Clinical Impact of Lymphadenectomy Extent in Resectable Esophageal Cancer

Esophageal cancer (EC) frequently presents with advanced stages and is associated with high recurrence rates after esophagectomy. The value of an extended lymph node dissection (ELND) remains unclear in this setting. An EC data set was created from the Surveillance, Epidemiology, and End-Results 1973–2003 database. Relationships between the number of lymph nodes (LNs) examined and overall survival (OS) were analyzed. From a cohort of 40,129 EC patients, 5,620 individuals were selected. The median age was 65 (range: 11–102), and 75% were men. The median tumor size was 5.0 cm (0.1–30). On multivariate analysis, total LN count (or negative LN count, respectively) was an independent prognostic variable, aside from age, race, resection status, radiation, T category, N category (all at p < 0.0001), and M category (p = 0.0003). Higher total LN count (>30) and negative LN count (>15) categories were associated with best OS and lowest 90-day mortality (p < 0.0001). The numeric LN effect on OS was independent from nodal status or histology. Greater total and negative LN counts are associated with longer EC survival. Although the mechanism remains uncertain, it does not appear to be limited to stage migration. ELND during potentially curative esophagectomy for EC can be supported by the data.     

淋巴结清扫总数和阴性淋巴结数对根治性远端胃大部切除胃癌患者预后的影响

目的 探讨淋巴结清扫总数和阴性淋巴结数目对根治性远端胃大部切除胃癌患者预后的影响.方法 1995年1月至2004年11月,对634例胃癌患者施行根治性远端胃大部切除手术(R0切除).分析淋巴结清扫总数与阴性淋巴结数目的相关性;对预后因素进行单因素及多因素分析;分析淋巴结清扫总数、阴性淋巴结数目与术后5年生存率的关系.结果 本组591例(93.2%)获得随访,时间5～14年,其中位生存期为62.0个月,术后5年生存率为57.6%.淋巴结清扫总数与阴性淋巴结数目的相关性具有统计学意义(P＜0.05).肿瘤浸润深度、阳性及阴性淋巴结数目和淋巴结清扫总数是影响本组患者预后的独立因素.相同TNM分期中,患者的术后5年生存率有随淋巴结清扫总数和阴性淋巴结数目增加而增高的趋势且具有统计学意义(P＜0.05).线性回归预测,淋巴结清扫总数每增加l0枚,患者术后5年生存率都有不同程度的提高:全组为13.1%、Ⅰ期为14.2%、Ⅱ期为20.5%、Ⅲ期为17.5%和Ⅳ期为10.9%;而每多清扫10枚阴性淋巴结,患者术后5年生存率亦可提高:全组为19.2%、Ⅰ期为20.1%、Ⅱ期为18.8%、Ⅲ期为18.4%和Ⅳ期为18.0%.结论 淋巴结清扫总数和阴性淋巴结数目可反映胃癌淋巴结清扫的程度并预测患者预后,应努力增加根治性远端胃大部切除胃癌患者的淋巴结清扫总数和阴性淋巴结数目,以提高远期疗效.     

Does the greater number of lymph nodes removed during standard lymph node dissection predict better patient survival following radical cystectomy?

Purpose

To determine whether the number of lymph nodes (LNs) removed during radical cystectomy (RC) and pelvic LN dissection (LND) is associated with patient survival.

Methods

Data on 450 patients who underwent RC and standard bilateral pelvic LND for urothelial bladder cancer without receiving neoadjuvant chemotherapy were reviewed. The extent of LND included common iliac artery bifurcation proximally, genitofemoral nerve laterally and the pelvic floor caudally. The impact of the number of LNs removed, analyzed as both continuous and categorical variables, on cancer-specific survival (CSS) and recurrence-free survival (RFS) was analyzed.

Results

The median number of LNs removed was 18 (mean 19.6, range 10?C94). Of total 450 patients, 129 (28.7%) had node-positive (N?+) disease. For entire patients, the number of LNs removed was not associated with CSS and RFS in the analysis with continuous variable (P?=?0.715; P?=?0.442, respectively), quartiles (P?=?0.924; P?=?0.676, respectively), or <18 versus ??18 LNs removed (5-year CSS rates: 67.0% vs. 69.4%, P?=?0.679; 5-year RFS rates?=?59.4% vs. 60.6%, P?=?0.725, respectively). Similarly, the number of LNs removed was not associated with CSS and RFS in both N0 and N?+?patients, and in each T stage. Multivariate analyses showed that T stage and lymphovascular invasion were significant predictors for survival in N0 patients, whereas adjuvant chemotherapy and LN density were predictors for survival in N?+?patients.

