Mesenteric Lymph Node Involvement in Advanced Ovarian Cancer Patients Undergoing Rectosigmoid Resection: Prognostic Role and Clinical Considerations

Background

The aim of this retrospective study was to investigate the incidence of mesenteric lymph node (MLN) involvement, and its prognostic role in advanced ovarian cancer (OC).

Methods

OC patients undergoing rectosigmoid resection during primary debulking surgery or interval debulking surgery were recorded. Progression-free survival (PFS) and overall survival were calculated from the date of diagnosis to the date of relapse/progression, death of disease, or the date of last follow-up.

Results

MLNs were detected in 102/148 cases (68.9 %); the rate of MLN involvement was 47.0 %. The percentage of metastatic MLNs was higher in cases with >5 MLNs removed compared with cases with ≤5 MLNs removed (62.7 % vs. 31.3 %; p = 0.0027). A progressive increase in the rate of metastatic MLNs was documented in association with depth of bowel infiltration (p = 0.026). Cases with metastatic MLNs experienced isolated celiac trunk or aortic lymph node recurrences more frequently than patients without MLN involvement (44.8 % vs. 10.7 %; p = 0.0008). PFS did not differ between cases with positive versus negative MLN involvement (2-year PFS = 31 % vs. 43 %; p = 0.58).

Conclusion

OC patients undergoing rectosigmoid resection showed metastatic MLN involvement in 47.0 % of cases. Metastatic MLN status is associated with a high rate of isolated aortic and celiac trunk lymph node recurrences.     

Thoracic Lymph Node Involvement in Adenocarcinoma of the Esophagogastric Junction and Lower Esophageal Squamous Cell Carcinoma Relative to the Location of the Proximal End of the Tumor

Background

It is difficult to determine preoperatively whether upper/middle thoracic lymphadenectomy is necessary in patients with adenocarcinoma of the esophagogastric junction (AEG) or lower esophageal squamous cell carcinoma (ESCC). Here, we investigated whether stratification based on the location of the proximal end of the tumor, as assessed using preoperative computed tomography (CT) images, would be useful for predicting upper/middle thoracic lymph node involvement for AEG and lower ESCC.

Methods

A total of 142 patients with AEG and lower ESCC treated by R0–1 surgical resection via a thoracotomy was retrospectively investigated. The location of the proximal end of the tumor in comparison with the vena cava foramen (VCF) was decided by inspecting preoperative CT images and then correlated with upper/middle thoracic lymph node involvement.

Results

The incidence of upper/middle thoracic lymph node involvement was low in AEG and ESCC tumors having proximal ends below the VCF (0 %, 0 of 13, and 5.9 %, 1 of 17, for AEG and ESCC, respectively). In contrast, when the tumors’ proximal ends were above the VCF, patients had higher frequencies of upper/middle thoracic lymph node involvement (36.4 %, 8 of 22, and 37.8 %, 34 of 90, for AEG and ESCC, respectively). Multivariate analysis showed that the location of the proximal end of the tumor is an independent risk factor related to upper/middle thoracic lymph node involvement (odds ratio 14.3, 95 % confidence interval 1.76–111, p = 0.013), whereas other clinical factors (cT, cN, tumor length, and histologic types) are not.

Conclusions

This manner of stratification using preoperative CT images could be useful in deciding the extent of thoracic lymphadenectomy in both AEG and ESCC.     

Die Positronenemissionstomographie zur präoperativen Lymphknotendiagnostik bei Ösophaguskarzinom

Background

Exact preoperative staging is a prerequisite for the indication and the choice of appropriate operative technique for patients with esophageal carcinoma. The objective of this prospective study was to assess whether positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) increases the accuracy of preoperative lymph node staging with standard computed tomography (CT) and thus leads to a different surgical approach.

Patients and methods

Fifty-eight patients with carcinoma of the esophagus (46 men and 12 women) with a median age of 61 years underwent FDG-PET imaging of the neck, chest, and abdomen as well as CT of the chest and abdomen. Sensitivity, specificity, and accuracy were calculated for both imaging techniques to evaluate the detection of histologically verified lymph node metastases.

