Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer

BACKGROUND: The presence or absence of lymph node metastases is known to be an important prognostic factor for patients with pancreatic cancer. Few studies have investigated the ratio of the number of lymph nodes harboring metastatic cancer to the total number of lymph nodes examined (lymph node ratio [LNR]) with regard to outcome after pancreaticoduodenectomy for ductal cancer of the pancreas. METHODS: Between 1995 and 2005, a total of 905 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma. Demographics, operative data, number of lymph nodes evaluated, number of lymph nodes with metastatic carcinoma, LNR, pathologic margin status, and long-term survival were analyzed. RESULTS: There were 187 (20.7%) of the 905 patients who had negative peripancreatic lymph nodes (N0), whereas 718 (79.3%) of the 905 patients had lymph node metastases (N1). The median number of lymph nodes evaluated in the N0 group was 15 versus 18 in the N1 group (P = .12). At median follow-up of 24 months, the median survival for all patients was 17.4 months, and the 5-year actuarial survival rate was 16.1%. Patients with lymph node metastases had a shorter median overall survival (16.5 months) compared with patients with negative lymph nodes (25.3 months; P = .001). Compared with the total number of lymph nodes examined or total number of lymph node metastases, LNR was the most compelling predictor of survival. As the LNR increased, median overall survival decreased (LNR = 0, 25.3 months; LNR > 0 to 0.2, 21.7 months; LNR > 0.2 to 0.4, 15.3 months; LNR > 0.4, 12.2 months; P = .001). After adjusting for other factors associated with survival, LNR remained an independent predictor of overall survival (P < .001). CONCLUSIONS: After pancreaticoduodenectomy for adenocarcinoma of the pancreas, LNR was one of the most powerful predictors of survival. LNR should be considered when stratifying patients in future clinical trials.     

The risk factors for the presence of pelvic lymph node metastasis in penile squamous cell carcinoma patients with inguinal lymph node dissection

Objective

To evaluate factors in penile squamous cell carcinoma predictive of pelvic lymph node metastasis and survival.

Materials and methods

Data were collected and analyzed retrospectively in 146 patients with squamous cell carcinoma of penis who underwent bilateral inguinal lymph node dissection in our center between January 1998 and April 2011. Variables recorded included serum squamous cell carcinoma antigen, primary tumor p53 immunoreactivity, histological grade, pathological tumor stage, lymphatic or vascular invasion, absent/unilateral or bilateral inguinal lymph node involvement, number of metastatic inguinal lymph nodes, presence of extracapsular growth and lymph node density.

Results

Seventy patients had inguinal lymph node metastasis (LNM). Of these, 33 (47.1 %) had pelvic LNM. Primary tumor strong p53 expression, lymphatic or vascular invasion, involvement of more than two inguinal lymph nodes and 30 % or greater lymph node density were significant predictors of pelvic LNM. Primary tumor strong p53 expression (odds ratio [OR] 5.997, 95 % confidence intervals [CI] 1.615–22.275), presence of extracapsular growth (OR 2.209, 95 % CI 1.166–4.184), involvement of more than two inguinal lymph nodes (OR 2.494, 95 % CI 1.086–5.728) and pelvic lymph node involvement (OR 18.206, 95 % CI 6.807–48.696) were independent prognostic factors for overall survival.

Conclusions

Primary tumor expression of p53, lymphatic or vascular invasion, number of metastatic inguinal lymph nodes and lymph node density were all predictors of pathologic pelvic lymph node involvement. Patients with pelvic LNM had an adverse prognosis, with a 3-year overall survival rate of approximately 12.1 %. Pelvic lymph node dissection should be considered in these cases.     

Predictors of lymph node metastasis in early gastric cancer.

