Sentinel Lymph Node Procedure Leads to Upstaging of Patients with Resectable Colon Cancer: Results of the Swiss Prospective, Multicenter Study Sentinel Lymph Node Procedure in Colon Cancer

Background

The value of the sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of debate. The objective of this prospective, multicenter trial was 3-fold: to determine the identification rate and accuracy of the SLN procedure in patients with resectable colon cancer; to evaluate the learning curve of the SLN procedure; and to assess the extent of upstaging due to the SLN procedure.

Methods

One hundred seventy-four consecutive colon cancer patients were enrolled onto this prospective trial. They underwent an intraoperative SLN procedure with isosulfan blue 1% injected peritumorally followed by open standard colon resection with oncologic lymphadenectomy. Three levels of each SLN were stained with hematoxylin and eosin (H&;E) and immunostained with the pancytokeratin marker AE1/AE3 if H&;E was negative.

Results

SLN identification rate and accuracy were 89.1% and 83.9%, respectively. SLN were significantly more likely to contain tumor infiltrates than non-SLN (P?P?=?0.021) and the sensitivity of the procedure (P?=?0.043) significantly improved with experience. The use of immunohistochemistry in SLN resulted in an upstaging of 15.4% (16 of 104) stage I and II patients considered node-negative in initial H&;E analysis.

Conclusions

The SLN procedure for colon cancer has good identification and accuracy rates, which further improve with increasing experience. Most importantly, the SLN procedure results in upstaging of >15% of node-negative patients. The potential advantage of performing the SLN procedure appears to be particularly important in these patients because they may potentially benefit from adjuvant therapy.     

Characteristics of Postoperative Recurrence in Lymph Node-Negative Superficial Esophageal Carcinoma

Background

This study aimed to evaluate the recurrence rates, timings, locations, and risk factors, and survival in patients with lymph node-negative superficial esophageal squamous cell carcinomas (ESCCs).

Methods

We investigated 167 patients with pathological T1 thoracic ESCC who underwent curative esophagectomy with lymphadenectomy between 1986 and 2013. They were classified into lymph node-negative and lymph node-positive groups, each of which included 15 relapsed patients. The recurrence rates, timings, locations, and risk factors, and survival were examined retrospectively.

Results

Significantly better recurrence (12.4 %) and the 5-year overall survival (85.7 %) rates were seen in patients with node-negative superficial ESCC compared with those with node-positive superficial ESCC. Relapsed patients with node-negative superficial ESCC showed a 5-month delay in the time to recurrence compared with relapsed patients with node-positive superficial ESCC, but the recurrence locations were similar. Upper thoracic tumors and the presence of lymph node metastases were independent risk factors for recurrence in superficial ESCC patients, but we did not determine any risk factors in patients who were node negative only. The 5-year overall survival rates did not differ between relapsed node-negative and node-positive patients. Furthermore, the mean times to death and the survival rates from recurrence to death were similar in the node-negative (20.3 months and 9.3 %, respectively) and in the node-positive patients (19.1 months and 13.6 %, respectively) who had relapsed.

Conclusions

Node-negative and node-positive superficial ESCC patients should be followed up similarly, because when recurrences occur, the prognoses and the times to death are similar in node-negative and node-positive superficial ESCC patients.

     

Clinical Efficacy of Sentinel Lymph Node Biopsy Using Methylene Blue Dye in Clinically Node-Negative Papillary Thyroid Carcinoma

Background

Sentinel lymph node biopsy (SLNB) has recently been used to detect occult lymph node metastases. The aim of this study was to assess the feasibility and clinical efficacy of SLNB in the treatment of clinically node-negative papillary thyroid carcinoma.

Methods

A total of 114 consecutive patients with clinically node-negative papillary thyroid carcinoma were enrolled and underwent SLNB. After injection of 1% methylene blue around the tumors, blue-stained sentinel lymph nodes (SLN) were collected from the central compartments. All the patients underwent total thyroidectomy with bilateral central compartment neck dissection after SLNB.

