Extended lymph node dissection in patients with urothelial cell carcinoma of the bladder: can it make a difference?

Objective  We compared extended and limited lymph node dissections performed during radical cystectomy with regard to impact on survival and time to recurrence in bladder cancer patients. Methods  We analyzed 170 patients who underwent radical cystectomy for urothelial carcinoma between January 1997 and December 2005. From 1997 to 2000, 69 of the patients were subjected to limited lymph dissection that included perivesical nodes and nodes in the obturator fossa. In 2001–2005, the remaining 101 patients underwent extended lymph dissection that included perivesical nodes; nodes in the obturator fossa; the internal, external, and common iliac nodes; and the presacral nodes. Results  Tumors penetrating the bladder wall (pT3 and pT4a) were more common in the extended than in the limited dissection group (48 and 33%, respectively). The median numbers of lymph nodes removed in the two groups were 37 and 8, respectively. Lymph node metastases were detected in 38% of the extended dissection patients but only in 17% of the limited dissection patients. There was no significant difference in survival or time to recurrence between the two groups. Subgroup analyses showed a significantly longer time to recurrence (HR 0.45, 95% CI 0.22–0.93; P = 0.032) in patients with non-organ-confined disease who underwent extended lymph node dissection. In a multivariate analysis adjusting for tumor stage, lymph node status, age, sex, and adjuvant chemotherapy, there was a significantly improved survival (HR 0.47, 95% CI 0.25–0.88; P = 0.018) and time to recurrence (HR 0.42, 95% CI 0.23–0.79; P = 0.007) in the patients with extended lymph node dissections. Conclusions  Extended lymph node dissection did not improve disease-specific survival, but was in multivariate analysis related to significantly improved disease-specific survival and prolonged time to recurrence in radical cystectomy patients. These results should be interpreted cautiously, since they might have been affected by stage migration and the shorter follow-up in the extended dissection group.     

Analysis of lymph node dissection in patients with ≥7-cm renal tumors

Purpose

To analyze the role of lymph node dissection (LND) in patients with large renal tumors.

Methods

We performed a retrospective study of patients with renal cell carcinoma ≥7 cm in size undergoing surgery between 1990 and 2012. Primary outcome measures were recurrence-free and overall survival of patients who did and did not undergo LND. Cox proportional hazards regression models were created to account for known risk factors for recurrence and survival. Secondary outcomes were recurrence-free and overall survival by lymph node status, lymph node template and number of lymph nodes removed.

Results

Of 524 patients, 164 had disease recurrence and 197 died. Median follow-up was 5 and 5.5 years for patients who did not die or have a recurrence, respectively. A total of 334 (64 %) patients underwent LND, and node-positive disease was identified in 26 (8 %). For patients who did and did not undergo LND, 5-year recurrence-free survival was 64 and 77 %, respectively. Five-year overall survival was 75 and 78 %, respectively. LND was not a predictor of recurrence or survival in multivariate analysis. Node-positive disease was associated with recurrence (p < 0.0005) and mortality (p = 0.032), although node-positive patients had a 5-year overall survival of 65 %.

Conclusions

We did not find a difference in recurrence-free or overall survival in patients with ≥7-cm tumors whether or not they underwent LND. Node-positive disease was associated with worse outcomes, suggesting that LND provides important staging information that can be important in the design of adjuvant clinical trials.     

What is the value of axillary dissection or sentinel node biopsy in patients with ductal carcinoma in situ?

BACKGROUND: Some surgeons have advocated sentinel node biopsy (SNB) for ductal carcinoma in situ (DCIS). The value of the information obtained is not clear. METHODS: From 1972 to 2005, 564 selected patients with pure DCIS had axillary staging with either SNB or axillary lymph node dissection (ALND). Data were collected in a prospective database. RESULTS: Only 2 of 564 patients had positive nodes by hematoxylin and eosin, and they were both in the ALND group. Both patients had mastectomies, were upstaged, received chemotherapy, and survived for more than 10 years without local or distant recurrence. Among 171 patients who had SNB, 10 had isolated tumor cells found by immunohistochemistry. Two patients who underwent SNB had local recurrence, neither developed distant or regional recurrence. Six of 564 patients in the ALND group developed local invasive recurrence and died of metastatic breast cancer, but none of them had positive nodes. CONCLUSIONS: Information from lymph node examination in DCIS patients failed to predict poor outcome. SNB is useful for DCIS in mastectomy, especially with immediate reconstruction. It may be indicated for DCIS at high risk for upgrading to invasive cancer on final excision, but reliable criteria for identifying these tumors are not yet available.     