Data were analysed on 396 patients with early gastric cancer who underwent resection in this department; special reference was made to lymph node metastasis. Metastases were present in the dissected lymph nodes of 47 patients (11.9 per cent). The survival rate for patients with metastasis to lymph nodes was lower than for those without such metastasis (P less than 0.05). Lymph node metastasis was associated with larger tumour, a higher incidence of submucosal invasion, a higher rate of lymphatic vessel involvement, an advanced stage of disease and a non-curative resection rate of 6.4 per cent. Multivariate analysis showed that the independent risk factors for lymph node metastasis in patients with early gastric cancer were large tumour size, lymphatic vessel involvement and invasion into the submucosal layer. In patients with these risk factors, lymph node dissection and postoperative adjuvant therapy should be performed in an attempt to prevent recurrence in the form of lymph node metastasis.     

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status

BACKGROUND: The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy. METHODS: Patients undergoing resection for primary pancreatic ductal adenocarcinoma or intrapancreatic bile duct adenocarcinoma were identified from a prospective database (September 1997-May 2003). RESULTS: Thirteen of 54 and ten of 44 evaluable patients had metastatic involvement of lymph nodes 8a and 16b1 respectively. Metastatic involvement of lymph node 8a was associated with a significantly shorter median survival (197 versus 470 days; P = 0.003) but metastatic involvement of lymph node 16b1 did not affect survival (457 versus 503 days; P = 0.185). Multivariate analysis showed lymph node 8a status to be the strongest predictor of outcome (P = 0.006). Median survival of those with metastatic lymph node 8a was not significantly different from that of 81 patients with overt metastatic periampullary cancer at the time of diagnosis (98 days; P = 0.072) CONCLUSION: Lymph node 8a was an independent prognostic factor in patients with periampullary malignancy, but lymph node 16b1 was not. Survival in those with metastatic lymph node 8a was not significantly different from that in patients with metastatic disease at presentation. Preoperative determination of lymph node 8a status may have important implications in selecting patients for treatment.     

Intraoperative lymphatic mapping and sentinel lymph node biopsy for Merkel cell carcinoma

BACKGROUND: Merkel cell carcinoma is a rare cutaneous neoplasm which commonly spreads to the regional lymph nodes. The feasibility of identifying the sentinel node in patients with clinically node-negative Merkel cell carcinoma was evaluated. METHODS: Sentinel lymphatic mapping was performed in 18 patients with stage 1 Merkel cell carcinoma using the combination of isosulphan blue dye and 99mTc-radiolabelled sulphur colloid. Patients with tumour metastasis in the sentinel node underwent complete dissection of the remainder of the lymph node basin. RESULTS: Eighteen patients underwent removal of 35 sentinel nodes. Two patients demonstrated metastatic disease in the sentinel lymph nodes; complete dissection of the involved nodal basin revealed no additional positive nodes suggesting that the sentinel lymph node had been identified. The node-negative patients received no further surgical therapy, with no evidence of recurrent disease in the sentinel nodal basin at a median of 7 months' follow-up. CONCLUSION: Sentinel node biopsy is feasible in patients with Merkel cell carcinoma. It can be used to stage patients and provides important prognostic information. In those with subclinical nodal disease, it may direct early regional lymphadenectomy but the effect of such surgery on survival remains unclear.     

����θ���ܰͽ�ת�ƹ��ɼ�Ԥ�����

目的 探讨早期胃癌的淋巴结转移规律及其对预后的影响。方法 对161例有癌病人术后进行长期随访，对24例伴有淋巴结转移的早期胃癌与137例无淋巴结转移的早期胃癌的临床病理特征及3、5年生存率进行比较。结果 早期胃癌的淋巴结转移与肿瘤大小、浸润深度及淋巴、静脉侵犯有关，伴有淋巴结转移的早期胃癌3、5年生存率分别为82.8%和80.5%，明显低于无淋巴结转移者，后者分别为96.1%和92.4%。结论 术前或术中正确评估早期胃癌的淋巴结转移状态是选择合理的治疗方案和改善预后的重要条件。     