Conclusions

If meticulous LND was performed based on standardized LND template during RC, the number of LNs removed was not associated with patient survival.     

Prognostic Significance of Metastatic Lymph Node Ratio in T3Gastric Cancer

The fifth International Union Against Cancer tumor node metastasis (UICC TNM) classification, based on the number of metastatic lymph nodes (LN), has proved to be a reliable and objective method for predicting the prognosis of patients with gastric cancer. However, the prognosis of patients with T3 gastric cancer is still heterogeneous. This study was carried out to investigate the validity of metastatic LN ratio as a prognostic factor in T3 gastric cancer. A retrospective analysis was performed on a total of 833 patients that had either T3N1M0 (n = 504) or T3N2M0 (n = 329) gastric cancer by the fifth UICC classification. A preliminary analysis revealed the cutoff values for T3N1M0 to be 10% and for T3N2M0 to be 25%. The mean metastatic LN ratio was 9.0% for T3N1M0 cancer and 26.9% for T3N2M0 cancer. For the T3N1M0 stage, the patients who showed less than 10% of the metastatic LN ratio were grouped as N1-low with the others grouped as N1-high. For the T3N2M0 stage group, those who had less than 25% of the metastatic LN ratio were grouped as N2-low, the remainder as N2-high. The metastatic LN ratio decreased in proportion to the extent of lymphadenectomy and it increased in relation to the increasing scale of the fourth N classification. The rates of recurrence were significantly different according to the metastatic LN ratio in N1 and N2 classification of the fifth UICC classification (p < 0.05). The 5-year survival rates after gastrectomy decreased significantly by increasing the metastatic LN ratio in both T3N1M0 cancers (p =0.0026) and T3N2M0 cancers (p = 0.0057). The metastatic LN ratio was an independent risk factor for recurrence and poor prognosis. Our data suggest that the metastatic LN ratio is a significant prognostic factor for T3 gastric cancer. Furthermore, the application of the metastatic LN ratio can provide information not only about the extent of LN metastasis but also about the extent of lymphadenectomy in T3 gastric cancer.     

Cancer‐specific survival after radical cystectomy and standardized extended lymphadenectomy for node‐positive bladder cancer: prediction by lymph node positivity and density

OBJECTIVE

To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer‐specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN‐positive bladder cancer.

PATIENTS AND METHODS

Between 2001 and 2006, 152 patients had RC with standardized extended LND for bladder cancer with curative intent. Patients with positive LNs were stratified according to the median of the LN variables (LNs removed, number of positive LNs, LN density). CSS was related to overall and topographically restricted LN variables, e.g. different levels of LND, and relationships were tested by univariate and multivariate analyses. Level 1 LND comprised the regions of the external and internal iliac LNs and of the obturator LNs, level 2 the templates of common iliac and presacral LNs, and level 3 the para‐aortic and paracaval LNs up to the inferior mesenteric artery. The mean (range) follow‐up was 22 (1–84) months.

RESULTS

LN metastases were diagnosed in 46 of the 152 patients (30%) with extended LND. In these 46 patients, the median number of removed LNs was 33 (level 1, 15.5; level 2, 9.0; level 3, 7.0), the median number of positive LNs was 3 (1.5, 0.5 and 0.0, respectively) and the median LN density was 0.11 (0.10, 0.02 and 0.0, respectively). The CSS was 76% at 1 year and 23% at 3 years. There were significant correlations between the 3‐year CSS and the overall LN density (≤0.11 vs >0.11; 34% vs 8%, P = 0.008), and the total number of positive LNs (≤3 vs >3; 33% vs 8%; P = 0.05). Overall LN density (hazard ratio 0.33, 95% confidence interval 0.15–0.72; P = 0.006) was an independent predictor for CSS in multivariate analysis.

CONCLUSIONS

Overall LN density is an independent predictor of survival after RC and extended LND with curative intent. Evaluation of topographically restricted LN positivity and density for different regions and levels of LND does not improve the prediction of CSS compared with overall LN positivity and density. A low incidence of level 3 LN positivity questions the clinical relevance of removing para‐aortic and paracaval LNs. However, our data need to be confirmed by a prospective randomized trial.     