Staging laparoscopy in patients with hepatocellular carcinoma: is it useful?

Background

Staging laparoscopy (SL) is not regularly performed for patients with hepatocellular carcinoma (HCC). It may change treatment strategy, preventing unnecessary open exploration. An additional advantage of SL is possible biopsy of the nontumorous liver to assess fibrosis/cirrhosis. This study aimed to determine whether SL for patients with HCC still is useful.

Methods

Patients with HCC who underwent SL between January 1999 and December 2011 were analyzed. Their demographics, preoperative imaging studies, surgical findings, and histology were assessed.

Results

The 56 patients (34 men and 22 women; mean age, 60 ± 14 years) in this study underwent SL for assessment of extensive disease or metastases. For two patients, SL was unsuccessful because of intraabdominal adhesions. For four patients (7.1 %), SL showed unresectability because of metastases (n = 1), tumor progression (n = 1), or severe cirrhosis in the contralateral lobe (n = 2). An additional five patients did not undergo laparotomy due to disease progression detected on imaging after SL. Exploratory laparotomy for the remaining 47 patients showed 6 (13 %) additional unresectable tumors due to advanced tumor (n = 5) or nodal metastases (n = 1). Consequently, the yield of SL was 7 % (95 % confidence interval (CI), 3–17 %), and the accuracy was 27 % (95 % CI, 11–52 %). A biopsy of the contralateral liver was performed for 45 patients who underwent SL, leading to changes in management for 4 patients (17 %) with cirrhosis.

Conclusions

The overall yield of SL for HCC was 7 %, and the accuracy was 27 %. When accurate imaging methods are available and additional percutaneous liver biopsy is implemented as a standard procedure in the preoperative workup of patients with HCC, the benefit of SL will become even less.     

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p < 0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p < 0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.     

BCG for upper-tract transitional-cell carcinoma: is it safe in patients with renal compromise?

We report three cases of end-stage renal failure necessitating hemodialysis subsequent to BCG administration for the treatment of upper-urinary tract transitional-cell carcinoma in patients with a solitary kidney, one with normal renal function and two with chronic renal failure prior to BCG instillation. We discuss treatment-related issues with pertinent literature review.     

Urinary ultrasonography in screening incidental renal cell carcinoma: is it obligatory?

Purpose  

To analyze the rate of incidental renal carcinoma in patients with no upper urinary tract symptoms (UUTS) or hematuria depending on the sonography reports and medical records of the patients and to determine whether there is a need for routine US screening for RCC.     

Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies?

Purpose

This study aimed to investigate the effects of lymph node dissection (LND) on upper tract urothelial carcinoma (UTUC) without suspicious lymph node (LN) metastasis on preoperative imaging studies.

Methods

From 1998 to 2012, 418 UTUC patients without suspicious LN metastasis on preoperative imaging studies were included. Patients were divided into two groups according to the performance of LND. The effects of LND on oncological outcomes were assessed after adjusting other variables. The mean follow-up duration was 69 months.

Results

Among the 132 patients who underwent LND, LN metastasis was pathologically identified in 16 patients (12.1 %). The median number of resected LNs for patients who underwent LND was 7. On multivariate analysis, the number of resected LNs and pathologic T stage was significant predictors of LN metastasis. The 5-year recurrence-free survival was 76.4 % for patients without LND and 65.4 % for patients with LND (p = 0.126). In addition, there was no difference in 5-year overall survival between the 2 groups (without LND; 71.7 % vs. with LND; 72.1 %, p = 0.756). Multivariate analysis showed that pathologic T stage, tumor grade, and lymphovascular invasion were risk factors for recurrence. Age at surgery, tumor size, pathologic T stage, tumor grade, and lymphovascular invasion were significantly associated with overall survival. However, performance of LND was not associated with recurrence and survival.

Conclusions

LND could be selectively performed in patients with clinically LN-negative UTUC based on patient/tumor characteristics and operative findings although sufficient LNs should be removed if LND is to be performed.

     

Digital photoplethysmography in the diagnosis of suspected lower limb DVT: is it useful?