胃癌孤立性淋巴结转移规律及其预后分析

目的 探讨胃癌孤立性淋巴结转移的规律及其预后.方法 回顾性分析1995年1月至2003年12月期间83例接受D2根治术的胃癌孤立性淋巴结转移患者的临床资料,探讨胃癌孤立性淋巴结转移发生的部位及其与原发病灶的关系;比较跳跃性与非跳跃性淋巴结转移患者的预后差异;对本组患者的预后因素进行单因素及多因素分析.结果 本组83例胃癌孤立性淋巴结转移患者中,第1站淋巴结转移者64例(77%),直接发生第2站淋巴结转移(跳跃性转移)者19例(23%),胃上、中、下部癌分别以No.3(40%)、No.3(42%)、No.6组(33%)淋巴结转移最为常见.本组77例(93%)患者获得随访,时间5～14年,其中位生存期为77.0个月,术后5年生存率为63%;跳跃性与非跳跃性淋巴结转移患者术后5年生存率分别为52%和67%,两者差异无统计学意义(P＞0.05).影响本组患者预后的相关因素是浆膜是否受侵和肿瘤病理类型,其中浆膜是否受侵为影响预后的独立因素.结论 第1站淋巴结是胃癌孤立性淋巴结转移的主要部位,可以作为胃癌前哨淋巴结导航外科中淋巴绘图的主要目标;肿瘤侵犯浆膜层的胃癌孤立性淋巴结转移的患者预后较差.     

胃癌转移淋巴结被膜外扩散和患者预后的关系

目的 探讨胃癌转移淋巴结被膜外扩散的相关因素及其对患者预后的影响.方法 通过对131例行胃癌根治术患者的临床病理和随访资料进行分析,评价胃癌转移淋巴结被膜外扩散与患者预后的关系.结果 78例(59.5%)患者有胃周区域性淋巴结转移,其中有46例转移淋巴结出现被膜外扩散,其5年累计生存率为13.5%;而32例无被膜外扩散的患者5年生存率为39.3%,生存率随胃周转移淋巴结出现被膜外扩散而明显下降(P=0.001).胃周转移淋巴结被膜外扩散与淋巴结转移数目、淋巴结转移距离、肿瘤浸润深度以及远处转移具有显著的相关性,是胃癌患者预后的独立影响因素(P=0.003).结论 胃周转移淋巴结被膜外扩散是一个简单有效判断预后的指标,是影响预后的一个独立因素.进行胃癌病理分期应当检查转移淋巴结被膜外扩散状况,并予以报道.

Abstract：

Objective The aim of the current study was to investigate the prognostic value of extracapsular lymph node spread in gastric cancer patients and to find correlations with clinicopathological parameters.Methods Clinicopathological data of 131 gastric cancer patients who underwent gastrectomy with lymphadenectomy were analyzed retrospectively. The number of metastatic lymph nodes with extracapsular spread were determined. Multivariate analysis was performed to find the clinical prognosis affecting extracapsular lymph node involvement. Results Seventy-eight patients (59.5%)had perigastric lymph node metastasis. Fortysix cases were detected extracapsular lymph node involvement. The 5-year cumulative survival rate for patients with extracapsular lymph node spread was 13. 5% , while 32 patients with lymph node metastasis but without extracapsular involvement had a 5-year survival rate of 39.3%. The survival rate decreased significantly with the increase of extracapsular lymph node involvement(P =0.001). Extracapsular lymph node involvement was significantly associated with the higher number of metastatic lymph nodes, the location of lymph node metastasis, tumor invasion depth and distant lymph node metastasis. In the multivariate analysis, extracapsular lymph node spread also remained as an independent prognostic factor(P =0.003). Conclusions Extracapsular lymph node involvement is a convenient and reliable prognostic index, and is an independent prognostic factor in gastric cancer patients. In future staging systems for gastric cancer, extracapsular lymph node involvement should be considered, be pathologically checked and reported in order to determine extracapsular spread status.     