Results

The FDG-PET showed higher specificity, whereas CT proved to be more accurate for detecting lymph node metastases not only of the abdomen (73% vs 59%) but also of the thorax (73% vs 63%). Resections were transhiatal in 23 patients and transthoracal in 16. As a supplement to conventional CT diagnostic procedure, FDG-PET was not decisive for the surgical approach.

Conclusions

Altogether, pretherapeutical PET imaging did not increase the accuracy of lymph node staging for our patients with esophageal carcinoma, which had already been defined through CT. Therefore, no new consequences resulted for the surgical procedure. Due to the high costs involved with PET investigation, lymph node staging with it is momentarily indicated mainly for clinical studies and when CT does not offer unequivocal results. Increased sensitivity of the already advantageous whole-body FDG-PET imaging by means of tumor-affinitive radiopharmaceuticals and optimized apparatus resolution could lead to new indications for this staging procedure.     

Factors Associated with Lymph Node Metastasis in Radically Resected Rectal Carcinoids: a Systematic Review and Meta-analysis

Background

Although various guidelines regarding neuroendocrine tumors were released, treatment for rectal neuroendocrine tumors with size between 1 and 2 cm has not been explicitly elucidated. The determinant factor of the choice between endoscopic resection and radical surgery is whether lymph node involvement exists.

Aim

This study aims to explore factors associated with lymph node involvement in rectal neuroendocrine tumors by conducting a meta-analysis.

Methods

A broad literature research of Pubmed, Embase&Medline, and The Cochrane Library was performed, and systematic review and meta-analysis about factors associated with lymph node involvement were conducted.

Results

Seven studies were included in this meta-analysis. Tumor size?>?1 cm (odds ratio (OR) 6.72, 95 % confidence interval (CI) [3.23, 14.02]), depth of invasion (OR 5.06, 95 % CI [2.30, 11.10]), venous invasion (OR 5.92, 95 % CI [2.21, 15.87]), and central depression (OR 3.00, 95 % CI [1.07, 8.43]) were significantly associated with lymph node involvement.

Conclusion

The available clinical evidence suggests that tumor size?>?1 cm, invasion of muscularis properia, venous invasion, and central depression could be risk factors of lymph node involvement, while other factors reported by few studies need further research.     

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

Objective

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

Materials and methods

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

Results

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

Conclusions

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

Survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved

Purpose

The effectiveness of lateral lymph node dissection for extending the survival of patients with advanced lower rectal cancer remains unclear. The purpose of this study was to clarify the survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved.

Methods

We reviewed 131 consecutive patients with advanced lower rectal cancer, who had undergone curative resection with total mesorectal excision plus extended lateral lymph node dissection at Wakayama Medical University Hospital. Twenty-six (19.1 %) of these patients had lateral lymph involvement. We performed univariate and multivariate analyses for the 3-year disease-free and overall survival of these patients.

Results

Multivariate analysis revealed that the number (>1) and the region (common iliac artery region or external iliac artery region) of lateral lymph node metastasis are independent predictive factors for recurrence and survival. The Kaplan–Meier analysis demonstrated that patients with one lymph node metastasis in the internal iliac artery or obturator region had better survival.

Conclusions

Lateral lymph node dissection resulted in survival benefit for patients with single lateral lymph node involvement in the internal iliac artery region or the obturator region.     

Evaluation of the Risk of Lymph Node Metastasis Using CRP 1846C>T Genetic Polymorphism in Submucosal Thoracic Esophageal Squamous Cell Carcinoma

Background

More than 40 % of patients with submucosal esophageal squamous cell carcinoma (ESCC) have lymph node metastasis. Furthermore, the potential presence of undetectable metastasis before treatment prompts surgeons to be aggressive with respect to lymph node dissection. Extending the indication for endoscopic resection, a minimally invasive treatment, to superficial ESCCs will require more accurate and individualized evaluation of lymph node metastasis.

Methods

The study participants were 121 esophageal cancer patients who underwent curative surgery for thoracic submucosal ESCC at three Japanese hospitals. DNA was extracted from blood samples, and the C-reactive protein (CRP) 1846C>T genetic polymorphism (rs1205) was investigated using polymerase chain reaction-restriction fragment length polymorphism. We then evaluated the value of CRP 1846C>T polymorphism for diagnosis of lymph node metastasis.