OBJECTIVE: to determine the role of digital photoplethysmography (D-PPG) in the diagnosis of deep-vein thrombosis (DVT), in comparison to the "gold standard" of either contrast ascending venography (ACV) or colour-flow duplex imaging (CFDI). METHOD: prospective study of 100 hospital inpatients (103 legs) referred to the X-ray department for ACV or CFDI with clinically suspected lower limb DVT in a district general hospital. Each patient was assessed by either ACV or CFDI, and D-PPG. RESULTS: thirty-seven limbs were found to have DVT as demonstrated by ACV or CFDI. All patients with a venous refilling time (RT) of greater than 20 s and venous pump (VP) of greater than 35 had a normal ACV or CFDI. Using RT of less than 21 s as the optimal cut-off point, D-PPG achieved a sensitivity of 100%, negative-predictive value of 100%, specificity of 47% and positive-predictive value of 51%. By using VP of less than 36 as the optimal cut-off point, a sensitivity of 100%, a negative-predictive value of 100%, a specificity of 35% and positive-predictive value of 46% were achieved. CONCLUSIONS: these results validate the use of portable D-PPG as a useful screening tool for the diagnosis of clinically suspected lower limb DVT. A positive test requires further confirmation by one of the "gold standard" methods, whereas a negative test effectively excludes DVT.     

Axillary lymph node metastases in patients with small carcinomas of the breast: is accurate prediction possible?

OBJECTIVES: To find out whether macroscopic classification of the tumour margin is predictive of axillary lymph node metastases and to identify a combination of clinical and pathological findings by which axillary node status can be predicted accurately in small carcinomas (T1) of the breast. DESIGN: Retrospective study. SETTING: Municipal referral centre, Japan. SUBJECTS: All 1003 patients with T1 invasive carcinoma of the breast who had axillary lymph node dissection between January 1970 and December 1996 as part of their treatment. MAIN OUTCOME MEASURES: The association between the incidence of axillary lymph node metastases and 10 clinical and pathological factors (age, palpability and size of tumour, macroscopic classification of tumour margin, clinical axillary status, radiating spiculation on a mammogram, histological type, lymphatic invasion, oestrogen and progesterone receptor status) were analysed. RESULTS: Clinical axillary node status, macroscopic classification of tumour margin, lymphatic invasion, and age of the patient were significant predictors of axillary lymph node metastases (p < 0.01 in each case). Among 47 patients aged 65 or more whose tumours had well-defined margins and with a clinical N0 status in the axillae, the incidence of histological axillary lymph node metastasis was only 6% (n = 3) whereas it was 65% in 57 patients with tumours of ill-defined margins whose axillae were N1 or N2. CONCLUSIONS: Macroscopic classification of tumour margins is an independent predictor of axillary lymph node metastases for patients with small carcinomas of the breast. However, even with combinations of the examined predictors of axillary node metastases, the subgroup of patients at minimal risk of metastasis was less than 5% in T1 breast cancer, whereas three-quarters of the patients had clear axillary lymph nodes. Most patients with T1 breast cancer will need surgical staging of the axillae by methods such as sentinel node biopsy.     

In patients undergoing lung resection for non-small cell lung cancer, is lymph node dissection or sampling superior?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In patients undergoing lung resection for non-small cell lung cancer, is lymph node dissection or sampling superior?' Altogether 845 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that in stage I tumours there is little difference in survival when performing either mediastinal lymph node dissection (MLND) or lymph node sampling. However, survival is increased when performing MLND in stage II to IIIa tumours. Increased accuracy in staging is not observed with MLND. However, MLND reliably identifies more positive N2 nodes which may offer advantages in postoperative adjuvant treatment in more advanced disease.     

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

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

Treatment of brain metastases in renal cell carcinoma: radiotherapy, radiosurgery, or surgery?

Metastases from renal cell carcinoma raise specific therapeutic problems because they are relatively unresponsive to whole brain radiation therapy and tend to bleed. Recently, stereotactically guided high-precision irradiation as a single dose application (radiosurgery) showed promising treatment results for selected patients with brain metastases from renal cell carcinoma. Radiosurgery appears attractive due to its low risk and minimal invasiveness. Multiple lesions can be treated at the same time and retreatments can be performed for local or distant recurrences.     

Sedation in neurocritical patients: is it useful?

Anesthetics are widely used in the management of neurocritical patients, although has never been proved that the use of these drugs can contribute to positive outcome. The aim of this review was to evaluate the expected benefit of anesthetics use in relation to the altered physiology of the damaged brain while considering possible related complications.