Metachronous hepatic metastases from gastric carcinoma: A multicentric survey

Background

The treatment of hepatic metastases from gastric cancer is controversial, due to biologic aggressiveness of the disease.

Objective

To survey the clinical approach to the subset of patients presenting with metachronous hepatic metastases as sole site of recurrence after curative resection of gastric cancer, focusing on the results achieved by different therapies and to investigate the prognostic factors of major clinical relevance.

Methods

Retrospective multi-center chart review evaluating 73 patients, previously submitted to D ≥ 2 gastrectomy for gastric cancer, who developed exclusive hepatic recurrence. Prognostic factors related to the patient, to the gastric malignancy and its treatment, and to the metastatic disease and its therapy were evaluated.

Results

Forty-five patients received supportive care, 17 were submitted to chemotherapy, and 11 to hepatic resection. Survival was independently influenced by the variables T (p = 0.019), N (p = 0.05) and G (p = 0.018) of the gastric primary and by the therapeutic approach to the metastases (p < 0.005). In particular, T4 gastric cancer, presence of lymph-node metastases and G3 tumor displayed a negative prognostic value. Therapeutic approach to the metastases was the principal prognostic variable: 1, 2, and 3 years survival rates were 22.2%, 4.4% and 2.2%, respectively, for patients without specific treatment; 44.9%, 12.8% and 6.4% after chemotherapy (p = 0.08) and 80.8%, 30.3% and 20.2% after surgical resection (p < 0.001).

Conclusions

Our data suggest some clinical criteria that may facilitate selection of therapy for patients with hepatic recurrence after primary gastric cancer resection. The best survival rates are associated with surgical treatment, which should be chosen whenever possible.     

Primary tumour resection and survival in the palliative management of metastatic colorectal cancer

Aim

To examine whether surgical resection of the primary tumour confers a survival benefit and to identify the predictive factors of outcome in patients presenting with asymptomatic metastatic colorectal cancer (CRC).

Materials and methods

A review of a hospital database in a tertiary institution over a 6-year period (1999–2005) revealed 70 patients with asymptomatic primary CRC and unresectable liver metastases treated initially by systemic chemotherapy. A multivariate regression analysis model was used to determine the relative influence of multiple tumours, single/multiple liver metastases, tumour site, differentiation, response of liver and primary tumour to chemotherapy, biochemical response to chemotherapy, age at presentation, performance status and surgical intervention for the CRC primary.

Results

In 67 cases (3 lost to follow-up), 63 had multiple and 4 single surgically irresectable liver metastases. A total of 41 deaths were recorded. All patients received systemic chemotherapy and surgery was performed for bowel obstruction, bleeding or stable disease (n = 32). Surgery (OR 0.26; p = 0.00013) and clinical response of the primary tumour (OR 0.53; p = 0.012) were independently associated with prolonged survival. Proximal tumours (OR 2.61; p = 0.0075) and multiple primaries (OR 3.37; p = 0.02) were associated with poor outcome.

Conclusions

Surgical resection and response of the primary tumour to chemotherapy may be associated with improved survival, but proximal or multiple cancers predict poor outcome in patients with asymptomatic CRC and unresectable metastatic disease.     

The value of MRI compared to mammography in the assessment of tumour extent in invasive lobular carcinoma of the breast

Aims

Invasive lobular carcinoma of the breast (ILC) is known to be substantially underestimated by mammography, which makes correct planning of treatment difficult. MRI has been proposed as a valuable adjunct to mammography. The purpose of the current study is to evaluate its value, compare it to mammography and assess the possible causes of over- and underestimation of lesion size on MRI.

Method

The mammograms and MRI scans of 67 consecutive patients with ILC were retrieved and re-evaluated. Size measurements were correlated to the sizes extracted from the pathology report.

Results

MRI measurements correlated better to pathologic size (r = 0.85) than mammographic measurements (r = 0.27). Underestimation of tumour size was more common on mammography (p < 0.001); overestimation occurred with equal frequency (p = 0.69). Overestimation on MRI, caused by non-malignant findings, was attributed to enhancing lobular carcinoma in situ.

Conclusion

MRI is a more accurate modality for determining tumour size in patients with ILC than mammography. The typical underestimation of lesion size by mammography can be prevented with the aid of MRI, without increasing the risk of lesion overestimation.     