Results

SLN were identified in 84 (73.7%) of the 114 patients. Of these 84 patients, 24 (28.6%) had metastases in the SLN. Among the 60 patients who had no metastases in their SLN in frozen biopsy samples, seven had metastatic foci in their SLN in the permanent biopsy samples and six had metastases in their non-SLN samples. Central compartment lymph node metastases were detected in 11 of the 30 patients in whom SLN were not identified. Thus, the sensitivity, specificity, and positive and negative predictive values of SLNB were 64.9, 100, 100, and 78.3%, respectively. The false-positive and false-negative rates were 0 and 35.1%, respectively. The detection of SLN led to no major complications.

Conclusions

SLNB using methylene blue in papillary thyroid carcinoma is a safe and technically feasible procedure. However, it is of limited use in the management of clinically node-negative papillary thyroid carcinoma because of low sensitivity and a high false-negative rate.     

Impact of Identification of Internal Mammary Sentinel Lymph Node Metastasis in Breast Cancer Patients

Background

Accurate assessment of the internal mammary (IM) nodal basin can impact prognosis and treatment in breast cancer. The goal of this study was to identify characteristics associated with positive IM sentinel lymph nodes (SLNs) and the impact on adjuvant treatment.

Methods

Clinically node-negative breast cancer patients who underwent SLN dissection including removal of IM SLNs were identified and medical records were reviewed. Statistical analysis was performed using Fisher’s exact test and rank-sum tests with a significance level of 0.05.

Results

IM SLNs were removed in 71 patients, 60 (85 %) had negative IM SLNs, whereas 11 (15 %) had positive IM SLNs. Clinicopathologic characteristics were similar between the groups. The majority of patients in both groups had axillary SLNs removed (95 % in the node-negative group vs. 91 % in the node-positive group). Four patients (36 %) with positive IM SLNs had axillary metastasis; thus, IM nodal metastases were the only nodal metastases in 64 % of patients with positive IM SLNs. The identification of IM metastases altered adjuvant therapy in 5 (45 %) patients with positive IM SLNs.

Conclusions

Patients with positive IM SLNs have clinicopathologic features similar to those of patients with negative IM SLNs limiting the ability to predict IM nodal metastasis preoperatively. The identification of IM nodal metastases significantly impacts treatment decisions, especially when IM nodes are the only site of nodal metastasis. Removal of IM SLNs should be considered when lymphoscintigraphy reveals IM drainage.     

Correlation Between Clinical Nodal Status and Sentinel Lymph Node Biopsy False Negative Rate After Neoadjuvant Chemotherapy

Background

Neoadjuvant chemotherapy (NAC) is the standard treatment for locally advanced breast cancer. It is now being used to treat operable breast cancer to facilitate breast-conserving surgery, but the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer patients receiving NAC remains open to considerable debate.

Methods

We enrolled 96 patients with stage II–III breast cancer who received NAC from January 2001 to July 2010. All patients underwent breast surgery and SLNB, followed immediately by complete axillary lymph node dissection (ALND). Sentinel lymph nodes were detected with blue dye and radiocolloid injected intradermally just above the tumor and then evaluated with hematoxylin and eosin and immunohistochemical staining.

Results

The overall identification rate for SLNB was 87.5?% (84/96); the false negative rate (FNR) was 24.5?% (12/49); and the accuracy rate was 85.7?% (72/84). The FNR was significantly lower in clinically node-negative patients than in node-positive patients before NAC (5.5?% vs. 35.5?%; p?=?0.001). Accuracy was also significantly higher in clinically node-negative patients than in node-positive patients before NAC (97.2?% vs. 77.1?%; p?=?0.009). The FNR was 27.3?% among 46 clinically node-positive patients before NAC who were clinically node-negative after NAC. Among 12 patients with a complete tumor response (CR), the FNR was 0?%, compared with 26.1?% for 83 patients with a partial response and stable disease (p?=?0.404).