Lymph Node Dissection Impact on Staging and Survival of Extrahepatic Cholangiocarcinomas,Based on U.S. Population Data

Cholangiocarcinomas (CC) frequently demonstrate lymphatic spread. We investigated lymph node (LN) counts after resection of extrahepatic CC and survival based on the SEER 1973–2004 database. Out of 20,068 CC patients, 1,518 individuals were selected based on M0 stage and at least one LN examined. Primary cancer sites included gallbladder (29%), extrahepatic bile ducts (26%), and intrapancreatic/ampullary bile ducts (45%); 42% of patients were LN-positive. The median number of LNs examined was four (range 1–39). Median survival was 37 months for LN-negative and 16 months for LN-positive cancers. Multivariate prognostic variables were the number of positive LNs, primary site, age (all at p < 0.0001), gender (p = 0.002), size (p = 0.005), T category (p = 0.009), and total LN count (or number of negative LNs obtained, p = 0.01). The impact of total LN counts was seen in LN-negative (median survival, 1 vs 10 or more LNs examined: 27 vs 51 months, p = 0.002) and LN-positive disease (10 vs 22 months, p < 0.0001). Survival prediction of extrahepatic CCs is strongly influenced by total LN counts and numbers of negative LNs obtained. Although the resulting incremental benefit is small, dissection and examination of 10 or more LNs should be considered for curative intent resections.     

腹腔镜辅助胃癌根治术淋巴结清扫效果的临床对照研究

目的 探讨腹腔镜辅助胃癌根治术中淋巴结清扫的可行性及临床效果.方法 2007年1月至2010年5月,对934例胃癌患者施行根治性手术(RO切除),其中行腹腔镜手术患者(腹腔镜组)506例,行开腹手术患者(开腹组)428例.对比两组患者淋巴结清扫数目的 差异,并分析两组淋巴结清扫数目与术后并发症发生率的关系.结果 全部患者平均淋巴结清扫数目为(29±10)枚/例,两组平均淋巴结清扫数目相似(P＞0.05),但腹腔镜组No.7、8组淋巴结清扫数目明显多于开腹组(P＜0.05).按浸润深度分层分析,除pT3期腹腔镜组平均淋巴结清扫数目多于开腹组外,pT1-2期差异无统计学意义(P＞0.05);按淋巴结清扫范围和胃切除方式分层分析,腹腔镜组平均淋巴结清扫数目均与开腹组相当(P＞0.05);按手术时期分层分析,≤50例腹腔镜组平均淋巴结清扫数目少于开腹组(P＜0.05),51～100例和≥101例则与开腹组相当(P＞0.05).腹腔镜组并发症发生率为11.1%,明显低于开腹组的20.1%,但两组淋巴结清扫数目与术后并发症的相关性均无统计学意义(P＞0.05).结论 随着腹腔镜外科医师技术逐渐成熟,腹腔镜胃癌根治手术能够达到与开腹手术相当的淋巴结清扫效果;合理增加腹腔镜辅助胃癌根治术的淋巴结清扫数目不会增加术后并发症发生率.

Abstract：

Objective To explore the feasibility and efficacy of laparoscopy assisted radical gastrectomy on lymph node(LN)dissection for gastric cancer and to compare it with open gastrectomy.Methods The clinical data of 934 patients with gastric cancer underwent radical resection from January 2007 to May 2010 were analyzed retrospectively. Among the patients, 506 cases received laparoscopy assisted gastrectomy(LAG group)and 428 cases received open gastrectomy(OG group). The number of retrieved LNs and the survival curve between the two groups was compared. Then, the relations between the number of dissected LNs and postoperative morbidity were analyzed. ResultsFor all patients, the mean number of dissected LNs was 29±10, there was no significantly differences between LAG group and OG group(P＜0.05). While the number of the retrieved No. 7, 8 LNs in LAG group were significantly more than those in OG group. No significant differences was found in the number of dissected LNs for the pT1-2stages tumors between the two groups, but significantly greater number of LNs was harvested by LAG group in pT3 stage(P＜0. 05). No significant differences were found in the number of dissected LNs in different gastrectomy types or extents of LN dissection between the two groups. In the first 50 cases, there were less dissected LNs in LAG group than that in OG group, while 51 cases later, there was no significantly differences in number of dissected LNS between the two groups(P＞0.05). The postoperative morbidity of LAG group and OG group was 11.1% and 20. 1%, respectively(P ＜0.05), but there was no significant correlations between the number of dissected LNs and postoperative morbidity in both groups. Conclusions With the improvement in surgical skills, laparoscopy-assisted radical gastrectomy with lymph node dissection is a safe and feasible procedure, and it is oncologically compatible with open gastrectomy. Suitable increment of dissected LN count would not increase the postoperative complication rate.     