Mode of spread in the early phase of lymphatic metastasis in pancreatic ductal adenocarcinoma: prognostic significance of nodal microinvolvement

BACKGROUND: The aim of this study was to assess the prognostic significance of nodal microinvolvement as well as the mode of spread in the early phase of lymphatic metastasis in patients with node-negative pancreatic ductal adenocarcinoma. METHODS: Lymph nodes from 48 node-negative patients with R0 resected pancreatic ductal adenocarcinoma were sampled from 3 different compartments: 1) distal hepatoduodenal ligament, 2) superior-anterior compartment, and 3) posterior-inferior. Tissue sections of 148 lymph nodes classified as tumor free by routine histopathology were examined, using a sensitive immunohistochemical assay with the antiepithelial monoclonal antibody Ber-EP4 for tumor cell detection. With regard to histopathologic tumor staging and grading, 26 (54.2%) of the patients were staged as pT1/pT2, 22 (45.8%) as pT3/pT4, while 31 (64.6%) as G1/G2 and 17 (35.4%) patients as G3.Of the 148 "tumor free" lymph nodes, 56 contained Ber-EP4-positive tumor cells. These 56 lymph nodes were from 28 of the 48 patients. The multivariate Cox regression analysis revealed the independent prognostic impact of nodal microinvolvement on relapse-free and overall survival. Analysis by compartment, from which the lymph nodes were collected, revealed that overall survival time (P = 0.006) and time to local recurrence (P = 0.015) depend on the presence of nodal microinvolvement in the superior-anterior compartment. CONCLUSIONS: The influence of occult tumor cell dissemination in lymph nodes of patients with histologically proven pancreatic ductal adenocarcinoma supports the need for further tumor staging through immunohistochemistry. This could be a helpful tool in proper selection of patients for adjuvant chemotherapy.     

Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus

OBJECTIVE: To determine the prevalence of occult cervical nodal metastases in patients with squamous cell cancer and adenocarcinoma of the esophagus, and to determine the impact of esophagectomy with three-field lymph node dissection on survival and recurrence rates. SUMMARY BACKGROUND DATA: Although esophagectomy with three-field lymph node dissection is commonly practiced in Japan, its role in the surgical management of esophageal cancer in the United States, especially in patients with esophageal adenocarcinoma, is essentially unknown. METHODS: This is a prospective observational study of esophagectomy with three-field lymphadenectomy. Eighty patients underwent resection between August 1994 and April 2001. Clinicopathological information and follow-up data were collected on all patients until death or June 2001. RESULTS: Hospital mortality and morbidity rates were 5% and 46%, respectively. Metastases to the recurrent laryngeal and/or deep cervical nodes occurred in 36% of patients irrespective of cell type (adenocarcinoma 37%, squamous 34%) or location within the esophagus (lower third 32%, middle third 60%). Overall 5-year and disease-free survival rates were 51% and 46%, respectively. Sixty-nine percent presented with nodal metastases. The 5-year survival rate for node-negative patients was 88%; that for those with nodal metastases was 33%. The 5-year survival rate in patients with positive cervical nodes was 25% (squamous 40%, adenocarcinoma 15%). CONCLUSIONS: Esophagectomy with three-field lymph node dissection can be performed with a low mortality and reasonable morbidity. Unsuspected metastases to the recurrent laryngeal and/or cervical nodes are present in 36% of patients regardless of cell type or location within the esophagus. Thirty percent of patients were upstaged, mainly from stage III to stage IV. An overall 5-year survival rate of 51% suggests a true survival benefit beyond that achieved solely on the basis of stage migration.     