Conclusions

Although associated with a high FNR after NAC, SLNB would have successfully replaced ALND in clinically node-negative patients before NAC and in patients with a CR after NAC.     

External Validation of Extranodal Extension and Lymph Node Density as Predictors of Survival in Node-positive Bladder Cancer after Radical Cystectomy

Background

Prognostic factors in pathologic node-positive patients after radical cystectomy are debated. Extranodal extension (ENE) and lymph node density (LND) are strong predictors of survival. The aim of this study was to assess factors predictive of survival and to evaluate the prognostic significance of the tumor, node, metastasis staging system (TNM) nodal classification in a retrospective cohort of node-positive bladder cancers after radical cystectomy.

Methods

We retrospectively reviewed the data of 75 patients with node-positive bladder cancer after radical cystectomy. Node pathological examination was performed by two experienced uropathologists. Cox regression analysis was performed to identify factors predictive of progression.

Results

The median number of removed lymph node was 18 (range 3–49). The median number of positive lymph nodes was 3 (range 1–35). Overall progression-free and cancer-specific survival were 5 and 12 %. In multivariate analysis, ENE, LND with a 20 % cutoff, and adjuvant chemotherapy were independent predictors of progression-free survival (p = 0.007, 0.006, <0.0001). Neither the 2002 nor the 2009 TNM nodal classification was associated with recurrence.

Conclusions

ENE and LND are strong predictors of clinical outcome in patients with node-positive bladder cancer treated by cystectomy. The actual TNM classification could probably be improved using these criteria, allowing better prognostic classification of node-positive bladder cancer after radical cystectomy.     

Clinical Implications of Occult Metastases and Isolated Tumor Cells in Sentinel and Non-Sentinel Lymph Nodes in Early Breast Cancer Patients: Serial Step Section Analysis with Long-Term Follow-Up

Background

This study was designed to clarify retrospectively the clinical significance of occult metastases in both sentinel lymph nodes (SLNs) and non-SLNs in patients with early breast cancer.

Methods

A total of 109 (80.1%) of 136 women with breast cancer who had consecutively undergone SLN biopsy (176 lymph nodes) were intraoperatively diagnosed as being free of SLN involvement. SLNs were routinely examined by hematoxylin–eosin (HE) staining of one to four frozen sections per node. Sixty-four (58.7%) of these patients also underwent backup axillary dissection. For the 109 patients, all formalin-fixed, paraffin-embedded tissues of SLNs and non-SLNs were entirely cut into 5-μm-thick sections. All serial step sections at 85-μm intervals were stained with HE and immunohistochemistry with pancytokeratin.

Results

Occult metastases in SLNs and non-SLNs were detected in 25 (23%) and 10 (16%) patients, respectively. The presence of occult SLN metastasis was marginally correlated with T-factor (P = 0.06), and predictive factors for occult non-SLN metastases were tumor nuclear grade (P = 0.039). With a median follow-up of 86 months, disease-free survival (P = 0.3) or overall survival (P = 0.8) did not differ between the patients with and without occult SLN metastases, regardless of backup axillary lymph node dissection.

Conclusions

SLN or non-SLN occult metastases detected by serial step sections at 85-μm intervals did not have significant prognostic implications.     

Effect of Axillary Lymph Node Dissection after Sentinel Lymph Node Biopsy on Overall Survival in Patients with T1 or T2 Node-positive Breast Cancer: Report from the Korean Breast Cancer Society

Background

The effect of axillary lymph node dissection (ALND) after sentinel lymph node biopsy (SLNB) in patients with clinically node-negative patients in preoperative evaluations on overall survival (OS) is uncertain. The study aimed to evaluate the difference of survival between node-positive patients who underwent SLNB alone and those who received ALND after SLNB using the Korean Breast Cancer Society registry.