Outcome of distal gastric cancer with pyloric stenosis after curative resection

Aims

Pyloric stenosis usually presents with symptoms, and this may lead patients to consult their physician. We evaluate whether distal gastric cancer patients with pyloric stenosis had a better outcome than those without.

Methods

A total of 551 distal gastric cancer patients who received curative subtotal gastrectomy between January 1988 and December 2003 at Taipei Veterans General Hospital were analyzed. Among them, 174 patients were sorted into the pyloric stenosis group according to obstructive symptoms. Their clinicopathological features, survival and prognostic factors were evaluated.

Results

The 5-year overall and disease-free survival rate of distal third gastric adenocarcinoma for the pyloric stenosis group was significantly lower than those without pyloric stenosis. Multivariate analysis revealed the pyloric stenosis group had deeper cancer invasion (relative to pT₁, RR of pT₂ 3.1, p = 0.009; pT₃ 6.1, p < 0.001; pT₄ 16.5, p < 0.001), and more lymph node metastasis (RR 3.6; p = 0.001). The pyloric stenosis group had a tendency to lymph node metastasis toward the hepatoduodenal ligament, but this did not reach statistical difference. However, the pyloric stenosis group had significantly higher lymph node metastasis in the retropancreatic region (5.17% vs. 0.53%; p = 0.001).

Conclusions

Distal gastric cancers with pyloric stenosis have worse biological behavior than those without, and consequently have a poor outcome.     

A small mammal model of tumour implantation,dissemination and growth factor expression after partial hepatectomy

Background

Surgical resection remains the most effective therapy for metastatic colorectal cancer confined to the liver, although the extrahepatic recurrence rate is high.

Aim of the study

To develop a mammal model in order to investigate by which mechanisms liver surgery affects distant tumour recurrence.

Methods

In this animal study the effect of partial hepatectomy (phX) on the development of tumour noduli in the lungs was evaluated. CC531 rat colon carcinoma cells were inoculated i.v. 24 h before, during or 24 h after surgery. Rat serum was obtained at different time-points after phX and added to in vitro CC531 cell cultures. Finally, phX was compared with an ileum resection (ilX).

Results

phX leads to increased tumour noduli in the lungs, compared to Sham operation (p = 0.002), but only when performed directly before the injection of tumour cells and not when performed 24 h before or after the inoculation. Comparable results were obtained for ilX. No growth stimulation of tumour cells after incubation with rat serum, obtained at different time-points after phX, could be detected in vitro.

Conclusion

Not only phX, but also surgery, in general promotes distant tumour recurrence exerting the effect during the early phase of tumour cell adhesion and not during tumour outgrowth.     

Procedure volume of gastric cancer resections versus 5-year survival

Aim

We used nationwide, population-based data to examine associations between hospital and surgeon volumes of gastric cancer resections and their patients’ short-term and long-term survival likelihood.

Methods

The study uses 1997–1999 inpatient claims data from Taiwan's National Health Insurance linked to “cause of death” data for 1997–2004. The total cohort of 6909 gastric cancer resection patients were categorized by their surgeon's/hospital's procedure volume, and examined for differences in 6-month mortality and 5-year mortality (post 6 months), by procedure volume, using Cox proportional hazard regressions, adjusting for surgeon, hospital and patient characteristics. We hypothesized that surgeons’ case volume and age but not hospital volume will predict short-term and long-term survival.

Results

Adjusted estimates show that increasing surgeon volume predicts better 6-month survival (adjusted mortality hazard ratio = 1.3 for low-volume surgeons relative to very high-volume surgeons; p < 0.01) and 5-year survival (adjusted mortality hazard ratios = 1.3; p < 0.001 for low-volume; 1.2 with p < 0.01 for medium volume) and increasing surgeon's age (adjusted hazards ratio = 1.4 for age < 41 years relative to 41–50 years; p ≤ 0.001; 0.8 for ≥51 years relative to 41–50 years; p < 0.05). In hospital volume regressions, surgeon's age is a consistent and significant predictor, not hospital volume. Findings suggest a key role of experience in surgical skill and sensitivity for early stage diagnosis in gastric cancer survival.

Conclusions

Although a key study limitation is the lack of cancer stage data, the pattern of findings suggests that experienced surgeons have relatively better survival outcomes among gastric cancer patients.     