A Comparison of Five Competing Lymph Node Staging Schemes in a Cohort of Resectable Gastric Cancer Patients

Background

New classifications for lymph node (LN) staging have recently been proposed to improve upon the UICC/AJCC N category staging convention. Ratio-based systems and logarithmic odds (LODDS) scores are two families of novel competing staging systems. We compared UICC/AJCC staging with 5 ratio and LODDS systems in predicting overall survival (OS) in patients with resected gastric cancer.

Methods

Using a large population-based dataset, we identified 12,184 nonmetastatic resectable gastric cancer patients between 1988 and 2004. We compared each subject’s UICC/AJCC N stage with five novel staging schemes. We analyzed the OS for each method. Our comparison metric was the log-rank Chi squared statistic; larger Chi squared statistics indicate improvements in N stage discrimination.

Results

Median OS was 2.1 years (95 % CI 2.0–2.2 years), while median patient follow-up for surviving patients was 8.3 years (range, 1 month–22 years). Although all 5 staging systems were either comparable or superior to the UICC/AJCC convention, a LN ratio method outperformed others in N stage discrimination based on log-rank tests for OS. This trend was independent of the number of LNs examined.

Conclusions

Novel LN staging methods have a higher degree of discrimination utility than the UICC/AJCC N convention. These methods may have a role in reducing the prognostic impact of LN count variability. Of the systems assessed, the LN ratio system that assigns greater risk attribution to cases with <16 LNs was the best classification method to predict OS in patients with resectable gastric cancer.     

Extent of Lymph Node Retrieval and Pancreatic Cancer Survival: Information from a Large US Population Database

Background Operative therapy of pancreatic cancer is associated with poor survival because of high recurrence rates after pancreatectomy. The effect of lymph node (LN) dissection on survival continues to be debated.Methods A pancreatic cancer data set was created through structured queries to the Surveillance, Epidemiology, and End Results 1973 to 2000 database. Stage information was created according to 6th edition American Joint Committee on Cancer tumor-node-metastasis criteria, and the effect of LN number on survival was analyzed.Results Out of a cohort of 20,631 patients with carcinomas of the exocrine pancreas, surgical details were available for 2,787 patients. Procedures included pancreatoduodenectomies (n = 1848; 66%), radical regional pancreatectomies (n = 516; 19%), other partial resections (n = 316; 11%), and total pancreatectomies (n = 107; 4%). For 1666 of these patients with complete clinicopathologic information, the median age was 66 years (range, 22–96 years), with an equal sex ratio. The median number of total LNs examined was 7 (range, 1–52), of positive LNs was 1 (range, 0–34), and of negative LNs was 6 (range, 0–30). Multivariate survival analysis yielded these prognostic variables: number of LNs examined, number of positive LNs, tumor size, extrapancreatic extension, radiotherapy (all P < .0001), and age (P = .0009). The greatest survival differences were observed for negative LN counts of 10 to 15.Conclusions Stage-based survival prediction of pancreatic cancer is strongly influenced by total LN counts and numbers of negative LNs obtained. Although the mechanism remains unclear and could reflect confounding factors (margin status and institutional volume), an attempt to resect and examine at least 15 LNs to yield preferably between 10 and 15 negative LNs seems sensible for curative-intent pancreatectomy.     

Critical analysis of the 2010 TNM classification in patients with lymph node–positive bladder cancer: Influence of lymph node disease burden

ObjectivesIn 2010, a new TNM staging system was published by American Joint Committee on Cancer, changing the nodal classification to include the presence of common iliac lymph node (LN) involvement as N3 category. The objective of this study was to define the capability of the current TNM nodal classification to separate patients with different prognostic stages and to evaluate the effect of LN disease burden.Methods and materialsA total of 93 patients with metastatic LNs after radical cystectomy and extended LN dissection for urothelial carcinoma of the bladder between 1999 and 2012 were included. The median follow-up was 21.5 months. The correlation between N3 and indicators of LN disease burden was analyzed using the Spearman correlation coefficient. Recurrence-free survival (RFS) and overall survival (OS) analysis was performed using the Kaplan-Meier and Cox proportional hazards methods.ResultsThe presence of N3 disease was associated with higher number of metastatic LNs (7 vs. 2, P<0.01); however, this was highly variable and correlation coefficients between common iliac metastatic LNs and other lymphatic disease burden indicators demonstrated weak association (0.39–0.63). Patients with N1 lesions were found to have a distinct RFS and OS (P<0.01 and P = 0.01, respectively). A trend toward worse RFS (P = 0.07) and OS (P = 0.08) was observed in patients with N3 lesions. However, no difference in RFS or OS was found between patients with N2 and N3 lesions (P = 0.83 and 0.50, respectively).ConclusionsThe N3 category in the current TNM classification defines a group of patients with high but heterogeneous disease burden. This may be the explanation for its lack of prognostic stratification when compared with N2 category bladder cancer.     