Methods

We enrolled 2,581 patients who met the eligibility criteria. All enrolled patients had T1 or T2 breast cancer, and received mastectomy or breast-conserving treatment followed by documented adjuvant systemic therapy.

Results

There were 197 patients with SLNB alone and 2,384 patients with ALND after SLNB. Smaller tumor size, lower number of nodal metastasis, and higher proportion of breast-conserving surgery were found in patients with SLNB alone than in those with ALND after SLNB. There was no significant difference in OS between the two groups by the log-rank test. ALND after SLNB showed no significant improvement in OS in multivariate analysis.

Conclusions

ALND in patients with sentinel metastasis who have T1 or T2 breast cancer receiving adjuvant systemic therapy may not have improved OS.     

Tumor Depth as a Predictor of Lymph Node Metastasis of Supraglottic and Hypopharyngeal Cancers

Background

The relationship between the histological parameters of primary lesions and lymph node metastasis in supraglottic and hypopharyngeal cancers has not been elucidated. This analysis is important to evaluate the requirement for additional elective neck dissection when clinically node-negative cancers are treated by transoral surgery.

Methods

This study included 40 previously untreated patients with supraglottic and hypopharyngeal cancers who underwent transoral en bloc tumor resection in two academic tertiary referral centers. Nodal status was confirmed by neck dissection for cases with findings or suspicion of lymph node metastases or by observation of clinically node-negative cases for more than 1 year. Patients’ medical records and pathological features were analyzed retrospectively. The correlation of histological parameters with lymph node metastases, including occult metastases, was evaluated by univariate and multiple logistic regression analyses.

Results

Univariate analysis showed that lymph node metastasis was correlated with tumor depth (P = 0.00087) and venous invasion (P = 0.027). Multiple logistic regression analysis showed that it was significantly correlated only with tumor depth (P = 0.007).

Conclusions

Tumor depth is the most useful parameter for predicting lymph node metastases. In clinically node-negative cases, when tumor depth exceeds 1 mm, elective neck dissection must be considered and, when it is less than 0.5 mm, regular clinical follow-up is recommended. Patients with tumor depth between 0.5 and 1 mm should be carefully observed, since they also have a chance of developing nodal metastasis. Venous invasion also indicates high rates of nodal metastasis, therefore elective neck dissection must be considered for these cases.     

Multimodale interdisziplinäre Therapie als Voraussetzung für Verbesserungen von Funktion und Langzeitüberleben bei Patienten mit einem hochmalignen Osteosarkom der Extremitäten

Introduction. The probability for survival of patients with highly malignant osteosarcoma of the extremities was essentially improved by (neo-)adjuvant chemotherapy. The goal was to further improve survival rates by introducing operative treatment of metastases. In the last 20 years, the percentage of limb-preserving operations has increased. Patients and methods. A consecutive series of 23 patients with localized highly malignant osteosarcoma of the extremities received (neo-) adjuvant chemotherapy according to the Cooperative Osteosarcoma Study (COSS) protocol. Local treatment was performed by wide (22 patients) or radical (1 patient) resection (17 limb salvage procedures, 5 amputations, and 1 rotationplasty). In four of seven patients who developed pulmonary metastases, the metastases (up to four) were resected. The patients did not receive salvage chemotherapy. Results. The cumulative survival was 87% at 174 months. The four patients who underwent metastasectomy survived between 42 and 116 months without evidence of disease. One local recurrence developed outside the operative field and could be resected without influencing the functional or oncological outcome. After limb salvage procedures, the mean score according to the Musculoskeletal Tumor Society (MSTS) was 83%, and after rotationplasty 67%. Conclusions. In patients with osteosarcoma of the extremities, limb salvage is possible in a high percentage of cases with a low risk of local recurrence by an effective interdisciplinary cooperation between diagnostic radiologists, oncologists, and orthopedic surgeons. The midterm survival could be improved by the multimodal therapy from about 20% up to about 80%. Metastasectomy gives patients with a limited number of pulmonary metastases a realistic chance to survive.     