Expression patterns of hypoxic markers at the invasive margin of colorectal cancers and liver metastases

Aim

To understand the role of hypoxia in cancer progression of primary colorectal cancer and colorectal liver metastases. To look at associations of hypoxia with more aggressive phenotypes.

Methods

Archival tissue was retrieved from 55 patients and tissue micro arrays were constructed using tissue from the margin and the centre of the tumour. Hypoxia markers Hif-1α, Vegf, CA-9, VHL and Glut-1 were visualised using immunohistochemical detection and quantified using semi-quantitative analysis of the digitised images. Clinical details and outcome data were retrieved by case note review and collated with hypoxia markers data in a statistical database.

Results

Significantly increased expression of all markers were found at the tumour margin compared to the tumour centre, both in primary colorectal cancer (CRC) and liver metastases. Pushing margin CRC was associated with increased Vegf expression. Positive correlations were observed between Hif-1α and Vegf (p < 0.001), and Hif-1α and VHL (p < 0.001) in primary CRC, but no relationship was seen between Hif-1α and either Glut-1 or CA-9. A significant trend to worse disease-free survival was also noted with increased margin expression of Hif-1α (p < 0.001) and VHL (p = 0.02) in primary CRC, but not for any of the other markers.

Conclusion

This study underlines the importance of the invasive margin in colorectal cancer biology. It is the area most responsive to hypoxic influences and its dependence on its ability to up-regulate Hif-1α has a significant impact on disease-free survival.     

Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence

Aims

The aim of this study was to evaluate the oncological outcome of portal triad clamping during hepatectomy in colorectal cancer patients.

Methods

160 patients with colorectal liver metastases underwent a partial hepatectomy with curative intent. Data were collected in a prospective database and were retrospectively analyzed for time to liver recurrence (TTLiR) and time to overall recurrence (TTR). The prognostic significance of portal triad clamping of any type and severe ischemia due to prolonged portal triad clamping was determined by Cox regression models.

Results

TTLiR was reduced after clamping of any type, although not statistically significant (p = 0.061). Severe ischemia due to prolonged portal triad clamping significantly decreased TTLiR (p = 0.022), but not TTR. Furthermore, severe ischemia independently predicted TTLiR in a multivariable analysis (p = 0.038).

Conclusions

Severe ischemia due to prolonged portal triad clamping during hepatic resection for colorectal liver metastases appears to be associated with decreased TTLiR. Further research remains necessary to determine the causative effect of prolonged vascular clamping on liver tumour recurrence.     

Improved survival after resectable non-cardia gastric cancer in the Netherlands: The importance of surgical training and quality control

Background

In the Netherlands, standardised limited D1 and extended D2 lymph node dissections in the treatment of resectable gastric cancer were introduced nationwide within the framework of the Dutch D1–D2 Gastric Cancer Trial between 1989 and 1993. In a population-based study, we evaluated whether the survival of patients with resectable gastric cancer improved over time on a regional level.

Methods

We compared 5-year overall and relative survival of patients with curatively resected non-cardia gastric cancer in the regional cancer registry of the Comprehensive Cancer Centre West in the Netherlands before the Dutch D1–D2 trial (1986 to mid 1989; n = 273), during the trial period (mid 1989 to mid 1993; n = 255), and after the trial (mid 1993 to 1999; n = 219), adjusting for prognostic variables.

Results

Unadjusted survival was highest in the post-trial period: 5-year overall and relative survival were 42% and 52%, respectively, compared to 34% and 41% in the pre-trial period, and 39% and 46% in the trial period (p = 0.31 and p = 0.06, respectively). After adjustment for age, gender, tumour site, pT-stage, nodal status and hospital volume, the effect of period on survival was more apparent (p = 0.009). Compared to the pre-trial period, the hazard ratio was 0.83 (95% confidence interval, 0.68–1.02) for the trial period, and 0.72 (0.58–0.89) after the trial. Less than 1% of the patients received adjuvant therapy.

Conclusion

Survival of patients with curatively resected non-cardia gastric cancer has improved. Standardisation and surgical training in D1 and D2 lymph node dissection are the most likely explanation for this improvement.     

Improving staging accuracy in colon and rectal cancer by sentinel lymph node mapping: A comparative study

Aim

To compare the predictive value of sentinel lymph node (SN) mapping between patients with colon and rectal cancer.