Results

Forty-nine (40 %) patients had lymph node metastasis. The CRP 1846 C/T genotype was C/C in 19 patients, C/T in 57 patients, and T/T in 45 patients. Fisher’s exact analysis of the CRP 1846C>T polymorphism showed a significantly higher frequency of lymph node involvement with the T/T genotype. Univariate and multivariate logistic regression models revealed that patients carrying the 1846 T/T genotype had a significantly greater likelihood of developing lymph node metastasis (odds ratio >2.6). Combining the CRP 1846 C/T genotype with clinical diagnosis, mainly using CT, brought a negative predictive value of 80 % to diagnosing lymph node involvement.

Conclusions

CRP genetic polymorphism may be a novel predictor of risk of lymph node metastasis in ESCC, which could enable better evaluation of the necessity for lymph node dissection.     

Impact of Multifocality and Lymph Node Metastasis on the Prognosis and Management of Microinvasive Breast Cancer

Background

There are few data on the long-term outcome of patients with microinvasive (T1mi) breast cancer. Moreover, predictors of lymph node involvement and the impact of multifocal microinvasion are not well understood.

Methods

Patients with T1mi cancer, defined as tumors ≤1 mm, surgically managed at our institute and who underwent axillary lymph node evaluation were identified. Specimen slides were independently reviewed. Multivariate analysis was used to identify factors predictive of lymph node involvement.

Results

Forty-five patients with T1mi cancer were identified. Median patient age was 52 years, and median size of in situ disease was 4 cm. Nine tumors (20.0 %) had more than one focus of microinvasion. Lymph nodes metastasis were identified in 9 patients: 1 macrometastasis (2.2 %), 4 micrometastases (8.9 %), and 4 isolated tumor cells (8.9 %). Seven of 9 patients with lymph node involvement underwent adjuvant chemotherapy. Estrogen receptor–negative invasive disease was a significant predictor of lymph node metastasis by multivariable analysis (p < 0.02). There was also a trend toward lymph node involvement in patients with multifocal microinvasion compared to unifocal disease (33.3 vs. 16.7 %, respectively). At a median follow-up of 83 months, 3 patients (6.3 %) had disease recurrence (1 local, 1 distant, 1 local and distant). All patients with recurrence initially had tumor-free lymph nodes and only one focus of microinvasion.

Conclusions

Microinvasive breast cancer clearly has the ability to metastasize and recur, but in this series, only 2 % of patients with nodal macrometastasis. Only two patients experienced local recurrence, neither of whom had lymph node metastasis. The importance of identifying nodal micrometastasis in T1mi disease needs to be further explored.     

Lymph-node metastases in rectal carcinoids

Background

Colorectal carcinoids are described as low-grade malignancy in the WHO classification. However, the survival is equally poor between carcinoids and adenocarcinomas if the tumors have lymph node metastasis or distant metastasis.

Patients and methods

We reviewed 17 patients with rectal carcinoid, who underwent surgical resection with lymph node dissection at our institution between March 2005 and November 2007. Our criteria for surgical resection were: tumor size of 10 mm or larger and positive resection margin or the presence of lymphovascular invasion in lesions to which endoscopic or surgical local treatment was carried out.

Results

Lymph node metastases were present in 12 patients. Three of them were with tumors less than 10 mm in size, of whom two patients had lymphovascular invasion. In eight out of the 12 with lymph node metastases, preoperative computed tomography (CT) identified lymph nodes of 5 mm or larger in size.

Conclusions

The present study demonstrated that rectal carcinoids with lymph node metastasis are common. Previously reported risk factors of lymph node metastasis in rectal carcinoid such as tumor size >?=?10 mm and lymphovascular invasion are useful in predicting lymph node metastasis. In addition, lymph nodes 5 mm or larger in size identified on preoperative CT suggest the presence of metastasis.     