Charakterisierung des EGF-Rezeptorstatus beim Peniskarzinom

Introduction

Therapeutic success in metastasized squamous cell carcinoma is poor. Some entities, such as head-and-neck tumors or non-small-cell lung cancer, show an over expression of the EGF receptor. In latest studies target-specific substances against the EGF receptor have already been combined with chemotherapy or radiotherapy. Some studies showed a clear advantage of this combination concerning remission rates as well as survival. EGF receptor status has not yet been examined in penile cancer, therefore, a retrospective analysis of the receptor status was performed in patients treated over the last 14 years and correlations with the clinical course were investigated.

Patients and methods

The analysis included 45 patients, who underwent primary or secondary treatment at the Department of Urology of the University of Essen during 1990 to 2004. Histological preparations existed for 44 patients. Using immunohistochemistry the expression of EGF receptors was determined.

Results

A total of 25 patients were primarily without positive lymph nodes (6 times cN0 and 19 times pN0), while 20 patients had pathologically proven lymph node metastases and 3 of them also had hematogeneous metastases. Out of 42 patients with follow-up 18 are still living of whom only 3 primarily had positive lymph nodes. These patients received adjuvant chemotherapy after resection. Out of the remaining 15 patients, 4 primarily N0 patients developed a lymphogenic recurrence, which was also resected and 3 patients also received adjuvant chemotherapy. Of the patients 24 died, 22 because of penile cancer. Of these 22 patients 16 primarily had positive lymph nodes and 5 of them also had an extensive primary tumor. Surgery was the treatment of choice in these cases and 10 patients also received chemotherapy. Nevertheless, 15 patients developed several recurrences. Distinguishing primarily node-negative and node-positive patients, the Kaplan-Meyer survival curves showed a significant difference (p<0.001). Median overall survival was 55.5 compared to 34 months and median 5-year survival was 76.9% compared to 15.8%. Of the tumors 40 out of 44 (91%) showed a positive or strong positive EGF receptor expression of the primary tumor as well as of the metastases. A correlation between EGF receptor expression and survival could not be shown.

Conclusion

Clinical data underline the prognostic value of the primary lymph node status as well as the therapeutic value of an ileoinguinal lymphadenectomy and adjuvant chemotherapy. It could also be shown that inductive chemotherapy is not very successful. EGF receptor expression was high and comparable to other squamous cell carcinomas, but there was no correlation to survival.     

Prophylactic Level II Neck Dissection Guided by Frozen Section for Clinically Node-Negative Papillary Thyroid Carcinoma: Is It Useful?

Background

Prophylactic lateral neck dissection (PLND) is generally not performed for papillary thyroid carcinoma (PTC). When performed, occult metastases are found in up to 50 % of patients, although the incidence of occult level II nodes seems low. Our aim was to evaluate frozen section analysis-oriented elective level II PLND in patients with clinically node-negative (cN0) PTC.

Methods

This retrospective study included patients with cN0 PTC treated with total thyroidectomy and prophylactic bilateral central and lateral neck dissection of ipsilateral levels III and IV. Frozen section analysis of PLND III and IV was performed. If positive, the PLND was extended to level II. We measured the accuracy of frozen section analysis, the incidence of occult level II metastasis, and oncologic outcomes.

Results

A total of 295 patients were included. For frozen section analysis, the sensitivity was 71.0 %, specificity 99.6 %, positive predictive value 97.8 %, negative predictive value 92.4 %, overall accuracy 93.2 %. Definitive analysis found lateral node metastases in 63 of the 295 (21 %) patients. Extension to level II was performed in 27 of 46 cases (59 %). Level II contained metastatic nodes in 12 of 27 (44 %) patients. There was no difference in total doses of ¹³¹I administered to patients with or without level II disease. Even when extension of PLND to level II was not performed, no cases of recurrent or persistent disease in level II occurred.