Race and Correlations Between Lymph Node Number and Survival for Patients with Gastric Cancer

Background

There is ongoing debate whether extended lymphadenectomy improves survival in gastric cancer patients who undergo surgical resection. We previously observed that Korean–American patients had the highest overall survival in Los Angeles County. Our objective was to assess lymph node (LN) number and its impact on survival for Korean–American gastric cancer patients.

Methods

We utilized the National Cancer Institute’s Surveillance, Epidemiology, and End Results registry to identify Korean–Americans with gastric adenocarcinoma treated with curative-intent gastrectomy between 1988 and 2008. We grouped patients according to examined LN number (1–15 and 16+) and compared characteristics. We performed similar analysis for white patients.

Results

Out of 982 Korean–American patients with gastric adenocarcinoma, most patients had 1–15 examined LNs (60 %). When we compared LN groups, we observed higher overall survival in the 1–15 group than the 16+ group (5-year survival, 59 % vs 52 %, respectively; p?=?0.04). However, LN number was not prognostic of overall survival on stepwise Cox proportional hazards analysis. In contrast, LN number was prognostic for white patients.

Conclusions

Although examined LN number may impact survival for white patients, outcomes of Korean–American gastric cancer patients were independent of LN number. Our data suggest that survival of Korean–American gastric cancer patients are comparable with outcomes from East Asian hospitals and may be independent of surgical technique.     

A population-based study of tumor-node relationship,resection margins,and surgeon volume on gastric cancer survival

BACKGROUND: Gastric cancer surgery literature is conflicting. Two European level I randomized controlled trials refute Asian lesser level evidence promoting more radical resections. Population-based study evidence is undefined. METHODS: Using this study design we examined the overall survival, the tumor-node relationship, margins, and surgeon volume on gastric cancer survival in a Canadian province. RESULTS: Between 1991 and 1997, 577 (71 +/- 13 years 60% male) gastric adenocarcinomas were diagnosed in Northern Alberta (population 1.7 million). Respectively, median survival in months for stage I (n = 67) was 77, stage II (n = 55) 75, stage III (n = 155) 12, stage IV (n = 235) 3, and 65 unstaged (n = 65) 4. Five-year survival for T1N0 (n = 28) was 68% versus T1N1 (n = 7) 71% (P = 0.80); for T2N0 (n = 29) 58% versus T2N1 (n = 19) 58% versus T2N3 (n = 7) 29% (P = 0.08); for T3N0 (n = 33) 57%, versus T3N1 (n = 98) 9% versus T3N2 (n = 47) 0% versus T3N3 (n = 8) 0% (P < 0.0001). Median gastrectomy survival (months) in stage III was 15 months margin negative versus 8 months margin positive versus 6 bypass and 5 for no surgery (P = 0.0004). In stage IV it was margin positive 8 versus margin negative 6 (nonsignificant), bypass 3 versus no surgery 2. Five-year survival for surgeons doing fewer than 20 gastrectomies (n = 196 patients) was 29% (median 1.4 years) versus 35% (median 2.3 years; n = 72 patients) for surgeons doing 20 or more (n = 4; P = 0.325). CONCLUSIONS: From these population data we conclude that (1) few patients present with "curable" gastric cancer, (2) node negative or small gastric cancer survival is not influenced by nodal stage, (3) positive margin resection survival is better than bypass or no surgery in stage IV but not stage III disease, and (4) surgeon volume does not appear to influence patient survival.     

When Is Curative Gastrectomy Justified for Gastric Cancer with Positive Peritoneal Lavage Cytology but Negative Macroscopic Peritoneal Implant?