Patients and methods

An ex vivo SN procedure was performed in 100 patients with colon and 32 patients with rectal cancer. If the sentinel node was negative, immunohistochemical analyses using two different antibodies against cytokeratins (Cam5.2 and CK 20) and one antibody against BerEp-4 were performed to detect occult tumour cells. Isolated tumour cells (<0.2 mm) were discriminated from micrometastases (0.2–2 mm).

Results

An SN was identified in 117 patients (89%), and accurately predicted nodal status in 106 patients (accuracy 91%). Both sensitivity and negative predictive value were higher in colon carcinomas than in rectal carcinomas (83% versus 57%, p = 0.06 and 93% versus 65%, p = 0.002 respectively). In patients with extensive lymph node metastases the SN procedures were less successful. Eleven of the 13 unsuccessful SN procedures were performed in patients with rectal cancer who had pre-operative radiotherapy. After immunohistochemical analysis 21 of the 73 N0 patients had occult tumour cells in their SN; eight patients had micrometastases and 13 patients had isolated tumour cells.

Conclusion

SN mapping accurately predicts nodal status in patients with colonic cancer. Immunohistochemical analysis demonstrates micrometastatic disease in eight out of 73 N0 patients, with a true upstaging rate of 11%. SN mapping is less reliable in patients with rectal cancer after pre-operative radiotherapy.     

Lymph node micrometastasis in node negative early gastric cancer

Aims

The clinical significance of lymph node micrometastasis for histologically node negative gastric cancer is not well documented. This study was to assess the incidence and to clarify the risk factors of lymph node micrometastasis in patients with node negative early gastric cancer (EGC).

Methods

We investigated the lymph node micrometastasis with using an anticytokeratin immunohistochemical stain in 90 patients with node negative EGC who underwent curative resection between 1991 and 2000.

Results

Among 3526 nodes from 90 patients, there were 17 cytokeratin immunohistochemical stain positive nodes from nine patients. The incidence of micrometastasis was higher in patients with lymphatic invasion (p = 0.012), venous invasion (p = 0.026) and larger tumor (p = 0.003). The independent risk factors for lymph node micrometastasis were lymphatic invasion (p = 0.004, RR = 22.915, 95% CI = 2.709 ∼ 193.828) and tumor size (p = 0.029, RR = 1.493, 95% CI = 1.042 ∼ 2.138). Although there were 10 deaths during the follow-up period of mean 67.6 months (1 month ∼ 147 months), there was no death from a cancer recurrence.

Conclusions

The incidence of lymph node micrometastasis in patients with node negative early gastric cancer was 10%, and the independent risk factors for micrometastasis were lymphatic invasion and tumor size.     

Tissue inhibitor of metalloproteinase-2 G-418C polymorphism is associated with an increased risk of gastric cancer in a Chinese population

Aims

To examine the effect of the TIMP-2 G-418C polymorphism on gastric cancer risk.

Methods

We conducted a hospital-based, case–control study using polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) method in 412 individuals (206 gastric cancer patients and 206 age, sex matched cancer-free controls).

Results

The genotype and allele frequencies were significantly different (P = 0.007 and 0.005, respectively) between cases and controls. Further analysis showed that the variant TIMP-2 genotypes (CC + GC) had a 51% increased risk of gastric cancer compared with GG [adjusted odds ratio (OR) 1.51, 95% confidence interval (CI) 1.00–2.26, P = 0.049]. The elevated gastric cancer risk was especially evident in younger individuals (age < 58 years old) (adjusted OR 2.21, 95% CI 1.18–4.16) and smokers (adjusted OR 2.61, 95% CI 1.01–6.72). However, no significant association was observed between the variant genotypes and clinicopathological features of gastric cancer.

Conclusions

These findings suggest that the TIMP-2 G-418C polymorphism is a genetic predisposing factor for gastric cancer.     

C-kit protein expression in Wilms' tumour: An immunohistochemical study

Aim

The use of a non-toxic tyrosine kinase receptor inhibitor, Imatinib Mesylate (IM), has become an ever-more common therapeutic alternative in some Kit (CD117) over-expressing neoplasms.As the treatment eligibility for these drugs hinges on CD117 expression, Kit immunostaining has recently been widely examined in various tumours. There are only limited data in the literature on the expression of c-kit expression in Wilms' Tumour. We examined CD117 expression in Wilms' tumour in order to correlate this marker with clinico-pathological data and to clarify its prognostic impact.