Conclusions

Frozen section analysis was highly accurate. The rate of occult metastases in level II was low. Detection of additional metastases in level II did not modify subsequent treatment or the rate of recurrence and is not useful for routine application.     

Randomized study on preoperative radiotherapy in rectal carcinoma

Background: A population based prospective randomized trial on preoperative radiotherapy in operable rectal cancer was conducted in Stockholm, Sweden. Five hundred fifty-seven patients from 12 institutions were included with histologically proven, clinically resectable rectal adenocarcinoma. Patients planned for local excision or previously irradiated to the pelvis were excluded. Methods: A total of 272 patients were allocated to preoperative irradiation with 25 Gy in five cycles during 5–7 days to the rectum and the pararectal tissues (RT+ group) and 285 patients were allocated to surgery only (RT? group). The median follow-up time was 50 months. No patient was lost to follow-up. Surgery was considered curative in 479 patients (86%). Results: Locoregional recurrence occurred in 10% of the patients in the RT+ group versus 21% in the RT? group (p<0.01). Among the curatively operated patients, distant metastases occurred in 19% in the RT+ group versus 26% in the RT? group (p=0.02). The overall survival was improved in the irradiated patients (p=0.02). Postoperative complications were more common after irradiation but were usually mild. The postoperative mortality was low in both groups. Conclusion: Preoperative short-term, high-dose radiotherapy as given in this trial reduces the risk of local and distant recurrence and improves survival after curative surgery for rectal carcinoma.     

The Prognostic Impact of Occult Lymph Node Metastasis in Node-negative Gastric Cancer: A Systematic Review and Meta-analysis

Purpose

To conduct a meta-analysis to clarify whether occult lymph node metastasis (OLNM), which is identified by molecular detection techniques but is not detected by routine histological examination within regional lymph nodes, represents a prognostic factor for patients with node-negative gastric cancer.

Methods

PubMed, Embase, and the Cochrane Library were searched from their inception to November 2012. The published studies that investigated the association between OLNM and the prognosis of patients with node-negative gastric cancer were included. We extracted hazard ratios (HRs) and associated standard errors from the identified studies and performed random-effects model meta-analyses on overall survival and disease-specific survival. Subgroup analyses were also conducted.

Results

A total of 14 eligible studies that included 1,478 patients were identified. Meta-analyses revealed that OLNM was associated with poor overall survival [HR 2.72; 95 % confidence interval (CI) 1.61–4.60], and disease-specific survival (HR 2.91; 95 % CI 1.25–6.79). Subgroup analyses suggested that OLNM was associated with poor survival in early gastric cancer (HR 3.57; 95 % CI 1.23–10.33). However, subgroup analyses of studies that exclusively enrolled patients with D2 lymph node dissection demonstrated that OLNM did not have an influence on the prognosis (HR 1.97; 95 % CI 0.82–4.70).

Conclusions

OLNM correlates with poor prognosis for patients with node-negative gastric cancer, and D2 lymph node dissection could eliminate this correlation. For OLNM-positive patients with node-negative gastric cancer, D2 lymph node dissection is necessary.     

Residual Lymph Node Disease After Neoadjuvant Chemotherapy Predicts an Increased Risk of Lymphedema in Node-Positive Breast Cancer Patients

Background

Axillary lymph node dissection (ALND) is recommended for patients with clinically node-positive breast cancer and carries a risk of lymphedema >30 %. Patients with node-positive breast cancer may consider neoadjuvant chemotherapy, which can reduce node positivity. We sought to determine if neoadjuvant chemotherapy reduced the risk of lymphedema in patients undergoing ALND for node-positive breast cancer.