Proposal of a new lymph node mapping system for pancreatic head cancer

The Japanese Pancreatic Society published the 4th edition of the general guidelines for the study of pancreatic cancer (JPS guidelines) in 1993. The current JPS guidelines differ from the UICC classification of lymph nodes. Thirty-five lymph node stations are divided into three groups in the JPS guidelines. Group 1 (n1) corresponds closely with the regional lymph nodes in the UICC classification. Group 2 (n2) and group 3 (n3) are distant metastases in the UICC classification. To clarify practical lymph node mapping, 2,449 resected tubular adenocarcinomas of the pancreas head registered with the JPS were analyzed. Lymph node involvement was observed most frequently in posterior pancreatoduodenal (PPD) and anterior pancreatoduodenal (APD) and then in paraaortic (n2) nodes. Fifty-six patients who achieved 5-year survival were registered, of whom 19 had lymph node involvement. The sites of lymph node involvement were limited to the PPD and/or APD nodes in 14 cases. PPD and APD nodes differ from the other n1 in terms of high incidence of metastasis and fair prognosis. In conclusion, we propose a new practical lymph node mapping system in which PPD and APD nodes are the first station and the other n1 are the second station.     

Histopathologic validation of the sentinel lymph node hypothesis for breast carcinoma.

BACKGROUND AND OBJECTIVE: The sentinel node hypothesis assumes that a primary tumor drains to a specific lymph node in the regional lymphatic basin. To determine whether the sentinel node is indeed the node most likely to harbor an axillary metastasis from breast carcinoma, the authors used cytokeratin immunohistochemical staining (IHC) to examine both sentinel and nonsentinel lymph nodes. METHODS: From February 1994 through October 1995, patients with breast cancer were staged with sentinel lymphadenectomy followed by completion level I and II axillary dissection. If the sentinel node was free of metastasis by hematoxylin and eosin staining (H&E), then sentinel and nonsentinel nodes were examined with IHC. RESULTS: The 103 patients had a median age of 55 years and a median tumor size of 1.8 cm (58.3% T1, 39.8% T2, and 1.9% T3). A mean of 2 sentinel (range, 1-8) and 18.9 nonsentinel (range, 7-37) nodes were excised per patient. The H&E identified 33 patients (32%) with a sentinel lymph node metastasis and 70 patients (68%) with tumor-free sentinel nodes. Applying IHC to the 157 tumor-free sentinel nodes in these 70 patients showed an additional 10 tumor-involved nodes, each in a different patient. Thus, 10 (14.3%) of 70 patients who were tumor-free by H&E actually were sentinel node-positive, and the IHC lymph node conversion rate from sentinel node-negative to sentinel node-positive was 6.4% (10/157). Overall, sentinel node metastases were detected in 43 (41.8%) of 103 patients. In the 60 patients whose sentinel nodes were metastasis-free by H&E and IHC, 1087 nonsentinel nodes were examined at 2 levels by IHC and only 1 additional tumor-positive lymph node was identified. Therefore, one H&E sentinel node-negative patient (1.7%) was actually node-positive (p < 0.0001), and the nonsentinel IHC lymph node conversion rate was 0.09% (1/1087; p < 0.0001). CONCLUSIONS: If the sentinel node is tumor-free by both H&E and IHC, then the probability of nonsentinel node involvement is <0.1%. The true false-negative rate of this technique using multiple sections and IHC to examine all nonsentinel nodes for metastasis is 0.97% (1/103) in the authors' hands. The sentinel lymph node is indeed the most likely axillary node to harbor metastatic breast carcinoma.     

Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest

BACKGROUND: The extent to which adenocarcinoma of the cardia with lymph node metastasis in the upper mediastinum is amenable to cure by radical surgery is open to debate. It remains unclear whether these relatively distant metastases have an effect on long-term survival. The aim of this study was to identify the incidence of such positive nodes and evaluate their prognostic significance. METHODS: Some 50 patients with adenocarcinoma of the gastric cardia and substantial invasion of the oesophagus (junctional type II), who underwent an extended transthoracic oesophagectomy as part of a prospective randomized trial between 1994 and 2000, were studied. RESULTS: Eleven patients (22 per cent) had lymph node metastasis in the proximal field of the chest. These patients had more positive nodes overall (P = 0.020) and a shorter median survival (P = 0.009) than those without such metastasis. Multivariate analysis identified positive nodes in the proximal field as an independent predictor of poor survival. CONCLUSION: Lymph node metastasis in the proximal field of the chest is common and is an indicator of poor prognosis in patients with adenocarcinoma of the cardia.     