Methods

This study included 40 cases of Wilms' tumour. Sections from paraffin-embedded tumour samples were immunostained by standard ABC technique using c-kit polyclonal antibody with antigen retrieval.

Results and conclusions

In the case of C-kit positive examples, the staining was focal, with patch distribution. On univariate analysis, significantly higher c-kit expression was observed in neoplasms in a more advanced stage of development than those in a less advanced stage (p = 0.0055). In addition, over-expression of this marker was significantly correlated with the death of patients (p = 0.0294) and recurrences of disease (p = 0.0118). Moreover, all our Wilms' tumour anaplastic subtypes showed over-expression of c-kit and this was significantly higher than in favourable histology examples (p = 0.0182). The results of multivariate analysis, instead, did not reveal any correlation of c-kit expression and prognosis. In our opinion these results could be due to the number of cases considered which is not particularly high. However, it seems likely that c-kit expression could be a secondary event related to tumour progression and could be influenced by chemotherapy and unfavourable histology.     

Referral bias in thyroid cancer surgery: Direction and magnitude

Aim

This study was conducted to clarify the impact of referral bias in thyroid cancer surgery.

Methods

Analysis of 1419 consecutive patients with papillary (n = 653), follicular (n = 248), and medullary thyroid cancer (n = 518) referred to a specialist center for initial surgery or reoperation.

Results

With increasing travel distance (successive postal code areas), mean age decreased among patients referred for initial surgery (from 53 to 35 years for papillary cancer, 65 to 49 years for sporadic medullary cancer, and 40 to 23 years for hereditary medullary cancer, all p ≤ 0.001; and from 65 to 54 years for follicular cancer, p = 0.26). The significant decline in mean age continued among patients reoperated on for papillary cancer (from 53 to 43 years, p < 0.001), but was lost among patients reoperated on for medullary cancers.For patients with differentiated, but not medullary cancers, greater travel distance was associated with higher frequencies of extrathyroidal extension at initial surgery (from 17% to 63% for follicular cancer, p = 0.003) and reoperation (from 18% to 47% for papillary, and 5% to 44% for follicular cancer, all p < 0.001), and higher frequencies of lymph node metastasis at initial surgery (from 23% to 58% for papillary, and 17% to 50% for follicular cancer, p ≤ 0.008) and reoperation (from 27% to 77% for papillary, and 0% to 35% for follicular cancer, all p < 0.001).

Conclusion

Referral bias in thyroid cancer surgery can include two components working in opposite directions: age and extent of disease. Controlling for these components should reduce the impact of referral bias on thyroid cancer research.     

Prognostic influence of immunohistochemically detected lymph node micrometastasis and histological subtype in pN0 oesophageal cancer

Introduction

Differences in frequency and clinical impact of lymph node micrometastasis between histological subtypes of oesophageal cancer have not been determined.

Methods

1204 lymph nodes from 32 squamous cell carcinomas and 54 adenocarcinomas with complete resection and pN0 status were re-evaluated using a serial sectioning protocol including immunohistochemistry. Intra-nodal tumour cells were classified as micrometastases (0.2–2 mm) or isolated tumour cells (<0.2 mm).

Results

There was no significant difference in the frequency of micrometastases between adenocarcinoma and squamous cell carcinoma (11.3% vs. 3.1%, p = n.s.). In the squamous cell carcinoma group, Kaplan–Meier curves showed a significantly prolonged 5-year survival (p = 0.02) and disease free interval (p < 0.01) for immunohistochemically node negative versus node positive patients. In patients with adenocarcinoma, no such difference (p = n.s. and p = n.s., respectively) was seen. In patients who did not undergo pre-treatment, those with adenocarcinoma had a significant 5-year survival (65% vs. 53%; p = 0.03) and disease free interval (83% vs. 58%; p < 0.05) advantage over those with squamous cell carcinoma. After pre-treatment, no difference between the histological subtypes was detected.Regression analysis did not reveal any factors that significantly affected overall survival in node negative patients. However, four factors did significantly influence disease free interval: pre-treatment (HR 3.3 [95% CI 1.2–9.1], p = 0.02); micrometastasis (HR 5.3 [95% CI 1.4–19.7], p = 0.01); UICC stage II vs. 0/I (HR 2.2 [95% CI 1.1–4.4], p = 0.03); and adenocarcinoma (HR 0.3 [95% CI 0.1–0.9], p = 0.03).