Pancreatic Neuroendocrine Tumors: Radiographic Calcifications Correlate with Grade and Metastasis

Background

Studies to identify preoperative prognostic variables for pancreatic neuroendocrine tumor (PNET) have been inconclusive. Specifically, the prevalence and prognostic significance of radiographic calcifications in these tumors remains unclear.

Methods

From 1998 to 2009, a total of 110 patients with well-differentiated PNET underwent surgical resection at our institution. Synchronous liver metastases present in 31 patients (28%) were addressed surgically with curative intent. Patients with high-grade PNET were excluded. The presence of calcifications in the primary tumor on preoperative computed tomography was recorded and correlated with clinicopathologic variables and overall survival.

Results

Calcifications were present in 16% of patients and were more common in gastrinomas and glucagonomas (50%), but never encountered in insulinomas. Calcified tumors were larger (median size 4.5 vs. 2.3?cm, P?=?0.04) and more commonly associated with lymph node metastasis (75 vs. 35%, P?=?0.01), synchronous liver metastasis (62 vs. 21%, P?P?P?=?0.01) and size (P?P?=?0.04), but not in the presence of radiographic calcifications.

Conclusions

Calcifications on preoperative computed tomography correlate with intermediate grade and lymph node metastasis in well-differentiated PNET. This information is available preoperatively and supports the routine dissection of regional lymph nodes through formal pancreatectomy rather than enucleation in calcified PNET.     

Differences of the Lymphatic Distribution and Surgical Outcomes Between Remnant Gastric Cancers and Primary Proximal Gastric Cancers

Background

Although remnant gastric cancer (RGC) following distal gastrectomy is located in the proximal stomach, little is known about the differences of the lymphatic distribution and surgical outcomes between RGC and primary proximal gastric cancer (PGC).

Methods

Between 1997 and 2008, 1,149 patients underwent gastrectomy for gastric cancer. Of these, 33 (2.9%) RGC patients and 207 (18.5%) PGC patients were treated at our department. We reviewed their hospital records retrospectively.

Results

Compared with the PGC patients, those with RGC had a slightly higher age at onset (p?=?0.09), higher incidence of undifferentiated cancer (p?=?0.06), higher incidence of vascular invasion (p?=?0.09), and higher incidence of T4 (p?=?0.07). Gastrectomy for RGC involved greater blood loss (p?p?=?0.01), combined resection, and high incidence of complications. However, the survival rate for RGC patients was similar to that for PGC patients (p?=?0.67). 2) Patients with RGC had a different pattern of lymph node metastasis compared with that in PGC. Particularly in advanced RGC with pT2?CT4 tumors, RGC frequently demonstrated jejunal mesentery lymph node metastases (RGC vs. PGC, 35% vs. 0%) and splenic hilar lymph node metastases (RGC vs. PGC, 17% vs. 10%). The jejunal mesentery lymph node metastases were detected only following Billroth II reconstruction (Billroth I vs. Billroth II, 0% vs. 67%).

Conclusion

Although the clinical behaviors of the two gastric cancers were different, the survival rates were similar. The pattern of metastasis indicates that the jejunal mesentery and splenic hilar lymph nodes should be specifically targeted for en bloc resection during complete gastrectomy in RGC.     

18F-fluorocholine PET/CT compared with extended pelvic lymph node dissection in high-risk prostate cancer

Purpose

To compare ¹⁸F-fluorocholine positron-emission tomography/computed tomography (PET/CT) with extended pelvic lymph node dissection (ePLND) for the detection of lymph node metastases in a large cohort of patients with high-risk prostate cancer.

Materials and methods

Patients with prostate-specific antigen levels between 20 and 99 ng/mL and/or Gleason score 8–10 cancers, planned for treatment with curative intent following a negative or inconclusive standard bone scan, were investigated with ¹⁸F-fluorocholine PET/CT followed by an ePLND. None of the patients received hormonal therapy prior to these staging procedures. Results for PET/CT were compared on a per-patient basis with histopathology from ePLND. Sensitivity, specificity, positive and negative predictive values were calculated.