Rational lymph node dissection for lung cancer according to the occurrence lobe and histological type]

Between January 1989 and December 1998, 134 cases of squamous cell carcinoma and 244 cases of adenocarcinoma underwent surgical resection of the lung with systematic lymph node dissection in our hospital. The cN diagnosis by CT scan and pN diagnosis were compared. In squamous cell carcinoma pN 2-3 cases were only one patient (2%) out of 60 patients with cN 0, 5 patients (18%) out of 28 patients with cN 1, and 21 patients (46%) out of 46 patients with cN 2-3. On the other hand in adenocarcinoma pN 2-3 cases were 27 patients (14%) out of 193 patients with cN 0, 3 patients (25%) out of 12 patients with cN 1, and 24 patients (62%) out of 39 patients with cN 2-3. The pathways of the lymphatic metastases to the mediastinal nodes were analized in 27 patients with squamous cell carcinoma and 54 patients with adenocarcinoma undergoing systematic lymph node dissection. All patients had histologically proven mediastinal metastasis. Histologically there was no difference in pathways of the lymphatic metastases to the mediastinal nodes. 1. The dominant lymphatic drainage from the right upper lobe flowed into the superior mediastinal nodes. The direct metastatic passages to the superior mediastinal nodes were observed (47%). Subcarinal and inferior mediastinal node involvement was rare (3%). 2. The dominant lymphatic drainage from the middle and the lower lobe flowed into the subcarinal nodes (85%). The involvement of the superior mediastinal nodes occurred in 53% of subcarinal node positive patients on the right side. 3. The dominant lymphatic drainage from the left upper lobe flowed into the subaortic or paraaortic nodes (69%). Subcarinal and inferior mediastinal node involvement was rare (6%). We conclude that subcarinal and inferior mediastinal lymph node dissection is not necessary for upper lobe lung cancers, and that superior mediastinal lymph node dissection can be omitted in middle and lower lobe lung cancers without hilar and subcarinal lymph node involvement, especially in the cases of cN 0.     

胰腺癌淋巴结转移情况对预后的影响

目的研究淋巴结转移情况对胰腺癌患者预后的影响。方法回顾性分析我院2009年1月至2015年8月72例行根治性手术的胰腺癌患者淋巴结转移情况及其对预后的影响。结果检出淋巴结961枚,平均13.3枚/例;其中阳性淋巴结87枚。单因素分析显示:得到随访的有淋巴结转移者(PN1)33例(47%),中位生存期为8.6个月;得到随访的无淋巴结转移者(PN0)37例(53%),中位生存期18.6个月;无淋巴结转移者生存率显著高于有淋巴结转移患者(P0.05)。在有淋巴结转移的患者中,淋巴结阳性比率(LNR)0.2者14例(42%),中位生存期为6.4个月;LNR≤0.2者19例(58%),中位生存期11.4个月;LNR0.2者生存率显著低于LNR≤0.2者(P0.05)。淋巴结转移局限于第1站的有17例(52%),中位生存期为11.0个月;第2站以上淋巴结转移者16例(48%),中位生存期7.5个月;第2站以上淋巴结转移者生存率显著低于淋巴结转移局限于第1站者(P0.05)。多因素分析显示:第2站以上淋巴结转移、淋巴结阳性比率0.2仍然是影响胰腺癌预后的独立危险因素(P0.05)。此外,肿瘤侵犯范围、综合治疗、肿瘤分化程度也影响胰腺癌预后(P0.05)。结论胰腺癌淋巴结转移率较高,LNR0.2及第2站以上淋巴结转移是影响胰腺癌预后的独立危险因素。     