Conclusion

The difference in frequency and clinical impact of immunohistochemically detected micrometastasis may indicate that adenocarcinoma and squamous cell carcinoma should not be treated as one entity.     

Treatment results for gastric cancer surgery: 12 years’ experience at a single institute in Korea

Aims

To evaluate the changing trends of clinicopathologic features, surgical procedures and treatment outcomes of gastric cancer in a large-volume center.

Methods

We divided the time period into two parts: the first is 1989–1996 (period I) and the second is 1997–2001 (period II). Then we analyzed prospectively collected data on 1816 patients treated at Kangnam St. Mary's Hospital, The Catholic University of Korea, from 1989 to 2001.

Results

Upper one-third cancer was seen more prevalently in period II than period I (9.4% versus 6.6%) (p = 0.000) and total gastrectomy was performed more frequently in period II than period I (25% versus 18%) (p = 0.000). A diagnosis of early gastric cancer was made more prevalently in period II than period I (40% versus 27%) (p = 0.000). D2 lymphadenectomy was done in 74% of the period I patients and 83% of their period II counterparts (p = 0.000). Between the two periods, there was a significant difference in the incidence of operation-related major complications (9.9% in period I versus 3.9% in period II) (p = 0.000) and the mortality (1.8% versus 0.6%) (p = 0.023). The overall 5-year and 10-year survival rates were significantly higher in period II than period I (63% and 57% in period I versus 69% and 64% in period II) (p = 0.009).

Conclusions

The overall survival of gastric cancer significantly increased because of the early detection and aggressive surgical approaches by experienced surgeons in a large-volume center. More effective multidisciplinary approaches are warranted to improve the prognosis of advanced gastric cancer.     

Preoperative predictors of vascular invasion in hepatocellular carcinoma

Aims

Vascular invasion is an established adverse prognostic factor in hepatocellular carcinoma (HCC). The aim of the current study was to identify the preoperative predictors of vascular invasion in patients undergoing partial hepatectomy for HCC.

Methods

A retrospective analysis of 227 consecutive patients who underwent partial hepatectomy for HCC was conducted. Vascular invasion was defined as gross or microscopic involvement of the vessels (portal vein or hepatic vein) within the peritumoral liver tissue.

Results

Seventy-six (33%) patients had vascular invasion. Among the preoperative factors, only the tumour size (relative risk, 16.78; p < 0.01) and the serum α-fetoprotein (AFP) level (relative risk, 3.57; p < 0.01) independently predicted vascular invasion. As the tumour size increased, the incidence of vascular invasion increased: ≤2 cm, 3%; 2.1–3 cm, 20%; 3.1–5 cm, 38%; and >5 cm, 65%. The incidence of vascular invasion was 32% in patients with serum AFP levels ≤1000 ng/mL, compared to 61% in patients with higher serum AFP levels (p < 0.01). Patients with both tumours >5 cm and serum AFP levels >1000 ng/mL had an 82% incidence of vascular invasion.

Conclusions

The tumour size and serum AFP level, alone or in combination, are useful in predicting the presence or absence of vascular invasion before hepatectomy for HCC.     

Important prognostic factors for lung cancer in tobacco predominant Eastern North Carolina: Study based on a single cancer registry

Background

It is known that lung cancer incidence and mortality rate are higher in African Americans (AA) than whites. In Eastern North Carolina, there is a higher percentage of AA population than the national average (30.2% vs. 12.4%) and a higher incidence of lung cancer in this region. We investigated demography and survival of lung cancer patients diagnosed and treated in a single institution.

Methods

The study includes 2351 patients diagnosed with lung cancer between 2001 and 2010 at East Carolina University. AA and whites were compared by age, sex, race, stage, histology, smoking history and insurance information using chi-square analyses. Patient survival was modeled using Cox proportional hazards regression (SAS version 9.2).