For gastric cancer patients who have no peritoneal seeding at a macroscopic level but positive results in the peritoneal lavage cytology (PLC), the prognostic benefit expected by surgical resection is still controversial. During the period 1975–1994 as series of 417 consecutive patients without distant organ metastases underwent surgical resection for gastric cancer that had invaded the subserosal or deeper layers of the stomach wall. Immediately after laparotomy, the pouch of Douglas was washed with 100 ml of physiologic saline solution, and the fluid was collected for cytologic examination (four slide glasses) using Giemsa and Papanicolaou staining methods. According to the macroscopic (P) and cytologic (Cyt) results, the 417 patients were classified into three groups: P⁺ (n = 97); P⁻/Cyt⁺ (n = 25); and P⁻/Cyt⁻ (n = 295). Their 3-year survival rates after surgical resection were 4%, 24%, and 48%, respectively (p = 0.0001: P⁻/Cyt⁺ vs. P⁻/Cyt⁻; p = 0.0018: P⁻/Cyt⁺ vs. P⁺. Among the 25 P⁻/Cyt⁺ patients, postoperative survival was not associated with the T stage, N stage, cellular atypism, or cluster formation but with the number of cancer cells per slide during PLC. The 3-year survival rate was 35% for the subgroup with fewer than 10 cancer cells per slide (17 patients) and 0% for the other subgroup with 10 or more cancer cells per slide (8 patients) (p = 0.017). For P⁻/Cyt⁺ patients, who represent a subgroup of gastric cancer patients with an intermediate survival rate between the P⁻/Cyt⁻ and P⁺ patients, the number of cancer cells observed during PLC offers a potent prognostic indicator for the gastrectomy.     

Recurrence patterns after radical gastrectomy for gastric cancer: Prognostic factors and implications for postoperative adjuvant therapy

Background A recent Intergroup trial demonstrated a significant survival advantage of postgastrectomy chemoradiation in gastric cancer patients, primarily because of a reduction of a relative locoregional recurrence (LRR) rate exceeding 70% in control patients. Radical gastrectomy with extended lymphadenectomy may reduce LRR, possibly affecting adjuvant treatment strategies. Methods Information on patients undergoing gastrectomy for potentially curable gastric cancer between 1990 and 2000 was reviewed. Patterns of first disease recurrence, survival, and disease-free survival were calculated, and predictors were identified. Results Gastrectomies were performed in 73 patients, with R0 resections in 82%. The median lymph node count was 24; positive nodes were found in 64% of patients. The median actuarial survival was 27 months, with a 5-year survival of 37%. Disease recurred in 35 patients (48%) after a median interval of 7 months (range, .5–67). Recurrent disease patterns included distant only (37%) peritoneal only (23%), peritoneal/locoregional (17%), all sites combined (14%), locoregional only (6%), and distant/locoregional (3%). Recurrence predictors were N3 category for distant recurrence (hazard ratio [RH], 10.2;P=.005), T3/4 category for peritoneal recurrence (HR, 4.8;P=.008), peritoneal relapse (HR, 40;P=.002), and a prior abdominal operation for LRR (HR, 3.2;P=.01). N2 disease had a distant failure risk similar to N1 status and an intraperitoneal failure risk similar to an N3 category. Conclusions Isolated LRR of gastric cancer after gastrectomy and extended lymphadenectomy is rare in this series. Most recurrences appeared diffusely at distant or peritoneal sites, and most LRRs occurred in conjunction with relapse at extraregional sites. Pathologic predictors of intraperitoneal (T3/4) or systemic failure (>N1) could be used to guide individualized, risk-oriented, adjuvant treatment.     

Lymph node involvement in Wilms tumor: results from National Wilms Tumor Studies 4 and 5

PurposeThe aim of the study was to determine the prognostic impact of lymph node (LN) involvement and sampling in patients with Wilms tumor (WT) and the minimum number of LNs needed for accurate staging.MethodsWe reviewed all patients with unilateral, nonmetastatic WT enrolled in the National Wilms Tumor Study 4 or 5. Data were abstracted on patient demographics, tumor histology, staging, number of LNs sampled, and disease-specific and overall patient outcomes.ResultsA total of 3409 patients had complete information on LN sampling. Five-year event-free survival (EFS) was lower in patients with nodal disease (P < .001); the effect of LN positivity was greater for patients with anaplastic (P = .047) than with favorable histology (P = .02). The likelihood of obtaining a positive LN was higher when sampling at least 7 LNs. However, after controlling for tumor histology and stage, the number of LNs sampled did not predict EFS variations (P = .75). Among patients with stage II disease, patients with LN sampling (P = .055) had improved EFS, largely reflecting poorer EFS in patients with anaplastic tumors (P = .03).ConclusionsLymph node sampling is particularly important for patients with stage II anaplastic WT. Although the likelihood of finding a positive LN was greater when more than 7 LNs were sampled, EFS was not impacted by the number of LNs sampled.     