Long-term survival of patients with biliary tract cancers with lymph node involvement

In extrahepatic biliary tract malignancies, the prognostic value of lymph node involvement remains unclear. For a total of 161 tumors of the gallbladder (GBC) and bile duct (BDC) resected between 1982 and 1992, the number and extent of metastatic nodes were investigated according to the location of the primary tumor. In GBCs and upper two-third BDCs, more than half of node-positive tumors involved multiple nodes (58% and 63%), and node-positive tumors were associated with a significantly poorer rate of patient survival compared with node-negative tumors. However, GBCs with one or two nodes involved resulted in a longer survival time than those with three or greater (P = 0.0045). In lower one-third BDCs, even patients with node-positive tumors showed a 60% 5-year survival rate. There were 15 long-term survivors (i.e., survived for more than 5 years after surgery) with node-positive tumors in the GBC group, 4 in the upper BDC group, and 6 in the lower BDC group. Thirteen GBCs had one or two involved nodes, and 12 of the 13 GBCs positive nodes were located within the hepatoduodenal ligament. In upper and lower BDCs, pericholedocal nodes and nodes around the pancreatic head respectively, were most frequently involved. We concluded that lymphatic spread is an important prognostic determinant in both GBCs and upper BDCs. The prognosis of GBCs is especially influenced by the number of nodes involved. In lower BDCs, lymphatic metastasis does not necessarily preclude long-term survival. Received for publication on Jan. 29, 1999; accepted on April 28, 1999     

Variables related to risk of recurrence in rectal cancer without lymph node metastasis

Background: There has been recent interest in the use of local excision for rectal cancer under consideration of patient's quality of life. However, local excision of the primary tumor does not remove the areas of lymphatic spread. Therefore, the decision to use this procedure must be considered carefully. Methods: The authors retrospectively analyzed 142 patients who underwent radical resection of rectal cancer without lymph node metastasis in order to define the risk factors for recurrence. The macroscopic and microscopic pathological characteristics, immunohistochemical staining for p53, and DNA ploidy pattern of the primary tumor were examined as potential predictors of recurrence. Results: The rates for 5-year disease-free survival, local control, freedom from distant metastasis, and overall survival in these 142 patients were 87%, 93%, 93%, and 91%, respectively. Factors related to recurrence and prognosis included the depth of tumor invasion, vascular/lymphatic involvement, tumor differentiation, and tumor size. However, p53 staining and DNA ploidy pattern were not useful indicators. Conclusions: Our findings suggest that adjunctive radiotherapy and chemotherapy should be considered for patients who have rectal cancer without lymph node metastasis in the following situations: tumor invasion of the serosa, vascular/lymphatic involvement, moderately differentiated adenocarcinoma, and lesions >2 cm in diameter. Local excision should not be used in these situations, even if there are no lymph node metastases. The results of this study were presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Impact of lymph node metastasis on survival with early gastric cancer

The impact of lymph node metastasis on the survival of early gastric cancer (EGC) cases remains controversial. A retrospective study of 621 patients with EGC undergoing gastrectomy with lymphadenectomy during the period 1966–1993 was performed to evaluate the influence of node involvement on long-term outcomes. Lymph node metastasis was observed in 63 cases (10.1%). Two groups, EGC with and without node involvement, were compared with respect to long-term results and various clinicopathologic factors. The median observation period was 123 months. EGC cases without metastatic nodes had significantly better outcomes than those with node involvement in terms of overall survival as well as survival excluding deaths due to diseases unrelated to the primary EGC. Survival rates for EGC patients with node involvement did not, however, differ significantly according to the number of metastatic nodes. Three factors-submucosal invasion, large tumor size, and recurrence-were significantly related to lymph node metastasis. Age, sex, family history of malignancy, histologic type, and multiple occurrence of gastric cancer were unrelated to the prevalence of node involvement. The frequency of recurrence in EGC cases without node involvement was low (1.8%, 10 of 558). Recurrence was not, however, exceptional in those with metastatic nodes (9.5%, 6 of 63). EGC patients with lymph node metastasis, even with only a single positive node, constitute a high risk group for EGC recurrence.     