Results

PET/CT detected a total of 76 suspected lymph node metastases and four suspected bone metastases in 33 (29 %) of the 112 included patients. Of these, 35 suspected lymph node metastases, only within the anatomical template area of an ePLND, were found in 21 of the patients. Histopathology of the ePLND specimens detected 117 lymph node metastases in 48 (43 %) of the 112 patients. Per-patient sensitivity, specificity, positive and negative predictive values for ¹⁸F-fluorocholine PET/CT for lymph node metastases within the ePLND template were 0.33, 0.92, 0.76 and 0.65, respectively. Only 11 patients had lymph nodes larger than 10 mm that would have been reported by CT alone.

Conclusions

¹⁸F-fluorocholine PET/CT detects lymph node metastases in a significant proportion of patients with high-risk prostate cancer with a high specificity, but low sensitivity.     

Prognostic significance of lymph node ratio in patients undergoing abdominoperineal resection of rectum

Background

Lymph node ratio (LNR) has been shown to be an independent prognostic factor in stage III colorectal cancer. Abdominoperineal resection (APR) of rectum is historically associated with poorer oncological outcomes compared to other colorectal resections, and significance of LNR in this group of patients has not been studied.

Objective

Our aim was to determine impact of LNR on oncological outcomes in a series of patients with rectal cancers undergoing APR.

Patients and methods

A series of patients who had undergone APR and had lymph node metastasis were identified from a prospectively maintained clinical, histopathological and radiological database. LNR was calculated, and Cox regression was used to determine the impact of factors affecting local recurrence, distal metastases and overall survival.

Results

Fifty-eight (42 males) patients were identified to have rectal cancer with lymph node involvement. LNR was an independent predictor of distal metastasis and overall survival at cutoff levels of 0.17, 0.41 and 0.69.

Conclusion

Lymph node ratio is an independent predictor of survival outcomes in patients with stage III tumours undergoing APR. LNR may help improve stratification of this group of patients.     

Clinicopathological Features and Prognostic Factors of Adenocarcinoma of the Esophagogastric Junction According to Siewert Classification: Experiences at a Single Institution in Japan

Background

Treatment strategy for adenocarcinoma of the esophagogastric junction (AEG) remains controversial. The aims of this study are to evaluate results of surgery for AEG, to clarify clinicopathological differences according to the Siewert classification, and to define prognostic factors.

Methods

We retrospectively analyzed 179 consecutive patients with Siewert type I, II, and III AEG who underwent curative (R0) resection at the National Cancer Center Hospital East between January 1993 and December 2008.

Results

Patients with AEG were divided according to tumor: 10 type I (5.6%), 107 type II (59.8%), and 62 type III (34.6%). Larger, deeper tumors and nodal metastasis were more common in type III than type II tumors. No significant differences were seen in 5-year survival rates among the three types: type I (51.4%), type II (51.8%), and type III (62.6%). Multivariate analysis showed that depth of tumor and mediastinal lymph node metastasis were independent prognostic indicators. The recurrence rate for patients with mediastinal lymph node metastasis was 87.5%. The risk factors for mediastinal lymph node metastasis were length of esophageal invasion and histopathological grade.

Conclusions

Mediastinal lymph node metastasis and tumor depth were significant and independent factors for poor prognosis after R0 resection for AEG. Esophageal invasion and histopathological grade were significant and independent factors for mediastinal lymph node metastasis.     

Role of the standardized uptake value of 18-fluorodeoxyglucose positron emission tomography–computed tomography in detecting the primary tumor and lymph node metastasis in colorectal cancers

Purpose

To assess the role of positron emission tomography–computed tomography (PET–CT) and multidetector-row CT (MD-CT) in detecting the primary lesion and lymph node metastasis in patients with colorectal cancers.

Methods

A collective total of 80 lesions resected from 77 patients were examined pathologically. We analyzed the significance of the standardized uptake value (SUV) and its relationship with the clinicopathologic findings of primary lesions and lymph node metastasis. The detectability of primary lesions and lymph node metastases on PET–CT images was compared with that on MD-CT images.