Results

The distribution of lung cancer was 70% in whites and 30% in AA. The proportion of AA and whites differed significantly for age, sex, histology, stage, and insurance. Patients aged >70 (p < 0.0001) and 51–70 (p = 0.0064) died sooner than those ≤50 years old. Compared with squamous cell, SCLC had inferior survival (HR = 2.0, 95%CI = 1.7–2.3). Privately insured patients survived longer than those with medicare (p < 0.0001), medicaid (p = 0.0009), or no insurance (p < 0.0001). The survival disadvantage for medicaid (p = 0.0076) and no insurance (p = 0.0033) persisted on multivariable analysis. Race was not a significant predictor of survival on multivariable analysis (p = 0.66).

Conclusion

This is one of the largest lung cancer patient populations from a single institution showing demographic differences between the two races with similar survival outcome. Age, histology and type of insurance were strong predictors of survival outcome. Older age, small cell histology and medicaid and no insurance had significantly shorter overall survival.     

Patterns of lymph node spread and its influence on outcome in resectable parotid cancer

Aim

To assess the metastatic topography of intraparotideal and neck lymph nodes in parotid cancer and its influence on tumour recurrence and survival.

Methods

The lymph node spread of 142 patients with primary parotid carcinoma treated from 1986 to 2006 was analysed. Disease-free survival (DFS) and overall survival (OS) were calculated. The role of the metastatic pattern as prognostic factors were univariately and multivariately analysed.

Results

A lateral, total or radical parotidectomy was performed in 19, 80 and 43 patients, respectively. A radical/radical-modified or selective neck dissection was performed in 68 and 74 patients, respectively. Eighty-seven neck dissection specimens were negative (pN0). Twelve patients had intraparotideal and cervical lymph node involvement (pPar+/pN+). In 24 patients only intraparotideal metastases were detected (pPar+/pN0). 19 patients only had cervical nodal involvement (pPar−/pN+). Twenty-five patients had occult locoregional lymph metastases (cN0/pN+). The median follow-up was 24.4 months. The disease-free survival rate was 81% at 5 years, and 62% at 10 years. By univariate analysis, R+ (p = 0.001), pT (p = 0.019), lymphangiosis carcinomatosa (p = 0.019), pN+ (p = 0.042), and extracapsular spread (p = 0.046) were prognostic for disease-free survival. Multivariate analysis revealed R+ as independent risk factor (p = 0.046). In pN+ patients, involvement of parotid lymph nodes (p = 0.013), nodes in neck level I (p < 0.0001) and IV (p = 0.005) were univariate risk factors. Multivariate analysis showed lymph node metastases in level I as independent risk factor (p = 0.022).

Conclusion

Total parotidectomy and radical-modified neck dissection is recommended as surgical treatment of parotid cancer and should be analysed in a prospective trial.     

Outcomes for a large series of radical cystectomies for bladder cancer

Aims

We present the characteristics and outcomes of a large Chinese series of patients treated with radical cystectomy and pelvic lymphadenectomy for invasive cancer of the bladder. Our aim is to determine the significant independent prognostic factors that determine this outcome.

Methods

The records of 356 patients with invasive bladder cancer, operated at three Chinese medical institutes between 1995 and 2004, were reviewed. Of the 356 patients, 324 (91.0%) were TCC, 24 (6.7%) were adenocarcinoma, eight (2.3%) were squamous carcinoma. The incidence of pelvic lymph node involvement was 22.8%. The mean (SD, range) follow-up of the 356 patients was 54.89 (31.66, 3–137) months. Multivariate analysis was used to assess the clinical and pathological variables affecting disease-free survival (DFS).

Results

The 1-, 2- and 5-year DFS rates were 87%, 75% and 48%, respectively. In multivariate analysis, tumor configuration (RR = 1.62, p = 0.012), multiplicity (RR = 1.41, p = 0.036), histological subtype (RR = 2.17, p < 0.001), tumor stage (RR = 2.50, p < 0.001), tumor grade (RR = 2.40, p < 0.001), node status (RR = 2.51, p < 0.001), neoadjuvant chemotherapy (RR = 0.46, p = 0.016) had independent significance for survival on multivariate analysis.

Conclusions

The results of this series show that radical cystectomy and pelvic lymphadenectomy provide durable local control and DFS in patients with invasive bladder cancer. Multivariates affect the prognosis after radical cystectomy for invasive bladder cancer. The treatment of invasive bladder cancer in China is still in need of improvement and normalization.