Long-term survival in 2,505 patients with melanoma with regional lymph node metastasis

OBJECTIVE: To examine the long-term outcomes of patients with melanoma metastatic to regional lymph nodes. SUMMARY BACKGROUND DATA: Regional lymph node metastasis is a major determinant of outcome for patients with melanoma, and the presence of regional lymph node metastasis has been commonly used as an indication for systemic, often intensive, adjuvant therapy. However, the risk of recurrence varies greatly within this heterogeneous group of patients. METHODS: Database review identified 2,505 patients, referred to the Duke University Melanoma Clinic between 1970 and 1998, with histologic confirmation of regional lymph node metastasis before clinical evidence of distant metastasis and with documentation of full lymph node dissection. Recurrence and survival after lymph node dissection were analyzed. RESULTS: Estimated overall survival rates at 5, 10, 15, and 20 years were 43%, 35%, 28%, and 23%, respectively. This population included 792 actual 5-year survivors, 350 10-year survivors, and 137 15-year survivors. The number of positive lymph nodes was the most powerful predictor of both overall survival and recurrence-free survival; 5-year overall survival rates ranged from 53% for one positive node to 25% for greater than four nodes. Primary tumor ulceration and thickness were also powerful predictors of both overall and recurrence-free survival in multivariate analyses. The most common site of first recurrence after lymph node dissection was distant (44% of all patients). CONCLUSIONS: Patients with regional lymph node metastasis can enjoy significant long-term survival after lymph node dissection. Therefore, aggressive surgical therapy of regional lymph node metastases is warranted, and each individual's risk of recurrence should be weighed against the potential risks of adjuvant therapy.     

Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy.

OBJECTIVE: The purpose of this study was to evaluate the regional pancreatectomy as surgical therapy for ductal adenocarcinoma of the pancreas and to evaluate potential prognostic factors. SUMMARY BACKGROUND DATA: Regional pancreatectomy was developed as a more adequate surgical procedure for pancreatic cancer in an attempt to improve the cure rate for this highly lethal disease. Few studies have evaluated large numbers of patients treated with this technique, and in recent years the emphasis has been on more limited surgery for pancreatic cancer. METHODS: Fifty-six patients with ductal adenocarcinoma of the pancreatic head were treated by regional subtotal or total pancreatectomy. Clinical and pathologic parameters were reviewed and potential prognostic factors were compared statistically. The three patients who died within 30 days of the operation were excluded from the survival analysis. RESULTS: Primary tumor size was the strongest determinant of prognosis. The mean tumor size was 3.9 cm (range, 1-7 cm). Eighty-five percent of patients had peripancreatic soft tissue invasion microscopically, and 58% had regional lymph node metastasis. Kaplan-Meier survival curves indicated a 33% 5-year survival for patients with tumor 2.5 cm or less in diameter (n=12) and 12% for patients with larger tumors (n=39). No patient with a tumor larger than 5 cm survived more than 5 years. Mean tumor size was not significantly associated with lymph node metastases, but 5 of 12 patients (42%) with primary tumor < or =2.5 cm had lymph node metastases. Twenty-four percent of patients with negative lymph nodes and 14% with positive lymph nodes survived 5 years. The difference was not statistically significant (p=0.3), but this is likely related to sample size. The 30- day operative mortality was 5.3%. The most common complications were infection, gastrointestinal bleeding, and gastric stasis. CONCLUSIONS: After regional pancreatectomy, tumor size is the strongest predictor of prognosis. A multi- institutional randomized prospective trial of regional pancreatectomy versus pancreaticoduodenectomy is warranted in previously untreated, noninfected cases.