Results

The detectability of primary lesions was better on PET–CT images than on MD-CT images (p = 0.0023). We observed no significant differences in the SUV with respect to staging, tumor grade, lymphatic or vessel invasion, and macroscopic type; however, primary tumor size analysis revealed that tumors larger than 3 cm had a higher SUV than those smaller than 3 cm. The sensitivity of PET–CT for detecting lymph node metastasis was lower than that of MD-CT, but the specificity of PET–CT was higher than that of MD-CT.

Conclusions

The SUV of primary cancers tends to increase in proportion to tumor size. Although the value of PET–CT in detecting lymph node metastasis is limited, PET -positive lymph nodes can be considered metastatic.     

Outcomes of patients receiving additional esophagectomy after endoscopic resection for clinically mucosal, but pathologically submucosal, squamous cell carcinoma of the esophagus

Purpose

This study investigated the actual rate or extent of lymph node metastasis or the survival outcomes among patients that underwent esophagectomy with lymph node dissection after ESD for clinical mucosal, but pathological submucosal, esophageal cancer.

Methods

Seventeen patients that received esophagectomy with two- or three-field lymph node dissection as additional treatment after ESD for clinical mucosal, but pathological submucosal, esophageal cancer between 2006 and 2010 were analyzed. The rate and extent of lymph node metastasis and the patient outcomes were determined.

Results

The tumor depths were diagnosed as SM1 in 8 (47 %) patients and SM2 in 9 (53 %), based on the analyses of resected specimens. Lymphatic invasion was evident in 13 (76 %) patients, while venous invasion was detected in 5 (29 %). Five (29 %) patients had pathologically detected lymph node involvement. Seven (0.8 %) of the 890 dissected nodes showed cancer involvement. Three patients had one involved node in the mediastinum or abdomen, and 2 patients had 2 involved nodes in the abdomen. The patients were followed up for 11–71 months (median 23 months), and all were alive without recurrence at the final follow-up.

Conclusion

Twenty-nine percent of the patients diagnosed with clinically mucosal, but pathologically submucosal, thoracic squamous cell esophageal cancer after ESD had 1–2 cancer-involved lymph nodes in the lower mediastinum and abdomen. Esophagectomy with lymph node dissection is therefore considered to be a necessary and effective additional treatment for these patients.     

Prediction of Lymph Node Involvement in Patients with Breast Tumors Measuring 3–5 cm in a Middle-Income Setting: the Role of CancerMath

Background

In settings with limited resources, sentinel lymph node biopsy (SNB) is only offered to breast cancer patients with small tumors and a low a priori risk of axillary metastases.

Objective

We investigated whether CancerMath, a free online prediction tool for axillary lymph node involvement, is able to identify women at low risk of axillary lymph node metastases in Malaysian women with 3–5 cm tumors, with the aim to offer SNB in a targeted, cost-effective way.

Methods

Women with non-metastatic breast cancers, measuring 3–5 cm were identified within the University Malaya Medical Centre (UMMC) breast cancer registry. We compared CancerMath-predicted probabilities of lymph node involvement between women with versus without lymph node metastases. The discriminative performance of CancerMath was tested using receiver operating characteristic (ROC) analysis.

Results

Out of 1,017 patients, 520 (51 %) had axillary involvement. Tumors of women with axillary involvement were more often estrogen-receptor positive, progesterone-receptor positive, and human epidermal growth factor receptor (HER)-2 positive. The mean CancerMath score was higher in women with axillary involvement than in those without (53.5 vs. 51.3, p = 0.001). In terms of discrimination, CancerMath performed poorly, with an area under the ROC curve of 0.553 (95 % confidence interval CI 0.518–0.588). Attempts to optimize the CancerMath model by adding ethnicity and HER2 to the model did not improve discriminatory performance.

Conclusion

For Malaysian women with tumors measuring 3–5 cm, CancerMath is unable to accurately predict lymph node involvement and is therefore not helpful in the identification of women at low risk of node-positive disease who could benefit from SNB.     

The Addition of Radiation to Chemotherapy does not Improve Outcome When Compared to Chemotherapy in the Treatment of Resected Pancreas Cancer: The Results of a Single-Institution Experience

Background

Pancreas cancer is highly lethal even at early stages. Adjuvant therapy with chemotherapy (CT) or chemoradiation (CRT) is standard following surgery to delay recurrence and improve survival. There is no consensus on the added value of radiotherapy (RT). We conducted a retrospective analysis of clinical outcomes in pancreas cancer patients treated with CT or CRT following surgery.