Methods

The 229 patients who underwent unilateral ALND and chemotherapy were divided into two groups: 30 % (68/229) had neoadjuvant and 70 % (161/229) had adjuvant chemotherapy. Prospective arm volumes were measured via perometry preoperatively and at 3- to 7-month intervals after surgery. Lymphedema was defined as relative volume change (RVC) ≥10 %, >3 months from surgery. Kaplan–Meier curves and multivariate regression models were used to identify risk factors for lymphedema.

Results

Fifteen percent (10/68) of neoadjuvant patients compared with 23 % (37/161) of adjuvant patients developed RVC ≥10 % (hazard ratio = 0.76, p = 0.39). For all patients, body mass index was significantly associated with lymphedema (p = 0.0003). For neoadjuvant patients, residual lymph node disease after chemotherapy was associated with a ninefold greater risk of lymphedema compared to those without residual disease (p = 0.038).

Conclusions

Patients who underwent neoadjuvant chemotherapy did not have a statistically significant reduction in risk of lymphedema. Among patients who receive neoadjuvant chemotherapy, residual lymph node disease predicted a greater risk of lymphedema. These patients should be closely monitored for lymphedema and possible early intervention for the condition.     

Clinically-Staged T3N0 Rectal Cancer: Is Preoperative Chemoradiotherapy the Optimal Treatment?

Background

Preoperative chemoradiotherapy has been widely adopted as the standard of care for stage II–III rectal cancers. However, patients with T3N0 lesions had been shown to have a better prognosis than other categories of locally advanced tumor. Thus, neoadjuvant chemoradiation is likely to be overtreatment in this subgroup of patients. Nevertheless, the low accuracy rate of preoperative staging techniques for detection of node-negative tumors does not allow to check this hypothesis. We analyzed a group of patients with cT3N0 low rectal cancer who underwent neoadjuvant chemoradiotherapy with the purpose of evaluating the incidence of metastatic nodes in the resected specimens.

Methods

Between January 2002 and February 2008, 100 patients with low rectal cancer underwent clinical staging by means of endorectal ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging. All patients received preoperative 5-fluorouracil-based chemoradiotherapy and surgical resection with curative aim.

Results

Of 100 patients with locally advanced rectal cancer, 32 were clinically staged as T3N0M0. Pathological analysis showed the presence of lymph node metastases in nine patients (28%) (node-positive group). In the remaining 23 cases, clinical N stage was confirmed at pathology (node-negative group). Node-positive and node-negative groups differ only in the number of ypT3 tumors (P < .01).

Conclusions

Our results indicate that immediate surgery for patients with cT3N0 rectal cancer represents an undertreatment risk in at least 28% of cases, making necessary the use of postoperative chemoradiotherapy. Preoperative chemoradiotherapy should be the therapy of choice on the grounds of the principle that overtreatment is less hazardous than undertreatment for cT3N0 rectal cancers.     

Discordance Between Conventional and Detailed Lymph Node Analysis in Resected Biliary Carcinoma at or Above the Cystic Duct: Are We Understaging Patients?

Background

Analysis of portal lymph node (LN) metastases following resection of biliary carcinomas at or above the cystic duct (BC) is used to select patients for adjuvant therapy, but no guidelines exist and LN yield is low. Some consider analysis of 7 LNs necessary for accurate staging. Conventional LN analysis may understage patients.

Methods

Portal LNs from 38 node-negative patients following resection of BC from 2000 to 2008 were re-examined in detail for occult metastases (OM) using a modified Weaver protocol. Outcomes measured were discordance in LN positivity and patient survival.

Results

On detailed examination, 5 of 38 patients had OM. There was no difference in survival between patients with and without OM (24 vs 17 months; p = .382). There was no association between OM and patient demographics or adverse tumor characteristics. The median LN yield was 3. Of the 27 patients with <7 LNs retrieved, 1 had OM, compared with 4 of 11 patients with ≥7 LNs retrieved (p = .030). OM in these well-staged patients were associated with reduced survival (9 vs 41 months; p = .032).

