and pelvic lymphadenectomy with (69 patients) or without (123) postoperative radiotherapy. The 5-year disease-free survival rate was 46 +/- 4% for all patients with adenocarcinoma. Postoperative radiotherapy improved the disease-free survival significantly. The 5-year disease-free survival rate for the postoperative radiotherapy group was 61 +/- 6% compared to 37 +/- 5% for the cystectomy alone group (P = 0.002). Local control rate was significantly improved from 53 +/- 7% for cystectomy alone to 96 +/- 3% for postoperative radiotherapy patients (P = 0.00001). Distant metastases were the leading cause of death in the postoperative radiotherapy group. CONCLUSIONS: Within the limitations provided by retrospective studies, it could be concluded that postoperative radiotherapy improved the disease-free survival through its effect on local control. The disease-free survival independent prognostic variables were tumor stage, postoperative radiotherapy, nodal involvement, and adenocarcinoma subclassification. These factors, except the adeno-subclassification, were also found to determine the local control rate. On the other hand, the independent prognostic factors for distant metastasis were lymph nodal involvement, stage, and adeno-subclassification.     

Minimum number of necessary lymph nodes for the accurate staging of adenocarcinoma of esophagogastric junction

ObjectiveThis study aims to explore the minimum number of lymph nodes (LNs) necessary for assessing the postoperative staging of adenocarcinoma of esophagogastric junction (AEG).MethodsWe extracted the data of patients from the Surveillance Epidemiology and End Results (SEER) database, who were pathologically diagnosed with AEG between 2000 and 2017. We explored the associations between the number of LNs and overall survival (OS) by univariate and multivariate analyses and determined the proper cutoff value of the number of LNs necessary for accurate postoperative staging.ResultsOf the patients with AEG in the SEER database, 2668 met our inclusion criteria. The total number of regional LNs dissected was found to be significantly associated with survival in analyses stratified by T stage. Univariate and multivariate regression showed that age, grade, positive LNs, number of LNs examined, and T stage were independently associated with OS. For patients with T1-2 tumors, the 5-year survival rate was 58.7%, and patients with more than 11 LNs examined obtained a greater survival benefit. Among patients with T3-4 tumors, the 5-year survival rates were 28.9% and 39.7% for those with 1–16 LNs examined and for those with more than 17 LNs examined, respectively.ConclusionTo accurately determine the pathological stage of patients with AEG, no less than 11 LNs must be resected for patients with stage T1-2 disease, and no less than 16 LNs must be resected for patients with stage T3-4 disease.     

Gastrointestinal sarcomas. Analysis of prognostic factors.

Clinical and pathologic data from 51 patients with primary sarcomas of the gastrointestinal tract treated from 1951 through 1984 were reviewed to determine clinical presentation, histologic features, treatment, and prognostic factors. The most common signs and symptoms were abdominal pain (62%), gastrointestinal bleeding (40%), and/or abdominal mass (38%). The primary site was stomach in 50%, small bowel in 30%, colorectum in 15%, and esophagus in 5%. Virtually all the sarcomas were leiomyosarcomas. Distribution was uniform among the three histologic grades; although 88% of Grade 1 tumors could be completely excised, only 35% of Grade 3 tumors could be completely resected. The 5-year survival rate was 75% for Grade 1 tumors, 16% for Grade 2 tumors, and 28% for Grade 3 tumors (p = 0.0013, Grade 1 vs. 2 and 3). Thirty of the 51 patients (59%) had curative resection with an operative morbidity rate of 24% and an operative mortality rate of 12%; at 5 years the disease-free survival rate was 58% and the overall survival rate was 63% (48% at 10 years). Eleven patients (42%) had recurrent disease develop at a median interval of 2 years after complete tumor excision. Twenty-one patients (41%) had partial excision or biopsy only of their tumors with an operative morbidity rate of 28%, operative mortality rate of 8%, and median survival of only 9 months. Overall, patients whose tumors were confined to the site of origin had a 58% 5-year survival rate compared with 20% for those whose tumors had invaded adjacent organs (p less than 0.05). If the tumor was less than 10 cm in size, the 5-year survival rate was 78%, significantly better than the 38% for tumors greater than 10 cm (p = 0.03). These data suggest that histologic grade, local invasiveness, size, and extent of resection are the most important prognostic factors for patients with primary gastrointestinal sarcomas. Patients who have resection of all gross tumor, especially if it is well differentiated and localized, have a good prognosis.     

Lymph node involvement: the only prognostic factor after curative resection of cancer of the stomach. Results of a multivariate analysis

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric adenocarcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.     

Pathological stage does not alter the prognosis for renal lesions determined to be stage T1 by computerized tomography

PURPOSE: Pathological stage has been the most widely used prognosticator for evaluating surgically managed cases of renal cell carcinoma. Minimally invasive surgical approaches are being increasingly used to treat small masses for which traditionally pathological information is lacking (morcellation) or absent (radio frequency ablation or cryoablation). Preoperative cross-sectional imaging by computerized tomography (CT) or magnetic resonance imaging has been used to stage renal tumors clinically but it can lead to variances with traditional pathological staging systems, particularly with respect to microscopic invasion beyond the renal capsule. In this study we assessed whether radiographically staged clinical T1 lesions that were pathological T1 behave differently than those that were clinical stage T1 and up staged to pT3a. MATERIALS AND METHODS: The records of 296 patients who underwent surgical treatment for renal cell carcinoma at The Johns Hopkins Hospital between 1990 and 1999 were retrospectively reviewed. All patients had undergone preoperative CT or magnetic resonance imaging, which was used to assign a clinical stage and size (largest diameter) to each tumor in accordance with the 1997 TNM staging system. Following surgical resection pathological stage, size and tumor grade were determined. Only the 186 patients with clinical T1 tumors were included in this analysis. RESULTS: Of the 186 patients who were clinically found to have T1 lesions 125 (67%) had pathological T1 and 57 (31%) had pathological T3a lesions. All surgical margins and lymph nodes were negative at surgical resection. Mean tumor size +/- SD was 3.9 +/- 1.5 cm for pT1 lesions and 3.8 +/- 1.5 cm for pT3a lesions. When comparing these pathological groups using Kaplan-Meier analysis, 5-year recurrence-free survival was not statistically different in patients with pT1 and pT3a lesions (90.6 and 97.5%, respectively). CONCLUSIONS: Patients in whom the initial classification of T1 renal cell carcinoma by CT was up graded to T3a on pathological analysis (invasion of fat within Gerota's fascia) showed the same recurrence-free survival rate as patients with pathologically confirmed T1 lesions. Thus, smaller tumors (less than 7 cm) that are up graded to T3a based on capsule invasion behave much like T1 tumors and exact pathological T staging does not appear to impact overall survival.