The extent of pelvic lymph node dissection correlates with the biochemical recurrence rate in patients with intermediate- and high-risk prostate cancer

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Pelvic lymph‐node dissection during radical prostatectomy for prostate cancer is certainly a fundamental staging procedure but its therapeutic role is yet under debate. This retrospective study suggests that, in patients with intermediate‐ and high‐risk of prostate cancer, the greater the number of lymph‐nodes removed, the lower the risk of biochemical relapse, even in the presence of 1 or 2 lymph‐node metastasis. However, the Will Rogers phenomenon must be considered due to the retrospective nature of the present study.

OBJECTIVE

• ? To assess the impact of pelvic lymph node dissection (PLND) and of the number of lymph nodes (LNs) retrieved during radical prostatectomy (RP) on biochemical relapse (BCR) in pNX/0/1 patients with prostate cancer according to the clinical risk of lymph node invasion (LNI).

PATIENTS AND METHODS

• ? We evaluated 872 pT2‐4 NX/0/1 consecutive patients submitted to RP between October 1995 and June 2009, with the following inclusion criteria: (i) a follow‐up period ≥12 months; (ii) the avoidance of neoadjuvant hormonal therapy or adjuvant hormonal and/or adjuvant radiotherapy; (iii) the availability of complete follow‐up data; (iv) no pathological T0 disease; (v) complete data regarding the clinical stage and Gleason score (Gs), the preoperative prostate‐specific antigen (PSA) level and the pathological stage.
• ? The patients were stratified as having low risk (cT1a‐T2a and cGs ≤6 and PSA level < 10 ng/mL), intermediate risk (cT2b‐T2c or cGs = 7 or PSA level = 10–19.9) or high risk of LNI (cT3 or cGs = 8–10 or PSA level ≥ 20).
• ? The 872 patients were divided into two LN groups according to the number of LNs retrieved: group 1 had no LN or one to nine LNs removed; group 2 had 10 or more LNs.
• ? The variables analysed were LN group, age, PSA level, clinical and pathological stage and Gs, surgical margin status, LN status and number of LN metastases; the primary endpoint was the BCR‐free survival.

RESULTS

• ? The mean follow‐up was 55.8 months.
• ? Of all the patients, 305 (35%) were pNx and 567 (65.0%) were pN0/1.
• ? Of the 567 patients submitted to PLND, the mean number of LNs obtained was 10.9, and 49 (8.6%) were pN1.
• ? In the 402 patients at low risk of LNI, LN group was not a significant predictor of BCR at univariate analysis, while in the 470 patients at intermediate and high risk of LNI, patients with ≥10 LNs removed had a significantly lower BCR‐free survival at univariate and multivariate analysis.

CONCLUSION

• ? In our study population, a more extensive PLND positively affects the BCR‐free survival regardless of the nodal status in intermediate‐ and high‐risk prostate cancer.

     

进展期胃底贲门癌淋巴结清扫数目对预后的影响

目的探讨D2根治术中淋巴结清扫数目对进展期胃底贲门癌患者的预后和术后并发症发生率的影响。方法总结施行D2根治术的236例进展期胃底贲门癌患者的临床资料,将其清扫淋巴结的数目与术后5年患者的生存率及术后并发症发生率的关系进行分析。结果236例进展期胃底贲门癌患者术后5年生存率为37．5％。相同病期患者的术后5年生存率随着淋巴结清扫数目的增加而增高（P=0．0013）。Ⅱ期患者淋巴结清扫数目超过或等于20枚（P=0．0136）、Ⅲ期超过或等于25枚（P〈0．0001）、Ⅳ期超过或等于30枚（P=0．0002）、整组病例超过或等于15枚（P=0．0024）时生存率高,且差异具有统计学意义。本组术后并发症发生率为15．7％,淋巴结清扫的数目与术后并发症发生率的相关性无统计学意义（P=0．101）。结论进展期胃底贲门癌患者在施行D：根治术时,淋巴结清扫数目与患者预后呈正相关;合理的淋巴结清扫数目并不增加患者术后并发症发生率。     

Prognostic Impact of Lymph Node Retrieval and Ratio in Gastric Cancer: a U.S. Single Center Experience

Introduction

Increased lymph node (LN) retrieval for gastric cancer has been associated with improved overall survival (OS). This study examines the impact of number of examined LN (eLN) and lymph node ratio.