Conclusions

There is discordance between conventional and detailed LN analysis in resected BC. LN yield ≥7 was associated with OM. The presence of OM may be associated with decreased survival. Conventional LN analysis may understage patients with resected BC.     

Nodal Counts and Lymph Node Ratio Impact Survival After Distal Pancreatectomy for Pancreatic Adenocarcinoma

Background

The number of lymph nodes required for accurate staging after distal pancreatectomy for pancreatic adenocarcinoma is unknown.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 1,473 patients who underwent distal pancreatectomy for pancreatic adenocarcinoma from 1998 to 2010. We evaluated the influence of the total number of lymph nodes examined (NNE) and the lymph node ratio (LNR-positive nodes/total nodes examined) on survival.

Results

The median NNE was 8. No nodes were examined in 232 (16 %) of the patients, and 843 (57 %) had <10 NNE. Of the patients who had at least one node examined, 612 (49 %) were node positive. In the node-negative subset, the median and 5-year overall survival for patients with ≤10 NNE was significantly worse than patients with >10 NNE (16 vs. 20 months and 13 vs. 19 %, respectively, p?0.1 (17 vs. 6 %, p?=?0.002).

Discussion

Patients with pancreatic cancer undergoing distal pancreatectomy should ideally have at least 11 lymph nodes examined to avoid understaging. For node-positive patients, LNR may be a better prognostic indicator than the total number of positive nodes.     

Individualized Surgery: Gamma-Probe-Guided Lymphadenectomy in Patients with Clinically Enlarged Lymph Node Metastases from Melanomas

Background

The value of a preoperative lymphoscintigraphy in melanoma patients with clinically evident regional lymph node metastases has not been studied. Therapeutic lymph node dissection (TLND) is regarded as the clinical standard, but the appropriate extent of TLND is controversial in all lymphatic basins.

Patients and Methods

Of the 115 consecutive patients with surgery on palpable lymph node metastases, 34 received a pre-operative lymphoscintigraphy. Lymphatic drainage to a second nodal basin outside the clinically involved basin was found in 15 cases. In 13 patients, the ectopic tumor-draining lymph nodes were excised as in a sentinel node biopsy. The lymph nodes from the TLND specimens were postoperatively separated and classified as either radioactive or non-radioactive.

Results

A total of 493 lymph nodes were examined pathologically. The largest macrometastasis maintained the ability to take up radiotracer in 77% of cases. Radioactively labeled lymph nodes carried a higher risk of being involved with metastasis. The proportions of tumor involvement for radioactive and non-radioactive lymph nodes were 44.5 and 16.9%, respectively (P=0.00002). Of the 13 ectopic nodal basins surgically explored, six harbored clinically occult metastases.

Conclusion

In patients undergoing TLND for palpable metastases, tumor-draining lymph nodes in a second, ectopic nodal basin should be excised, because they could be affected by occult metastasis. With respect to radioactive lymph nodes situated within the nodal basin of the macrometastasis but beyond the borders of a less-radical lymphadenectomy, further studies are needed.     

Abdominoperineal excision of the rectum: A prospective study based on a standardized method

A prospective and consecutive series of 72 patients with rectal carcinoma was subjected to excision of the rectum. The operations were performed according to a standardized program based on previous studies and established surgical principles:

1. Two days on a liquid diet, laxative, and enemas.
2. Irrigation of the pelvic cavity with 5 liters of saline solution after removal of the specimen.
3. Leaving the pelvic peritoneum unsutured.
4. Obliteration of the presacral cavity with living omentum, uterus, or small intestine.
5. Suprapubic, closed suction drainage.
6. Primary closure of abdominal and perineal wounds without drainage.
7. Antibiotic prophylaxis against aerobic as well as anaerobic bacteria.
8. Parenteral nutrition from the first postoperative day and until the bowel acts properly.

Two patients died postoperatively (3%), and 93% achieved primary healing of the perineal wound.