Methods

Patients with resected pancreas adenocarcinoma were identified in our institutional database. Relevant clinicopathologic and demographic data were collected. Patients were grouped according to adjuvant treatment: group A: no treatment; group B: CT; group C: CRT. The primary endpoint of overall survival was compared between groups B vs. C. Univariate and multivariate analyses of potential prognostic factors were conducted including all patients.

Results

A total of 146 evaluable patients were included (group A: n = 33; group B: n = 45; group C: n = 68). Demographics and pathologic characteristics were comparable. There was no significant survival benefit for CRT compared with CT (mOS 16.8 months vs. 21.5 months, respectively, p = 0.76). Local recurrence rates were similar in all three groups. Univariate analyses identified absence of lymph node involvement (hazards ratio [HR] 1.43, p = 0.0082) and administration of adjuvant therapy (HR 0.496, p = 0.0008) as significant predictors for improved survival. Multivariate analyses suggested that patients without nodal involvement derived the most benefit from adjuvant treatment.

Conclusions

The addition of RT to CT did not improve survival over CT. Lymph node involvement predicts inferior clinical outcome.     

Is Total Mesorectal Excision Always Necessary for T1–T2 Lower Rectal Cancer?

Background

The goal of this multicenter study was to clarify the determinants of local excision for patients with T1–T2 lower rectal cancer.

Methods

Data from 567 consecutive patients who underwent radical resection for T1–T2 lower rectal cancer at 12 institutions between 1991 and 1998 were reviewed. Rates of lymph node metastasis were investigated using a tree analysis, which was hierarchized using independent risk factors for nodal involvement.

Results

The independent risk factors for lymph node metastasis were female gender, depth of tumor invasion, histology other than well-differentiated adenocarcinoma, and lymphatic invasion. According to the first three parameters that can be obtained preoperatively, only 0.99% of the patients without risk factors had lymph node metastasis. On the other hand, even if the lower rectal cancer was at stage T1, women with histological types other than well-differentiated adenocarcinoma had an approximately 30% probability of having lymph node metastasis. Lymphatic invasion was most useful to predict nodal involvement among patients with T2 lower rectal cancer. The rates of lymph node metastasis in T2 patients with and without lymphatic invasion were 32.9% and 9.1%, respectively.

Conclusions

Gender is one of the most important predictors for lymph node metastasis in patients with early distal rectal cancer. Three parameters, including depth of tumor invasion, histology, and gender, are useful determinants for local excision. Additional studies are required to establish the minimum optimal treatment for T2 lower rectal cancer.     

Modified concept for radioisotope-guided sentinel lymph node dissection in prostate cancer

Purpose

To present a modified concept for sentinel lymph node (SLN)-guided pelvic lymph node dissection in prostate cancer.

Methods

A total of 463 patients with histologically proven prostate cancer underwent SLN-guided lymph node dissection. The day before surgery patients received intraprostatic injection of Tc-99 m-labeled nanocolloid (Tc-NC) under transrectal ultrasound guidance. At the time of surgery, the lymph nodes of the obturator fossa were dissected routinely in all patients. After meticulous testing with a handheld gamma probe, all lymphatic tissues in predefined anatomic regions (external iliac, internal iliac, common iliacal and presacral) with Tc-NC uptake were additionally resected.

Results

In 146 (12.8%) patients, SLN were located exclusively in the obturator fossa, but 317 patients (87.2%) underwent resection of additional sentinel regions. In 28 (6.1%) patients, 62 lymph node metastases were detected, and 32 (51.6%) of these were located outside the obturator fossa. Eight (28.6%) patients displayed lymph node metastases exclusively outside the obturator fossa and had been resected only because of positive SLN probing.

Conclusions

The obturator fossa comprises the major landing site of lymph node metastases, but more than half of the metastases are located outside this anatomic region. Routine resection of the obturator fossa with additional resection of positive sentinel regions improves staging accuracy compared to resection of the obturator fossa only.