Methods

Patients referred for surgical care of gastric cancer were stratified by number of eLN, positive LNs (LN+), and lymph node ratio (LN+/eLN). Clinicopathologic factors were compared; OS and disease-free survival (DFS) were the primary endpoints.

Results

From 1997 to 2012, 222 patients, median age 67 (range, 17–92)?years, were analyzed. Of 220 (99 %) explored, 164 (74 %) underwent resection. Median OS was 22 (range, 0.3–140)?months. Perineural and lymphovascular invasion and poor differentiation adversely affected OS, p?<?0.05. A median 14 eLN (range, 0–45), with median 1 LN+ (range, 0–31), was observed. There were no OS or DFS differences when comparing the eLN groups. Both OS and DFS were impacted by LN+. Lymph node ratio demonstrated worse median OS with increasing ratio: 49 months (0) to 37 months (0.01–0.2), 27 months (0.21–0.5), and 12 months (>0.5), p?<?0.0001. DFS was similar: 35 months (0), decreasing to 22 months (0.01–0.2), 13 months (0.21–0.5), and 7 months (>0.5), p?<?0.0001.

Conclusion

Number of eLN did not impact survival, while LN+ adversely affected survival. Lymph node ratio may predict prognosis better than number of eLN or LN+ in gastric cancer.     

Remnant gastric cancer: An ordinary primary adenocarcinoma or a tumor with its own pattern?

BACKGROUNDRemnant gastric cancer (RGC) is defined as a tumor that develops in the stomach after a previous gastrectomy and is generally associated with a worse prognosis. However, there little information available regarding RGCs and their prognostic factors and survival.AIMTo evaluate the clinicopathological characteristics and prognosis of RGC after previous gastrectomy for benign disease.METHODSPatients who underwent curative resection for primary gastric cancer (GC) at our institute between 2009 and 2019 were retrospectively evaluated. All RGC resections with histological diagnosis of gastric adenocarcinoma were enrolled in this study. Primary proximal GC (PGC) who underwent total gastrectomy was selected as the comparison group. Clinical and pathological data were collected from a prospective medical database.RESULTSA total of 41 patients with RGC and 120 PGC were included. Older age (P = 0.001), lower body mass index (P = 0.006), hemoglobin level (P < 0.001), and number of resected lymph nodes resected (LN) (P < 0.001) were associated with the RGC group. Lauren type, pathological tumor-node-metastasis, and perioperative morbimortality were similar between RGC and PGC. There was no difference in disease-free survival (P = 0.592) and overall survival (P = 0.930) between groups. LN status was the only independent factor related to survival. CONCLUSIONRGC had similar clinicopathological characteristics to PGC. Despite the lower number of resected LN, RGC had a similar prognosis.     

Borrmann Type IV: An Independent Prognostic Factor for Survival in Gastric Cancer

Background  Borrmann type IV gastric cancer has a poorer prognosis than other gastric carcinomas. This study compared the clinicopathological features of Borrmann type IV gastric cancer with those of other types of cancer and examined the significance of a Borrmann type IV carcinoma as a prognostic factor after gastrectomy. Methods  The clinicopathological features, tumor–node–metastasis (TNM) stage, and survival rates of 4,191 advanced gastric cancer patients, who had undergone a gastrectomy at the Samsung Medical Center between 1995 and 2005, were reviewed. Results  Borrmann type IV gastric cancer was found to be associated with more advanced and unfavorable clinicopathological features at diagnosis than the other cancers. The 5-year survival rate of the patients with Borrmann type IV cancer was 27.6%. In contrast, the 5-year survival rate of patients with the other types of cancer was 61.2%. The 5-year survival rate for each stage of Borrmann type IV gastric cancer and the other type gastric cancer was 61.0% and 88.8% for stage Ib (P < 0.001), 49.8% and 76.1% for stage II (P < 0.001), 36.4% and 55.1% for stage IIIa (P < 0.001), 15.2% and 38.5% for stage IIIb (P = 0.001), and 10.2% and 20.1% for stage IV (P = 0.008), respectively. Multivariate analyses revealed a Borrmann type IV carcinoma, the surgical extent, curability, tumor stage, including T, N, and M status, and adjuvant therapy to be independent prognostic factors for survival. Conclusion  A Borrmann type IV carcinoma has unique clinicopathological features compared with other types of gastric carcinomas and is an important independent prognostic factor.